A Cup Of Coffee

by Catriona M. O'Neil

N Engl J Med. 2018 Jul 26;379(4):312-313. doi: 10.1056/NEJMp1804728.  

This fine essay speaks to the importance of all members of the care team.  The author, an oncologist, learns that her transcriptionist is deeply invested in their patients' welfare.  Many of us will find this piece useful as an "aha" moment.

"It is our ability to connect with and comfort our patients at their most vulnerable that is perhaps the most satisfying part of working in oncology. But while the psychological impact on doctors, nurses, and allied health professionals of working in oncology and palliative care settings is well recognized, little attention has been paid to the support staff who are also faced with distressed patients and their families, confrontations with death and dying, and the struggle to balance the emotional and task-oriented aspects of their roles."

Link  (if if does not work, you can email me for a pdf.)

Mammalian Meat Allergy

The Alpha-gal Story

Wikipedia

This fascinating topic was exhaustively covered in a recent NY Times article: What the Mystery of the Tick-Borne Meat Allergy Could Reveal.¹

It’s a far-reaching story that touches on immunology, infectious disease, the microbiome, ecology and many other areas of the basic sciences as they apply to a newly evolving human disease.  Much of the early and current work has been done by Thomas Platts-Mills and his associates at the University of Virginia School of Medicine.²

The NY Times article is a great introduction to this important topic.  It will be of particular interest to Biology majors,  medical students and physicians.

References

1. Moises Velasquez-Manoff. What the Mystery of the Tick-Borne Meat Allergy Could Reveal. New York Times, July 24, 2018.  Link.

2. Wilson JM, Platts-Mills TAE. Meat allergy and allergens. Mol Immunol. 2018 Aug;100:107-112. (Good Basic Review)

Abstract: IgE-mediated hypersensitivity to ingested animal products, including both mammalian and avian sources, is increasingly appreciated as an important form of food allergy. Traditionally described largely in children, it is now clear that allergy to meat (and animal viscera) impacts both children and adults and represents a heterogeneous group of allergic disorders with multiple distinct syndromes. The recognition of entities such as pork-cat syndrome and delayed anaphylaxis to red meat, i.e- the α-Gal syndrome, have shed light on fundamental, and in some cases newly appreciated, features of allergic disease. These include insights into routes of exposure and mechanisms of sensitization, as well as the realization that IgE-mediated reactions can be delayed by several hours. Here we review mammalian and avian meat allergy with an emphasis on the molecular allergens and pathways that contribute to disease, as well as the role of in vitro IgE testing in diagnosis and management.

On Medicine: What Can Odd, Interesting Medical Case Studies Teach Us?

by Siddhartha Mukherjhee

NY Times,  July 17, 2018

“Late one evening in the medical library of the hospital where I work, I opened The Lancet, the medical journal, and came across a case report written by the neurologist-writer Oliver Sacks and colleagues. ‘In July 2011, a 52-year-old woman presented to our psychiatric outpatient clinic in The Hague with a lifelong history of seeing people’s faces change into dragonlike faces.’*

Hooked, I continued: ‘She could perceive and recognize actual faces, but after several minutes, they turned black, grew long, pointy ears and a protruding snout and displayed a reptiloid skin and huge eyes in bright yellow, green, blue or red. She saw similar dragonlike faces drifting toward her many times a day from the walls, electrical sockets or the computer screen.’ ”

Osler wrote: To talk of diseases is a sort of Arabian Nights entertainment.   This is frequently quoted, but the full sentence actually reads “To talk of diseases is a sort of Arabian Nights entertainment to which no discrete nurse will lend her talents.” Nurse and Patient Chapter IX, Aequanimitas.

Oliver Sacks certainly was never discrete, and all physicians have a fascination with weird clinical tales.  Mukherjee’s reflective  essay  NY Times is worth reading.  It indirectly comments on the many patients we see with “medically unexplained symptoms” and the importance of reporting these since in the future their true nature may be elucidated. Case reports are not readily published in our major journals because they reflect badly on the Impact Factor.  And so, the boring and predictable grind us down as we slog like penitents through our professional journals.

* Prosopometamorphopsia and facial hallucinations. Blom JD, Sommer IE, Koops S, Sacks OW. Lancet. 2014 Nov 29;384(9958):1998. PMID: 25435453

    

Background Quotes

I don't decry research. Some fine things are done.

Not nearly enough for the amount of money spent. Too much machinery, too much administration, and not enough brains and intuition. Research harbors a lot of second- and third-rate people.

The huge labs are what monasteries were before Henry the VIII took the axe to them. 

More humanism and less science – that's what medicine needs. But humanism is hard work and a lot of science is just Tinkertoy^®.Robertson Davies, The Cunning Man

Jules and Angelina

Yesterday, I visited Jules, a 71 year-old home hospice patient with disseminated carcinomatosis .  He he’s had psoriatic erythroderma for over three decades and we became friends since he moved here twenty years ago.  As his dermatologist, there’s not much I can do for him now, but I don't want to abandon him. So, I go to sit with him and visit a couple of times a week.  Over the past month he's been dwindling.  Yesterday, I saw a different Jules.

A childhood friend of his deceased son and her husband drove 14 hours from their Midwest town with Paddy, their 9 week old cockapoo puppy to be with him and share some laughs.  Angelica is an outgoing woman in her early 40s and she's known Jules since she was a kid.  She brought pictures of him, his son and herself from the village where they lived.  She effected a connection to a happier time.

I haven't seen him look this animated or happy in months.  Maybe, ever.  His visage was completely different.  He was relaxed, joking, vibrant.  There was no pathos. I was tempted to take a picture – but not everything has to be documented by a Smartphone.

When Angie and her husband left, you could appreciate the love she and Jules have for one another.  What a great gift she gave him!  They hugged, both cried – her visit was a true anodyne.  All the morphine, all the Fentanyl patches did not help his pain like the magic of her visit.

I learned a lesson yesterday that somehow escaped me in 40 years of sitting in exam rooms and rounding on hospital wards.  All we see in those settings clinical.  The occasion of a social visit let me witness the opposite of clinical. 

Image from: warrenphotographic.co.uk/

Twitter Tailwinds

Full many of gem of purest ray serene,
The dark unfathomed caves of the ocean there;
For many a flower is born to blush unseen,
And waste its fragrance on the desert air.

Thomas Gray

Twitter Tailwinds — Little Capsules of Gratitude

by Lisa Rosenbaum, M.D. 

N Engl J Med 2018; 379:209-211 (July 19, 2018)  Free Link.

The venerable New England Journal of Medicine has been published since 1812. It prides itself on being the gold standard for clinical medical periodicals,  and its stratospheric Impact Factor is the envy of all other medical journal editors. NEJM is the go-to journal for articles on the new and expensive Biologics and its clear to me, that the advertising revenue they derive from these are of vital importance to their Editors.

However, every month or two there's an article that touches on the art of medicine. These usually appear in the Perspective section.  In the current issue is one such essay by Lisa Rosenbaum, entitled Twitter Tailwinds.

Background: Lisa Rosenbaum is the granddaughter of Edward Rosenbaum, a rheumatologist from Portland Oregon who wrote the memoir, "A Taste of My Own Medicine" in 1988. It was made into the movie, The Doctor, starring William Hurt. On a visit to Portland in 1993, I met Ed Rosenbaum and he took me his favorite seafood restaurant. Later we sauntered in the sylvan Washington Park that was across the street from his home, if my memory serves.

Twitter Tailwinds is a reflective piece about some of the simple pleasures and satisfactions that we can partake of, as physicians, from interactions with our patients. Dealing as we do with burn-out, emotional exhaustion, and compassion fatigue, we need to be reminded of the good moments in our professional lives that make it so worthwhile. We all experience flashes of grace with patients but don't often dwell on them. Lisa's reflective piece is a good reminder.

In the dreasy unfathomed caverns of our scientific medical literature, one occasionally stumbles on brilliant gems. Twitter Tailwinds is one.  You can read it full text at this link.

Unseen Flowers in Martha's Williamstown Garden

Children Play on the Seashores of the World

from the Gitanjali, by Rabindranath Tagore

On the seashore of endless worlds children meet.  The infinite

sky is motionless overhead and the restless water is boisterous.

On the seashore of endless worlds the children meet with shouts

and dances.

They build their houses with sand and they play with empty

shells.  With withered leaves they weave their boats and

smilingly float them on the vast deep.  Children have their play

on the seashore of worlds.

They know not how to swim, they know not how to cast nets.  Pearl

fishers dive for pearls, merchants sail in their ships, while

children gather pebbles and scatter them again.  They seek not

for hidden treasures, they know not how to cast nets.

The sea surges up with laughter and pale gleams the smile of the

sea beach.  Death-dealing waves sing meaningless ballads to the

children, even like a mother while rocking her baby's cradle.

The sea plays with children, and pale gleams the smile of the sea

beach.

On the seashore of endless worlds children meet.  Tempest roams

in the pathless sky, ships get wrecked in the trackless water,

death is abroad and children play.  On the seashore of endless

worlds is the great meeting of children.