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OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
CORONARY ARTERY BYPASS SURGERY MULTIPLE PRIMARY CANCERS ACUTE CARE BED NEED IN SOUTH CAROLINA THE OPERATING ROOM: HISTORICAL PERSPECTIVE
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VOLUME 81 NUMBER 1 JANUARY 1985
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THOUGHTS FROM THE AMA MEETING
Having recently returned from the AMA Interim Meeting in Hawaii, I have fond memories of this meeting and its accomplishments. The address of the President, Joseph F. Boyle, M.D., was thought- provoking and forceful. He again challenged and chastised physicians. Our own Billie Brady spoke to the House on the many objectives and accomplishments of the Auxiliary, and particularly offered to assist in any way with education, distribution or support (moral and physical) in our nationwide struggle to change or alter the professional liability climate.
AMA-ERF President, Dr. Rufus Bradaway, declared that the number of contributions was increasing and urged all members to contribute and allow credit to be extended for these contributions to the Auxiliary. AMP AC Chairman, Fred Rainey, M.D., stated that 82 percent of candidates supported were elected and that AMPAC was truly bipartisan.
I happened to listen to a debate on Channel 17 (Atlanta) of the House of Delegates’ decision to support the Resolution to ban boxing. The AMA was maligned for meeting in Hawaii and criticized for not also supporting banning all violent sports including football, basketball and baseball. It was suggested that anyone who went to Waikiki Beach would have voted in favor of any Resolution. I find this remark by the former Editor of Ring Magazine to be both obnoxious and disrespectful in suggesting that the members of the House would support anything simply because of the area in which we met. He further suggested that if our decision had been made in Cleveland it would have been more effective.
The House of Delegates of the American Medical Association is a more democratic body than any I have ever witnessed. I believe that we should endeavor to implement every improvement in any sport which would diminish the possibility of injury or death; however, I must also state that we must be prepared to justify whatever approach we take. If banning boxing is the way to stop senseless injury and death, then perhaps we should ban automobiles; many more lives are lost because of careless or incapacitated drivers. Although I must profess to little enthusiasm for the sport of boxing, I believe we must support the decision of the House. I also do not believe that we will be successful if what is to be sought is a legislative ban — this is one of those decisions which is in the "no win" category.
A Resolution presented by the American Academy of Family Physicians, if passed in its original form, would require that Family Medicine be taught as a specific subject in medical school. There was extensive debate in the Reference Committee, with the result that the wording was changed to urge the schools to offer a course in Family Medicine. The matter of a specialty publication in OB/GYN was referred to the Board of Trustees.
Many other items were considered, and had it not been for the diligence of the House on Tuesday afternoon, the meeting could not have adjourned by Noon on Wednesday — all in all a very pleasant experience.
Until next month,
Kenneth N. Owens, M.D. President
January 1985
3
OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038*3139)
|
VOLUME 81 |
JANUARY 1985 |
NUMBER 1 |
EDITOR
Charles S. Bryan, M.D.
SCMA, P. O. Box 11188 Columbia, S. C. 2921 1
EDITORIAL BOARD
Edward E. Kimbrough, M.D., Columbia, Editor Emeritus
Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
William H. Hunter, M.D., Clemson
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
Stanley Gould, M.D., Greenville
Rocco D. Cassone, M.D., Orangeburg
E. Conyers O'Bryan, M.D., Florence
MANAGING EDITOR
Joy Drennen
SCMA OFFICERS
Kenneth N. Owens, M.D., President
Leonard W. Douglas, M.D., President-Elect
John W. Simmons, M.D., First Vice President
Benjamin E. Nicholson, M.D., Second Vice President
J. Gavin Appleby, M.D., Secretary
Thomas C. Rowland, Jr., M.D., Treasurer
COUNCILORS
J. Frank Biggers, III, M.D., 1st District Bartolo M. Barone, M.D., 1st District
B. Daniel Paysinger, M.D., 2nd District Jack Ratliff, M.D., 2nd District
E. Mims Mobley, Jr., M.D., 3rd District
Charles R. Duncan, Jr., M.D., 4th District, Chairman
William J. Goudelock, M.D., 4th District
William M. Hull, Jr., M.D., 5th District
William H. Hester, M.D., 6th District
S. Perry Davis, M.D., 7th District
John W. Rheney, Jr., M.D., 8th District
J. Sidney Fulmer, M.D., 9th District
DELEGATES TO THE AMA
C. Tucker Weston, M.D., Delegate Waitus O. Tanner, M.D., Delegate John C. Hawk, Jr., M.D., Delegate Euta M. Colvin, M.D., Alternate Randolph D. Smoak, Jr., M.D., Alternate Leonard W. Douglas, M.D., Alternate
RESIDENT PHYSICIANS’ SECTION
Danny Mikell, M.D., President Bonnie Ramsey, M.D., Vice President Leonard W. Douglas, Jr., M.D., Secretary
EXECUTIVE VICE PRESIDENT
Mr. William F. Mahon
ORIGINAL SCIENTIFIC ARTICLES
Safety of Combined Coronary Artery Bypass Surgery — L. Dieter Voegele, M.D., William H. Prioleau, Jr., M.D.,
William Hairston, M.D
Multiple Primary Cancers in the Same Patient: Case Reports
and a Review of the Literature — J. Sidney Fulmer,
M.D., John N. Fleming, M.D 13
SPECIAL ARTICLES
Uncertainty in Projecting Acute Care Bed Need in South
Carolina — Samuel L. Baker 25
The Operating Room: An Historical Perspective — Brent V.
Stromberg, M.D 31
EDITORIALS
Medical Student, Medical Student; Where Art Thou? — W.
Marcus Newberry, M.D 34
An Alternative to Capital Punishment — William H.
Hunter, M.D 35
FEATURES
Auxiliary Page 46
Letters to the Editor 36
On The Cover 43
President s Page 3
ASSOCIATION
Financial Checkup 39
Impaired Physicians’ Program 47
In Memoriam 49
Information for Authors 44
Legislative Update 5
SCMA Newsletter 19
THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.
Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.
The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association
INFORMATION FOR AUTHORS
Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 11188, Columbia, S.C. 29211.
All manuscripts should be accompanied by a transmittal letter with the following paragraph: This original work has not been submitted or published elsewhere, in entirety or in part I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA "
We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e g , "Bottsford, et al.3", and should conform to the following style: “3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983 1 1 Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate Reprints will be made available by the publisher.
4
The Journal of the South Carolina Medical Association
From the State House:
LEGISLATIVE UPDATE
January 1985
The 1985-86 Legislative Session will have begun by the time this update reaches you. Foremost on the agenda in the coming year will be debates on the newly proposed indigent care plan, adequate funding to settle lawsuits and other concerns surrounding conditions at our state- run prison system, and how to go about spending the relatively modest 80 to 100 million dollars in estimated new revenues. In other words, money matters should be the major topics this year.
CONFIDENTIALITY BETWEEN PHYSICIAN & PATIENT
South Carolina remains one of the ten-odd states which does not have a provision in the state law protecting the communications between patients and physicians. This has led to sane situations of abuse, where physicians have been forced to reveal matters involving their patients to the court. This violates medical ethics and, of course, tends to break down the relationship between patient and doctor to the detriment of correct diagnosis and treatment .
SCMA precipitated the introduction of legislation to have such a provision enacted in 1984; however, certain attorney groups successfully utilized the parliamentary process to stall and eventually kill all chances of passage into law. That bill would have provided that confidential communications properly entrusted to "physicians" (and other health care professionals) are privileged and cannot — except in exceptional circumstances — be subject to disclosure or testimony in court proceedings.
We will once again attempt to have a bill considered and passed to provide for appropriate confidentiality. If you, the physician, have an attorney or attorneys in your local legislative delegation, approach them and ask them to study the bill carefully this year without automatically voting against it. We feel this legislation, as currently drafted, affords adequate opportunities for appropriate medical/health evidence to come before the court when necessary, yet affords protection when no valid reasons exist to invade the patient's privacy.
EFFORTS TO DF1T.F1TE M,D. REQUIREMENT FOR COMMISSIONER OF MENTAL HEALTH Various legislators failed last year in their attempts to do away with a Statutory provision which requires that an M.D. serve as the Commissioner of the State Department of Mental Health. The Commissioner oversees the various hospitals which house our state's mentally ill population. A bill (H— 2864) that would accomplish this purpose never even came to a vote on the House floor, and in the waning days of the '83- '84 session attempts were made to attach a "rider" to the state budget bill to accomplish this purpose. This attempt also failed.
What did pass into law was a provision stipulating how a replacement would be found for the retiring Caranissioner — a task force or committee made up largely of government-types which would scrutinize etc., candidates for the job.
What is extremely disappointing is that this committee has sat on its hands since its creation in early summer of '84. Reportedly the Search Committee will continue to drag its feet, hoping that certain legislators will get a bill passed early in this session deleting the M.D. requirement. Apparently there is little intention of searching for an M.D. to fill this position as the legislators involved take the viewpoint that all M.D. 's are "poor administrators."
Talk to your local House & Senate members about this issue because the handwriting on the wall indicates another push to ensure that a professional (and non-M.D.) bureaucrat runs the Department of Mental Health in the future.
MORE GROUPS LINING UP TO GAIN "LICENSURE"
State House watchers have viewed a predictable pattern with professional and semiprofessional groups pushing to become a "licensed profession" — especially in regard to paramedical groups. They always approach legislative bodies arguing that some in and out of their particular profession could do great harm unless a board made up from that group was legislatively created to oversee the profession.
This pattern that is seen usually presents itself in the following order: 1. The group
receives formal government recognition by the state of the practitioner group and of the need to regulate the practice in the "public interest" either by registration, certification, or licensure; 2. Scope of practice — the nature and boundaries of the practitioners' "practice" (usually denied to others) is defined usually in the form of expansion of the original scope of practice into additional services involving presumed higher levels of education, training, skill, judgment, and renumeration; 3. Practice Autonomy — the extent to which the practitioner may provide services directly to the public and independently of any other practitioner, in the absence of requirements for the referral, approval, consultation, supervision or direction of another is set forth; 4. Third Party Reimbursement — legislation is enacted reflecting the various methods of encouraging or assuring payment by third parties for services rendered by the practitioner to the public, including government or private insurers, such as non-discrimination, "mandated lifting," "mandated offering," or "mandated coverage" provisions; and 5.
Hospital Admitting Privileges — a legislative or court-oriented push for the authority of the practitioner to utilize the facilities and resources of a hospital for the delivery of services, either independently or conditionally.
This development always serves the particular professional group and its interests well, but the public is often ill served — especially since costs tend to rise with professional licensure. Studies also reflect that these groups often tend to protect their own and utilize their best efforts mainly to keep others and the "part-timers" out of business.
The social workers have, for several years, been attempting to gain licensure in South Carolina. In anticipation of the upcoming session, they were claiming that since the legislature last year listed them as an "Examination Board" in the State Budget bill, they now have the right to "license" instead of "register" social workers. Even their leadership has admitted that a chief goal of licensure is to gain third party reimbursement. The public at large will surely pay more if that ever becomes the case.
On the eve of the opening of the 1985 session their Board abruptly rescinded these proposed regulations. We are not certain as to what will be their next move: however, we know only too well their ultimate desires.
As was the case last year, we fully expect to, again in the upcoming session, hear from social workers. Likewise, we also expect the respiratory therapists, occupational therapists, "counselors", and "family therapists" to come forth asking for licensure.
Their goals, of course, are working down the five-step procedure listed above.
OF THE SOUTH CAROLINA MEDICAL ASSOCIATION VOLUME 81 JANUARY 1985 NUMBER 1
SAFETY OF COMBINED CORONARY ARTERY BYPASS SURGERY*
L. DIETER VOEGELE, M.D.**
WILLIAM H. PRIOLEAU, JR., M.D.
PETER HAIRSTON, M.D.
The safety of coronary artery bypass graft sur- gery (CABG) combined with resection of ven- tricular aneurysm, repair of post-infarction ven- tricular septal defect, aortic valve replacement, mitral valve replacement, simultaneous carotid endarterectomy, and ascending aortic aneurysm repair was reviewed in 55 patients. Twenty-five patients underwent concomitant aortic valve re- placement, 14 patients ventricular aneurysm re- section, six patients each simultaneous carotid endarterectomy and mitral valve replacement, one patient ascending aortic aneurysm repair and three patients underwent ventricular septal defect closure.
Bypass grafting of atherosclerotic obstructed coronary arteries has become a well-established surgical procedure in many centers today, with an operative mortality ranging from less than one percent to 10 percent for elective, routine re- vascularization cases.1 However, concomitant op- erations for other cardiovascular pathology, in particular the life-threatening complications of myocardial infarctions carry a significantly higher mortality. Perioperative myocardial in-
From the Department of Surgery, Roper Hospital, Charleston, S. C. 29401.
Address correspondence to Dr. Voegele at Ashley House, Commercial Suite One, Lockwood Blvd., Charleston, S. C. 29401.
farction rates as high as 21 percent to 36 percent have been reported in combined CABG surgery.2
One can assume that the risk of correcting two pathological processes during one operation might be greater than that of operating on indi- vidual isolated conditions, and this may well ob- tain in the case of concomitant peripheral vas- cular pathologic processes. However, in the case of valvular hemodynamic compromise or more tellingly in the case of complications from myo- cardial infarction, to omit correction of a second- ary condition could jeopardize the outcome of the repair of the primary condition. For this reason, in those properly selected patients, combined cor- rection should lower the risk factors in patients in whom two different pathological conditions exist.
This report reviews our experience with the operative treatment of this group of patients re- quiring CABG surgery combined with other car- diovascular operative interventions.
MATERIALS AND METHODS
From September, 1976 to August, 1983, 55 patients underwent CABG surgery combined with either aortic valve replacement, mitral valve replacement, ventricular aneurysm repair, as- cending aortic aneurysm repair, post-infarction ventricular septal defect repair, or simultaneous carotid endarterectomy (Table III). There were 46 males and nine females with a mean age of 64
January 1985
7
CORONARY BYPASS SURGERY
years, ranging from 40 years to 76 years of age. Nine patients underwent emergency operation, four with preinfarction angina and five in car- diogenic shock. Six patients had critical left main occlusive disease. Sixty-one percent of the patients had unstable angina and 33 percent of them had overt symptoms of congestive heart failure. Six patients had acute infarction (Table I). Six pa- tients further had suggestive signs or symptoms of critical carotid stenosis. The preoperative elec- trocardiogram was abnormal in over 90 percent of the patients, including 51 percent of the patients with demonstrated Q waves. Severe compromise of the myocardium could be inferred in patients as evidenced by 18 percent of the patients having ejection fractions below 40 percent, and 62 per- cent demonstrating segmental dyskinetic abnor- malities. Four patients required preoperative intraaortic balloon pump (IABP) support (Table II).
Table I
CLINICAL CHARACTERISTICS OF 55 PATIENTS UNDERGOING COMBINED CORONARY ARTERY BYPASS SURGERY
Baseline Data:
|
Mean Age (yrs) |
64 |
|
Males (%) |
83 |
|
Females (%) |
17 |
|
Unstable Angina (%) |
61 |
|
Congestive Failure (%) |
33 |
|
Acute Infarct (%) |
11 |
|
Vascular Disease (%) |
18 |
|
Emergency Intervention (%) |
16 |
Table II
LAB AND CATHETERIZATION CHARACTERISTICS OF 55 PATIENTS UNDERGOING COMBINED CORONARY ARTERY BYPASS SURGERY
Parameters:
E. F. < 40 (%) 18
Preop EKG Abnormal (%) 91
EKG With Q Waves (%) 51
Hypokinesis/Akinesis (%) 62
Preop IABP (%) 7
Left Main Obstruction (%) 11
Twenty-five patients underwent aortic valve replacement at the same time as coronary artery bypass grafts and six patients underwent mitral valve replacement concomitantly. In 14 patients a ventricular aneurysm was resected along with coronary artery bypass surgery. Three patients had coronary surgery in conjunction with repair
Table III
COMBINED CORONARY ARTERY BYPASS SURGERY 1976-83
Operations:
CABG + Aortic Valve Replacement 25
CABG + Ventricular Aneurysm Resection 14
CABG + Carotid Endarterectomy 6
CABG + Ventricular Septal Defect Closure 3
CABG + Ascending Aortic Aneurysm Repair 1
CABG + Mitral Valve Replacement 6
TOTAL 55
of a post-infarction ventricular septal defect. One patient had simultaneous repair of a large ascend- ing aortic aneurysm and six patients had carotid endarterectomy simultaneously performed with their bypass operation because of critical stenosis. Two patients represented reoperation cases, one for progression of coronary occlusive disease, graft occlusions and development of a ventricular aneurysm; the other for prosthetic bacterial endo- carditis. One hundred and forty-two grafts were performed for an average of 2.58 grafts per patient.
All operations were performed using cardiopul- monary bypass. Protection of the myocardium has taken an increasing importance and consists of core cooling to moderate hypothermia (26° C. to 30° C.), cold potassium cardioplegia, topical well- type cooling, and monitoring of myocardial septal temperatures. Reoperation patients were cannu- lated through the femoral artery, however, all other patients had proximal aortic cannulation employed. For carotid endarterectomy, the car- otid incision was performed simultaneously with median sternotomy including entry into the peri- cardium. Purse string sutures were placed in the usual manner and the patient systemically totally heparinized. At this time, an option could be exercised to proceed to cannulation immediately prior to, or following endarterectomy, depending on the individual patient requirements. No car- otid intra-luminal shunts were used. During aortic valve replacement, the left coronary ostium was cannulated for perfusion with cold cardioplegic solution.
RESULTS
Among the 55 patients studied, there were 50 survivors and five hospital deaths for a periopera- tive mortality of nine percent. Excluding emer- gency or rescue operations in three patients, the perioperative mortality was 3.6 percent. Only one
8
The journal of the South Carolina Medical Association
CORONARY BYPASS SURGERY
death occurred among elective, first operation patients for a perioperative mortality of 1.9 per- cent (Table IV). Four patients required pre- operative IABP support. One patient was a long- term survivor. Four patients required postopera- tive IABP support. The mortality rate was 50 percent, indicating that IABP is a poor prognostic indicator. A total of nine patients were operated upon as emergency cases, including two patients with ruptured mitral papillary muscles and three patients with post-infarction ventricular septal defect who were in cardiogenic shock. Four pa- tients had unstable pre-infarction angina.
The efficacy of myocardial preservation is often gauged by the perioperative occurrence of myocardial infarction.3 Criteria used to that ef- fect have included enzyme profiles, electrocar- diographic changes, and radionuclide scans. No survivors showed signs of unequivocal periopera- tive infarction, however, in the total group, sev- eral patients had preoperative indications of recent or remote infarction which made the ap- plication of selection criteria difficult. Two early survivors, one of which had an evolving infarct and ruptured papillary apparatus had une- quivocal evidence of infarction and subsequently succumbed. Thus, the incidence of perioperative
myocardial infarction is judged to be no higher than 3.6 percent for the entire group.
Thirty patients had early as well as late com- plications of varying degrees (Table V). Exclusive of the group with ventricular power failure which led to the five hospital deaths, there were five patients with early complications whose discharge was actually delayed because of these com- plications.
Five patients succumbed in the course of their illness and an analysis of the associated circum- stances is listed in Table VI. Of note is a 64-year- old male who underwent four-vessel re- vascularization and ventricular aneurysm resec- tion having undergone coronary artery surgery nine years previously. There was a period of in- stability immediately preceding cardiopulmo- nary bypass possibly related to his eventual fatal outcome.
DISCUSSION
This group of patients represents a particularly high risk category due to the cumulative effects of the various pathological processes present at the time of intervention. In the preoperative setting, both the short-term and long-term outlook in this
Table IV
RESULTS OF COMBINED CORONARY ARTERY BYPASS SURGERY
|
Patients |
Emergency |
Pre-IABP |
Post-IABP |
Enzymes + |
EKG + |
Death |
|
|
CABG + AVR |
25 |
1 |
1 |
2(4) |
1 |
1 |
|
|
CABG + V. A. |
14 |
1 |
2 |
3(2) |
1 |
||
|
CABG + CEA |
6 |
2 |
1 |
1 |
|||
|
CABG + VSD |
3 |
3 |
1 |
1 |
|||
|
CABG + AscA |
1 |
||||||
|
CABG + MVR |
6 |
2 |
2 |
(1) |
1 |
2 |
|
|
Grafts/Patient |
2.58 |
||||||
|
Coronary Endarterectomy % Patients |
11 |
16 |
7 |
7 |
9 |
3.6 |
9/3. 8/1. 9 |
Table V
COMPLICATIONS FOLLOWING COMBINED CORONARY ARTERY BYPASS SURGERY
|
Early Complications |
Late Complications |
||
|
Harvest Site Healing |
1 |
Residual VSD |
1 |
|
Reoperation for Bleeding |
3 |
Cerebrovascular Accident |
1 |
|
LVPF (Ventricular Power Failure) |
6 |
Permanent Pacemaker |
2 |
|
Leg Ischemia |
1 |
Hepatitis |
1 |
|
Respiratory Insufficiency |
3 |
SBE |
1 |
|
Visual Defect |
1 |
Reoperation |
2 |
|
Peripheral Nerve Deficit |
2 |
Colon Polyp |
1 |
|
Central Neurologic Deficit |
2 |
Congestive Failure |
1 |
|
Sternal Dehiscence |
1 |
||
|
Renal Insufficiency |
1 |
January 1985
9
CORONARY BYPASS SURGERY
Table VI
ANALYSIS 5 FATAL RESULTS COMBINED CORONARY ARTERY BYPASS SURGERY
|
Procedure |
Patients |
Emergency |
Reoperation |
Associated Circumstance |
|
CABG + V.A. |
1 |
1 |
Reop — LVPF — Post IABP |
|
|
CABG + MVR |
2 |
2 |
E — OMI + AMI — Pre IABP — LVPF |
|
|
E — AMI — Pre IABP — LVPF |
||||
|
CABG + AVR |
1 |
150 mm Hg Grad — IABP |
||
|
CABG + VSD |
1 |
1 |
E — AMI — Pre — IABP — Vent. Volume |
|
|
Total Survival |
9% |
3.8% |
1.9% |
LVPF — left ventricular power failure
Post IABP — post operative intra-aortic balloon
Pre IABP — preoperative intra-aortic balloon
E — emergency
OMI — old myocardial infarct
AMI — acute myocardial infarct
group of patients is quite grim and even in those in whom there is not an immediate proximity of death, a high later mortality is expected. Surgical intervention is thus indicated to save and prolong life.4
Advances in cardiac surgery, anesthesia, and perfusion technology have made it possible to offer a reasonable chance of survival to this ex- tremely compromised group of patients. The safety of the procedure has been improved by (1) complete revascularization, (2) moderate body hypothermia, (3) excellent myocardial preserva- tion. Even in the complex repairs when the clinical setting allows a first intervention and an elective choice, the safety of the operation ap- proaches that attained in routine revasculariza- tion procedures.
SUMMARY
The presence of simultaneous multiple patho- logical processes in patients afflicted with the
10
ravages of atherosclerotic cardiovascular disease makes for a high risk group of surgical patients when it comes to reparative intervention. A retro- spective study was undertaken to analyze the efficacy or safety of treatment in a group of 55 patients undergoing CABG surgery combined with aortic valve replacement, ventricular septal defect, mitral valve replacement, ascending aor- tic aneurysm resection and simultaneous carotid endarterectomy. There were 50 survivors and five hospital deaths. A first-time elective operation carried a mortality risk of 1.9 percent. □
REFERENCES
1. Loop FD: Achievements in coronary artery surgery. Sur- gical Rounds, 136, Oct. 1983.
2. Ciaravella JM, Ochsner JL, Mills NL: Combined procedure of coronary artery bypass grafting and valve repair. Ann Thor Surg 23: 20-25, 1976.
3. Balderman SC, et al: Perioperative myocardial infarction: a diagnostic dilemma. Ann Thor Surg, 30, 4: 370-376, 1980.
4. Jamieson SW, Miller DC: Surgical implications of low car- diac output syndrome after myocardial infarction. Am J Surg 147: 735-742, 1984.
The Journal of the South Carolina Medical Association
MULTIPLE PRIMARY CANCERS IN THE SAME PATIENT: CASE REPORTS AND A REVIEW OF THE LITERATURE
J. SIDNEY FULMER, M.D.*
JOHN M. FLEMING, M.D.
Multiple cancers occurring in the same patient can no longer be considered rare. Since Billroth first presented his cases, nearly 100 years ago, some 30,000 cases have been reported in various publications world- wide.1 Most reports have been of simultaneous or sequential tumors of the same organ system. Less commonly reported have been those tumors involving more than one organ sys- tem. Reports of three or four distinct carcinomas have been rarer.2
For the practicing physician, however, aware- ness that a patient may have more than one pri- mary malignancy, and that this is not some isolated freak of nature, becomes of increasing importance. Dr. William Cahan, in introductory remarks at the 1976 International Workshop on Multiple Primary Cancers, stated that such can- cers are certainly a part of the overall oncologic problem, and can no longer be considered a frag- ment of the cancer experiment. That multiple primary cancers are actually increasing in fre- quency, Dr. Cahan reports, is attributable to bet- ter recognition by both pathologists and clinicians, in part to the myriads of carcinogenic forces en- gendered by our contemporary way of life, and indeed an ironic tribute to the better control of cancer, which enables between five and 10 per- cent of patients who survive their first cancer to live long enough to develop a second cancer at another site.3
Three cases of multiple primary malignancies are included in this report.
CASE REPORTS
Case #1 — L.D.M. — A 76-year-old white female who first presented for a “routine” gynecological examination. The patient gave a history of having had a left radical mastectomy four years pre-
° Address correspondence to Dr. Fulmer at 1 Catawba Street, Spartanburg, S. C. 29303.
viously for adenocarcinoma of the breast. Prior to that, at the age of 36, the patient had had her right ovary removed for a benign tumor but the exact pathological diagnosis could not be obtained.
The patient presented with no complaints but on pelvic exam was found to have a large mass (measuring 16 x 20 cm) arising from the pelvis.
The patient was admitted to the hospital for preliminary work-up and exploratory laparot- omy. Chest film was negative. Barium enema showed diverticulosis of the sigmoid colon and on I.V.P. — in addition to the large pelvic mass, partially obstructing the right ureter — a mass was described in the left kidney. Renal ultra- sonography showed a 3 cm cyst in the upper pole of the left kidney and the lower pole showed a solid renal mass suggestive of renal cell car- cinoma. Bilateral selective renal angiography was highly suspicious of carcinoma of the left kidney involving the lower pole.
At surgery the large ovarian tumor was re- moved intact with pathological report showing well-differentiated papillary cystadenocarci- noma of the ovary. The left kidney was removed during the same operation with pathological re- port of renal cell adenocarcinoma. The renal cell carcinoma was a small lesion confined to the kidney without regional node spread.
Slides from this operation and from the pre- vious breast surgery were reviewed and the pa- thologist reported that neither malignancy was related to the previous carcinoma of the breast.
Because of the possibility of seeding in the pelvis from the cystadenocarcinoma of the ovary, the patient received 5000 rads cobalt 60 tele- therapy to the whole pelvis during a five-week span post-operatively.
The patient did well for approximately five months before she was seen in the emergency room with difficult breathing, nausea and vomit- ing and a hemoglobin of 5.1 and hematocrit of 15.7 percent. The patient w^as transfused and im-
January 1985
13
MULTIPLE PRIMARY CANCERS
proved. Upper G.I. series showed a small hiatal hernia, otherwise negative. A barium enema was negative except for diverticulosis, proctoscopic exam was negative. A chest film was also reported as negative.
Forty-eight hours after admission, the patient suddenly expired. An autopsy was not obtainable.
This patient’s family history was significant in that several cousins had died of cancer but of unknown type.
Case #2 — W.G.H. — This patient is a 45-year- old white female who in 1954 had excision of a lesion of the third toe, left foot. Pathological re- port showed malignant melanoma and described both epidermal and dermal involvement with in- filtration of the subcutaneous fibro-fatty tissue. Subsequently, the patient had amputation of toe of the left foot and left groin dissection, with report of one node positive for metastatic mela- noma.
Following this surgery the patient did well, without any apparent problems until September, 1971 (some 12 years later) when on physical ex- amination a mass was discovered in the upper outer quadrant of the left breast. From this same physical exam, a pap smear was reported as show- ing cells with severe dysplasia approaching car- cinoma-in-situ. Excisional breast biopsy was positive for adenocarcinoma of the breast. A radi- cal mastectomy was performed with lymph nodes negative for metastatic disease. Final pathological report was poorly differentiated adenocarcinoma of the breast.
Subsequent conization of the cervix revealed intraepithelial carcinoma of the cervix. Multiple sections of cervical tissue revealed fairly broad areas of severely dysplastic stratified epithelium with foci of full thickness differentiation but no demonstrated invasion. A total abdominal hys- terectomy was performed with final pathological report showing mild to moderate epithelial dys- plasia of the cervix with no residual in-situ.
In October of 1979, a 1 x .8 cm lesion on the right side of the patient’s nose was removed with pathological report of a multifocal basal cell car- cinoma, totally excised.
In July of 1982 a 3 x 2 cm firm nonfixed mass was discovered in the upper outer quadrant of the right breast. But subsequent excisional biopsy of the mass was benign — fibrocystic disease.
In August of 1982, an excisional biopsy of a 0.9
cm x 0.5 cm lesion of the right vulvar was done. Pathological report was in-situ squamous cell car- cinoma of the vulva. The pathologist commented that this was an extensive multifocal process with the in-situ areas limited to the more central region of the lesion, but with variable degrees of dys- plasia extending close to the surgical margins.
The patient’s family history is significant in that her maternal grandmother and grandfather both died of stomach cancer. Two maternal aunts had cancer, but type is not known.
At present this patient is doing well.
Case #3 — A.B.H. — This patient is an 87-year- old white female who in March of 1958 (at the age of 63) had a diagnostic D & C for post-menopausal bleeding. A diagnosis of adenocarcinoma of the endometrium was made and the patient subse- quently had a total abdominal hysterectomy and bilateral salpingo-oophorectomy.
The patient did well after this surgery and had no further problems until July of 1971 (some 13 years later) when she developed a mass in the left parotid area. A left parotidectomy was performed with pathological diagnosis of benign adenoma of the parotid gland.
In May of 1979, the patient had excision of a small lesion of the right eyebrow and a 2 x 1 cm lesion of the right lower leg. Pathological diag- nosis of each lesion was poorly differentiated squamous cell carcinoma of the skin but not in- volving the margins of the excision.
In January of 1980, a 2 x 2 cm mass developed in the right parotid area. A right parotidectomy was performed with pathological diagnosis of mucoepidermoid carcinoma of the parotid gland.
In October of 1980, a lesion of the right hand was excised with pathological report of intra- epithelial carcinoma of the skin.
In August of 1982, the patient was admitted to Spartanburg General Hospital for rectal bleeding. Barium enema was negative except for diver- ticuli. On proctoscopic exam an actively bleeding polyp was encountered at 10 cm. The polyp was excised and pathological report was benign-ade- nomatous polyp.
At present, except for increasing senility, this patient is doing well.
Summary — Case #1
(1) Adenocarcinoma of left breast — age 72.
(2) Renal cell carcinoma left kidney — age 76.
14
The Journal of the South Carolina Medical Association
MULTIPLE PRIMARY CANCERS
(3) Papillary cystadenocarcinoma left ovary — age 76.
Summary — Case #2
(1) Malignant melanoma third toe of left foot
— age 22.
(2) Adenocarcinoma of the left breast — age 34.
(3) Cancer-in-situ of the cervix — age 34.
(4) Basal cell carcinoma of the right side of nose — age 42.
(5) In-situ squamous cell carcinoma of vulva
— age 45.
Summary — Case #3
(1) Adenocarcinoma of the uterus — age 53.
(2) Mucoepidermoid carcinoma of right parot- id gland — age 66.
(3) Squamous cell carcinoma of the skin — age 74.
(A) right eyebrow
(B) right lower leg
(4) Intraepithelial carcinoma of right hand — age 76.
DISCUSSION
In 1884, Billroth established criteria for diag- nosis of multiple primary malignancies in the same patient (criteria which one investigator has called “too severe and typically Germanic”).4 These criteria stated that
(1) Each tumor must have an independent his- tologic appearance.
(2) The tumors must be separate and situated in different organs.
(3) Each tumor must produce its own metasta- sis.
In 1932, believing that these criteria were in- deed too strict, Warren and Gates modified them after having found 1,259 patients from the liter- ature with reasonably well-documented multiple primary cancer.5 In their criteria
(1) Each suspected tumor must be distinct and must be malignant.
(2) The probability that one has a metastatic lesion from the other must be excluded.
Moertel et al, in a 10 year survey of 37,580 cancer patients at the Mayo Clinic found 1,909 patients or 5.1 percent with multiple primary
neoplasms. One thousand forty-nine of these pa- tients or 2.8 percent of the surveyed population were found to have multiple malignancies of dif- ferent tissue origins.6
Mersheimer and Ringer report an incidence of multiple primary malignancies of 3.2 percent. After analyzing the records of 140,000 cancer patients, they found 96 percent of the 3.2 percent with multiple cancers to have had two primary- cancers, 4.5 percent had three primaries, and 0.5 percent had four or more.7
Schottenfeld in a review of 41,341 cancer pa- tients treated at the Sloan-Kettering Institute from 1949-1962 reported that of 5,636 autopsies on cancer patients 176 (or 3.1 percent) had occult second primary cancers in different organs or tissues.8
Other necropsy studies have shown that be- tween 5.3 and 8.1 percent of cancer patients have second primary cancers, either occult or clinically apparent, in different organs or tissue.9
IMPORTANT ASSOCIATIONS
In surveying the literature, many interesting and significant positive associations involving multiple primary cancers have been reported. These associations have raised the very important question of whether the existence of a specific type of cancer implies a predisposition to another specific type of cancer or to a group of cancers. If a woman develops breast cancer, does this pre- dispose to uterine cancer or other genital cancers? These associations may aid the practicing physi- cian to predict those patients at increased risk.
Schottenfeld and others in a study of over 40,000 cancer patients have established certain important associations in multiple cancers. For example:
(1) breast, ovary, endometrium
(2) large intestine, breast, female genital tract
(3) leukemias, lymphomas, and skin.10
In a study by Berg and Schottenfeld of 9,792 women with breast cancer, ovarian cancer ac- counted for 10 percent of all new primaries.11
In a 1963 study of patients in the Connecticut cancer registry, Bailar observed that females with endometrial cancer had a 1.5 times higher expec- tation of developing breast cancer.12
Schoenberg studied a similar population of females with breast cancer and found that the subsequent risk of a new primary cancer in the
January 1985
15
MULTIPLE PRIMARY CANCERS
uterus or ovary was approximately doubled.13
Newell and Krementz, in a 23-year period (1948-1978) at Charity Hospital in New Orleans, reported that white and black women with initial breast cancer had an excess risk of developing cancers of the buccal cavity and pharynx and an additional breast cancer. White women with breast cancer had a slightly increased risk for developing cancer of the corpus uteri and leuke- mias in this series.14
One of the best documented associations has been between breast cancer and cancer of the corpus uteri, ovary, and colon in women. Since infertility or low fertility has been a factor associ- ated with all four of these malignancies, this has provided a basis for further thought and investi- gation.15
Certain studies have suggested that a signifi- cant percentage of patients with a gynecologic malignancy will subsequently develop another genital malignancy. Also suggested is that patients with cervical cancer, because of their youth and retained genital organs, may be more likely to develop a subsequent malignancy.
Buchler, in a series from the University of Wisconsin of patients with cervical cancer, found that 41 percent developed their subsequent can- cers more than 10 years after treatment, making continued observation beyond 10 years in these patients mandatory.16 The study also concluded that long-term follow-up should not be directed toward the pelvic area alone. As Nolan and others have also pointed out, concern must also be di- rected toward the breast and abdominal examina- tions and unusual complaints should not be ignored. As they have stated, “Even cancer phobes may develop cancer and succumb to it.”
As important as these associations may be and the implications of risks, not all of these reviewed studies have been able to document certain of these reported associations.
For example, Berg has reported an increased risk of approximately eight-fold for women with a malignancy of the salivary gland of subsequently developing breast cancer.17 However, other inves- tigators, including Moertel, have failed to substan- tiate this association.
Bailar and his associates have reported an in- creased incidence of oral cavity tumors in patients with uterine cancer. Studies by Schottenfeld and Berg have found no such increase.18
Schoenberg found a statistically significant
16
two-fold excess of rectal cancer following both cervical and corpus cancer,19 but studies by McMahon, Schottenfeld, and others have found no excess of colon cancer following either cervical or corpus cancer.20
CLASSIFICATION OF MULTIPLE PRIMARY MALIGNANT NEOPLASMS
A classification of patients with multiple pri- mary cancer has been presented by Moertel and his associates.21
I. Multiple primary malignant neoplasms of multicentric origin —
(A) The same tissue and organ (for example, multiple epitheliomas of the skin)
(B) A common, contiguous tissue shared by different organs (for example, squamous cell carcinoma of pharynx and squamous cell carcinoma of larynx)
(C) Same tissue in bilaterally paired organs (for example, bilateral breast cancer).
II. Multiple primary malignant neoplasms of different tissues or organs (example — ade- nocarcinoma of the breast and osteogenic sar- coma or squamous cell carcinoma of the mouth, squamous cell carcinoma of cervix).
III. Multiple primary malignant neoplasms of multicentric origin plus a lesion(s) of a differ- ent tissue or organ. (Combines the first two.)
ETIOLOGICAL CONSIDERATIONS
In spite of many important contributions in the field of cancer research, the origin of cancer re- mains a mystery. Modes of cancer therapy, hor- monal and hereditary influence have all come under careful scrutiny as possible etiologic factors in the development of multiple primary malig- nancies. To date there is no true evidence that the patterns of occurrence of these multiple primary malignancies are governed by anything more than coincidence.
In a recently reported retrospective 10-year study of 116 patients with multiple primary ma- lignancies at M. D. Anderson Hospital, three on- cogenic factors were considered:22
(1) That the immuno-suppressive effects of ra- diation and chemotherapy may render pa- tients susceptible to develop other malig- nancies.
(2) Anticancer agents can damage directly the cells producing mutagenic effects, and
The Journal of the South Carolina Medical Association
MULTIPLE PRIMARY CANCERS
(3) The association of several factors (malnutri- tion, family history of cancer, viral infec- tions, environmental factors, radiation) could also predispose to the “polycan- cerization syndrome.”
Wynder et al. have hypothesized that dietary habits may be a common factor in increasing both colon and breast cancer.23
That there may be a hormonal link between breast cancer and meningiomas has been sug- gested since, interestingly, meningiomas are the only intracranial neoplasms with a higher inci- dence in women, and an abrupt appearance of meningiomas during pregnancy is reported.24
Newell and Krementz have reported an excess risk of developing cancers of the oral cavity, lung and bladder following cervical cancer. This high level of risk had not been previously suspected. Since excess cigarette smoking has been reported among women who develop cervical cancer, Krementz feels that it is interesting to speculate that cigarette smoking could account for these observed increases.25
It is known that medical, surgical and X-ray methods of treating cancer are capable of produc- ing profound changes in the neoplasm being attacked.
Steward and Treves (in 1948) reported the oc- currence of lymphangiosarcoma in chronic lymph stasis. All of their reported cases developed at the site of lymphadema after radical excision of carcinoma of the breast.26
Babcock has reported an uncommon tumor- peritoneal mesothelioma — originating in the right lower quadrant seven years after internal and external radiation for carcinoma of the cervix. Cases have been reported in the surgical literature of radiation-induced carcinoma of the rectum as a late complication of pelvic irradiation.27
Both normal and abnormal cells are affected by chemotherapeutic agents. Penn has reported 166 new cancers in 160 patients treated with chem- otherapy. The most common types were leuke- mias, solid lymphomas, and carcinoma of the urinary bladder.28
In the previously-mentioned M. D. Anderson retrospective study, however, it was concluded that while certain modes of cancer therapy could render a patient more susceptible to develop a second neoplasm, the use of anticancer treatment cannot be suppressed in fear of the increased risk of developing a second tumor.
Vora has reported that nothing about cancer has been more accepted than its hereditary nature, but nothing is less satisfactorily proven. Although hereditary factors have been evident in the genesis of malignant neoplasms in experimen- tal animals, there is little factual information to support the concept that such factors have an influence in man.29
Moertel performed a retrospective study to as- sess the influence of heredity in multiple primary cancers. He found that when the occurrence rate of cancer was determined for all family members, the rate for members of the families with single cancers did not differ significantly from that of families without cancer. However, members of the families of patients with multiple cancer showed a 26 percent increase in the incidence of cancer over that found in members of the families of patients without cancer.30
But Berg and Schottenfeld have reported in their series of multiple primary cancers at Memo- rial Hospital (1949-1962) that they uncovered no convincing examples of cancer families even with extra attention to patients with three or four or more primaries.31
SUMMARY
In summary, while multiple primary cancers in a single patient can no longer be considered a rarity, case reports such as those presented here do continue to appear and re-emphasize for the prac- ticing physician that by increasing surveillance there will be a continuing increased frequency of cancer detection, diagnosis, and reporting.
The literature has provided some significant associations, many more contradictions and un- proven hypotheses, and many inherent warnings. Too many of the studies have included very small samples to reach very broad conclusions. Factors such as heredity have been difficult to analyze due to poor recording in the first place.
And seemingly important correlations in one study have not necessarily been borne out in another.
But most cancer patients, as the M. D. Anderson study points out, do seemingly have increased risks for specific later cancers, depending on their original cancer types, and knowledge of these risks is of true clinical importance. □
REFERENCES
1. Moertel, C.: Multiple primary malignant neoplasms. Can- cer 40:1786-1791, 1977.
January 1985
17
MULTIPLE PRIMARY CANCERS
2. Baker, M. S. Multiple primary carcinoma. Military Medi- cine 141:109-110, 1976.
3. Cahan, W. G.: International workshop on multiple pri- mary cancers: introductory remarks. Cancer 40:1785, 1977.
4. Moertel, op. cit., pg. 1786.
5. Warren, S., and Gates, O.: Multiple primary malignant tumors. American Journal of Cancer 16:1358-1414, 1932.
6. Moertel, C., Dockerty, M., and Baggenstoss, A.: Multiple primary malignant neoplasms. Cancer 14:221, 1961.
7. Mersheimer, W., Ringer, A., Eisenberg, H.: Some charac- teristics of multiple primary cancers. Annual New York Academy of Science 114:896-921, 1964.
8. Schottenfeld, D : The epidemiology of multiple primary cancers. Cancer 27:233-240, 1977.
9. Ibid.
10. Ibid.
11. Schottenfeld, D., and Berg, J.: Incidence of multiple pri- mary cancers. Cancers of female breast and genital organs. Journal of National Cancer Institute 46:161-170, 1971.
12. Schottenfeld, D.: The epidemiology of multiple primary cancers. Cancer 27:233-244, 1977.
13. Ibid.
14. Newell, G., and Krementz, E.: Multiple malignant neo- plasms in the Charity Elospital of Louisiana tumor regis- try. Cancer 40:1812-1820, 1977.
15. Ibid.
16. Buchler, D.: Multiple primary and gynecologic malignan- cies. American Journal of Obstetrics-Gynecology 123:379, 1975.
17. Berg, J., and Hunter, H.: The unique association between
salivary gland cancer and breast cancer. Journal of Amer- ican Medicine 204:771-774, 1968.
18. Newell, G., and Krementz, E., op. cit. pg. 1817.
19. Schoenberg, B., and Greenberg, R.: Occurrence of certain multiple primary cancers in females. Journal of the Na- tional Cancer Institute 43:15-32, 1969.
20. Newell, G., and Krementz, E., op. cit. pg. 1819.
21. Moertel, C., op. cit., pg. 1786.
22. Extremera, B.: Incidence of multiple primary malignan- cies. A retrospective study of 10 years.
23. Wynder, E.: Correlations of international cancer rates — an epidemiological exercise. Cancer 20:113-126, 1967.
24. Schoenberg, B.: Multiple primary neoplasms. Persons at High Risk of Cancer, J. F. Fraumeni, Jr., New York, Academic Press: 111, 1975.
25. Newell, G., and Krementz, E., op. cit., pg. 1819.
26. Vora, N., and Gelt, A.: Multiple primary carcinomata: A case presentation and review of the literature. Delaware Medical Journal 51:211-216, 1979.
27. Babcock, T., Powell, D.: Radiation induced peritoneal mesothelioma. Journal of Surgical Oncology 8:369-373, 1976.
28. Penn, I.: Second malignant neoplasm associated with im- muno-suppressive medications. Cancer 37:1024-1032,
1976.
29. Vora, N., and Gelt, A., op. cit., pg. 215-216.
30. Moertel, C., and Dockerty, M.: Multiple primary malig- nant-neoplasms. Cancer 14:231-237, 1961.
31. Berg, J. and Schottenfeld, D.: Multiple primary cancers at Memorial Hospital 1949-1962. Cancer 40:1801-1805,
1977.
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The Journal of the South Carolina Medical Association
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UNCERTAINTY IN PROJECTING ACUTE CARE BED NEED IN SOUTH CAROLINA
SAMUEL L. BAKER*
The certificate of need (CON) remains a major vehicle for state regulation of hospital construc- tion and renovation. The requirement that new or expanding hospitals obtain CONs prior to the start of any large project determines over time what facilities will be available to physicians and their patients. In South Carolina, CON applications for adding acute care beds are evaluated against bed need projections made by the Division of Medical Facilities Planning of the State Department of Health and Environmental Control (DHEC). This paper examines the methodology used to make these projections. The projections are found to be quite sensitive to random year-to-year changes in hospital bed usage rates and population estimates. They are also markedly affected by apparently minor changes in methodology.
DHEC calculates future need for acute care beds for each county individually, except for some counties deemed to constitute a market area. Table I shows how this was done for Richland County. As of 1984, the Richland hospitals’ mar- ket is taken to be all of Richland County plus one- half of Lexington County. To save space, Table I gives detailed figures only for Richland Memorial Hospital.
DHEC projects into the future on the basis of a single year’s bed usage. Because of lags in the availability of data from hospitals, that single year is two years before the date of the plan. In Table I, Actual Patient Days is what each hospital re- ported to DHEC for 1982. Adjusted Patient Days, a reform newly introduced in 1984, is an estimate of what patient days would have been if 30 per- cent of surgery were outpatient. (For the details of the methodology, see the 1984 State Health Plan, pp. 11-8,9.) The adjustment reduces patient days by about 1.6 percent in Richland County. Ad- justed Average Daily Census is Adjusted Patient Days divided by 365 days/year.
° Department of Health Administration, School of Public Health, University of South Carolina, Columbia, S. C. 29208.
For the bed demand projection the 1982 Ad- justed Average Daily Census by age group is in- creased by the projected population growth for that age group. Summing across the three age groups gives the projected average daily census for each hospital.
The projected average daily census is divided by a target occupancy rate, 75 percent for rural hospitals, 80 percent for small urban hospitals, and 85 percent for large urban hospitals. This step is the sole reason that separate calculations are made for each hospital, so that the target occu- pancy rate specific to that hospital can be used as divisor.
The quotient of bed demand divided by target occupancy rate is the projected future bed need. Summing over all the hospitals gives the total number of beds that need to be added by the projection date, here 41 for Richland County. Acute care beds in institutions with restricted public access, such as the University’s Thomson Student Health Center, the Moncrief Army Hos- pital, and the Dorn Veterans’ Hospital, are essen- tially ignored in these calculations. Though bed needs are shown for individual hospitals, in no sense do these beds “belong” to the particular hospital. Any institution, existing or new to the county, may be granted a certificate of need for the beds to be added.
This bed need estimate is dependent upon sev- eral numbers, each of which is subject to uncertain variation from year to year. Hospital utilization can vary due to changes in morbidity patterns, changes in medical practice, movements of medi- cal staff, and changes in financial arrangements. Future population growth estimates also change. Even current population figures are only esti- mates based on incomplete data. As more data become available from federal and state sources, current population estimates change, as do future projections. All these combine to produce uncer- tain change in the number of beds that the for- mula says need to be added in a locality. Health
January 1985
25
ACUTE CARE BED NEED
Table I
BED NEED FOR 1988, RICHLAND COUNTY
South Carolina DHEC method, based on 1982 usage Adapted from the 1984 State Health Plan
Population (includes one-half of Lexington County population.)
|
1982 |
1988 Increase |
|||||||
|
under 15 years old |
74,427 |
75,257 |
1.12% |
|||||
|
15-64 |
233,230 |
265,777 |
13.95% |
|||||
|
over 64 |
27,599 |
33,688 |
22.06% |
|||||
|
Actual |
Adjusted |
Adjusted |
Projected |
Target |
||||
|
Patient |
Patient |
Avg. Daily |
Avg. Daily |
Occu- |
Bed |
Actual |
To |
|
|
-days |
-days |
Census |
Census |
pancy |
Need |
beds |
Be |
|
|
Hospital |
1982 |
1982 |
1982 |
1988 |
Rate |
1988 |
1983 |
Added |
|
Richland Memorial |
||||||||
|
under 15 |
12,754 |
12,506 |
34.26 |
34.65 |
||||
|
15-64 |
98,734 |
96,514 |
264.42 |
301.32 |
||||
|
over 64 |
46,956 |
46,908 |
128.52 |
156.87 |
||||
|
sum over all ages |
492.84 |
+ .85 |
580 |
579 |
1 |
|||
|
Providence |
176.51 |
+ .80 = |
221 |
239 |
-18 |
|||
|
Baptist Medical Center |
406.13 |
-5- .85 = |
478 |
420 |
58 |
|||
|
Restricted public access beds (Thomson, Moncrief, VA) |
305 |
305 |
||||||
|
Total |
1,584 |
1,543 |
41 |
NOTE: The presentation in Table I is not identical to that of Part II of the State Health Plan, but it is mathematically equivalent.
planners find themselves shooting at moving targets.
THE POPULATION ESTIMATES
The population figures reported in the State Health Plan are estimates. This is as true of the figures for the current year as it is true of the figures for the future year. The State Budget and Control Board Division of Research and Statistical Services directly estimates population by county only for decennial years. Other years are interpo- lated. Thus, for example, the figures in the 1984 plan for 1982 and 1988 were interpolated from the most recent estimates for 1980 and projections for 1990.
Every year the estimates for the decennial years, past and future, are modified to reflect results newly available from the prior decennial census, late trends in birth and death rates, and new estimates of migration patterns. As the de- cennial year estimates change, the interpolated estimates for in-between years change as well, which makes projected growth rates change. As Table II shows, the projected growth rate of the number of elderly has generally been rising, matched by a fall in the projected growth rate in the number of children. This shift in projected growth to the high-usage elderly population im-
26
plies that recent state health plans are showing a greater future need for beds, holding other factors constant.
USAGE RATE VARIATIONS
Bed usage is necessarily subject to variation from year to year which cannot be fully antici- pated. Because bed demand is projected from one year s usage, usage variations translate directly into projected need variations. Thus in the usage rate fraction, bed-days per year divided by esti- mated population, both the numerator and the denominator vary.
As the entries on the diagonal in Table III show, a review of past plans would give the impression of a sharp decline in usage from 1979 to 1980, and again from 1981 to 1982. Consistent population
Table II
PROJECTED ANNUAL RATES OF POPULATION GROWTH BY AGE CATEGORY IMPLICIT IN STATE HEALTH PLANS 1981-1984
State Health Plan of
|
Ages |
1981 |
1982 |
1983 |
1984 |
|
0-14 |
1.47% |
1.73% |
.48% |
.50% |
|
15-64 |
2.44% |
2.31% |
2.47% |
2.45% |
|
65 + |
2.74% |
3.20% |
3.77% |
3.70% |
|
all |
2.22% |
2.24% |
2.14% |
2.13% |
The Journal of the South Carolina Medical Association
ACUTE CARE BED NEED
Table III
ACUTE CARE HOSPITAL BED USAGE RATES, PATIENT-DAYS PER YEAR PER 1,000 POPULATION, RICHLAND AND LEXINGTON COUNTIES, ALL HOSPITALS COMBINED. ENTRIES ACROSS ROW USE CONSISTENT POPULATION ESTIMATES. ENTRIES ON THE DIAGONAL ARE FIGURES PUBLISHED IN THE RESPECTIVE STATE HEALTH PLANS, EXCEPT AS NOTED BELOW.
Population
|
Estimate |
Age |
||||
|
from |
Group |
1979 |
1980° |
1981 |
1982 |
|
1981 |
0-14 |
296 |
|||
|
plan |
15-64 |
1,025 |
|||
|
65 + |
4,556 |
||||
|
all |
1,097 |
||||
|
1982 |
0-14 |
250 |
|||
|
plan |
15-64 |
974 |
|||
|
65 + |
4,636 |
||||
|
all |
1,056 |
||||
|
1983 |
0-14 |
245 |
|||
|
plan |
15-64 |
950 |
|||
|
65 + |
4,326 |
||||
|
all |
1,055 |
||||
|
1984 |
0-14 |
300 |
263 |
244 |
241 |
|
plan |
15-64 |
954 |
964 |
943 |
915 |
|
65 + |
4,086 |
4,213 |
4,281 |
4,303 |
|
|
all |
1,040 |
1,054 |
1,047 |
1,036 |
|
|
°NOTE: |
Modified usage |
data for |
1980. Baptist and |
Provi- |
dence Hospitals underreported usage in some age groups and overreported usage in others for the 1982 State Health Plan. For 1980, patient-days were redistributed among age groups according to suggestions by officials of the two hospitals. The DHEC formula is not very sensitive to this sort of error, so long as the total usage for all age groups is accurately reported.
estimates reveal that there was little trend on usage over the period. Reading horizontally shows that usage actually rose from 1979 to 1980, then diminished in 1981 and 1982, finishing only slightly lower in 1982 than it had been in 1979. For the 65-and-over age group, the usage rate marched upward over 1979-82, though figures gleaned from the plans would indicate a drop.
This demonstrates the importance of using con- sistent population estimates in any analysis of usage rates. There has been much discussion of declining hospital usage. These figures suggest that though usage rates for persons under 65 have fallen, the rise in usage among persons over 65, the fastest growing segment of the state’s population, may mitigate any tendency for shrinkage of over- all hospital bed demand. Hopefully data coming available for 1983 will help clarify the direction of the trend.
THE DYNAMICS OF THE BED NEED PROJECTION
The effects of the various causes of change in the bed need projection can be roughly separated by making one change at a time and tracking the resultant change in the bed need projection. The separation is not perfect because the population interpolation and extrapolation are not linear. Thus it matters in what order one makes the changes. However, because of the short time pe- riod involved, the imperfection is on the order of one or two beds, which is small enough to be ignored.
Table IV presents the results of a stepwise anal- ysis for 1981 through 1984. Richland and Lex- ington counties are used as the example. The relatively small changes in usage rates and popu- lation estimates and projections shown in Tables II and III translate into relatively large changes in the number of beds to be added. A small, say two percent, drop in the usage rate will reduce the projected total need by about the same two per- cent, an apparently negligible change. However, when one subtracts the current number of beds from the total need, that two percent translates into a 20 percent drop in the number of beds that need to be added. To cite a case in which this might have been important, in 1982 Humana, Inc., and Hospital Corporation of America each applied for a certificate of need to build a free standing 88-bed hospital in Richland County. To some observers, 88 beds seemed barely minimal for consistency with efficient allocation of health care resources. If the usage rate had not jumped in 1982 compared with 1981 and 1983, the 1982 State Health Plan would have shown a need for only 72 beds in the area. This need figure might have been small enough to have discouraged a certificate of need application for a new hospital.
The effect of the outpatient surgery adjustment also shows how highly sensitive the projection is to small changes in usage rates. Adjusted usage rates are only 1.7 percent and 2.7 percent less than actual rates in Richland and Lexington counties respectively, but the effect on beds to be added is about ten times as great as these percentages.
SUMMARY AND RECOMMENDATIONS
Two approaches should be explored to reducing the uncertainty in bed need projections. Future usage rates should be projected on the basis of several years’ experience, not just one. The relia-
January 1985
27
ACUTE CARE BED NEED
Table IV
CAUSES OF YEAR-TO-YEAR CHANGE IN ACUTE CARE BED NEED PROJECTIONS, RICHLAND AND LEXINGTON COUNTIES, SOUTH CAROLINA STATE HEALTH PLANS, 1981-1984
A. Richland and Lexington Counties Combined as in State Health Plans 1981-83
|
Beds to |
Beds |
||||
|
Change from |
Add in |
Changed |
Changed |
One Year’s |
Authorized |
|
Plan |
Earlier |
Population |
Usage |
Population |
in Year |
|
of: to: |
Plan ° |
Estimates |
Rates |
Growth |
(subtracted) |
|
1981 1982 |
90 |
9 |
13 |
40 |
-64 |
|
1982 1983 |
88 |
22 |
-15 |
45 |
0 |
|
1983 1984 |
140 |
- 4 |
-31 |
[46] |
0 |
|
Average Absolute Value of Change Relative to Average |
11.7 |
19.6 |
43.7 |
||
|
Beds to be Added |
12% |
20% |
44% |
B. Separating the Counties, 1984 methodology. (Note: A 1984 change in a rounding convention subtracted two beds from total need.) Beds to be added (change) Remarks
|
Total |
Richland |
Lexington |
|
|
105 |
61 |
44 |
Splitting counties added 2 beds to total need. |
|
75 |
40 (-21) |
35 (-9) |
Outpatient surgery adjustment. Corresponds to 1984 Plan. |
|
[121 |
73 ( + 33) |
49 ( + 14) |
If 5-year projection had been used] |
bility of the population estimates should be im- proved. Physicians, hospital administrators, and health planners have an interest in supporting efforts to enhance the ability of the Division of Research and Statistical Services to acquire timely relevant data, such as from tax returns now closed to it. These steps would improve the consistency and reliability of the bed need projections, reduc- ing the likelihood of surprises that might disrupt hospital planning efforts.
Three reforms of the bed need projection for- mula that were implemented in 1984 deserve comment with regard to their impact on Richland and Lexington counties. Shortening the time hori- zon for projections from five years to four in effect put off 46 beds for one year. Separating the two counties eliminated the possibility that a new free standing hospital can be granted a CON in accor- dance with the State Health Plan for the near future. The number of beds available in one county alone is simply too small. In general, sepa- rating counties favors existing institutions, while larger market areas favor new entrants. The out- patient surgery adjustment was DHEC’s first for- mal effort to project based on something other than a snapshot of current usage rates. As such it represents progress, and will surely be improved in the future.
Finally, because the shortened time horizon and the outpatient surgery adjustment reduce the bed need, they increase the relative importance of
28
the uncertainty that usage rate and population estimate variations introduce into the bed need projections. Though there may be legal and politi- cal obstacles to altering the Division’s projection method, the case for developing a more sophisti- cated statistical model of usage and for obtaining better estimates of population is becoming even more compelling.
SUMMARY
Under the current methodology, acute care bed need projections for South Carolina counties are subject to considerable uncertain variation from year to year. The main causes of the uncertainty are variations in usage rates and the population estimates. The uncertainty could be reduced if a statistically more satisfactory method could be devised for predicting usage rates, and if better population estimates were available. In this paper, the impact of 1984 methodological reforms is estimated, including the shortening of the plan- ning time horizon from five years to four. For Richland County, for example, beds-to-be-added is reduced by 33. The outpatient surgery adjust- ment reduced bed need in Richland County by 21. □
REFERENCE
1. South Carolina Statewide Health Coordinating Council,
South Carolina State Health Plan, Volume II: Medical
Facilities, 1981, 1982, 1983 (draft), and 1984.
The Journal of the South Carolina Medical Association
THE OPERATING ROOM:
AN HISTORICAL PERSPECTIVE
BRENT V. STROMBERG, M.D.*
The modern twentieth century operating room has its beginnings in 16th century Italy and France. Prior to this era there is little mentioned of either operating room or amphitheatre in med- ical history. The first permanent operating the- atre used predominantly for anatomical dissec- tions is credited to Fabricius eb Aquapendente (1533 a.d.). It is said that he built his own amphi- theatre in Padua at his own expense. It was in this same theatre a century later where Morgagni (1682-1771) did much of his work. It is evident from the historical description that the purpose of this amphitheatre, as well as others of this era, was for anatomical dissections and not for operations upon live patients. Indeed, the monumental work of Vesalius, the Fabric of the Human Body, (1543-1555) and its accompanying illustrations denote a public amphitheatre for anatomical dis- section. These were meant for educational pur- poses, and in large part, for public entertainment. It can be postulated that little anatomic discovery was actually made in such locations. It is far more likely that Vesalius did his significant work in quieter surroundings. The expansion of such areas into France proceeded relatively quickly. By the late 17th century numerous amphitheatres had been built in France and Germany. The gradual extension of their usage to include live operations was slow however. From France came numerous barber surgeons who made significant contribu- tions. LaFranc (1315), Pierre Franco (1500-1561), Ambroise Pare (1510-1590), and Charles Felix were a few of the surgeons who provided signifi- cant contributions to the instruction of anatomy and the care of surgical problems in the latter half of the century.
A significant controversy existed for genera- tions between the faculty of medicine in the vari- ous locations and the surgeons. The physicians
° Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of South Carolina, 171 Ashley Avenue, Charleston, S. C. 29425.
claimed their knowledge rested upon book learn- ing and felt that practical experience was unnec- essary. The barber surgeons held the opposite view, that practical experience was all important and book learning was of little value. As a conse- quence, through the years surgeons at the Faculty of Medicine in Paris were required to take an oath acknowledging that medicine was always better than surgery. This humiliating requirement was maintained until the mid-18th century. The be- ginning of the demise of the humiliation of the surgeons was with the success of Charles Felix of Paris in operating upon the rectal fistula of Louis XIV1 2- 3 By royal decree, barber surgeons were then given advanced standing. They were given the privilege of dissecting cadavers as well as treating open wounds. Shortly after this, a large amphitheatre was constructed at St. Come for operating and public lectures. This had a seating capacity for more than a hundred individuals. It was constructed in 1694 and eventually became the center of the Royal Academy of Surgery of France. This increased favor resulted in signifi- cant contention between the physicians and sur- geons of the day. Nevertheless, the surgeons had a strong foothold now with the approval of the royalty of France and the barber surgeons in- creased their power.
It should be emphasized that despite this new- found respectability, almost all actual surgical procedures were still performed at the patient’s bedside. The amphitheatres were used predomi- nantly for public lecture and anatomical dissec- tion. In the 18th century, the increasing skill in surgical anatomy and dexterity of the surgeons fostered a desire among surgeons to be seen by more of the public. More and more operations were brought into the amphitheatres in an at- tempt to spread the fame of individual surgeons. The surgical amphitheatre grew in size and or- nateness. Often constructed adjacent to large pub- lic areas and marketplaces, surgery became a
January 1985
31
THE OPERATING ROOM
public event. Certainly with the lack of anesthesia and understanding of good hemostasis, each oper- ation had a significant morbid drama to it.
The swiftness and dexterity of the operating surgeon became his advertisement and claim to fame. As the means of attracting patients and spreading their influence in the preanesthesia era, surgeons would openly advertise their speed at doing various operations. An account of an opera- tion for a gluteal aneurysm in 1860 by the great surgeon Syme relates that 800 spectators observed the operation. A large applause both preceded and followed the surgery.4 The entire operation had lasted a matter of minutes.
Another recollection of a famous surgeon was that of Lister. His first operation using ether anes- thesia was in 1846 before a large number of vis- itors at the amphitheatre at Guy’s Hospital. The operation was an amputation of the leg. As a matter of technique, Lister did the entire pro- cedure, from first incision to final ligature in less than five minutes.5
Evolution in surgical thinking is represented best in the German universities. It was there that chairs of surgery were first created. It was consid- ered, at that time, beneath the dignity of those who taught surgery to actually perform it. Thus Haller (1708-1777) who was a professor of surgery at Goettinggen and Berne, never was known to have performed an operation himself. It was not until a century later that this philosophy would be permanently changed.6
It was said that pain, hemorrhage, and infection were the three great evils which had limited pro- gress in the practice of surgery. In the late 1800’s, all three were dramatically changed by the dis- covery of anesthesia and asepsis. These two dis- coveries permitted careful surgical technique and hemostasis7; a new era had dawned. In addition, this marked the end of the surgical amphitheatre as a place of public display and surgical instruc- tion.
Discovery and routine use of anesthesia in- creased the volume of surgery geometrically. The statistics from the Massachusetts General Hospital regarding the volume of surgery before and after the introduction of anesthesia are informative. In the ten years preceding the introduction of anes- thesia, fewer than 40 operations were performed per year. In the ten years following the introduc- tion of ether anesthesia, an average of 190 cases were recorded per year; a four and one-half fold
32
increase. In the next 40 years, this number would swell to greater than 3,000 operations per year, within this one institution. Similar statistics were reported from other hospitals of this era.8 At the end of the 19th century, elegant new operating rooms were being constructed. In 1895, the Mid- dlesex Hospital constructed a new operating area with teakwood benches for 130 students, teak staircases and a marble floor.9
The dramatic change of the size of the audience was brought as a direct consequence to advances in antisepsis. The monumental labor of Pasteur and the realization of its importance by Lister marked the end of surgery as a public spectacle. Lister’s contribution rests predominantly in his appreciation of the practical application of Pas- teur’s work. In 1867, Lister made his clear contri- bution with the reduction of wound infections with carbolic acid. That it took a generation of surgeons to accept these principles is a tribute to stubbornness. The tenets of Pasteur and Lister implied that a limitation should be placed upon the number of spectators within the operating room. For a while this was ignored. At the large meeting of the Clinical Congress of the American College of Surgeons in Chicago in 1913, large operating clinics were still utilized for instruc- tion.10
The numerous advances in asepsis and antisep- sis afforded new emphasis upon the attire of the surgical team as well as sterility of instruments and surroundings. Each of these areas, as well as associated areas of the development of surgical gloves, masks, air flow systems, wound and skin preparations, and antibiotics have all altered the drama and flair of the operating room. However, it has been this conversion of the large operating amphitheatre of history to the modern sterile op- erating room with good anesthesia that allows meticulous surgical technique which has in- creased dramatically the effectiveness and science of surgery. What we consider to be a modern operating room today can be expected to evolve significantly in the coming years.
SUMMARY
The operating room as an integral part of the hospital involved in patient care and teaching has undergone a dramatic evolution through the cen- turies. Formerly designed as a large surgical am- phitheatre with much emphasis on instruction of
The Journal of the South Carolina Medical Association
THE OPERATING ROOM
Anatomy and entertainment, an evolution in its purpose and form has occurred in relatively re- cent times. Fostered by the principles of advances in surgical technique, hemostasis, antisepsis, and anesthesia, the drama of surgery has decreased. At the same time the emphasis upon changing pat- terns of education and instruction of surgery has demanded a different format of surgical educa- tion. A brief outline in this evolution of the operat- ing room is presented. □
REFERENCES
1. Garrison FH: An Introduction to the History of Medicine, ed. 4, Philadelphia, 1929, W.B. Saunders Company, p. 154, 223.
2. Le Monnier L: Traite de la fistule de L’anus . . ., Paris, 1689, Aunoy, p. 86-89.
3. Vallot A, D’Aquin A, Fagon GC in LeRoi J.A., editor: Journal de la sante du roi Louis XIV de l’annee 1647 a l’anne 1711, Paris 1862, Durand, p. 395-404.
4. McKay WJS: Lawson Tait, his life and work, London, 1922, Baillieve, Tindall and Cox, p. 409, 538.
5. Brock R: The operating theatre of old Guy’s Hospital, Guy’s Hosp. Rep. 113:131, 1964.
6. Lehren u. Lehren, p. 45, Wien, 1876.
7. Vanderhandlungen der deutschen Ges. F. Chirurgie, 1896, von Esmarch.
8. Halsted. W.S.: The Training of the Surgeon. Bulletin of the Johns Hopkins Hospital, Vol. 15, p. 267-275, 1904.
9. Middlesex Hospital: New operation theatre, unsigned edi- torial, Lancet 2:224, 1895.
10. Clinical Congress of American College of Surgeons (Pro- gram), Surg. Gynec. Obstet. 65:558, 1913.
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January 1985
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Following is the sixth in a series of articles on medical education in South Carolina. Guest editorials reflect the opinions of the authors and do not necessarily reflect the policy of the Editorial Board and the South Carolina Medical Association.
— CSB
MEDICAL STUDENT, MEDICAL STUDENT; WHERE ART THOU?
The study of history provides an outlook on change which includes an appreciation for the flow and relationship of events. There has been an accelerating pace of change and a proliferation of inter-relating factors which impinge upon events throughout history. Further, the perspective re- quired for sharp insight and understanding has been achieved infrequently by those who are con- temporary observers or participants in change. These circumstances have created relentless pres- sures upon people, institutions and society, often generating insecurity and instability. A fre- quently observed response has been the return to basic values. Students and patients have taken the lead for such a response in medical education and medicine.
Medical education and the practice of medi- cine are inseparable. Change in one of these com- ponents invariably influences the other. My comments relate primarily to medical education but keep in mind that changes have been concur- rently underway for the practice of medicine as well.
The traditional concept in academic medicine of the “three legged stool” consisting of teaching, research and service has provided balance for vitality, capital development and progress. This discussion will focus upon how change has influ- enced the relationship between these basic func- tions within the medical school.
The demands of scientific research have led to dedicated efforts by a nationally and interna- tionally oriented faculty. Scientists have re- sponded to a competitive environment. Within this environment graduate students or post-doc- toral fellows who are more involved in research activities are often the recipients of the faculty’s primary teaching efforts while the education of
34
medical students may be perceived to be on a lower priority.
There is little doubt that subspecialization, Medicare and Medicaid, faculty salary expecta- tions, service to referring physicians and the med- ical center dependency on clinical income have been rewriting the teaching agenda of the clinical faculty. The clinical environment brings focus upon the patients. Because of their intense in- volvement in the care of patients, residents are the recipients of the clinical faculty’s primary atten- tion. As a result, medical students are frequently secondary recipients of the faculty’s clinical in- struction. Also, rapid technological development and its application narrows the view of patient care and precludes a holistic approach to patients for medical students. Students are aware of this problem in clinical education and have expressed their concern.
Task dedicated faculty, a highly competitive research environment and specialty oriented medicine have created a subdivided and highly structured medical school. In turn, this organiza- tion has generated an internal political environ- ment with built-in conflict in securing recognition and resources. Further, the attention and energies of institutional leadership have been effectively channeled by the medical school concept of ad- ministration to serve the faculty, the focus upon influencing political and regulatory processes at all governmental levels, and the emphasis upon raising funds for all institutional purposes. The development of entrenched special interests among the faculty has been a force to sustain the status quo. Within this framework, teaching has not been a special interest but instead has served as an almost mystical background activity utilized by each interest group to justify its support in the
The Journal of the South Carolina Medical Association
medical school.
Collectively, these concerns have attracted na- tional attention. In response, a report recom- mending changes in the general professional education of physicians has been published. This published report reaffirms the basic principle that a strong educational base is built one layer at a time from the ground up. At the same time, we have recognized that the educational process re- quires as much dedication as does research or clinical care and none of these activities can exist successfully in isolation.
The medical school environment requires a value system which is basic to all dedicated inter- ests. This value system must contain the precepts that the institutions’ primary activity is education, its primary focus is the medical student, its pri- mary outcome, a quality physician and the pri- mary institutional mission is service. The pro- ductivity of medical education should be mea- sured in the capability of our graduates, not in the number. Capable physicians are oriented to peo-
AN ALTERNATIVE TO CAPITAL
About 2,400 years ago, Socrates was found guilty of crimes against the polis (i.e. state) and was sentenced to either exile or ingestion of a cup of hemlock. Socrates’ description of his death, as recorded by Plato, makes for intriguing reading. For the physician, it’s interesting to speculate on the physiology of his death. He describes the paresthesias of his lower extremities that gradu- ally ascended until he died a very easy death. Prior to his drinking the hemlock, Plato quotes Socrates as saying, “Nobody knows, in fact, what death is, not whether to man it is not perchance the greatest of all blessings, yet people fear it as if they surely knew it to be the worst of all evils.” Herein Socrates describes death as rather pleasant and not to be feared. This predated Christian thought that came to a similar conclusion several hundred years later.
We physicians who are constantly concerned with life and death have always known; it is life that is painful, death is easy and a great release.
It is, therefore, paradoxical that in our society of today there exists a law that requires the state to punish certain criminals by putting them to death.
Is this then our approach, in a free and hopefully civilized society, to deter the most heinous of
pie and service, they have a highly developed sense of inquiry and they are prepared to pursue their education over the span of their careers.
The medical school can best serve its purpose by identifying the basics and doing them well. Every effort should be made to select bright students who have acquired a liberal arts education with good value systems. The medical school should have a clear concept of the basic education of a medical student which includes clinical problem solving and self learning. The faculty should es- tablish and maintain clear academic standards for medical students. Above all, effective professional education should be based upon teachers whose principal aim is to stimulate students to learn.
W. Marcus Newberry, M.D.
Vice President for Academic Affairs and Dean, School of Medicine MUSC, 171 Ashley Ave.
Charleston, S. C. 29425
PUNISHMENT
crimes? We must admit there is little deterrent in our present method due to the lack of the prompt carrying-out of capital punishment and the un- equal effect of its administration. What we have now is near random chance and anarchy in re- spect to the ability of an individual to predict the cost of his criminal behavior. For instance, in South Carolina, you will probably spend more time in jail for forgery than for voluntary man- slaughter.
My thesis is that death, while the ultimate de- privation for an individual, is very little punish- ment. Further, that capital punishment is amoral in a civilized society. It is the worst of examples that a government can set for its citizens, that is, the killing of an individual in cold blood. What then can a free and civilized society do to deter the most heinous of crimes? There must be an alter- native, something other than just being against the death penalty.
I would propose a new law. The person that would ordinarily be sentenced to death would instead be sentenced to what I like to call lethe (from Greek mythology meaning oblivion, or river of oblivion). That is, he would be placed in a cell alone with no chance of parole for the re-
January 1985
35
mainder of his life; he would have no contact with anyone other than his jailers and he would never leave his cell. This would be real punishment and such a criminal may well yearn for the release of death. With such dire punishment, the prisoner should probably be offered a “cup of hemlock” on his tenth year of incarceration and annually there- after; however, this latter would probably not be acceptable to a Christian society.
We physicians, who are in a constant battle with the grim-reaper, by our very nature should oppose the death penalty. An obvious civilized step forward was taken by the Council of the South Carolina Medical Association in 1982 when
LETTERS TO THE EDITOR
To The Editor:
Re: “Think Yeast — the Expanding Spectrum of Candidiasis,” September, 1984 issue of The Journal of the South Carolina Medical Asso- ciation
While anecdotal observations may be of some value in medicine, the statements and conclusions made in the article, “Think Yeast,” published in The Journal of the South Carolina Medical Asso- ciation, September, 1984, are not supported by current research. Except for anecdotal observa- tions, no well documented studies in the medical literature have shown that this type of therapeutic approach to allergic or emotional diseases would be of any benefit whatsoever.
Since the injudicious use of Nystatin and Ket- oconazole might induce potential severe allergic reactions or initiate drug intolerance to these agents, it is essential that these drugs be used only in situations where they would reasonably be ex- pected to be helpful. Certainly there is a well recognized condition of systemic candidiasis but this is not the disease described in this article.
The readership should be aware that in addi- tion to allergic reactions and drug intolerances, there also exists the rare potentially serious hepa- totoxic effect of Ketoconazole.
Unfortunately, we don’t have the definitive therapy for many emotional and allergic diseases and it might be tempting to reach for certain anecdotal therapies with little proven scientific merit. Hopefully, continuous scientific efforts using the tools of objective research techniques
a motion passed objecting to any physician taking part in carrying out capital punishment. If physi- cians should not take part in killing a prisoner, then should we be in favor of anyone doing so?
As physicians we could make a difference if we give our support and influence to the now emerg- ing “South Carolina Coalition Against Capital Punishment.” A better name for this organization might well be “The South Carolina Coalition for an Alternative to Capital Punishment.”
William Harvey Hunter, M.D.
One Hunter Court
Clemson, S. C. 29631
will give us the answers to these perplexing prob- lems in the near future.
Yours very truly,
Charles H. Banov, M.D.
P. O. Box 2728 Charleston, S. C. 29403
The above letter was referred to the authors, whose response is as follows:
Dr. Banov refers to the article as anecdotal and that the statements and conclusions are not sup- ported by current research.
In response, let me first comment on the term — anecdotal, a word that has recently crept into medical terminology. Webster defines anecdotal as a short entertaining account of some happen- ing, usually personal or biographical.
The article “Think Yeast — The Expanding Spectrum of Candidiasis” is definitely not anec- dotal. The paper was written to confirm the ear- lier reports of other physicians, and in particular, of Dr. C. Orian Truss, who began his studies in 1964. In addition, the Bibliography lists six refer- ences, including Dr. W. G. Crook’s book, “The Yeast Connection,” which itself contains fifty-five references.
Since publication of the paper, I am delighted to report Drs. Truss, Allan Levin, and Edward Winger, in independent studies have noted T-cell changes, lowering of the ratio of helper cells to
36
The Journal of the South Carolina Medical Association
suppressor cells, and an elevation of the IgG and IgM in patients with chronic candidiasis. Dr. Ka- zue Iwata, of Tokyo, has spent a lifetime studying Candida, and has identified over fifty toxins pro- duced by the yeast.
His observations were presented at the De- cember 1983, Birmingham symposium “The Yeast-Human Interaction. ” He reported that tox- ins from several Candida strains:
1. Suppress T and B cells, both in number and function
2. Enhance vascular permeability
3. Promote the release of histamine
4. Induce anaphylactic reactions.
I agree with Dr. Banov that rare potentially serious hepatotoxic effects of Ketoconazole have been reported. I would expect any patient on
prolonged Ketoconazole to be monitored with liver function studies. To date, we have had no adverse effects from the use of Ketoconazole.
Nystatin, which has been around for over thirty years, is notably free of untoward reactions.
In summary, the purpose of the article was to confirm the results of the original reports, and to stimulate interest in the subject of chronic can- didiasis. In view of the controversy generated, this article has definitely achieved its goal. I think my friend, Dr. Jim Willoughby says it best when he notes that if a physician isn’t “up” on a subject, he tends to be “down” on it.
Sincerely yours,
Martin H. Zwerling, M.D.
P. O. Box 2456 Aiken, S. C. 29802
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January 1985
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When your insurance agent has sold you policies that are more profitable for him in the short term than they are for you in the long term, your insurance is bleeding you.
When your portfolio hasn’t been updated to capitalize on the wealth of new financial products on the market, your insurance is bleeding you.
And when your insurance hasn’t been integrated with the rest of your investments into a strong, coherent whole, you’re getting doubly bled.
That’s why you should talk to a Connecticut Mutual of South Carolina associate.
Our people have the experience and the superior product line it takes to examine an individual doctor’s or a medical group’s insurance mix, diagnose weaknesses and prescribe precisely the right cure.
We’re also experts at total financial planning. With an in-depth knowledge of all the financial tools that can be put at your disposal, including everything from tax-advantaged investments like real estate and oil & gas, to mutual funds to Ginnie Mae funds (Securities offered by Connecticut Mutual Financial Services, Inc.).
Talk to a Connecticut Mutual associate soon.
The longer you wait, the more you’re getting bled.
The Connecticut Mutual Companies of South Carolina
Suite 800 First National Bank Building Columbia, SC 29201 (803) 771-6040
Suite 503 One Southpark Circle Charleston, SC 29407 (803) 556-5890
880 South Pleasantburg Drive P0 Box 17975 Greenville, SC 29606 (803) 242-4154
1447 East Main Street Spartanburg, SC 29302 (803) 585-2563
HOWTO STOP YOUR INSURANCE FROM BLEEDING YOU.
FINANCIAL CHECKUP
MARTIN LEFKOWITZ Certified Financial Planner Tax Shelter Co-Ordinator: E.F. Hutton
Vol. 4, Issue No. 1
January 1985
LOCKING IN YIELDS: OPPORTUNITIES THAT RATE ATTENTION.
"A bird in the hand is worth two in the bush." Today’s interest rates
can bring to mind this old saying and add to its validity. Ever since fixed income investments were introduced, the question of whether to lock into today's rate or wait "until tomorrow" in hope of a better one has dogged even the most
seasoned investors E.F. Hutton’s outlook is for continued low inflation.
And with rates apparently having peaked in June, the current economic envi- ronment translates into what could be a substantially profitable opportunity.
An Interesting Perspective: It’s important to remember that the real rate of return - the spread between interest rates and the rate of inflation - reflects • your actual spendable income from an investment. With the inflation rate currently hovering around 4% to 5% and interest rates approximately 7% to 8% higher, the current real rate of return is its highest in years.
Choosing the Right Key: There are literally dozens of ways to take advan- tage of the current favorable interest rate scenario in the taxable, tax-
deferred and tax-exempt areas If you decide that tax-exempt investments are
best-suited to your current needs, you can invest in:
Municipal bonds that offer income exempt not only from federal tax, but in many cases, state and local taxes as well. The bonds usually pay semi-annual interest and are available in a wide variety of terms and maturities, from several months to 30 years.
Zero Coupon municipal bonds that pay no semi-annual interest but allow you to earn up to 30 times your initial investment, since they are purchased at deep discounts from par and redeemed at par value at maturity.
Put bonds that lock in today's rates for a few years with an "escape clause" — the option of selling bonds to their issuer after a specified period at par should current rates reverse themselves.
Tax exempt unit trusts - diversified, fixed portfolios of municipal bonds available for a minimum investment of $1,000; and municipal bond funds , which are both diversified and professionally managed, with bonds traded regularly to maximize market opportunities. Both offer monthly tax-free distribution of income.
Your choice of taxable investments, whose yields are generally higher than tax-exempts, is equally extensive. These include corporate bonds and U.S. Treasury
bonds, bills and notes, which may have particularly attractive yields now. In addition, there are:
Certificates of deposit with maturities from three months to 10 years. Corporate and government mutual bond funds.
Treasury Bond Receipts (TBRs) and Certificates of Accrual on Treasury Securities (CATS). Like zero coupon bonds, TBRs and CATS pay no current interest but offer investors a known return at a specific point in the future, with the added advantage of a U.S. government guarantee on the underlying government bond or note. Since investors are taxed yearly as if accrued interest were actually received, TBRs and CATS are excel- lent funding vehicles in tax-advantaged accounts such as IRAs or Keoghs.
COMPLETION PROGRAMS: OIL AND GAS OPPORTUNITY WITHOUT THE RISKS.
If you’ve always associated oil and gas investing with placing high stakes at high
risk for potential high rewards, a completion program may disappoint you. That’s because oil and gas completion programs combine relative safety and a potentially attractive rate of return with a participation price as low as $5,000. So if you want to invest in oil and gas, but have steered clear in the past, consider a completion
program A completion program is a limited partnership that enables you to share in
the economic potential of oil and gas drilling without assuming traditional drilling risks. And, while some other programs — such as oil and gas income limited partner- ships — offer attractive returns, they often don’t give investors the tax advantages available in a completion program.
Last and Safest Phase: How does it work? Completion is the last and safest phase of oil and gas development. It involves installing the equipment needed to remove the
oil and gas from the ground and bring it to market. It does not involve drilling
Furthermore, the only wells included in completion programs are those that demon- strate the potential for successful production after they have been drilled to a total
depth and tested for the presence of hydrocarbons The completion program finances
a portion of these material costs. In return, program investors receive a share of production during the economic life of each well. If completion is unsuccessful and a well is plugged or abandoned, program investors may be provided with insurance to reimburse them for this loss.
Steady Income Stream: In short, the completion program can translate into a steady stream of income that could outpace the rate of inflation. This income stream may
continue for approximately 15 years Tax benefits improve the economics even more.
Investors are entitled to several deductions that shelter a significant portion of the
income and, in addition, there is an attractive investment tax credit Industry
reports indicate that the U.S. is currently experiencing its first real growth in oil consumption in the past five years, and might now offer better investment opportunities than have been available in recent years — expecially in a low-risk program.
FURTHER INFORMATION
If you would like to receive further information on any of the topics covered in this newsletter, please write to Martin Lefkowitz, CFP, E.F. Hutton & Company, 2700 Middle- burg Drive, Suite 200, Columbia, SC 29204; or Call (800) 922-1112.
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The information contained herein has been obtained from sources believed reliable but is not necessarily complete and cannot be guaranteed. Any opinions expressed are subject to change without notice. Neither the information presented nor any opinion expressed constitutes a representation by us or a solicitation of the purchase or sale of any securiti South Carolina Medical Assoication and E.F. Hutton & Company, Inc. 1985.
ON THE COVER:
CHARLTON HENRY LELAND, M.D. 1829-1894
Charlton Henry Leland, M.D., presented his inaugural dissertation on Cynanche Maligna (L. Gangrenous Pharyngolarvngitis to the Faculty of Medicine at the Medical College at Charleston, South Carolina in 1851. Dr. Leland described C. Maligna “as one of the most fatal diseases to which children are liable, often prevailing epidemi- cally.” He describes the symptoms as “languor, inability of motion, loss of appetite . . . great de- jection often with nausea and vomiting.” He noted that the “voice appeared also to have under- gone a change, sometimes hoarse and in others unnaturally shrill” (no doubt due to the extension of diptheritic membranes into the larynx).
Treatment at the time consisted of “the ap- plication of leeches to the angle of the jaw, and cups applied to the neck to reduce the swelling.” “Purgatives and diaphoretics” seem to be used PRN. “Stimulating gargles of nitrite of soda, or alum, capsicum, vinegar and honey” were recom- mended. The French treatment was application “of a sponge, wet with hydrochloric acid to the membranes daily.” To “excite the flagging cir- culation” he reported that “wine and even brandy were very serviceable.
Charlton Henry Leland (b. 1829, Charleston, South Carolina, d. 1894, McClellanville, South Carolina) was one of five accomplished sons of the distinguished theological Reverend Doctor Aaron W. Leland, who settled in Charleston after gradu- ating from Williams College, Massachusetts, in 1808. The Reverend Doctor Leland held the pulpit of Charleston s First (Scots) Presbyterian Church when the present structure was con- structed in 1816. Three of the Reverend Doctor Leland’s sons became physicans, and two were scholars and professors. Briefly:
Charlton Henry Leland, M.D., received his Medical Degree in 1851 and practiced medicine in Darlington, South Carolina; Davidson, North Carolina; and Charleston, South Carolina. During
the Confederate War, he served as surgeon at Fort Johnson, Charleston, South Carolina.
Horace Wells Leland, M.D. (b. 1820, d. 1885) graduated from the Medical College of the State of South Carolina in 1843. His thesis was on “De- rangements of the Catamenia.” He died at the family’s plantation, Walnut Grove, in Charleston County.
Samuel Wells Leland, M.D. (b. 1824, d. 1856) wrote his thesis on "Inflammation and received his degree from the Charleston Medical College in 1849. He practiced general medicine in Mills Creek near Columbia, South Carolina.
John Adams Leland (b. 1817, d. 1892) was educated at Williams College, as had been his father. He held the chair of mathematics at Davidson College in 1854, but after five years “fearing that North Carolina would not secede with South Carolina and that he should be left in the Union,” he moved to South Carolina. In 1861, he formed a company of men known as the Tren- ton Rifles which was composed primarily of his former students. This unit achieved many distinc- tions during its service in the war. After the war, Major Leland was called to the Presidency of Laurens Female College.
James Hibben Leland (b. 1810, d. 1897) took his education in mathematics and Latin at Amherst College in Massachusetts, and was called as Head- master of the Mt. Pleasant Academy (near Charleston, South Carolina). Piously religious like his Puritan father, Professor James Hibben Le- land was an “ardent advocate of state’s rights and devoted son of South Carolina.”
Many other descendents of the Reverend Doc- tor Aaron Whitney Leland have entered the pro- fessions of medicine and higher education; all have contributed to the “history of medicine in South Carolina.”
— Thomas M. Leland, M.D., Ph D.
January 1985
43
INFORMATION FOR AUTHORS
We encourage original articles and letters to the editor of potential benefit and interest to the members of the South Carolina Medical Associa- tion.
CORRESPONDENCE: All manuscripts and cor- respondence should be addressed:
The Editor
JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION Post Office Box 11188 Columbia, S. C. 29211.
COPYRIGHT: All manuscripts should be accom- panied by a transmittal letter to the editor, which should contain the following paragraph:
“This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA.” The above takes into account The Copyright Re- vision Act of 1976, effective January 1, 1978. We request authors to advise the editor of any prior or anticipated duplication of their work in other publications. Submission of material as a “com- panion article” to material submitted elsewhere is discouraged.
PRIORITY FOR PUBLICATION: The Journal was founded in 1905 especially as a place for practicing physicians to publish their original ob- servations. This purpose continues to receive pri- ority. Growth of institutions, especially of medical school faculties, during this century may be, at least in part, responsible for a decreased tendency for practicing physicians to attempt scholarly work. Concerned about this trend, The Journal encourages practicing physicians to report origi- nal observations, including series of cases or indi- vidual case reports.
The Journal also welcomes timely review arti- cles by institution-based physicians. However, it is the philosophy of the Editorial Board that state medical journals do not represent an appropriate forum for research findings of a specialized nature. Such findings, it is felt, belong in national or regional specialty or subspecialty journals. Arti- cles by institution-based physicians should serve
44
the information needs of a general physician readership.
Articles dealing with social, economic, and eth- ical issues are strongly encouraged. Historical or philosophical essays are also welcomed, although these are given lower priority compared to the above categories.
TYPES OF ARTICLES ESPECIALLY WELCOMED FOR CONSIDERATION
1. Original scientific observations (including case reports) made by practicing physicians.
2. Concise, timely review aricles (see “Priority for Publication”).
3. Articles pertaining to current so- cial, economic, and/or ethical is- sues affecting the practice of medicine.
4. Information uniquely pertinent to the health care of South Carolin- ians.
REVIEWING AND RESPONSIBILITY TO READERSHIP: We will make every effort to review manuscripts promptly. All manuscripts will be reviewed by our editorial office, and when indicated the opinions of outside consultants will be solicited.
We welcome criticisms of journal content by members of the South Carolina Medical Associa- tion.
REPRINTS: These will be made available by the publisher at established rates, at the time of mail- ing of galley proofs.
LENGTH OF ARTICLES: We prefer concise articles of approximately 2,500 words (approx- imately 8 typewritten pages, double-spaced), with no more than ten references.
We regret that space considerations limit our ability to publish longer articles, and request that authors adhere to the above guidelines. Similarly, tables and illustrations (see below), should be kept to a minimum, and be specific and pertinent.
The Journal of the South Carolina Medical Association
INFORMATION FOR AUTHORS
Authors desiring to make additional data or additional references available to readers are en- couraged to do so by adding footnotes to the effect that “additional references (or tables derived from this data base, etc.) are available from the author(s) upon request.”
MANUSCRIPTS: These should be typewritten, double-spaced, and on one side of the paper. The original and one copy should be submitted. The title page should indicate the title, author(s), au- thor’s address, and academic appointments, if any. We request that the author’s name not ap- pear on subsequent pages, to permit “blind” re- view of the article, when desired. Authors should retain one copy for use in proofing. Written corre- spondence concerning proposed (potential) man- uscripts is welcomed.
ILLUSTRATIONS: These should be submitted as glossy, black-and-white prints no larger than a standard page; smaller prints are desired. Or- dinarily, publication of 4 small illustrations or tables, or the equivalent, will be paid for by The Journal. Any number beyond this must be paid for by the author except under unusual condi- tions. Illustrations should not be mounted, stapled, or clipped. On the back side of each illustration, the article title, figure number, and top of figure (but not the author) should be noted lightly in pencil. Legends for illustrations should be typed on a separate sheet of paper.
REFERENCES: These should be cited con- secutively in the text, in superscript, e.g., “Botts- ford, et al ,3 ...” We recommend no more than ten references, selected from more recent publica- tions in accessible journals in most instances. Stan- dard journal abbreviations should be used, with the style for journal articles being as follows:
3 Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1983.
MATERIAL FOR COVER: The illustrations for the cover of The Journal are selected by a mem- ber of the Editorial Board, Thomas M. Leland, M.D., 2741 Speissegger Drive, Charleston, SC 29405. Dr. Leland welcomes illustrations and sug- gestions for the cover, including appropriate com- mentary. Such suggestions should be sent to him in writing at the above address.
ROE FOUNDATION AWARDS
Through a gift by the Roe Founda- tion, a Thomas xA Roe and Shirley W. Roe award of $3,000 will be given each year at the annual meeting be- ginning in 1985. All manuscripts sub- mitted by South Carolina physicians will be considered for the award. The award will be made, on alternate years, to a practicing physician or to an institution-based physician, and will be based on articles published in The Journal during the two previous years.
Articles written by practicing phy- sicians will be judged by members of the Editorial Board of The Journal on the basis of original scientific content and clarity of presentation. Practicing physicians are encouraged to report observations in The Journal, which was originally established for this purpose.
■Articles written by institution- based physicians will be judged by outside referees, to be selected by the Editorial Board. The current editorial policy of The Journal is that original scientific observations made by physi- cians such as medical school faculty members should, ordinarily, be sub- mitted to peer-reviewed specialty journals rather than to the state medi- cal journal. Therefore, the Thomas A. Roe and Shirley W. Roe award will be based on review articles by institu- tion-based physicians. Referees will be instructed to base their selection on (1) the quality of the review article, and specifically its instructional value for a general physician readership, and (2) the significance of the author’s contributions to his or her field. In- stitution-based physicians should sub- mit a current curriculum vitae and reprints of articles representative of their work, as published in specialty publications.
lanuary 1985
45
SOUTH CAROLINA MEDICAL ASSOCIATION
AUXILIARY
MALPRACTICE IS A FAMILY AFFAIR
Every South Carolina medical family deserves to have the advantage of an organized Malpractice Litigation Support Group. Local societies and auxiliaries must work together to help each other find a better way to face the enormous amount of stress in everyday living brought on by malpractice litigation. Because the entire family is involved, husbands and wives need to meet together to explore the problems, improvements and goals of our medical communities in addressing the malpractice situation. Education is the key factor in strengthening our defenses to combat STRESS.
In Greenville there have been four malpractice meetings since the support group was organized in November, 1983. Subjects have included: Stress In Relation to Medical Malpractice; Malpractice: The Effect of the Media; The Effect of the Physician’s Public Image; A Malpractice Case from Beginning to End; Resources in the Battle Against Malpractice Litigation. These meetings were attended by physicians and wives who have already undergone litigation, those who have a case pending and those who have never felt the sting of a lawsuit. Open discussion always follows the program and an atmosphere of emotional support prevails.
A steering committee meets after each general meeting for review, evaluation and planning. This committee is served by the President of the auxiliary, the President of the medical society plus five appointed members from each organization. The purpose of the committee is “to serve and to collect information.” This is being accomplished through offering informed speakers, through personal contact with anyone seeking support before or during a trial and through exchanges of printed information. Members have written letters and articles, have talked with newspaper representatives and hospital personnel and have been kept informed about risk management progress on the state level.
Every medical community is encouraged to organize a support group. It does not take a lot of time for we have learned that every aspect of malpractice is slow. Litigation can go on for years. This is one reason the family feels so much pressure. Litigation does not stop to observe events such as Christmas, a birthday, a daughter’s wedding, a baby’s arrival, the death of a parent.
A statewide office has been established for an exchange of information for support groups. A file has been set up under the direction of Mrs. Joy Drennen, Editor of the “Risk Management Bulletin” and Manager of Information Services. Included in the material you may order: an article about stress by Sara C. Charles, M.D., titled “Malpractice: A Different View” (March 1984); a presentation by Salvatore A. Rini, M.D., titled “An Update of the Professional Liability Crisis” (Nov. 1983); detailed reports of the general meetings in Greenville; and copies of the booklet, “Understanding Malpractice Claims.” Do you have an article or report to share? Send it to Joy. She may be contacted at SCMA, P. O. Box 11188, Columbia, SC 29211 (telephone 798-6207). We need your contributions to make the exchange effective.
SCMA members are hard at work to develop the Risk Management Program. The “Medical Malpractice Bulletin,” published quarterly, is mailed to all state physicians. It is meant to be shared with the spouse for she, also, needs to read this life-line publication. Our doctors are being abused and we want to help.
There is no place for apathy here. It was Will Rogers who said, “Even if you’re on the right track, you’ll get run over if you just sit there.”
Margaret B. Ashmore, Chairman Greenville Malpractice Support Group
46
The Journal of the South Carolina Medical Association
DO YOU KNOW A DISABLED PHYSICIAN?
SCMA CAN HELP
TURN PAGE TO LEARN HOW
DO YOU KNOW A DISABLED PHYSICIAN?
THE SOUTH CAROLINA MEVICAL ASSOCIATION CAN HELP
The SCMA's Committee on Alcohol, Drug Abuse and Impaired Physicans is the disabled doctor's advocate. The Committee views abuse and addiction to alcohol and other drugs as an illness and deals with it non-judgementally , non-punitively and therapeutically.
The program functions as a peer to peer activity, whereby an impaired physician will undergo evaluation and receive a treatment program tailored to his or her specific needs in work, family, finances and community. Vol- untary participation results in committee advocacy and a protective role with the local hospital, medical society. State Board of Medical Examiners and Drug Enforcement Agency. Voluntary participants following through with treatment are not reported to either the State Board or any other group or agency.
WHAT IS AN IMPAIRMENT?
The impaired physician has been defined as one who for any reason is unable to perform professionally at an optimal capacity. That is to say any disability (impairment) that causes a physician to be unable to do anything other than his very best. It is felt by this committee that this definition covers everything from Alzheimer's disease to Alcoholism. This committee has been asked by the State Medical Association to address all forms of impairment or disability in regards to the physicians in the State.
[UHAT CAN YOU VO?
Disabled doctors are usually unable to ask for aid themselves. You can help them by:
Writing: George M. Grimball, M.D., Chairman
Committee on Alcohol, Drug Abuse and Impaired Physician
South Carolina Medical Association
P. 0. Box 11188
Columbia, SC 29211
(803) 271-9145
Calling: SCMA Headquarters, (803) 252-6311 or after hours
leave your message at (803) 765-9347
WHAT THE COMMITTEE WILL VO
Your report will be investigated by a committee member and if verified, a pair of committee members will contact the impaired physician. Should they fail to recruit the physician, a second and third team will follow. The physician signs a contract with SCMA limiting, as mutually agreeable, his or her practice and enters treatment. A second contract is executed following treatment for follow-up and assistance in maintaining recovery. At this time a colleague is also appointed to work with the impaired physician for a period of up to two years.
CARING ANV ANONYMITY ARE KEYS TO THE SUCCESS OF THIS PROGRAM
WHY SHOULD WE SUPPORT OUR SPORTS MEDICINE COMMITTEE?
Three years ago, the Medical Aspects of Sports Committee requested and was granted a three-hour segment of the clinical aspect of our Annual Meeting. The program presented was outstanding and no one, least of all the committee members, anticipated that participation by our membership would be so significant as to overflow the accommodations provided for the program.
All aspects of the programs presented at the Annual Meeting have now been increased and solidified, and the Sports Medicine program is a permanent portion of the clinical program.
In addition, the committee has offered sports mini-clinics in any county so requesting the program in an effort to educate coaches, trainers and other groups sponsoring sports programs concerning the treatment and prevention of sports injuries.
I want to urge every county medical society which has not availed itself of the opportunity to participate in such a program to begin the necessary preparations for such a clinic during the summer of 1985. The effect of these programs not only will benefit all those who are responsible for the athletic activities in their schools, but the more significant effect is directed to the athletes. Our benefit is professional and aesthetic — there is no better opportunity for each county society to obtain complete coverage by notifying the news media of these clinics (TV, radio, newspapers).
The members of the committee are available to assist in planning and conducting the clinic. The Association will provide whatever administrative assistance is needed.
On behalf of the South Carolina Medical Association, I would like to thank the members of the Medical Aspects of Sports Committee for their dedication to the profession and to the improvement in the way in which young athletes are handled to allow them to reach their most productive potential. I would especially like to thank Dr. Roland Knight for his continued service to this Association as the Chairman of this committee. He has not requested any change and persists in offering more to the profession than anyone serving in such a position.
Until next month,
Kenneth N. Owens, M.D. President
February 1985
55
OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139)
VOLUME 81 FEBRUARY 1985 NUMBER 2
EDITOR
Charles S. Bryan, M.D.
SCMA, P. O. Box 11188 Columbia, S. C. 2921 1
EDITORIAL BOARD
Edward E. Kimbrough, M.D., Columbia, Editor Emeritus
Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
William H. Hunter, M.D., Clemson
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
Stanley Gould, M.D., Greenville
Rocco D. Cassone, M.D., Orangeburg
E. Conyers O'Bryan, M.D., Florence
MANAGING EDITOR
Joy Drennen
SCMA OFFICERS
Kenneth N. Owens, M.D., President
Leonard W. Douglas, M.D., President-Elect
John W. Simmons, M.D., First Vice President
Benjamin E. Nicholson, M.D., Second Vice President
J. Gavin Appleby, M.D., Secretary
Thomas C. Rowland, Jr., M.D., Treasurer
COUNCILORS
J. Frank Biggers, III, M.D., 1st District Bartolo M. Barone, M.D., 1st District
B. Daniel Paysinger, M.D., 2nd District Jack Ratliff, M.D., 2nd District
E. Mims Mobley, Jr., M.D., 3rd District
Charles R. Duncan, Jr., M.D., 4th District, Chairman
William J. Goudelock, M.D., 4th District
William M. Hull, Jr., M.D., 5th District
William H. Hester, M.D., 6th District
S. Perry Davis, M.D., 7th District
John W. Rheney, Jr., M.D., 8th District
J. Sidney Fulmer, M.D., 9th District
DELEGATES TO THE AMA
C. Tucker Weston, M.D., Delegate Waitus O. Tanner, M.D., Delegate John C. Hawk, Jr., M.D., Delegate Euta M. Colvin, M.D., Alternate Randolph D. Smoak, Jr., M.D., Alternate Leonard W. Douglas, M.D., Alternate
RESIDENT PHYSICIANS’ SECTION
Danny Mikell, M.D., President Bonnie Ramsey, M.D., Vice President Leonard W. Douglas, Jr., M.D., Secretary
EXECUTIVE VICE PRESIDENT
Mr. William F. Mahon
SPECIAL ISSUE: COST EFFECTIVE TREATMENT OF
CARDIOVASCULAR DISEASE GUEST EDITOR: E. CONYERS O’BRYAN, M.D.
Cardiovascular Disease and Cost — An Introduction — E.
Conyers O’Bryan, M.D 59
Cost Containment and the Treatment of Hypertension —
Shawn A. Chillag, M.D 61
A Case of Congestive Heart Failure — Peter C. Gazes,
M.D 71
The Medical Therapy of Angina Pectoris — With an Eye
on Cost — Kenneth H. Hanger, Jr., M.D 79
EDITORIALS
The Effect of DRGs on Office Practice — E. Conyers
O’Bryan, M.D 86
Of Cost-Containment and Cat-Bellers — Charles S. Bryan,
M.D 87
The Joint National Committee Recommendations on
Detection, Evaluation and Treatment of High Blood Pressure — Frances C. Wheeler, Ph.D., Susan C.
Oakes, R.N 88
FEATURES
Auxiliary Page 98
Book Review 97
Letter to the Editor 89
On The Cover 90
President s Page 55
ASSOCIATION
Financial Checkup 91
Legislative Update 57
Physician’s Recognition Award 99
SCMA Newsletter 75
THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.
Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.
The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.
INFORMATION FOR AUTHORS
Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.
All manuscripts should be accompanied by a transmittal letter with the following paragraph: ‘This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."
We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e g., "Bottsford, et al.3”, and should conform to the following style: “3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1983." Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.
56
The Journal of the South Carolina Medical Association
From the State House:
LEGISLATIVE UPDATE
February 1985
;
The South Carolina General Assembly is now well into the *85-86 session and just now beginning to pick up steam. Many actions have been coming about slowly — probably because of great leadership changes in the Senate which have had reverberations in the House of Representatives. Nuclear waste has become a big issue along with seat belt legislation and blue laws reform.
In the medical realm, things started with a bang and haven't let up. One major hearing has been held on the subject of indigent care (see discussion below) and also on three other medically important topics. Numerous other issues are demanding our attention in what seems to be thus far the most active year ever for SCMA.
"INSURANCE EQUALITY" RTT.T.S GATN SPOTLIGHT
In January, four bills were introduced to mandate that when physicians are reimbursed under health insurance policies for certain procedures that other non-MD professionals who perform similar procedures must also be reimbursed by private insurance companies to the same extent. SCMA has historically opposed laws mandating benefits in health policies.
The bills introduced pertain to Psychologists (S-ll, introduced in the Senate and H-2055, introduced in the House) and Chiropractors (see S-53, introduced in the State Senate, and H-2319, introduced in the House) and the benefits under the legislative directives would have to be focused toward them. On January 31, H-2055 (mandating coverage for Psychologists) was the subject of a hearing before a House Medical Affairs Subcommittee.
Hospitals, physicians (SCMA) , the insurance industry, and representatives from business and industry testified in opposition. They cited (1) the lack of demand from the public for inclusion of such coverages, (2) the fact that such coverage is available now as options in most policies, (3) the cost to non-users goes up when you mandate coverages to industry, consumers, etc., (large business concerns, of course, pay for the coverage for their employees) , (4) the high probable financial impact on health care costs in general due to higher utilization by these particular professions, and (5) the sentiment that the government should not be telling private insurance companies what they should cover in health care policies. These were just some of the arguments against this measure.
Only Psychologists (and other professionals such as Chiropractors, Optometrists,
etc., — who hope to pass legislation for their own bailiwick in the near future) supported
the concept. They argued that they are being "unfairly kept out of the lucrative
insurance market" via a discriminatory conspiracy by doctors, hospitals, and insurance
companies.
FRANK ROGERS ACCEPTS NEW POSITION
Frank Rogers, who has served as SCMA's attorney and state government representative for almost seven years, is leaving March 1 to assume a similar position in North Carolina. He has been appointed Manager of Governmental Affairs for Glaxo, Inc., a national pharmaceuticals concern with corporate headquarters at Research Triangle Park, N.C.
Rogers will supervise Glaxo' s legislative liaison program in all 50 states in addition to overseeing its congressional efforts in Washington, D.C.
SCMA's legislative program is continuing a revamping and upgrading that began to take shape last year. Bill Mahon, the organization's Executive Vice President, is becoming a familiar face at the Legislature where he is functioning as a full-time lobbyist. Additionally, Ron Scott, a prominent Columbia attorney and former aide to several Senate Committees, is serving as an advisor and legislative liaison for SCMA. Another full-time governmental affairs person is expected to be added to staff as a replacement for Frank late this month.
The clerical administrative staff has also been reorganized to provide greater assistance to the legislative program. Along with the extra staff are the new word processors to get letters out quickly to the SCMA SCAPELL (South Carolina Auxiliary-Physician Educational Legislative Liaison) program.
Rogers, in commenting on his leaving, noted: "When I came on board in 1978, I could
easily do both the legislative and legal work that needed to be done; not so anymore.
Since that time, the focus on legislation has shifted from Washington to the States, and paramedical groups are more prone to attacking the high standards set by medicine. The Association is wise in strengthening the legislative program."
INDIGENT CARE PACKAGE GETS HEARING
The medically indigent assistance bill in the form of H-2118 (there is also a senate version, S-112 which is in the Senate Medical Affairs Committee) was the subject of a hearing on January 30 before the House Medical Affairs Committee. SCMA testified in support of the concept and cited its many projects as evidence of our efforts to provide for the indigent in South Carolina. Quite a number of other prominent entities including the Governor's office, the State Hospital Association, and representatives of the Health Care Planning and Oversight Committee testified in support. The measure now has snowballed and appears headed for relatively easy passage into law.
The bill as drafted would call for the appropriation of $15 million in state funds, an assessment on counties of $7.5 million and a tax on participating hospitals of $7.5 million. This would be paired up with an attractive matching program of the Federal Government — making a grand total of some $90 million. A large amount of this would pay for indigent care costs in hospitals across the state. The legislation would also increase the AFDC Standard of Need thereby increasing the eligible Medicaid population by 42,600.
"LIVING WILL" LEGISLATION PASSES HOUSE OF REPRESENTATIVES
SCMA has long supported a bill to provide for a "Living Will" type document which would allow a terminally ill patient to instruct a doctor not to utilize life sustaining equipment or procedures in certain undisputable cases.
The Living Will legislation, in the form of House bill H-2041, stipulates that the document utilized for this purpose must take on many aspects similar to an actual Will left by a deceased person. There are also a number of safeguards to prevent against possible abuse or manipulation of a terminally ill patient. Additionally, the document allows for easy (even verbal) revocation by the patient himself.
Our association is in support of this measure due to the fact that there is oftentimes much confusion as to what should be done in cases where patients are terminally ill. Physicians and other health support personnel are not always sure of the legal, social, and ethical ramifications of their decisions. This proposed law will help in that regard.
OF THE SOUTH CAROLINA MEDICAL ASSOCIATION VOLUME 81 FEBRUARY 1985 NUMBER 2
CARDIOVASCULAR DISEASE AND COST — AN INTRODUCTION
E. CONYERS O'BRYAN, M.D.*
At the completion of a lecture on the treatment of refractory congestive heart failure, a seasoned family practitioner remarked that he had taken careful notes and felt comfortable in a plan to handle patients with this clinical entity but also estimated that over fifty percent of his patients would be unable to afford the medications on a daily basis.
As referral physicians we often fall into the trap of outlining academic plans which fail in the “real world” of patient compliance. It is hoped that this special issue of The Journal will offer some prac- tical hints on managing the foremost common problems in cardiovascular disease often requir- ing multiple medications — seldom at low costs.
An unfortunate truism in clinical medicine is that the most ill patients characteristically require the most costly therapy while earning the lowest incomes.
It is beyond the scope of this special issue to debate the therapeutic efficacy and possible cost- containment of invasive treatments such as aor- tocoronary bypass, intracoronary Streptokinase, and angioplasty which may later reduce the number of medications required over a prolonged period of time and promote earlier return to work.
Another knotty clinical problem is deciding when to reduce multiple drug therapy when pa- tients stabilize or improve objectively, subjec- tively, or both. We know from experience that a significant number of patients with cardiovascu- lar disease, and particularly those with arterio-
sclerotic heart disease, will improve with time and may safely have a reduction or even discontinuing most of their medications.
Every physician involuntarily groans when confronted with a patient who has multiple dis- eases accompanied by two family members re- quired to carry the sacks of medicines. This issue highlights means of optimally treating with less medications and achieving the same or improved clinical goals. For instance, a beta blocker may be used to treat the angina patient with ventricular ectopy who is also hypertensive and even may have migraine headaches. The calcium channel blocker agent, Nifedipine, may be used for treat- ment for obstructive and spasm angina, hyperten- sive vascular disease and peripheral vascular arterial insufficiency (including Raynaud’s).
Another calcium blocking agent, Verapamil, may be used to treat angina and re-entrant supra- ventricular tachycardias as well as hypertension.
The applauded significant decline in car- diovascular disease and mortality over the past two decades has been accompanied by tech- nological and pharmacologic advances of ex- plosive proportions and it is certainly not the intent of this special issue of The Journal to sug- gest at anytime that quality patient care be com- promised because of cost. The contributing authors to this special issue of The Journal have all had excellent academic and practical treatment backgrounds and we are indeed fortunate for the opportunity to share their expertise. □
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February 1985
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COST CONTAINMENT AND THE TREATMENT OF HYPERTENSION
SHAWN A. CHILLAG, M.D.*
Cost containment in medicine refers to limiting the expense of evaluation and therapy. Cost con- tainment is different from cost effectiveness which attempts to determine if the costs of the medical endeavor are justified given the antici- pated benefits. Clearly, cost containment cannot be totally separated from cost effectiveness, but much of the arbitrary monetary value placed on an outcome is avoided. Cost effectiveness deci- sions determine whether to treat; cost contain- ment strategies attempt to provide this treatment as inexpensively as is prudent. Sixty million adults in the United States have hypertension. 1 The aver- age internist, family practitioner, or general prac- titioner sees 20 to 40 patients with hypertension per week. Accurate diagnosis, appropriate evalua- tion and timely reasoned therapy are the key- stones of effective management of hypertensive patients.
The diagnosis of hypertension carries with it profound implications for the individual. Even when mild hypertension is present the treatment can be worse than the disease. Proper consider- ation should be taken before a label is applied and life insurance premiums elevate or coverage is jeopardized. Ambulator} and home blood pres- sures are lower than those taken in the office.2 However, blood pressures taken in a medical set- ting are usually the basis for the risk profiles for hypertension or for judging the effectiveness of treatment. Home blood pressure monitoring is a rational basis for initiating and adjusting therapy after a ''casual' high reading has been found. It is somewhat frightening that a measurement that is so important is undertaken in such a casual fash- ion. A discussion of the accurate measurement of blood pressure is beyond the scope of this paper, but there is an excellent recent review that dem- onstrates man} potential pitfalls in the measure- ment of blood pressure.3 The Joint National
° Assistant Professor. USC School of Medicine. Columbia. S. C. 29203.
Committee (JNC recommendations for classifi- cation of blood pressure are reasonable for the most part Table I .4 The higher the blood pres- sure is. the greater the mortality. This is true even at "normal levels, but the benefits of therapy are miniscule. The alphabet soup of clinical trials ( HDFP. YA. MRFIT have failed to convincingly prove that the treatment of mild diastolic hyper- tension 90-100 mm Hg is beneficial. 5-8 In the absence of other significant cardiovascular risk factors, my inclination is to delay pharmacologic treatment of diastolic hypertension in the 90 to 94 mm Hg range for up to one year. Xon-phar- macologic therapy (weight control, cessation of tobacco use. a decreased salt diet and even relaxa- tion methods should be especially strongly pur- sued in this borderline group. If even one with hypertension of 160 95 mm Hg or greater were treated with medicines, the annual expenditure would more than double from S2.0 billion to 84.3 billion.9 This excludes detection, verification and initial diagnostic evaluation. The cost for prevent- ing a single coronary event based on Fra- mingham data in a 55-year-old hypertensive male is SI 1.000 and for a female, 821,000. 10 In a 40-} ear-old woman, treatment of a diastolic of 100 mm Hg costs S10.000 for each year of quality- adjusted life expectancy saved.9 It is 86.000 if the diastolic is 110 mm Hg.
Table I
CLASSIFICATION OF BLOOD PRESSURE*
Diastobc — mm Hg less than 85 85 — 89 90 — 104 105 — 114 greater than 115
— normal
— high normal
— mild hypertension
— moderate
— severe
Systolic, when diastolic less than 90 less than 140 — normal
140 — 159 — borderline isolated systolic
hypertension
greater than 160 — isolated sy stolic
° JNC Report4
February 1985
61
TREATMENT OF HYPERTENSION
Whom to evaluate with laboratory testing and the nature of the testing are important in cost containment. The history and physical examina- tion will direct the laboratory evaluation. The JNC report gives very useful guidelines for a disease specific intake evaluation. The initial tests recommended by the JNC (Table II) are reason- able. Other testing for secondary hypertension should be directed by the above data. Those hy- pertensive patients with family history of thyroid or adrenal tumors, with onset before age 30 or past age 55, with unusual signs or symptoms (weight loss, heart palpitations, hematuria, hypokalemia, hypercalemia or renal failure), with uncontrolla- ble hypertension or with rapidly rising levels of blood pressure and rapid blood vessel damage despite therapy should be considered for rapid sequence intravenous pyelogram, renin profiling, digital subtraction angiography, urine elec- trolytes, etc.11
After the diagnosis has been established, the decision to treat should be made in concert with the patient. The patient should have a reasonable understanding of the problem and realize that long term follow-up and perhaps therapy will be required. Education about the problems and se- qualae of hypertension makes for an informed and understanding patient, but is unlikely to help with compliance with the therapeutic regimen. The extensive review by Sackett and Haynes did not support that education of the patient about the disease process effectively improves com- pliance.12 Non-pharmacologic measures should be recommended prior to pharmacologic manage- ment in the mild hypertensive, and these mea- sures should continue to be supported by the physician after medications are needed. How- ever, compliance is very poor with diet, smoking and exercise prescriptions. Compliance with pharmacologic regimens is hardly more than fifty percent. Incomplete adherence dramatically es- calates the costs of the benefits. The therapeutic regimen must be designed for effectiveness, but if it is not taken all is lost. Of the fantastic number of variables reviewed that could affect compliance, only a few are under the control of the physician. When more than two medications are prescribed, when more than twice a day dosing is required, when the duration of therapy is greater than five days, and when in the older patient costs are high, compliance rapidly falls away.13 Of these factors, only duration of therapy cannot benefit from
62
Table II
LABORATORY TESTING IN HYPERTENSION”
hemoglobin ECG
hematocrit total cholesterol
urinalysis High Density Lipoprotein cholesterol
potassium fasting glucose
creatinine uric acid
° JNC Report4
appropriate manipulation in the hypertensive pa- tient. It must be remembered that the bottom-line is control of blood pressure, whether control be by the newest medication with numerous theoretical advantages, by moss placed in the shoe as by a recent patient or by root medicine. Whatever intervention controls the blood pressure with min- imal interference in the patient’s life is the best medicine. The characteristics of such an ideal medication regimen are relief of increased pe- ripheral vascular resistance; inexpensive, twice or less daily dosing; two or fewer medications; few side effects and little follow-up laboratory testing required.
The stepped-care approach to antihypertensive therapy is very useful as outlined in the JNC, but there are several other maneuvers to be tried that may improve this approach. To Step 1 drugs, prazosin should be added as an effective agent with few side effects. It attacks the etiology of most hypertension, increased peripheral vascular resistance, unlike B-blockers and diuretics. Prazosin does not have the deleterious effects on potassium, glucose, cholesterol, uric acid, bron- chial smooth muscle, heart rate or myocardial contractility.14- 15 Unfortunately, it is more expen- sive than diuretics and usually requires at least twice a day dosing. There is strong feeling that rather than pushing a Step 1 drug to maximally recommended or tolerable levels and then adding a Step 2 drug, that modest dosages should be used.1 The additional patients controlled by going from 50 mg of hydrochlorothiazide (HCTZ) to 100 mg are few, but the side effects are multi- plied. Now would be the time for substitution therapy. ” Many patients may be controlled on one first line drug when they have failed on another class of drug.16 Because there is no great urgency in mild hypertension, the switch between di- uretic, B-blocker and other adrenergic inhibiting agents (reserpine, clonidine, methyldopa, pra-
The Journal of the South Carolina Medical Association
TREATMENT OF HYPERTENSION
zosin) may be made. Blacks may respond better to thiazide diuretics, and whites may respond better to B-blockers.17, 18 If blood pressure is well-con- trolled on a low or modest dose of a Step 1 drug, consideration should be given to reducing and/or discontinuing therapy and observing. Studies have shown this to be an effective maneuver in ten to 20 percent of mild hypertensives.19’ 20 This may be particularly advantageous if you did not initi- ate therapy, question the therapy or do not feel non-pharmacologic therapy was given an ade- quate trial. The non-diuretic medications may cause sodium retention so that dietary sodium restriction should be emphasized. Of course, if sodium retention took months to develop, there is no reason that short course or intermittent diuret- ics cannot be tried. Dosages and medications should not be changed too frequently (3-4 weeks) because it takes a while to reach a steady state.
There are several simple prescribing maneu- vers that may lessen cost and reduce the number of medications and pills. Combination medica- tions are often regaled against because there is little flexibility in dosing. So what? It may save money, although usually not much because the combined drug usually includes a cheap thiazide. More importantly it reduces the numbers of pills — one of the few proven methods of improving compliance. As the naval couplet says,
“Of what avail the loaded gun, torpedo, or the shell
if signals fail, the fleet will go to hell.’’21 One hundred pills or multiples thereof are often much less costly than an exact month’s supply. This is especially true for inexpensive drugs. Thirty of the 50 mg hydrochlorothiazide tablets are $2.65; 100 are $3.35. Medicaid regulations do not allow this type of prescribing. When the dos- age range is wide, often multiple size scored tab- lets are available. When financial considerations are paramount, V2 tablets of a larger sized tablet may be less expensive than the equivalent smaller sized whole tablet. Thirty of the 20 mg furosemide tablets cost $2.85, thirty of the 40 mg tablets are $3.00. With a few exceptions, generic substitutions have therapeutic equivalency. When a drug that has had a strong hype pre- viously and is no longer advertised or detailed, it has usually gone off patent.
Diuretics are and should be frequently used as Step 1 therapy, especially in blacks, as mentioned earlier, and in the elderly. The elderly hyperten-
sive often responds well to low doses of diuretics.22 Beta-blocking agents are more likely to cause problems in the older patient. There will be fewer problems with hypokalemia when a maximum dose comparable to 50 mg of hydrochlorothiazide (HCTZ) is used. Twenty-five or 12.5 mg should be the starting dose. Nonetheless, hypokalemia may be a problem, especially in the patient with car- diac disease or when digitalis is also prescribed. Furosemide is probably as effective as HCTZ in hypertension and causes less hypokalemia than HCTZ alone or even when HCTZ is used in com- bination with a potassium sparing diuretic.23 When potassium supplements are required, high potassium foods are probably the most expensive way to supplement potassium. The least expensive potassium supplement is a salt substitute. For ex- ample, 5 gm of Morton’s Salt substitute (1 level teaspoon) supplies 60 meq of KCL for about one tenth of the cost of the least expensive prescription potassium supplement.24 One-half teaspoon could be used twice daily at meal time.
When another problem requiring pharmaco- logic management is present along with hyperten- sion, a change to a medication that effectively treats both problems may reduce costs and im- prove compliance. The hypertensive patient who develops angina might have both problems wholly or partly treated with a calcium channel blocker. Beta blockers are very useful in migraine sufferers, so that if hypertension is present, this group is a likely first choice in therapy. Other combination uses for B-blockers in hypertension include mitral valve prolapse, arrhythmias, hy- pertrophic cardiomyopathy and post-myocardial infarction. An arterial and venous dilator such as prazosin or an arterial dilator such as hydralazine can treat hypertension and congestive heart failure. Hypercalciuria calcium stone formers with hypertension could have thiazides included in their regimen. The hypertensive insomniac might benefit from the nocturnal use of reserpine, clonidine or methyldopa. As the number of agents increase that attack the treatment of various parts of the schema of hypertension, multiple uses for medications will grow.
The costs of evaluating and treating hyperten- sion are usually not significant barriers to the success of therapy. It is a relatively inexpensive disease directly, but there are so many millions who may develop expensive renal, cardiac or ce- rebrovascular disease that therapeutic regimens
February 1985
63
TREATMENT OF HYPERTENSION
for containing cost and improving compliance are of vast importance. Cost and compliance are in- separable. These treatment suggestions reflect this opinion:
1. Observe mild hypertension for months prior to making a diagnosis.
2. Consider longer observation when the di- astolic pressure is 90-94 mm Hg when other cardiovascular risk factors are absent.
3. Try non-pharmacologic therapy first and continue to stress such therapy if medica- tions are needed.
4. The stepped care approach should con- tinue to be used with some modification.
5. Substitute Step 1 drugs for one another if therapy is ineffective prior to Step 2.
6. Do not push to maximal dosages unless well tolerated.
7. Allow dosage and medication adjustments time to succeed (three to four weeks).
8. Attempt single daily dosing; bid dosing may work even when tid and qid are recommended.
9. Step down or discontinue therapy after good control has been easily obtained.
10. Home blood pressure monitoring has much to recommend it.
11. Try to use no more than two medications; use combination drugs when feasible.
12. Generics are generally safe and less expensive.
13. One hundred pills or multiples thereof are less costly than odd lot monthly supplies.
14. Larger size pills are cheaper on a per milli- gram basis.
15. Salt substitutes are the least expensive way to supplement potassium.
16. Use one drug for more than one disease
when possible. □
REFERENCES
1. Synopsis: What is Hypertension? Chapter 1 in McMahon
FG: Management of Essential Hypertension: the New
Low-Dose Era. 2nd ed. Mount Kisco, Futura Publishing
Co., Inc., 1984, pp. 1-35.
64
2. Waeker B, DesCombes BJ, Porchet M, et al: Ambulatory blood pressure recording to identify hypertensive patients who truly need therapy. J Chron Dis 37:55-57, 1984.
3. Nelson WP, Egbert AM: How to measure blood pressure — accurately. Primary Cardiology Sept: 14-26, 1984.
4. The 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pres- sure. Arch Intern Med 144:1045-1057, 1984.
5. Paul O: Hypertension and its treatment. JAMA 250:939-940, 1983.
6. Pickering TG: Treatment of mild hypertension and the reduction of cardiovascular mortality: the ‘Of or By’ di- lemma. JAMA 249:399-400, 1983.
7. McAlister NH: Should we treat ‘mild’ hypertension? JAMA 249:379-382, 1983.
8. Kaplan NM: Therapy for mild hypertension. Toward a more balanced view. JAMA 249:365-367, 1983.
9. Weinstein MC, Stason WB: Economic considerations in the management of mild hypertension. Ann NY Acad Sci 304:424-440, 1978.
10. Forsyth RA: Hypertension and primary care practice. J Fam Prac 10:803-807, 1980.
11. Tips to differentiate secondary and essential hypertension. Geriatrics 39:29-30, 1984.
12. Sackett DL, Haynes RB: Compliance with Therapeutic Regimens. Baltimore: Johns Hopkins University Press, 1976.
13. Chillag SA: Therapeutics in the elderly. Chapter 3 in Withersty DJ:Communication and Compliance in a Hos- pital Setting. Springfield: Charles C. Thomas, 1980, pp. 42-64.
14. Gunnells JC, Kaplan N, Cutler N, et al: Roundtable discus- sion. Am J Card 51:657-660, 1983.
15. Okun R: Effectiveness of prazosin as initial antihyperten- sive therapy. Am J Card 51:644-650, 1983.
16. Kaplan N: New approaches to the therapy of mild hyper- tension. Am J Card 51:621-627, 1983.
17. Veterans Administration Cooperative Study Group on Antihypertensive Agents: Comparison of propranolol and hydrochlorothiazide for the initial treatment of hyperten- sion. JAMA 248:1996-2003, 1982.
18. Veterans Administration Cooperative Study Group on Antihypertensive Agents: Comparison of propranolol and hydrochlorothiazide for initial treatment of hypertension. JAMA 248:2004-2011, 1982.
19. Levinson PD, Khatri IM, Freis ED: Persistence of normal BP after withdrawal of drug treatment in mild hyperten- sion. Arch Intern Med 142:2265-2268, 1982.
20. Eisalo A, Totterman KJ: How to avoid inappropriate anti- hypertensive treatment. Acta Med Scand (Suppl) 626: 56-57, 1979.
21. Lillie DC: Doctor-patient information. Gerontologia Clinica 16: 44-53, 1974.
22. Franklin SS: Geriatric hypertension. Med Clin North Am 67:395-412, 1983.
23. Licht JH, Haley RJ, Pugh B, et al: Diuretic regimens in essential hypertension. Arch Intern Med 143:1694-1699, 1983.
24. Sopko, JA, Freeman RM: Salt substitutes as a source of potassium. JAMA 238:608-610, 1977.
The Journal of the South Carolina Medical Association
A CASE OF CONGESTIVE HEART FAILURE
PETER C. GAZES, M.D.*
A. This case began 22 years ago when Mr. Albert, an active lawyer, was 56 years old. At that time, he had an initial episode of substernal pain. Five years later, at age 61, he developed atrial flutter which responded to cardiover- sion. His physician prescribed quinidine 300 mg. tid to maintain sinus rhythm. For the next 14 years on this regimen, Mr. Albert had very infrequent angina, until 1981 when, after a prolonged attack of angina, he developed dyspnea. At this time, he was referred to us.
At examination, Mr. Albert appeared very ill. He had neck vein distention at 45 degrees from the horizontal, hepatomegaly, car- diomegaly, at S3 gallop, bibasilar rales, and peripheral edema. Non-specific ST-T changes were noted on his electrocardiogram, al- though no significant cardiac enzyme changes occurred. Chest x-ray revealed pulmonary congestion, pleural effusion and cardio- megaly.
B. Our treatment choice was to give Mr. Albert a combination of digitalis and furosemide. Within one week, he lost 30 pounds and be- came compensated from a cardiac standpoint. Two weeks later, he was discharged on di- goxin, oral nitrates, nitroglycerin ointment, and furosemide. Mr. Albert responded well to this regimen and remained compensated after two months. However, he complained that the frequent periods of diuresis were disturbing his social life. Our decision was to discontinue
C. his furosemide and start him on bumetanide 1 mg/day. On this regimen, Mr. Albert did well for over a year. However, 14 months after his hospitalization, he once again developed symptoms and physical findings of congestive heart failure. Our choice was to increase Mr. Albert’s bumetanide to 3 mg/day and to add
D. metolazone 5 mg a day and continue po- tassium supplements. He improved but his BUN went to 55, his creatinine to 1.8 and his
Professor of Medicine, Director, Cardiovascular Division, Medical University of South Carolina, 171 Ashley Avenue, Charleston, S. C. 29425.
potassium to 3.1. We concluded that he devel- oped prerenal azotemia. Our response was to discontinue Mr. Albert’s dose of metolazone. Within a few days, his BUN and creatinine concentrations returned to normal values. On this regimen, Mr. Albert initially did well. However, two months later, he had to be read- mitted to the hospital because of increasing dyspnea and peripheral edema. Again, he was found to have a neck vein distention, car- diomegaly, S3 gallop, hepatomegaly and pe- ripheral edema. Chest x-ray showed less pleural effusion and cardiomegaly. He was started on a combination of bumetanide 4 mg/
E. day, spironolactone 100 mg bid and his dose of nitrol ointment was increased to two inches on the chest tid. His oral nitrates were continued.
Mr. Albert improved. The only remaining problem to solve was occasional nocturnal dyspnea and excessive fatigue. Mr. Albert was
F. begun on hydralazine, 50 mg tid, as an after- load reducing agent. Once again, he im- proved. Radionuclide angiography revealed an ejection fraction of 21 percent. When last seen, Mr. Albert was still compensated but still suffered from some exertional dyspnea.
A. Atrial flutter is very sensitive to DC shock. Quinidine is still one of our best agents to prevent further attack. In view of its half-life of six to eight hours, it will take at least 40 hours to reach a steady stable blood level. Therefore, the dosage should be adjusted at two-day intervals.
B. Digitalis and a diuretic are indicated in this setting. Only patients with mild congestive heart failure should be treated with diuretics alone. Digitalis is usually effective for supra- ventricular arrhythmias. However, it should be given even in the presence of regular sinus rhythm, if one has cardiomegaly and an S3 gallop. Furosemide (Lasix) is a loop diuretic and is effective even if there is renal damage. Hydrochlorothiazide is less expensive, less po- tent and does not work well if renal insuffi- ciency is present.
February 1985
71
CONGESTIVE HEART FAILURE
C. Bumetamide has a quicker onset of action and a shorter duration of action compared to other diuretics.
D. Metolazone (Zaroxolyn, Diulo) is a very potent diuretic and is a sulfonamide similar to the thiazides and acts at the early distal tubule. Its action can persist for 24 hours. It is effective in the presence of renal disease, but can cause potassium loss and hypocholoremia with re- sulting hypokalemic metabolic alkalosis.
E. Potassium-sparing agents such as spironolac- tone (Aldactone), triamterene (Dyrenium) and amiloride (Midamor) work at distal sites as well as in the collecting duct. These are considered as the least potent diuretics and are given primarily to reduce the likelihood that hypokalemia will develop. They also can aug- ment the diuresis induced by other diuretics.
The potassium-sparing agents have a slow onset of action, usually eight to 24 hours and must be continued for several days to achieve maximal effect. Nitrates, in addition to their action of dilating the coronaries and collat- erals also reduce the preload (venodilator) which will drop the left ventricular end di- astolic pressure and lessen dyspnea. It can be
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administered sublingually, transdermallv, or orally. The oral dosage will be up to 40 mg q.i.d. since the liver has to be saturated before a systemic response occurs.
F. Hydralazine is an arteriole dilator that reduces peripheral vascular resistance and the after- load. □
|
Name of Drug |
Table I MEDICATION COST |
Cost per Tablet (Based on quantities of 100) |
|
Quinidine Sulfate |
300 mg. |
13c |
|
Digoxin |
.25 mg. |
3.5c |
|
Furosemide (Lasix) |
40 mg |
13.5c |
|
Bumetanide (Bumex) Metolazone (Diulo |
1 mg. |
13c |
|
or Zaroxyln) |
5 mg. |
18c |
|
Spironolactone (Aladctone) |
50 mg. |
42c |
|
Triameterene (Dyrenium) |
100 mg. |
20c |
|
Amiloride |
5 mg. |
23c |
|
Hydrochlorothiazide |
50 mg. |
4.5c |
|
Hydralazine (Apresoline) |
50 mg. |
18c |
|
Captopril |
25 mg. |
26c |
|
Sublingual Nitro |
1/150 |
4c |
|
Oral Isorbide Dinitrate |
10 mg. |
lie |
|
Nitro Disc Patch |
10 mg. |
1.00 |
|
Nitro Dur Patch |
5 mg. |
96c |
|
Transderm Nitro |
5 mg. |
1.00 |
|
Nitrol Oint. |
1 tube |
3.00 |
72
The Journal of the South Carolina Medical Association
NEWSLETTER
February , 1985
•k Hr k k
BLUES CREATE CONFUSION AMONG MIT MEMBERS
Recently, the SCMA Members' Insurance Trust elected to change, from Blue Cross and Blue Shield to Provident Life and Accident Company for the claims administration of the SCMA MIT self-insured program.
As a result, Blue Cross and Blue Shield has been using the MIT subscriber list in marketing the Blue Cross and Blue Shield "Dimension" program. In their "marketing" efforts, they have been giving the erroneous impression that MIT members will no longer have health insurance coverage. The SCMA MIT health and hospitalization programs , however , will remain the same with lJO_ change in benefits. Claims will now be filed with Provident Life effective 2/15/85.
The SCMA Council has expressed serious concern over Blue Cross and Blue Shield's "marketing" techniques and has filed a formal complaint with the South Carolina Insurance Commi ss i oner .
The MIT will continue to provide health and hospitalization insurance as a member benefit and the Board has expressed the hope that SCMA members will support their program. For information on the coverage offered , including the new age-banded rate structure , contact the SCMA at 798-6207 .
SCMA SUPPORTS CONCEPT OF MEDICALLY INDIGENT ASSISTANCE ACT
At its January meeting, the SCMA Council reviewed the Governor's Medically Indigent^ Assistance Act, and voted to support the concept of this legislation. The Bill has been referred to the SCMA Committee on Medicaid and Indigent Care for its study and comments. The Governor has been advised that the association offers its input and assistance in reviewing the Act's provisions. See this month's "Legislative Update" for additional information.
GUEST SPEAKERS ; SCMA LEADERSHIP CONFERENCE
Guest speakers for the Leadership Conference to be held in Columbia on February 27, 1985 have been announced.
Representative David O. Hawkins , Chairman of the House Medical, Military, Public and Municipal Affairs Committee, will be the luncheon speaker. Speaking on current legislative issues and trends on the national level will be Bruce D. Blehart , Assistant Director of the AMA Department of Federal Legislation. Robert Hitt , Managing Editor of the Columbia Record will moderate the Media Relations Workshop.
Invitees who have not returned their registration cards should do so immediately .
NOT AT THE TOP
BUT STILL CLIMBING
In the first three months of the 1985 membership campaign, SCMA has increased more than six percent in the active member category over the comparable period last year.
According to SCMA President, Kenneth N. Owens, M. D. , "the membersh i p response is directly related to the recent positive accomplishments of the SCMA and the enthusiasm engendered by our long range program." "We expect this trend to continue," Dr. Owens added .
Response by Housestaff members is encouraging, and student leaders at both medical schools have embarked on a program to increase membership among medical students.
The American Medical Association also reports that its membership reached an all-time high for the year 1984 -- more than 4,000 over the previous year -- with the greatest gains in regular memberships.
MORE ANNUAL MEETING NEWS; SHERATON CHARLESTON HOTEL, APRIL 24-28, 1985
Since last month's " Newsletter ," the scientific portion of the 137th Annual Meeting of the SCMA has been announced.
James Long, M. D., Chairman, and the SCMA Committee on Continuing Medical Education have planned and coordinated an excellent scientific assembly for 1985- Plenary Sessions will be held on Friday and Saturday mornings, April 26 and 27. Friday's topic will be "Update in Endocrinology,” moderated by Kay F. McFarland, M. D., and Saturday morning's topic will be "Psychiatric Disorders in Primary Care Practice ," moderated by R. Ramsey Mellette , M. D.
The Sports Medicine Symposium will cover such topics as facial injuries and derma- tological problems of athletes, and will feature former coach and present Athletic Director of Presbyterian College, Cally Gault, discussing guidelines for returning athletes to participation. A Symposium on Pulmonary Medicine is also scheduled and will be moderated by j. Daniel Love, M. D.
A Risk Management Seminar on Friday afternoon will feature the topics of Family Stress in Relation to Medical Malpractice Lawsuits , as well as a Mock Deposition .
Other workshops will be held Wednesday through Friday afternoons, and pre- reg i s t ra t i on for all scientific sessions is encouraged. AMA Category I Credit and AAFP Prescribed Credit will be awarded on an hour-for-hou r basis.
All information and pre-registration materials have been mailed from SCMA Headquarters. Members are reminded that tickets for the SOCPAC luncheon, at which James J. Kilpatrick will be the featured speaker, are limited to 150, AMD MEMBERS OF SOCPAC WILL BE GIVEN FIRST PREFERENCE FOR TICKETS.
- PLAN TO ATTEND THE 137TH ANNUAL MEETING - PRE-REGISTER TODAY!
MEDICARE "PARTICIPATING" MDS
Nearly 30 percent of the nation's Doctors of Medicine and Doctors of Osteopathy elected to become "pa rt i c i pat i ng physicians" under Medicare, according to a detailed analysis by the Health Care Financing Administration.
HCFA reported in late January that 118,424 individual physicians or groups (29.8%) signed participation agreements. In all, there are 396,840 physicians who bill under Medicare.
The highest rate of participation (53-9%) among physicians is in Alabama. The lowest rate (5.6%) is in South Dakota. The participating rate among 1 i mi ted- 1 i cense practitioners was 34 percent which included 19,571 of 58,125 such practitioners.
Among suppliers, the rate was 23.8 percent. This includes 17,822 of the 75,014 Medicare suppliers.
HCFA noted that 65.6 percent of all claims submitted in November, 1984 were assigned. This is substantially higher than the November, 1983 rate of 52 percent.
STATUS OF AMA MEDICARE LAWSUIT
The freeze on physician reimbursement under the Medicare program has forced the nation into a two-tier system of medical care in which Medicare patients become "second-clas citizens," the AMA said in a brief filed in U. S. District Court in Indiana. The AMA said it was challenging the Medicare provisions of the Deficit Reduction Act of 1984 because it "profoundly alters and dramatically enlarges the role of government in the delivery of health care." The AMA filed documents examining data on the causes of increased spending on health care. The documents state that "virtually all of (the increased spending) -- apparently over 95 percent -- is due to three factors: general inflation, increased Medicare enrollment, and increased utilization of physicians' services by Medicare patients.
In real economic terms, physicians' fees to Medicare patients have increased very slowly and average charges and reimbursements have been declining." The AMA said that "physicians' f ees ... measured in constant dollars have been growing by only 1.0 percent annually since the early 1970s," that physicians' real net incomes have been declining on average (by 0.2% a year), and that MDs ' fees to Medicare patients "have grown no faster than other fees, and appear to have grown more slowly."
HCFA IMPLEMENTS NEW PAYMENT AND ADMINISTRATIVE POLICIES
On January 10, 1985, the Health Care Financing Administration published final regula- tions implementing the new payment and administrative policies affecting Medicare contracts with health maintenance organizations (HMOs) and competitive medical plans (CMPs ) . These rul es follow the statutory changes agreed to by Congress in the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) .
It is important to understand that these new Medicare "at risk" contracts represent a major structural reform in Medicare payment to providers. Permitting HMOs and CMPs to enroll Medicare beneficiaries at 95 percent of the Adjusted Average Per Capita Cost will strongly encourage the expansion of prepaid delivery systems. One need only look at the per capita payment rates published in the back of the Regulation to realize how strong the inducement will be, particularly in certain market areas.
(From AMPRA Bulletin , January 16 , 1985)
DHEC BOARD CHANGES
SCMA President-Elect Leonard W. Douglas , M. D. , has resigned from the Board of Directors of the S. C. Department of Health and Environmental Control, effective January 31. Dr. Douglas served on the board for nearly 11 years and was Vice Chairman when he resigned. Dr. Douglas will assume the Presidency of the SCMA in April, and his election to this leadership role was a major factor in the decision to resign, along with increasing demands of a busy family practice.
DHEC Commissioner, Robert S. Jackson , M. D. , expressed his regret over Dr. Douglas' resignation on behalf of the agency and its employees. "His considerable contri- butions to the board and the agency will be missed without question," said Dr.
Jackson. Moses Clarkson , Chairman of the DHEC board, observed that Dr. Douglas brought a special insight to the deliberations of the board with his background as a physician.
Of special note is the fact that another physician will replace Dr. Douglas on the board. Governor Richard W. Riley has appointed, and the Senate has confirmed,
Euta M. Colvin, M.D., a former President of the SCMA, and presently Chairman of the Board of SCIMER and Chairman of the SCMA Professional Liability Committee.
In commenting on Dr. Colvin's appointment, Dr. Douglas said, "It was a privilege for me to recommend Dr. Colvin to Governor Riley. The Governor holds Dr. Colvin in very high esteem and has been an acquaintance of his for a number of years. As an officer in the SCMA, I have worked very closely with Euta. Having served on the DHEC board for an extended period of time, I know the importance of very deliberate decisions and the great amount of time that is required to serve. Dr. Colvin is a very thought- ful and concerned citizen as well as a physician in this state, and he will serve the board and the Department extremely well."
CAPSULES . . .
. , , . , Honorary membership status has been granted the following loyal SCMA members:
E , C. Kinder , M. D .; William Hamilton , M. D . ; Dana C. Mitchell , Jr., M. D . ; Rudolph H. Hand, M. D. ; L. Charles Bailes , M. D . ; Henry Ross, M. D . ; Casper E. Wiggins, M. D . ; D. Strother Pope, M. D. ; Harold Miller, M. D . ; Edward F. Parker, M. D . ; and J.
Manly Stallworth , M. D
John Brown, M. D. , Columbia, has been appointed to the Advisory Council of the
Division of Emergency Medical Services of DHEC, as SCMA representative to replace Edmund R. Taylor, M. D., who recently resigned after many years of service....
SCMA representatives to the New Technology Task Force of the Statewide Health Co- ordinating Council will be John Thomas, M. D . , Columbia Radiologist, and Thomas Kirkland, M. D. , Charleston Urologist
SOCPAC / AMPAC MEMBERSHIP
Recent reports from the American Medical Political Action Committee indicate that South Carolina ranks in the first 10 nationwide of PAC members who are also members of the AMA, with a total of 28 percent of AMA members Joining the PAC. Meantime, membership in SOCPAC/AMPAC in 1985 has been most gratifying. In recognition of dedicated giving to* political actions, members will soon be receiving their 99+ lapel pins as Sustaining Members in AMPAC and SOCPAC.
THE MEDICAL THERAPY OF ANGINA PECTORIS — WITH AN EYE ON COST
KENNETH H. HANGER, JR., M.D.*
The author and The Journal Editorial Board express grateful appreciation to C1BA Phar- maceutical Company which generously funded the publication of this article.
Death from coronary artery disease, despite its decline from 1968 to 1976 of 21 percent,1 is still the leading cause of death in the United States. In fact, in 1969, 29 percent of all deaths in the United States were cardiac related. This disease is devas- tating because it kills and disables people in their most productive years and accounts for nearly $10 billion annually spent on cardiovascular services. Two percent (four million) of Americans have coronary heart disease, half below age 65. There are over 500,000 heart attacks each year with one in five American males to develop this disease before age 60.2 Often the presenting complaint in women is angina, while in men sudden infarction or sudden death are commonly found. Thus this disease represents a major challenge still facing the modern world despite new awareness, risk modifications, coronary care units and medical and surgical therapy.
Angina pectoris is a symptom of coronary ar- tery disease described by Heberden as a “sense of strangling and anxiety ... a painful and most disagreeable sensation in the breast . . , ”.3 Angina pectoris results from a complicated series of events, a series that we are still attempting to unravel. Most commonly fixed atherosclerotic coronary artery disease is the underlying cause in most patients with angina pectoris, however, there are other causes (Table I). A simple ap- proach towards the pathophysiology of angina invokes a supply and demand scheme to describe the events that cause myocardial ischemia and thus pain.
What is threatened is the nutritional supply of myocardial cells. Their demand for nutrition (oxygen, glucose, ATP, etc.) are generally gov- erned by the following factors:
° 501 S. Coit Street, Florence, S. C. 29501.
1. Heart rate
2. Afterload (systemic vascular resistance or more easily determined, blood pressure)
3. Preload (in simple terms, the filling pressure of the ventricle)
4. Contractility
The demand for myocardial nutrients, in an- gina, is not able to be met by the supply of nutrients. The “supply side” is generally affected by4
1. Fixed atherosclerotic disease of the coronaries,
2. Coronary artery spasm, and
3. Platelet deposition and thrombus formation.
Thus it is believed that an imbalance of the supply and demand accounts for the occurrence of myocardial ischemia and angina pectoris. Therapy is directed towards correcting this im- balance. (Table II.)
Generally the medical therapy of angina also includes risk factor reduction such as weight re- duction, stop cigarette smoking, lessen stress,
Table I
DISEASES THAT MAY UNDERLIE ANGINA PECTORIS12
Coronary Artery Disease
Atherosclerotic luminal narrowing Non atherosclerotic diseases Coronary artery spasm Congenital coronary anomalies Coronary thrombo-embolic events Coronary artery vasculitis Valvular Heart Diseases
Aortic stenosis or insufficiency Mitral valve prolapse or stenosis Pulmonic stenosis Hypertrophic cardiomyopathy
Other (hypertension, normal coronary arteries with no identi- fiable disease)
February 1985
79
THERAPY OF ANGINA PECTORIS
Table II
MEDICAL THERAPY OF ANGINA PECTORIS
|
SUPPLY Vasospasm Fixed Lesion |
DEMAND Heart Rate Contractility |
Preload |
Afterload |
|||
|
Nitrates |
i 4 |
|
|
— |
4 4 |
4 |
|
Beta Blockers |
— |
— |
i i i- |
— |
4~4 |
|
|
Calcium Blockers |
4 l |
— |
i — |
— |
lower elevated cholesterol levels and control hy- pertension and diabetes. Then three major groups of medicines are used in addition, consisting of ni- trates, beta blockers and calcium channel blockers to control symptoms of angina.
The nitrates have been used to treat angina for over a century. Their points of attack are several. Nitrates can do the following to reduce myocar- dial ischemia:
1. Relieve coronary spasm (supply)
2. Dilation of collateral blood vessels (supply)
3. Dilation of atherosclerotic areas of narrow- ing (supply)
4. Redistribution of flow to subendocardium (supply)
5. Reduce afterload (demand)
6. Reduce preload (demand)
Nitrates produce vasodilatation by two mecha- nisms in vascular smooth muscle. One mechanism is by promoting the production of cyclic GMP (guanosine 5', 3' monophosphate) which then af- fects calcium influx into the cell. Another is the ability to promote prostacyclin formation which again affects vasodilatation.5
Nitrates are generally the most inexpensive of the three types of antianginal medications. Sub- lingual nitroglycerin is rapidly absorbed and has an onset of action within two to five minutes. Longer acting nitrates come in various forms. Two percent nitroglycerin ointment has sustained action for four to six hours. Unfortunately, this preparation is sometimes messy. Oral and sub- lingual isosorbide dinitrate also have sustained action, the sublingual form from two to four hours and the oral form from four to six hours.6 Recently the transdermal sustained release discs have been met with great popularity.7 Their attractiveness is their ability to sustain action for 24 hours with a pleasant delivery vehicle and this has produced
80
sales of over $150 million in the last two years. Unfortunately, little clinical efficacy was proved prior to their release and now increasing reports8’ 9 have scientifically deduced that it often takes very large doses (25 mgs. or more per day) to sustain effectiveness. Thus, in terms of cost, it becomes very expensive to be clinically effective. More data are needed before this form of therapy can be better quantitated in terms of the dosage needed for patients.
Nitrates in general have several drawbacks, mainly from side effects. Headaches are common, but usually diminish after continued use. Dizzi- ness and light-headedness also are not uncommon. Nitrate tolerance is becoming more important and probably plays an important role in the lack of sustained action of 24-hour discs.
The beta blockers have been used for two dec- ades in the treatment of angina pectoris. They can be divided into non-selective and selective agents.10 Non-selective drugs block both sub- groups of beta receptors at approximately the same dose and decrease heart rate (demand), lower contractility (demand), and thus decrease oxygen consumption. Cardioselective drugs block beta! receptors and not beta2 receptors and are less likely to induce bronchospasm and claudication. This advantage is lost at higher doses. There are other distinguishing factors of the beta blockers including lipid solubility (long or short acting), membrane stabilizing activity (quinidine-like ef- fect at levels well above therapeutic) and presence of intrinsic sympathomimetic activity. (Table III.) Overall, the beta blockers’ clinical efficacy has been well proven and combined with the use of nitrates, have been the mainstay of anginal ther- apy until the arrival of calcium channel blockers two years ago.
Beta blockers also have drawbacks. Congestive heart falure, heart block, asthma and peripheral vascular disease are all relative contraindications.
The Journal of the South Carolina Medical Association
THERAPY OF ANGINA PECTORIS
Table III
PROPERTIES OF BETA BLOCKERS
|
Duration of Action |
Cardioselectivity |
Membrane Stabilizing Activity (MSA) |
Intrinsic Sympathomimetic Activity (ISA) |
|
|
1. Propanolol |
Short |
— |
+ + |
— |
|
2. Metoprolol |
Short |
+ + |
+ - |
— |
|
3. Nadolol |
Long |
— |
— |
— |
|
4. Timolol |
Short |
— |
— |
— |
|
5. Atenolol |
Long |
+ + |
— |
— |
|
6. Pindolol |
Short |
+ + |
+ + + |
Depression, nightmares and impotence are not uncommon. Thus these drugs need to be tailored to each patient’s need.
The newest group of antianginal drugs are the calcium channel blockers. Three currently avail- able drugs all act slightly differently but have as their end point the manipulation of calcium movement in smooth muscle cells and in the myo- cardial conduction system. Calcium channel blockers can produce coronary artery dilatation (supply), reduce blood pressure ( demand ) and lower heart rates (demand).11 Nifedipine is the most potent vasodilator and has little effect upon either conduction or contractility of the myocar- dium. Diltiazem is not as potent a vasodilator but has more effect upon conduction (it can cause a resting bradycardia and occasionally heart block) and can decrease contractility. Verapamil is the least potent vasodilator and the most likely to induce heart block (thus its efficaciousness for paroxysmal supraventricular arrhythmias by sup- pressing conduction through the AV node) and heart failure in patients with reduced contractility.
All of these drugs can cause side effects such as dizziness, headaches, gastrointestinal problems and edema. Again, drug choice depends upon the individual receiving therapy.
Table IV presents a survey of three pharmacies in the Florence area to obtain a “feel” one might get for the average cost of some of the antianginal medications that have been previously described. Based upon these figures and with the knowledge of the patient’s history, physical examination and laboratory data, one can begin to develop a “cost conscious” approach to antianginal therapy. However, these are merely suggestions and the patient’s needs should be considered and therapy individually tailored to fit these needs. Therapy should be flexible enough to meet changes in the patient’s activities and changes in the activity of the disease process itself.
Nitrates still remain the first choice in the treat- ment of angina pectoris. They are inexpensive and effective. Here only the delivery system needs questioning. Nitroglycerin ointment is inex- pensive but as noted previously, can be messy. Discs can be effective but perhaps are only effec- tive in very high dosages and may need a thrice daily dosage. If the patient doesn’t like the oint- ment form, then cost-wise isosorbide dinitrate is the next effective form. In fact, the generic form of this is about one-third of the price listed in Table IV and thus is equal to nitroglycerin oint- ment. If one starts with a transdermal patch, start with a “high” dose, say 10 to 15 mgs. per twenty-
Table IV
REPRESENTATIVE COSTS OF VARIOUS ANTIANGINAL MEDICATIONS*
|
Drug Store A |
Drug Store B |
Drug Store C |
Average |
|
|
1. Nitroglycerin ointment, 1" q.i.d. 60 gm tube |
$ 6.68 |
$ 9.75 |
$ 8.41 |
$ 8.28 |
|
2. Isosorbide Dinitrate (Isordil) 20 mg. q.i.d. |
20.50 |
22.85 |
22.35 |
21.90 |
|
3. 10 mg nitro disc (Transderm) t.q.d. |
31.19 |
37.95 |
38.09 |
35.74 |
|
4. Verapamil (Calan) 80 mg. t.i.d. |
23.58 |
25.59 |
24.28 |
24.48 |
|
5. Nifedipine (Procardia) 20 mg. t.i.d. |
45.08 |
33.58 |
32.43 |
37.03 |
|
6. Diltiazem (Cardiazem) 60 mg. t.i.d. |
31.39 |
38.25 |
38.85 |
36.16 |
|
7. Propanolol (Inderal) 20 mg. q.i.d. |
17.30 |
19.25 |
17.63 |
18.06 |
|
8. Atenolol (Tenormin) 50 mg. q.d. |
13.62 |
15.49 |
14.39 |
14.50 |
° Prices are cost to patient, quoted on January 7, 1985 for one month’s supply.
February 1985
81
THERAPY OF ANGINA PECTORIS
four hours. If there is no clinical response consider adding on another type of medicine or changing to another type of nitroglycerin. A patient with side effects needs to be changed to another type of antianginal medication.
When the patient is still symptomatic on nitra- tes then another drug needs to be added. In pa- tients with contraindications to beta blocker therapy (asthma, heart failure, claudication) a calcium channel blocker would be necessary. A calcium blocker that tends to decrease contrac- tility or lower heart rate such as diltiazem or verapamil would make for an excellent combina- tion. However, verapamil should not be used in a patient with congestive heart failure symptoms. Patients without contraindications to beta block- ers would benefit from beta blockade in addition to nitrates. A once daily beta blocker such as atenolol certainly would be cost effective and also promote compliance. The combination of nitrates and beta blockers still forms a cost effective team against angina in patients that can tolerate both.
However, if angina persists or the patient has side effects from beta blocker therapy, then cal- cium channel drugs can be safely added. These drugs are not generally considered first line drugs (the only exception being a patient with coronary artery spasm or a patient intolerant to nitrates). Again with an eye on costs, if a beta blocker can be used as a “second-line” drug, then costs are kept down as the calcium channel blockers are the most expensive of the antianginal drugs. Each of the calcium channel blockers has its advantages and disadvantages. Nifedipine is the most potent and expensive but also can cause side effects fre- quently. Verapamil is the least expensive, fits best the patient with tachyarrhythmias and angina, but as noted previously, can worsen heart failure. Diltiazem also is fairly expensive, but seems to have the fewest side effects. These drugs in gen- eral are adding a new and exciting dimension to treating angina pectoris.
What if your patient still has angina on “triple therapy” i.e. nitrates, beta blockers and calcium channel blockers? What this paper purposely stayed away from is the role of angiography, stress testing, coronary artery bypass grafting and an- gioplasty. A recent review12 is excellent and ad- dresses these issues. Needless to say, the recent Coronary Artery Surgery Study (CASS)13 found that during the use of beta blockers and nitrates,
82
medical and surgical mortality in general was low without significant differences, although a trend towards better surgical survival was found in pa- tients with depressed left ventricular function and three vessel coronary artery disease. There are some important limitations to this study, but over- all it suggests that medical therapy will continue to play an important role in the treatment of angina pectoris.
In summary, the three types of antianginal medications all have their strengths and weak- nesses. Discerning each patient’s particular prob- lems and needs, knowing about costs and being aware of what the medications have to offer makes the best combination in not only being cost effective, but also in bringing about a successful treatment approach to angina pectoris. □
ACKNOWLEDGEMENT
I would like to thank Mrs. Judy Allen for her excellent help in preparation of this manuscript.
REFERENCES
1. Stern MP: The recent decline in ischemic heart disease mortality. Ann Intern Med 91:630-640, 1979.
2. Kannel WB: Incidence, prevalence and mortality of car- diovascular diseases, in W.J. Hurst (editor) “The Heart”, Fifth edition, McGraw-Hill.
3. Heberden W: Some account of a disorder of the breast. Med Trans Roy Coll Physicians 2:59-67, 1772.
4. Epstein SE, Palmeri ST: Mechanisms contributing to pre- cipitation of unstable angina and acute myocardial infarc- tion: implications regarding therapy. Am J Cardiol 54:1245-1252, 1984.
5. Zelis R: Mechanisms of vasodilation. Am J Med 74 (6B): 3-12, 1983.
6. Abrams J : Nitroglycerin and long-acting nitrates. N Engl J Med 302:1234-1237, 1980.
7. Abrams J: The brief saga of transdermal nitroglycerin discs: paradise lost? Am J Cardiol 54:220-224, 1984.
8. Reichek N, Priest C, Zimrin D, Chandler T, Sutton M: Antianginal effects of nitroglycerin patches. Am J Cardiol 54:1-7, 1984.
9. Crean PA, Ribeiro P, Crea F, Davies GJ, Ratcliffe D, Maseri A: Failure of transdermal nitroglycerin to improve chronic stable angina: a randomized, placebo-controlled, double-blind, double crossover trial. Am Heart J 108:1494-1500, 1984.
10. Nestico P, Segal BL. Beta-blocking drugs in patients who have survived myocardial infarction. Practical Cardiology 8:96-108, 1982.
11. Braunwald E: Mechanisms of action of calcium-channel- blocking agents. N Engl J Med 307:1618-1627, 1982.
12. Silverman KJ, Grossman W: Angina pectoris. Natural his- tory and strategies for evaluation and management. N Engl J Med 310:1712-1717, 1984.
13. CASS principal investigators et al. Coronary Artery Sur- gery Study (CASS): a randomized trial of coronary artery bypass surgery survival data. Circulation 68:939-950, 1983.
The Journal of the South Carolina Medical Association
Outstanding Leadership in Charter Medical Corporation.
leadership Stands Out in South Carolina.
For many patients, the most effective treatment can be best delivered by psychiatrists, working with highly qualified professionals, in a freestanding hospital whose entire staff is dedicated to quality psychiatric care.
Commitment to this philosophy is exemplified in each and every Charter Medical Hospital. All across America. Without exception.
You can depend on the fact that the staff will work with you to design and implement an individu- alized treatment plan for your patient. Involvement of the patient’s family in the treatment process will be encouraged. There will be regular communication, between the hospital and the referring professional, about the patient’s status. All psychiatrists on staff are Board Certified or Board Eligible. There is a wide variety of therapies available to enhance individualized treatment. And every Charter Medical Hospital has been designed to provide a modern therapeutic environment to promote your patient’s recovery.
Here’s where you can expect to find this outstanding leadership in South Carolina.
Charter Rivers Hospital
2900 Sunset Boulevard
West Columbia, South Carolina 29171
(803) 796-9911
Beds: 80
Psychiatric Staff: 17
Programs: Adolescent and Adult Psychiatric; Adolescent and Adult Addictive Disease
Other Programs: Outpatient Chemical Dependency Program
For further information about Charter Rivers or admission procedures, contact:
Medical Director: Thomas W. Messervy, M.D. Hospital Administrator: Bill Gibson
i
CHARTER
MEDICAL
CORPORATION
The following is the sixth in a series of editorials on diagnosis related groups (DRGs).
— CSB
THE EFFECT OF DRGs ON OFFICE PRACTICE
Public Law 98-21, the Prospective Payment System for Hospitals, in October, 1983, instituted the diagnosis-related group (DRG) classification and reimbursement system for payment of Medi- care patients while in the hospital. There have been numerous articles published and much spec- ulation on the outcome of this system in regards to the economic survival of hospitals and the effect eventually on other parameters of medicine. However, very little has been said about the effect of the DRG system upon the outpatient office practice of physicians and, indeed, a recent search of the literature failed to uncover any published articles in this regard.
One would probably immediately assume that the initial effect would be acceleration of outpa- tient volume, profits and malpractice risks.
The system obviously rewards hospitals who are able to discharge patients more rapidly and those who have had less use of ancillary services and expensive therapies. It is conceivable that patients then may have some of these diagnostic tests and even treatment modalities performed on a pre- and post-hospital basis in the office rather than in the hospital. Physicians now have most of the highly technical diagnostic equipment available in their offices and can perform the same tests as the hospital at a lower rate because of less over- head. The unit cost of such procedures would be less than hospital costs to the payer and has be- come increasingly popular among insurance com- panies who formerly required patients to be in the hospital to insure payment for such testing. Also, it is more rewarding from a diagnostic aspect and generally more pleasant for the patient to perform certain procedures (such as ambulatory arrhyth- mia monitoring) in the patient’s usual environ- ment and with him actually at work, which has definite appeal to industry on work days lost due to illness.
The above illustrations indicating extensive use of physician facilities and diagnostic equipment would obviously increase his profits as would the
ability to see patients in his office, an environment more conducive to effectively handling a high volume of patients in a given unit of time rather than traveling floor to floor in the hospital and trying to “catch” patients between hospital rou- tine procedures.
Since over seventy percent of physicians are participating in the voluntary freeze on their fees in a time of continuing inflation, higher produc- tivity would be one means of maintaining ade- quate economics without sacrificing high quality academic care. It is also usually more cost effec- tive for patients to obtain their medications through their own pharmacies or organizations which offer generics at a lower cost than the hospital fees for the same medications.
Unfortunately, a large segment of our society believes that the only acceptable way to expire is in a hospital bed. It appears that the wave of the future in medicine will be toward more outpatient care and less inhospital days which will require a great deal of education to the general public. Quality of life will necessarily have to be stressed, and particularly with our aging population, who are most reluctant to end their active life styles by being put in a “protective environment” for the peace of mind of their relatives. Medicine must be prepared for its role of leadership in accomplish- ing these goals and should encompass the coopera- tion of the legal profession to afford a system of sound and practical academic treatment and eliminate the “economic gamesmanship” occa- sionally seen in malpractice suits.
The effect of DRGs on office practice will also be markedly manifest from a medical education aspect. Tertiary-care teaching hospitals stand to be the biggest losers on a payment pattern and need to promptly foster training of medical stu- dents and residents in more efficient outpatient care. Usually physicians who have completed training enter private practice with the primary notion of treating illnesses inside a hospital setting, with very little experience or even inclination in
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treating the same patients in their offices. It will become increasingly obligatory to change these teaching patterns to accurately reflect changing trends in medicine as a specific tool in cost effec- tive management.
It would be remiss not to point out that the medical profession has an urgent need to take a leadership role of the developmental process of
the DRG system and to remember that the speed of legislation and implementation allow no time for bemused reflection.
E. Conyers O’Bryan, Jr., M.D.
501 S. Coit Street
Florence, South Carolina 29501
OF COST-CONTAINMENT AND CAT-BELLERS
Reprove not a scorner, lest he hate thee: rebuke a wise man, and he will love thee.
— Proverbs 9:8
A prerequisite for worthwhile evaluation ... is for all doctors to cultivate a self- critical attitude to their practices. The authoritarian natures of medical practice and medical knowledge tend to stifle criticism. . . J
In this issue of The Journal, Dr. Conyers O’Bryan of Florence has both edited a symposium on cost-effective cardiovascular drug therapy and also written the preceding editorial on the im- plications of DRGs for office-based physicians. In next month’s issue, Dr. Mims Mobley of Green- wood will provide the last of our planned series of editorials on DRGs, conceived during 1983 and begun a year ago. We can anticipate that dialogue regarding these two topics — cost-effective ther- apy and the implication of DRGs — will continue to appear in these pages for years to come. In the meantime. Dr. O’Bryan points out that although DRGs may seem to cloud the future of medical practice, there may be at least one silver lining: incentive for high-volume, cost-effective outpa- tient medical care.
The delivery of a greater proportion of medical care in outpatient settings will spawn predictable attempts to extend the concept of DRGs to those settings. We have already been told that the De- partment of Health and Human Services plans to extend the DRG approach to ambulatory care.2 Like it or not, the issue of cost-effectiveness in all of what we do is here to stay.
The percentage of our gross national product spent on health care delivery more than doubled during the past 25 years. During this period, lead- ers of our profession frequently sounded the need for cost containment and for medicine to “main- tain its own house.’’ Why did these cries fail to
— Lancet 2: 77-78, 1984
bring about effective self-regulation long before the enactment of PL 98-21 in October, 1983? Were our leaders ineffective?
I suggest that our failure to bring about cost control prior to the recent legislation was due not to lack of leadership but rather to the nature of the problem. Talented persons from many areas — organized medicine, academic medicine, practic- ing physicians, and the lay public, to name a few — addressed the issues both frequently and force- fully. However, the problem was analagous to that facing the wise mouse of the fable who proposed placing a bell around the cat’s neck. Who was to actually bell the cat?
Our attempts to promote cost-effectiveness were stymied by at least two factors. The first of these is the failure of society to provide us with a suitable ethical and legal framework upon which to base decisions, in part, on cost-effectiveness issues. As patient advocates, we understandably feel the frequent need to do “everything possible” even when the cost-potential benefit ratio seems exceedingly high. The second factor is human nature, which poses powerful barriers to truly effective peer review. Knowing that our fellow physicians — like most other people and like even ourselves — sometimes tolerate criticism poorly, we are usually reluctant to give it. We therefore keep to ourselves our opinions that some of our colleagues could practice medicine in a much more cost-effective manner.
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As individuals, we cannot bell the cat ourselves. We need society’s advice and consent regarding the extent to which we can base clinical decisions upon estimates of cost-effectiveness. We need our profession’s help to provide the data for making these estimates. As a recent editorialist put it:
“It will be far better (compared to a compli- cated set of rules and regulations) if Ameri- can doctors begin to build up a social ethic and behavioral practices that help them de- cide when medicine is bad medicine — not simply because it has absolutely no payoff or because it hurts the patient — but also be- cause the costs are not justified by the mar- ginal benefits. ”3
We must encourage the development, both on a national and local basis, of effective guidelines
upon which to base such judgments. We must encourage the development of more effective quality assurance and peer review activities at our hospitals. We must become more self-critical and more willing to give criticism to others and accept their criticism in turn.
A new mind-set for medical practice (code name: cost-effective medicine) must support and supplement the old one (code name: scientific medicine). We must all become cat-bellers.
— CSB
REFERENCES
1. High technology medicine: a luxury we can afford? (edi- torial). The Lancet 2: 77-78, 1984.
2. Omenn GS, Conrad DA: Implications of DRGs for clini- cians. New Engl J Med 311: 1314-1317, 1984.
3. Thurow LC: Learning to say “no”. New Engl J Med 311: 1569-1572, 1984.
1984 JOINT NATIONAL COMMITTEE RECOMMENDATIONS ON DETECTION, EVALUATION AND TREATMENT OF HIGH RLOOD PRESSURE
In 1984, the Director of the National Heart, Lung and Blood Institute reestablished the Joint National Committee (JNC) on Detection, Evalua- tion and Treatment of High Blood Pressure to advise the National High Blood Pressure Educa- tion Program on issues of hypertension manage- ment and control. They were charged with reviewing the 1980 JNC report and with reaching a consensus on guidelines for practicing physi- cians and other health professionals participating in high blood pressure control programs across the nation.
Under Dr. Harriet Dustan’s leadership, the Committee developed recommendations on a va- riety of management problems and questions rel- ative to hypertension control. Key areas addressed by the Committee include: screening and referral procedures; classification of blood pressure levels; use of nonpharmacologic therapies for reducing risk factors; revised stepped-care approach; man- agement of mild hypertension; management of special populations (such as black patients, chil- dren, and pregnant women); and patient-profes-
sional interaction. In addition, the Committee has reviewed and revised the listing of available anti- hypertensive agents, their dosages, side effects, and special considerations for use. Substantial in- formation was developed to guide practitioners in the management of hypertensive emergencies.
Additional information about these recommen- dations or a copy of the JNC Report can be ob- tained by contacting the Division of Chronic Disease, South Carolina Department of Health and Environmental Control, 2600 Bull Street, Co- lumbia, S. C. 29201 (telephone: 803/758-0338).
Frances C. Wheeler, Ph D., Director
Division of Chronic Disease
Susan C. Oakes, R.N.,
Program Nurse Consultant
Division of Chronic Disease
S. C. DHEC
P. O. Box 2202
Columbia, S. C. 29202
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The Journal of the South Carolina Medical Association
LETTER TO THE EDITOR
To The Editor
On behalf of the S. C. Diabetes Control Project, I want to thank you and your staff for your as- sistance in the publication of our editorial about the Diabetes Guide (The Prevention and Treat- ment of Five Complications of Diabetes: A Guide for Primary Care Practitioners). As a re- sult of the editorial, we have received a number of requests for copies of the Guide, and we are most appreciative of your Journal’s effectiveness in reaching the practitioners for whom the Diabetes Guide was intended.
Many thanks for your help — we look forward to working with you again. Have a happy holiday season.
Frances C. Wheeler, PhD., Director
Division of Chronic Disease
S. C. DHEC P. O. Box 2202 Columbia, S. C. 29202
WE'RE FIGHTING FOR YOUR LIFE
You don’t have to drink to have a drinking problem.
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And their physicians are expected to offer the solution.
By giving help to the drinker or drug addict, the Lancaster Recovery Center solves problems for a lot of other people too. We’re South Carolina’s
first hospital-based treatment center for alcohol and drug abusers. And we’re building a reputation around the country for our ability to help patients rebuild their lives.
If drinking or drug use is causing problems for your patients, we’d like to help you deal with them.
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24 Hour Admissions
(803)286*1491
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ELLIOTT
WHITE
SPRINGS
Memorial Hospital Inc.
ON THE COVER:
CORNELIUS KOLLOCK, M.D. 1824-1897
The year 1887 was a relatively comfortable and peaceful time for South Carolina physicians, as compared to the “reconstruction” period of only 20 years earlier. Cornelius Kollock, M.D., who served in the Confederate War, described that conflagration as being fought “to gratify the pas- sions of a set of whimpering philanthropists and bring political aggrandizement to unprincipled and designing demagogues.”
Physicians returning home after Appomatox found the aftermath of war a dreary specter in- deed. Stagnant and scorched countryside led to cities and desolation and ruins. Columbia was described as a “wilderness,” with its “heart a mass of blackened chimneys and crumbling walls.” Charleston was a place of widowed women, weed- wild gardens, grass-grown streets, vacant houses, rotting walls and acres of pitiful barrenness.
In Charleston, a returning doctor reported that he was “living in two rooms where I made my own fires, helped cook and