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I

NEW JERSEY

MEDICINE

'HE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY JANUARY 1990

8MEAL1TH SCIENCES LIBRARf

MEDICATION

ERRORS

Y - O - U - R

PRACTICE

MADE MORE

PERFECT

WITH OVERHEAD EXPENSE INSURANCE FROM BLANKSTEEN

If you get sick, we’d like to help keep your practice well with overhead expense coverage that can reimburse office salaries, rent, insurance premiums, and utilities during an extended disability. Your needs are special, so call and talk with us. The only time to draw a blank in your insurance is when you fill it in with Blanksteen.

The steen Companies

The Blanksteen Companies 253 Washington Street Jersey City, NJ 07302 201-333-4340 1-800-BLANK-AG The Blanksteen Companies 161 William Street New York, NY 10038 212-7 32-9435 1-800-BLANK-AG

The MEDICAL SOCIETY OF NEW JERSEY endorsed plans, including Professional 0'’<“neat* Expenie underwritten by National Casualty Company.

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

27

35

41

Medication trrors:

1977 to 1988

Suzanne L. Kuehm, MPH Michael J, Doyle, MD

The Contemporary Alcoholic

Norman S. Milier, MD MarkS. Gold, MD

Whipple Operation Revisited

David A. Spain, MD Ralph S. Greco, MD

45

47

Thomas Jefferson University:

Tradition and Heritage

Morris H. Saffron, MD

Case Report:

Malignant Fibrous Histiocytoma Induced by Thorium

Mark T. DiMarcangelo, DO Eriberto T. David, MD Koson Kuroda, MD

■ DEPARTMENTS ■

7 Professional Liability

James E. George, MD, JD A. Ronaid Rouse

1 1 MSNJ Newsletter

.j -j President’s Page

' Paul J. Hirsch, MD

ty. | Editor’s Desk

Howard D. Slobodien, MD

25 Book Reviews 61 Continuing Education 66 in Memoriam

The Cover: We review the experience in medical malpractice claims for medication errors in a New Jersey study beginning on page 27.

Cover: Will Harmuth

Wm NOTEBOOK ■

52 Trustees’ Report

53 UMDNJ Notes

54 Annual Meeting Schedule

55 MSNJ Auxiliary

55 AMNJ Update

56 Legislative Bulletin 58 Placement File 68 Editorial Criteria

4

NEW JERSEY MEDICINE

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MIDLANTIC SPECIALIZES IN ONE OF THE MOST CRITICAL AREAS OF YOUR PRACTICE.

Your financial health. Keeping it in tip top condition demands an inordinate amount of time and attention. Yet, because your patients must come first, all too often this im- portant part of your practice suffers. To address this concern Midlantic National Bank/North created the Medical/Dental Banking Group.

As professionals in the field, Midiantic’s Medical/Dental Specialists offer a full range of financial management services. Whether you’re starting a new practice, purchasing an estab- lished one or buying into a group practice, our specialists work with you on an individual basis, every step of the way.

We’ll help secure the loan you need for new equipment, leasehold improvements or for working capital. If you’re just starting out, there’s our “Healthy Start” Cash Flow Man- agement Program— a conveniently scheduled series of one- on-one consultations for optimal financial returns.

For more information and to receive your copy of “A Complete Financial Services Program for Health Care Professionals” call 1-800-633-0400 or (201) 881-5191.

Talk with a Midlantic Medical/Dental Specialist about your unique financial needs. He’ll help put this critical area of your practice in excellent condition.

Member FDIC

Equal Opportunity Lender

Midlantic is a registered service mark of Midlantic Corporation.

Midlantic

Midlantic National Bank/North

Hungry Bankers

VOL. 87— NUMBER 1 JANUARY 1990

3

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

105

108

113

115

Sexual Harassment and Discrimination

Diane K. Shrier, MD

Mesmer and His Critics

Daniel Parish

Spacer-Induced Atrial Fibrillation

Christopher C. Breeden, MD Benjamin H. Safirstein, MD

Medical Waste Regulations

Edward A. Hogan, Esq. Joseph J. McGovern, Esq.

121

127

Cutaneous Malignant Melanoma

Jonathan O. Nwiloh, MD Barry Sussman, MD Rosemary Tambouret, MD Herbert Dardik, MD

Pasteurella Multocida Meningitis

Omar Costa-Cruz, MD Anna Marie Sesso, MD, MPH Shrikrishna Mate, MD Elliot Frank, MD

■ DEPARTMENTS

79 MSNJ Newsletter

85 Professional Liability

James E. George, MD, JD A. Ronald Rouse

NEW JERSEY

medicine

4n*»i'.a

The Cover: Sexual harassment and discrimination are pervasive problems with serious consequences to physical and mental health. Our report begins on page 105. Cover: Frank Cecala

91 President’s Page

Paul J. Hirsch, MD

95 Editor’s Desk

Howard D. Slobodien, MD

99 Book Reviews 101 Letters & Viewpoints 147 In Memoriam

NOTEBOOK
131	Trustees’ Report
132	UMDNJ Notes
132	MSNJ Assessment
135	Placement File
137	Annual Meeting Application
139	Continuing Education
151	Editorial Criteria
153	Classified Advertising

76

NEW JERSEY MEDICINE

■KCI10US WA$n DISPOSAL SOUITIONS FOR

The number one disposal company on the east coast is expanding its fam- ily of infectious waste services to include doctor’s offices and clinics.

BioSystems’ unique disposal service eliminates your infectious waste prob- lems with regularly scheduled pick up and delivery of our own containers by trained and qualified technicians. We’ve designed a full line of rigid and non-rigid containers to handle all of __ your infectious and medical waste.

Just drop it in the box and we’H do the rest. Pick it up, document it, transport it, destroy it and leave you fresh con- tainers at the point of use.

Choose from one of our safe, con-

venient and fully compliant programs that take the worry out of waste dis- posal. All for a fixed monthly rate designed to fit your budget. To help get you started, we’ll visit your facility at no charge, and suggest a plan that suits your needs.

BioSystems is a licensed disposal service now serving over 85 major acute care facilities and over 2500 professional offices and clinics in the eastern U.S. region. All containers are transported in our own locked vehicles. Contents are destroyed utilizing only sound environmental techniques at our own facilities, eliminating the possibili- ties of mishandling by subcontractors.

. To find out more fill out this form and drop it in the mail, or call us at (215) 672-8888.

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NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

187 Grace Under Pressure:

The First Women To Join the County Medical Societies of New Jersey

Geraldine R. Hutner, MA

193	Rebecca Hallowell	213	Ruth Clement	219	Emma Clark
	Atlantic County		Gloucester County		Morris County
195	Caroline Van Horne	214	Florence De Hart	221	Marie Chard
	Bergen County		Hudson County		Ocean County
199	Emma Weeks	oi e	n 1 ■ AN AN f " 1 AN ■» 1 a	223	Ellen Smith
	Burlington County		AIICG 1 3 1* K Hunterdon County		Salem County
201	Sophia Presley			224	Mary Gaston
	Camden County	216	S. Mabel Grier		Somerset County
205	Anna Hand		Mercer County	226	Katherine Stewart
	Cape May County	216	Caroline Marsh		Sussex County
207	Mary Dunlap		Middlesex County	227	Eleanor Galt
	Cumberland County	217	Sarah Mackintosh		Union County
211	Eleanor Haines		Monmouth County	229	Doreen Sheffield
	Essex County		Passaic County		Warren County

DEPARTMENTS ■

163 MSNJ Newsletter

173 Professional Liability

James E. George, MD, JD A. Ronald Rouse

177 President’s Page

Paul J. Hirsch, MD

181 Editor’s Desk

Howard D. Slobodien, MD

185 Book Reviews 245 In Memoriam

mm NOTEBOOK ■■

231 Annual Meeting Application

233 Trustees’ Report

234 UMDNJ Notes

235 MSNJ Auxiliary

235 Annual Meeting Schedule

236 Placement File

238 Continuing Education 247 Editorial Criteria 249 Classified Advertising

160

NEW JERSEY MEDICINE

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NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

291

Long Odyssey of Babesiosis

Sandra W. Moss, MD

297

Cancer Recurrent at Stapled Colon Incision

J. Thomas Davidson, MD Lucius D. Clay, III, MD Michael Umanoff, MD James J. Chandler, MD

305

Clinical Decision Making

Howard Holtz, MD Leonard Bielory, MD Neil Freund, MD Norman Lasker, MD

311

Hazards Smokers Impose

K.H. Ginzel, MD

301 Colonic Lipomas

Geobel A. Marin, MD Gabriele L. Villa, MD

319

Idiopathic Chronic Fatigue

Robert J. Van Amberg, MD

327 Report of the

Nominating Committee

DEPARTMENTS

261	MSNJ Newsletter
269	Professional Liability James E. George, MD, JD A. Ronald Rouse
273	President’s Page Paul J. Hirsch, MD
277	Editor’s Desk Howard D. Slobodien, MD
283	Letters & Viewpoints
287	Book Reviews
345	In Memoriam

We present the detectives who uncovered the clinical and epidemiological features of human babesiosis. The story begins on page 291 . Photography: Stan Godlewski

NOTEBOOK
331	Trustees’ Report
332	UMDNJ Notes
333	MSNJ Auxiliary
334	AMNJ Report
335	Placement File
338	Continuing Education
348	Editorial Criteria
351	Classified Advertising

256

NEW JERSEY MEDICINE

IIWOVATIVE MEDICAL SYSTEMS, IMC.

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THE IMS ADVANTAGE

• IMS has demonstrated its success by INCREASING COLLECTIONS AMD CASH FLOW WHILE ENHANCING THE PHYSICIAN'S PROFESSIONAL IMAGE

• IMS is a fully BONDED ORGANIZATION OF MEDICAL MANAGEMENT SPECIALISTS with over 15 years experience in practice management.

FOR INFORMATION CONTACT: 609-770-1160

GLEHDALE EXECUTIVE CAMPUS • 1000 WHITE HORSE ROAD SUITE 512 • VOORHEES, HEW JERSEY, 08043

VOL. 87— NUMBER 4 APRIL 1990

255

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

393

Medical Malpractice Claims in Cardiology

Suzanne L. Kuehm, MPH Emanuel Abraham, MD

413

Tuberculosis, AIDS, and IV Drug Abuse

R.J. Lamb, PhD I -Tien Yeh, MD

401

Malignant Melanoma of the Skin

Kristen Mertz, MD Henry C. Lewis, Jr, MPH Lawrence A. Meinert, MD, MPH

41 7 MinoritV Health Status

in New Jersey

George Hampton Douglas H. Morgan Billie Slaughter, PhD

409

Luetic Aortic Aneurysm

Jock N. McCullough, MD Ronald M. Abel, MD

421

Professional Medical Conduct Reform Bill

Michael B. Grossman, DO

DEPARTMENTS

365	Professional Liability James E. George, MD, JD A. Ronald Rouse
369	MSNJ Newsletter
379	President’s Page Paul J. Hirsch, MD
381	Editor’s Desk Howard D. Slobodien, MD
385	Book Reviews
389	Letters & Viewpoints
433	In Memoriam

NEW JERSEY MEDICINE	To decrease patient injury and lower the incidence of
	malpractice suits, MIIENJ
	analyzed data from its files
	The story begins on page
	393.
m	Cover: Will Harmuth
• IttUWCnCE OJWS M CAffltCtOGY

NOTEBOOK
423	Trustees’ Report
424	UMDNJ Notes
425	MSNJ Auxiliary
426	New Members
427	Placement File
429	Continuing Education
435	Editorial Criteria
437	Classified Advertising

360

NEW JERSEY MEDICINE

atUSAA

When you compare auto or homeowners insurance, look at all the variables.

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SELECT, ECONOMICAL

Because of your military affiliation, you may be eligible to join USAA — a very select group. We take pride in knowing that the members we serve (current and former commissioned and warrant officers in the U.S. armed forces) are responsible and mature drivers and property owners.

Because of the Association's selectivity, our insurance rates are highly competitive, highly desirable. But favorable rates are just a part of the USAA story.

We offer safe driver dividends, multiple car and carpooler discounts.* When you protect your new home

with USAA coverage, you can save up to 20%. And save even more by installing an approved fire and burglar protection system.

When you insure with USAA, you become an owner of the Association. And, down the road, you'll share in the company's profits through the Subscriber's Savings Account.

TOPS IN SERVICE

Our economical coverage may bring you to us, but our service will

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INSURANCE AND OTHER FINANCIAL SERVICES

USAA — a unique company which offers you more than auto and homeowners protection. One call can connect you to our experts in life and health insurance, mutual funds, banking services, travel, buying services. A one-stop approach to meet your special needs, designed to SAVE YOU TIME AND MONEY.

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'Safe driver dividends are no I available in California.

Those eligible for USAA membership include anyone who is now or ever has been an officer in the U.S. military. In addition, cadets/midshipmen of the U.S. military academies,

OCS/OTS candidates, ROTC cadets under government contract, and other candidates for commission are also eligible to apply for membership

VOL. 87— NUMBER 5 MAY 1990

359

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

471 Inaugural Address

Douglas M. Costabile, MD

47C Panic Disorder & Agoraphobia

Morton Fier, MD

A7 Q Claustrophobia During ^ ^ MR Imaging

Roger B. Granet, MD Lawrence J. Gelber, MD

485 Cancer in

Inguinal Hernias

James W. Knecht, MD

488 Radiol°gy Rounds: Cystic

James H. Jacoby, MD

489 Marketing the ** Technologist in the Physician Office Laboratory

Kathleen L. Voldish, CLA

400 Contraceptive Use for Planned Parenthood Patients

Lewis E. Savel, MD

496 A Successful Partnership

Stephanie Lichtman, MPA Joseph Gorrell, JD

Right Upper Quadrant Mass

DEPARTMENTS

449 MSNJ Newsletter

455 Professional Liability

James E. George, MD, JD A. Ronald Rouse

459 Editor’s Desk

Howard D. Slobodien, MD

Douglas M. Costabile, MD, is the 198th president of the Medical Society of New Jersey.

NOTEBOOK

463 Book Reviews

467 Letters & Viewpoints

500 Golden Merit Award Recipients

508 In Memoriam

502 Trustees’ Report

503 UMDNJ Notes

504 MSNJ Auxiliary 504 Placement File

507 Continuing Education 509 Editorial Criteria 513 Classified Advertising

444

NEW JERSEY MEDICINE

Magnetic Resonance Imaging

(609) 983-5599

(within 24 hours, off sii

An Affiliate of NMR of America, Inc.

TO OBTAIN MORE INFORMATION ABOUT MAGNETIC RESONANCE (MRI)

Name _ Address

Send Me:

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MRI Case Study Information

Scheduling

Information

NMR of America

Attn: Physician Outreach Dept. 355 Madison Avenue Morristown, NJ 07960

Phone

Other (Specify) Or Call:

(201) 539-1082

VOL. 87— NUMBER 6 JUNE 1990

443

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

541	Lyme Disease: Prevention and Control Anita S. Curran, MD, MPH	563	Neurological Manifestations of Lyme Disease Andrew R. Pachner, MD
544	Psychological Impact of Media Coverage Mary E. Swigar, MD	567	Immunology of Lyme Disease Leonard H. Sigal, MD
549	Clinical Manifestations of Lyme Disease Leonard H. Sigal, MD	573	Lyme Disease in Small Animals Barry A. Lissman, DVM
557	Lyme Disease During Pregnancy Sandra J. Edly, MD	575	Lyme Disease in Large Animals John E. Post, DVM, PhD

cyq Lyme Disease in New Jersey

*** ^ Marcia J. Goldoft, MD, MPH; Terry L. Schulze, PhD;

William E. Parkin, DVM, DrPh; Robert A. Gunn, MD, MPH

DEPARTMENTS

525 MSNJ Newsletter

531 Professional Liability

James E. George, MD, JD A. Ronald Rouse

535 Editor’s Desk

Howard D. Slobodien, MD

537 Book Reviews

539 Special Issue: Lyme Disease in New Jersey

589 Continuing Education

593 In Memoriam

Highlights from a two-day symposium on Lyme disease are presented in this special issue, to help readers explore the disease.

Cover: Frank Cecala

NOTEBOOK
585	UMDNJ Notes
586	MSNJ Auxiliary
587	Interest Charges
587	Placement File
591	Lyme Disease Issue
595	Editorial Criteria
597	Classified Advertising

520

NEW JERSEY MEDICINE

Short cuts and quick fixes can compromise your staff’s safety, your practice’s reputation, and expose you to stiff non- compliance tines. . . or worse. MSD’s Full Cycle Solution is practice-tailored for utmost safety, compliance, and economy with . . . on-call service visits, complete handling, NJDEP docu mentation, incineration, computer monitoring ... and regular, year-to-date DEP-oriented reports . . . made directly to you.

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Phone (201) 757-4414,	IBB
(800) 548-9789,
FAX (201) 561-7319

VOL. 87— NUMBER 7 JULY 1990

519

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

631

637

641

Tracheal Stenosis

Jean-Philippe Bocage, MD Robert Caccavale, MD Ralph Lewis, MD Glenn Sisler, MD James MacKenzie, MD

Kallmann’s Syndrome: Reproductive Success

Michael Goldman, MD Albert Riddle, MD Eugene Markham, MD

Clinical

Decision Making Howard Holtz, MD Robert Restifo, DO

648

Thrombolytic Therapy

Nicholas J. Schneeman, MD Elliott M. Stein, MD

651

653

674

Pelvic Papillary Neoplasia Along the Round Ligament Simulating Inguinal Hernia

Bernard Peison, MD Barry Benisch, MD Anthony Tonzola, MD

Radiology Rounds:

Calcified Liver Lesions

James H. Jacoby, MD Francis X. O’Brien, MD

Pneumothorax: Complication of Needle EMG of Thoracic Wall

Jeffrey Miller, DO

1990 Transactions of the Medical Society of New Jersey

DEPARTMENTS

607 MSNJ Newsletter

615 Professional Liability

James E. George, MD, JD A. Ronald Rouse

619 Editor’s Desk

Howard D. Slobodien, MD

623 Book Reviews 627 Letters & Viewpoints 661 Continuing Education 667 MSNJ Annual Meeting

NEW JERSEY

MwSc* Soc«x> 1990 Tran

We present the reports and the actions of the 1 990 Medical Society of New Jersey Annual Meeting. Cover: Jean Hough

NOTEBOOK

655 Trustees’ Minutes 658 UMDNJ Notes

658 New Members

659 Placement File

659 Lyme Disease Issue Update 673 Editorial Criteria 675 Classified Advertising

604

NEW JERSEY MEDICINE

atUSAA

When you compare auto or homeowners insurance, look at all the variables.

Do you get the kind of service you deserve? Are your insurance rates competitive? Do you earn dividends? Do you share in the company's profits?

At USAA, the bottom line is VALUE. You save both time and money when you insure with us. Here's why.

SELECT, ECONOMICAL

Because of your military affiliation, you may be eligible to join USAA — a very select group. We take pride in knowing that the members we serve (current and former commissioned and warrant officers in the U.S. armed forces) are responsible and mature drivers and property owners.

Because of the Association's selectivity, our insurance rates are highly competitive, highly desirable. But favorable rates are just a part of the USAA story.

We offer safe driver dividends, multiple car and carpooler discounts.* When you protect your new home

with USAA coverage, you can save up to 20%. And save even more by installing an approved fire and burglar protection system.

When you insure with USAA, you become an owner of the Association. And, down the road, you'll share in the company's profits through the Subscriber's Savings Account.

TOPS IN SERVICE

Our economical coverage may bring you to us, but our service will

USAA

keep you with us. Speedy policy and claims service is bottom line. Just ask your friends who are already USAA members. And, we're always just a phone call away.

INSURANCE AND OTHER FINANCIAL SERVICES

USAA — a unique company which offers you more than auto and homeowners protection. One call can connect you to our experts in life and health insurance, mutual funds, banking services, travel, buying services. A one-stop approach to meet your special needs, designed to SAVE YOU TIME AND MONEY.

ONE FREE CALL

You'll find out why 9 out of 10 active duty military officers save time and money with USAA. Request a free auto or homeowners insurance rate quote. There's no obligation. Then consider the "big picture." We think you'll save with USAA. Call us today.

1-800-531-8185

'Safe driver dividends are not available in California.

Those eligible for USAA membership include anyone who is now or ever has been an officer in the U.S. military. In addition, cadets/midshipmen of the U.S military academies,

OCS/OTS candidates, ROTC cadets under government contract, and other candidates for commission are also eligible to apply for membership

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW |ERSEY

CONTRIBUTIONS

703

Pediatric Cancer Mortality Rates

Dona Schneider, PhD Michael R. Greenberg, PhD Bonnie Stach, MCRP

723 physicians’

Office Laboratories

Kathleen L. Voldish, CLA (ASCP)

71 *5 Intussusception in f Childhood

Irwin H. Krasna, MD Bonna G. Benjamin, MD Jeffrey L. Zitsman, MD David Rosenfeld, MD

727

Focal Candida Hepatitis in a Patient with Richter’s Syndrome

J.G. Barone, MD C.A. Abouchedid, MD R.L. Moser, MD

731 Polyposis Coli and Gardner’s Syndrome

W. Mark Nannery, MD Joseph G. Barone, MD Claude Abouchedid, MD

DEPARTMENTS

685 Professional Liability

James E. George, MD, JD A. Ronald Rouse

689 MSNJ Newsletter

695 Editor’s Desk

Howard D. Slobodien, MD

699 Book Reviews 739 Continuing Education 747 In Memoriam

NEW JERSEY MEDICINE

Our report on pediatric cancer mortality rates for the 25-year study period begins on page 703. Cover: Will Harmuth

NOTEBOOK
735	Trustees’ Minutes
736	MSNJ Auxiliary
737	AMNJ Report
737	Placement File
743	Special Issue Orders
751	Editorial Criteria
756	Classified Advertising

682

NEW JERSEY MEDICINE

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W. ORANGE, NJ 07052

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SPECIALISTS IN PHYSICIAN BILLING SERVICES AND CREDIT AND COLLECTIONS

SERVICES PROVIDED

H Professional management of acocunts receivable, including the handling of all patient level inquiries (written and by telephone) and the resulting follow-up activities.

■ Specific knowledge of reimbursement issues in the local market area.

■ Tape-to-tape billing submitted to third party for improved cash flow, accuracy, speed and control.

■ Flexible approaches to data collection using hospital data through electronic media inter- faces; and/or off-site paper data entry.

COMPREHENSIVE BILLING SERVICES

□ We utilize tape-to-tape interface to submit weekly claims to Medicare, Medicaid and other insurance carriers.

■ We perform all residual billing.

■ We provide crossover billing to Medicaid from Medicare.

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CREDIT AND COLLECTIONS

Prime Mark Corporation provides a complete range of collections services, individually tailored to the needs of our clients. We have a proven track record in successfully resolving delinquent accounts while maintaining the highest levels of professionalism.

Our automated collection system produces a complete selection of management reports which enable clients to monitor our performance on a monthly basis.

■ Acknowledgements — all new accounts SI Monthly remittance reports

■ Trial balances of open accounts US Deletion reports

Prime Mark is a member of Healthcare Financial Association, New Jersey Patient Accounts Managers Association, and the New Jersey Hospital Association.

Prime Mark is incorporated in the state of New Jersey as a collection agency.

To find out more about how Prime Mark can improve your billing and/or bad debt collections call Joseph W. Delaney at 201-669-8987.

VOL. 87— NUMBER 9 SEPTEMBER 1990

681

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

803

785 health Access New Jersey

Position Paper of the Medical Society of New Jersey

701 *-e9a* Implications of

Routine Screening for Asymptomatic Silent Myocardial Ischemia

Leon G. Smith, MD Richard E. Brennan, ESQ Kathleen H. Dooley, ESQ

795 Carotid Endarterectomy Under Local Anesthesia

Kenneth S. Fried, MD Steven M. Elias, MD Robert Raggi, MD

799 Maintaining an

Office Laboratory

Kathleen L. Voldish, CLA (ASCP)

811

Carcinoma of the Male Breast

Jeffery W. Seitzinger, MD

Squamous Cell Cancer of the Larynx in an IV Drug User with AIDS

J.G. Barone, MD D. Hutchinson, MD A.L. Cuppari, MD J.E. Barone, MD

81 5 Parathyroid Adenoma

Michael H. Goldman, MD Arati Suresh, MD

819

Medical Services for the Developmentally Disabled

Ted Kasiner, MD Joan Luckhardt, PhD

DEPARTMENTS

767 MSNJ Newsletter

773 Professional Liability

James E. George, MD, JD A. Ronald Rouse

777 Editor’s Desk

Howard D. Slobodien, MD

781 Book Reviews 827 Continuing Education 833 In Memoriam

NEW JERSEY

Health Access New Jersey

The Medical Society of New Jersey offers proposals to strengthen the New Jersey health care system. The position paper begins on page 785.

Cover: Frank Cecala

NOTEBOOK
760	MSNJ Officers/Trustees
824	UMDNJ Notes
825	MSNJ Auxiliary
825	Placement File
835	Editorial Criteria
839	Classified Advertising

762

NEW JERSEY MEDICINE

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MIDLANTIC SPECIALIZES IN ONE OF THE MOST CRITICAL AREAS OF YOUR PRACTICE.

Your financial health. Keeping it in tip top condition demands an inordinate amount of time and attention. Yet, because your patients must come first, all too often this im- portant part of your practice suffers. To address this concern Midlantic National Bank/North created the Medical/Dental Banking Group.

As professionals in the field, Midiantic’s Medical/Dental Specialists offer a full range of financial management services. Whether you’re starting a new practice, purchasing an estab- lished one or buying into a group practice, our specialists work with you on an individual basis, every step of the way.

We’ll help secure the loan you need for new equipment, leasehold improvements or for working capital. If you’re just starting out, there’s our “Healthy Start” Cash Flow Man- agement Program— a conveniently scheduled series of one- on-one consultations for optimal financial returns.

To discuss your unique financial needs and to receive your copy of “A Complete Financial Services Program for Health Care Professionals” call Midiantic’s Patrick Robin- son, Vice President, Group Manager at 1-800-633-0040 or (201) 881-5191. He’ll help put this critical area of your prac- tice in excellent condition.

Member FDIC

Equal Opportunity Lender

Midlantic is a registered service mark of Midlantic Corporation.

Midlantic

Midlantic National Bank/North

Hungry Bankers

VOL. 87— NUMBER 10 OCTOBER 1990

761

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY

CONTRIBUTIONS

871

873

881

889

895

901

Medical Research in New Jersey

Alan J. Lippman, MD, Guest Editor

Innovative Methods of Cardiac Defibrillation

Lawrence J. Gessman, MD

Laser Energy for Tachycardia Ablation

Sanjeev Saksena, MD

Cancer Research in New Jersey

Ann Marie Hill; Frederick B. Cohen, MD

Biologic Therapy of Cancer

Alan W. Dunton, MD; John Hanagan, MD; Daniel Levitt, MD, PhD;

Robert J. Spiegel, MD; Jacob Zeffren, MD

Responsible Weight Loss in New Jersey

Marvin A. Kirschner, MD;

George Schneider, MD;

Norman Ertel, MD; Anton Heins, III, MD; Patricia McAleavy, MSW;

Maryann Merrell, RD

907 Research in Sleep Medicine

Jeffrey Nahmias, MD; Monroe Karetzky, MD

913

Monoclonal Antibody Therapy of Cancer

David M. Goldenberg, ScD, MD;

Robert M. Sharkey, PhD;

Hildegard Goldenberg, MD;

Thomas C. Hall, MD; Sumathi Murthy, MD; Daniel 0. Izon, MD; Pedro Gascon, MD; Lawrence C. Swayne, MD

919 Nuclear Cardiology; Perfusion,

Viability, and Function

Margaret LaManna, MD

923 Vascular Surgery and Cardiac Pacing

David E. Eisenbud, MD

927 New Jersey Pediatric Hematology Oncology

Milton H. Donaldson, MD

931 Surfactant Replacement Therapy

Jeffrey R. Greenwald, MD;

I. Mark Hiatt, MD;

Thomas Hegyi, MD

DEPARTMENTS

851	MSNJ Newsletter
857	Professional Liability James E. George, MD, JD A. Ronald Rouse
861	Editor's Desk Howard D. Slobodien, MD
865	Book Reviews
938	Statement of Ownership
941	Quality of Life and Health Theresa H. Hauber, MPH
944	Annual Meeting Application
946	Continuing Education
952	In Memoriam

NEW jEi^ftL

MEDICINE

R

This special issue focuses attention on medical research in New Jersey, and the far-reaching effects of such progress.

Cover: Jean Hough

NOTEBOOK
939	Trustees’ Report
940	UMDNJ Notes
941	MSNJ Auxiliary
942	MSNJ Directory
942	Placement File
943	Annual Meeting Schedule
957	Classified Advertising
954	Editorial Criteria

846

NEW JERSEY MEDICINE

may be bronchitis

Brief Summary.

Consult tta package literature for prescribing information. Indication: Lower respiratory infections, including pneumonia, caused by Streptococcus pneumoniae, Haemo0ilus influenzae, and Streptococcus pyogenes (group A p-hemolytlc streptococci!.

Contraindication: Known allergy to cephalosporins. Warnings: CECLOR SHOULD BE ADMINISTERED CAUTIOUSLY TO PENICILLIN-SENSITIVE PATIENTS. PENICILLINS AND CEPHALOSPORINS SHOW PARTIAL CROSS-ALLERGENICITY. POSSIBLE REACTIONS INCLUDE ANAPHYLAXIS.

Administer cautiously to allergic patients. Pseudomembranous colitis has been reported with virtually alt broad-spectrum antibiotics. It must be con- sidered In differential diagnosis of antibiotic-associated diarrhea. Colon flora is altered by broad-spectrum antibiotic treatment, possibly resulting in antibiotic- associated colitis.

Precautions:

• Discontinue Ceclor m the event of allergic reactions to it.

• Prolonged use may result in overgrowth of non- susceptible organisms.

• Positive direct Coombs’ tests have been reported during treatment with cephalosporins.

■ Ceclor should be administered with caution In the presence ot markedly impaired renal function. Although dosage adjustments in moderate to severe renal Impairment are usually not required, careful clinical observation and laboratory studies should be made.

• Broad-spectrum antibiotics should be prescribed with caution in individuals with a history of gastrointestinal disease, particularly colitis.

• Safety and effectiveness have not been determined In pregnancy, lactation, and infants less than one month old. Ceclor penetrates mother's milk. Exercise caution in prescribing for these patients.

Adverse Reactions: (percentage of patients) Therapy-related adverse reactions are uncommon. Those reported include:

• Hypersensitivity reactions have been reported in about 1.5% of patients and include morbilliform eruptions (1 in 100). Pruritus, urticaria, and positive Coombs’ tests each occur hi less than 1 in 200 patients. Cases of serum-sickness-llke reactions have been reported with the use of Ceclor. These are characterized by (hidings of erythema multitorme, rabies, and other skin manifestations accompanied by aithritis/arttiralgia, with of without fever, and differ from classic serum sickness

and proteinuria, no circulating immune complexes, and no evidence to date of sequelae of the reaction. While further investigation is ongoing, serum- sickness-itke reactions appear to be due to hypersensitivity and more often occur during or following a second (or subsequent! course of therapy with Ceclor. Such reactions have been reported more frequently m children than in adults with an overall occurrence ranging from 1 in 200 (0.5%) in one focused trial to 2 in 8,346 (0.024%) in overall clinical trials (with an incidence in children in clinical trials of 0.055%) to 1 in 38,000 (0.003%) in spon- taneous event reports. Signs and symptoms usually occur a few days after initiation of therapy and subside within a few days after cessation of therapy; occasion- ally these reactions have resulted In hospitalization, usually of short duration (median hospitalization = two to three days, based on postmarketing surveillance studies). In those requiring hospitalization, the symp- toms have ranged from mild to severe at the time of admission with more of the severe reactions occurring In children. Antihistamines and glucocorticoids appear to enhance resolution of the signs and symptoms. No serious sequelae have been reported.

• Stevens-Jobnson syndrome, toxic epidermal necrolysis,

and anaphylaxis have been reported rarely. Anaphylaxis may be more common in patterns with a history of penicillin allergy.

• Gastrointestinal (mostly diarrhea): 2.5%

• Symptoms of pseudomembranous colitis may appear either during or after antibiotic treatment.

• As with some penicillins and some other cephalo- sporins. transient hepatitis and cholestatic jaundice have been reported rarely.

• Rarely, reversible hyperactivity, nervousness, insomnia, confusion, hypertonia, dizziness, and somnolence have

■ Other: eosinophitia, 2%; genital pruritus or vagfnttis, less than 1% and, rarely, thrombocytopenia and reversible interstitial nephritis.

Abnormalities m laboratory results of uncertain etiology.

• Slight elevations in hepatic enzymes.

• Transient lymphocytosis, leukopenia, and. rarely, hemolytic anemia and reversible neutropenia.

• Rare reports of increased prothrombin time with or without clinical bleeding in patients receiving Cedar and Coumadin concomitantly.

• Abnormal urinalysis; elevations in BUN or serum creatinine.

• Positive direct Coombs' test

• False-positive tests for urinary glucose with Benedict's or Fehling’s solution and CIfnitest* tablets but not with Tes-Tape* (glucose enzymatic test strip, Lilly).

PA 8791 AMP (021490 lf8)

Additional information available to the profession on reguest from Eli Lilly and Company, Indianapolis, Indiana 46285.

EH Lilly Industries, Inc Carolina, Puerto Rico 00630 A Subsidiary of Ell Lilly and Company Indianapolis, Indiana 46285

CR-0525-B-049333 © 1990, EU LILLY AM COMPANY

“Recent research has delineated early, more subtle changes in lung and immune functions. These alterations directly predispose smokers to respiratory tract infection.”

Am Fam Phys 1987;36:133 140

Established therapy for today’s patients

For respiratory tract Infections due to susceptible strains of indicated organisms

VOL. 87— NUMBER 11 NOVEMBER 1990

845

II

NEW JERSEY

MEDICINE

THE JOURNAL OF THE MEDICAL SOCIETY OF NEW |ERSEY

CONTRIBUTIONS

983

Professional Review and Regulations

James E. George, MD, JD Madelyn S. Quattrone, JD Joann Phillips, CMSC

1005

QQQ Professional Medical Conduct Reform Act

995

1001

Sean Patrick Murphy, JD

Maternal Deaths in New Jersey: 1988

Gerard F. Hansen, MD, MPH Ronald A. Chez, MD

Crack-Induced Enteric Ischemia

David C. Hon, MD Leslie J. Salloum, MD Howard W. Hardy, III, MD James E. Barone, MD

1009

1011

Noninvasive Diagnosis of Deep Vein Thrombosis

Edward G. Moss, MD James Alexander, MD

Profiles in Medicine: Nicholas A. Bertha, MD

Nancy M. Propsner

Antisense DNA- Analogs: Inhibition of Human Immuno- deficiency Virus

Yon Ebright, PhD Karel Raska, Jr, MD Sunanda Gaur, MD Lawrence Frenkel, MD Jonglin Tsao Stanley Stein, PhD

1045

1990 NEW JERSEY MEDICINE Index

DEPARTMENTS

965 MSNJ Newsletter

971 Professional Liability

James E. George, MD, JD A. Ronald Rouse

UTaTT

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V JERSEY MEDICINE 19»

The 1990 year-end index is included in this issue of NEW JERSEY MEDICINE, beginning on page 1045. The journal also is abstracted in Index Medicus.

975 Editor’s Desk

Howard D. Slobodien, MD

979 Book Reviews 1016 Committees & Councils 1023 Liaison Representatives

NOTEBOOK
1029	Trustees’ Minutes
1030	UMDNJ Notes
1031	Presidential Address
1033	New Members
1034	Placement File
1037	Continuing Education
1042	In Memoriam
1044	Editorial Criteria

962

NEW JERSEY MEDICINE

The Committee on Publication, the Editorial Board, and the Staff of the award-winning NEW JERSEY MEDICINE

would like to thank all our readers and advertisers for a successful 1 990.

w a,

\J'0'yC'U4' $€6404*

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VOL. 87— NUMBER 12 DECEMBER 1990

961

MERIN ADOPTS MALPRACTICE SURCHARGE

In an effort to address a $65 million deficit and to cover-up ineffective regulatory action and negligent management, Insurance Commissioner Kenneth Merin announced the adoption of his ill-advised medical malpractice surcharge proposal.

The Medical Society of New Jersey (MSNJ) and the Medical Inter-Insurance Exchange of New Jersey (MIIENJ) have filed suits in the appellate division of the Superior Court contesting Merin' s decision. Another MSNJ suit to require Merin to proceed against the Property-Liability Guaranty Association has been appealed to the appellate division and will be consolidated with the other suits.

Neither the New Jersey Hospital Association nor the Princeton Insurance Company is objecting to the surcharge .

MSNJ believes this protracted and bitter litigation ultimately will be decided by the State Supreme Court .

MEDICAL WASTE BILL AWAITS ACTION BY GOVERNOR

A new medical waste bill has been passed by both the Assembly and the Senate. It provides for a much lower fee schedule. Generators with under 50 pounds per year would pay $100. Further, under its regulation, the Department of Environmental Protection is required to make refunds of fees collected which exceed that amount.

MEDICAL LICENSING REFORM

S-2936 has passed both the Senate and the Assembly and awaits the governor's signature. This bill reforms the medical licensing and discipline system in New Jersey. It assures patients that physicians with impairments are not a risk to the public health while providing an unbiased and fundamentally fair review process for doctors.

in

.

'

PROFESSIONAL

LIABILITY

HOW TO CONDUCT PEER REVIEW

RULE 1

RULE 2

RULE 3

RULE 4

RULE 5 RULE 6

RULE 7

Comprehensive guidelines for the conduct of peer review are contained in the Health Care Quality Improvement Act of 1986. It is not necessary to follow those guidelines to the letter in order to have fair procedures. The guidelines provide a good framework. In general, hospitals, medical staffs, and peer reviewers should observe the following guidelines:

In any situation where it appears that a disciplinary proceeding may be instigated against a physician that could result in the substantial loss or termination of the physician’s clinic privileges, the advice and guid- ance of legal counsel should be sought by those persons who are involved in this phase of the peer review process. The attorney’s participation should continue in preparation for the hearing including the written notice of charges, the marshalling of evidence and the facts, and the selection of witnesses. The attorney should be instructed that his role is not that of a prosecutor, but as an advisor in assuring that the proceedings are conducted fairly, bearing in mind the objective of protecting consumers of health care and the physician involved against false or exaggerated charges.

The attorney advising the hearing panel and the attorney representing the physician involved in the proceeding should be accorded reasonable latitude in cross-examination, but acrimony should not be allowed by the hearing panel.

Substantial latitude should be permitted in the presentation of evidence, medical reference works, and testimony, within reasonable time con- straints and the discretion of the hearing panel.

A court reporter should be present to make a verbatim transcript of the hearing that should be available to the parties and paid for by the hospital or health care entity.

Within the discretion of the hearing panel, witnesses may be requested to testify under oath.

The hearing panel should consist of physicians, none of whom are direct economic competitors with the physician involved or who stand to gain through a recommendation or decision adverse to the physician. It is desirable that members of the hearing panel be physicians who have the respect of the medical community, but they need not be in the same specialty as the physician involved.

Physicians who are direct economic competitors of the physician in- volved may testify as witnesses whether they are called by the physician, the hearing panel, or the hospital, but a physician should not be deprived of his privileges solely on the basis of medical testimony by economic competitors. In any proceedings that result in the termination of privi- leges, there should be testimony from one or more physicians who are not economic competitors or who do not stand to gain economically by

VOL. 87— NUMBER 1 JANUARY 1990

7

RULE 8	an adverse action, but who are knowledgeable in the treatment, patient care management, and areas of medical practice or judgment upon which the adverse action is based. When investigation indicates that a disciplinary proceeding is warranted for the purpose of terminating a physician’s hospital privileges, he should not be permitted to resign without a finding that his termination oc- curred without cause. The disciplinary proceedings should be conducted by the hearing panel with the presentation of testimony and evidence, irrespective of whether the physician involved chooses not to be present. (Reprinted with permission from The Citation, American Medical Association, Volume 59, July 15, 1989)
HEDONIC DAMAGES CONCEPT GROWING	Hedonic damages, or the loss of pleasure derived from the pursuits of life, appear to be on the increase. That is the conclusion reached by Ted Miller, an economist at the Urban Institute, a Washington, DC, think tank, in a forthcoming study to be published this fall by the North- western University Law Review. According to Wall Street Journal columnist Paul M. Barret, Miller’s study shows that “despite fierce opposition by defense lawyers, the idea is quickly gaining acceptance.” As of early July, courts in Connecticut, Mississippi, New Mexico, and New York had accepted hedonic damages, and lawyers have introduced such damages with varying degrees of success in cases in an additional 27 states. Properly “fine-tuned,” the economist warns that hedonic damages could yield a value between $1 and $1.5 million for a person 38 years of age. The problem is that “some overly high awards” could result, posing a lot of headaches for the insurance industry and defense attorneys. Miller’s advice is to accept hedonic damages as a legitimate measure, but learn to fight for their appropriate application. ( Medical Liability Monitor, September 29, 1989)
JUDGES GET SUED TODAY	Judges, whose immunity against liability actions has been diminished by recent court decisions, are increasingly buying protection, according to a recent Wall Street Journal article. “Judges are sued far more often than the public would believe,” said Kent Batty, court administrator for the state courts in Wayne County, Michigan. “And for the past few years, there has been a mounting concern over liability.” Judge Phillip J. Roth of the Oregon Supreme Court said, “Judges realize now that one moment they can be on the bench and the next, they are in the pit being defended.” Judge Roth, chairman of the Judicial Im- munity Committee of the American Bar Association, stated at least 800 suits are filed against judges each year. One insurance broker estimates that about 3,000 state judges and 300 federal now carry liability policies. ( Medical Liability Monitor, August 25, 1989)
PROFESSIONAL LIABILITY	James E. George, MD, JD, is the director of the Department of Pro- fessional Liability Control, Medical Society of New Jersey. If you have any questions, concerns, or complaints about your professional liability, please contact A. Ronald Rouse, director of Special Projects, Medical Society of New Jersey, Two Princess Road, Lawrenceville, NJ.

8

NEW JERSEY MEDICINE

MSNJ

NEWSLETTER

1989 MEDICARE The Hospital Rate-Setting Commission (HRSC) approved the revised COST SHIFT Medicare Cost Shift methodology for 1989 at its October 27, 1989, meet- APPROVED revised statewide Medicare shortfall now is estimated by the

Department of Health to be approximately $116 million, up from the previous estimate of $34 million. Approximately 70 percent of Chapter 83 hospitals are expected to have a shortfall of Medicare payments in 1989. The Department anticipates incorporating the new cost shift amounts into hospital November markup factors. In order to mitigate the impact of wide changes in markup factors as a result of the an- nualization of these cost shifts over the last two months of 1989, the Department will adjust the markup factors based on a corridor policy that also was approved by HRSC.

NEW DIRECTOR The Department of Health announced that Anne Weiss has been ap- OF HOSPITAL P°inted as the director of hospital reimbursement at the Department REIMBURSEMENT health. The appointment became effective as of October 16, 1989.

Ms. Weiss’s background includes working on the professional staff of the U.S. Senate Committee on Finance and experience with the federal Office of Management and Budget and the federal Medicare system. The position of director of hospital reimbursement has been vacant since the resignation of Alan Rosenberg in April 1989.

The New Jersey Department of Health has announced the establishment of a State Cholesterol Standardization Program. Funds have been provided by the Department to the Robert Wood Johnson School of Medicine in New Brunswick to develop and implement a statewide standardization program. The purpose of the program is to help the state’s licensed clinical laboratories meet the National Institute of Health’s recommended levels of precision and accuracy reporting cholesterol test results. All licensed clinical laboratories in New Jersey are invited to participate in the program. One outcome of the program will be the publishing of a directory of the standardization laboratories by the New Jersey affiliate of the American Heart Association and the Robert Wood Johnson School of Medicine. Interested parties should contact the Department of Health for more information.

The Health Care Administration Board (HCAB) adopted the Depart- ment of Health’s amendments to the Uncompensated Care Credit and Collection Regulations, with some modifications, at its November 9 meeting. The dollar threshold for compliance was raised from $150 to $200 and the requirement of using a two-color envelope was removed. The language of the regulation was changed to remove the requirement of deferring medical services. However, if hospitals cannot obtain com- plete information from the patient, they must document why the infor- mation was not obtained.

The Department indicated that it will develop flexible audit guidelines. The audit guidelines must be presented to the Hospital Rate-Setting

UNCOMPENSATED CARE REGULATION APPROVED

CHOLESTEROL

STANDARDIZATION

PROGRAM

VOL. 87— NUMBER 1 JANUARY 1990

11

MSNJ NEWSLETTER

	Commission for final approval. The HCAB also requested the Depart- ment to provide a cost/benefit analysis of the new Uncompensated Care Credit and Collection Regulations.
HOSPITAL PROFILES REQUIRED BY HRSC	The Hospital Rate-Setting Commission (HRSC) has notified all hospi- tals that an updated hospital profile must be submitted before action will be taken on a hospital’s schedule of rates. The profile includes historical information through 1988 on statistical items such as ad- missions, patient days, payer mix, uncompensated care, charity care, same-day surgery cases, and other outpatient data. HRSC sends a copy of the hospital’s most current profile to the hospital when a meeting date has been assigned and requests the hospital to review the data and correct and update it as necessary.
NURSING	The Department of Health has completed its review of 71 hospital

AWARDS proposals for the nursing incentive reimbursement awards. The Depart- ment awarded a total of $7.1 million to 23 hospitals. Awards ranged from

	$126,000 to $500,000 for individual hospitals. Areas in the approved proposals included management computers, bedside computers, staff training, other equipment, and organizational restructuring. The De- partment will recommend 1990 rate increases for the 23 hospitals to the Hospital Rate-Setting Commission. The Department also will rec- ommend a monitoring and evaluation component to assure that funds are spent in accordance with the approved proposals. Department staff will be involved in the monitoring activities.
GME LIABILITY	The final published Medicare regulations on medical education pro- grams cite that the Medicare program is due approximately $440 million in overpayments. Until now, the medical education methodology reim- bursed hospitals for all residency programs based on reasonable costs. Now, a hospital will be reimbursed for allowable medical education costs divided by the number of interns and residents, which then will be multiplied by the weighted average number of FTE residents during the period and adjusted for inflation by using the consumer price index in each consecutive year after the base period. The base period utilized will begin on or after October 1, 1983, and end before October 1, 1984. The new methodology will have a substantial impact on teaching hospi- tals since the cost received under the previous methodology has long been spent. In addition, many hospitals will have to revise their 1990 budgets to reflect the change. It is anticipated that more than 50 percent of the hospitals effected will be filing an initial appeal challenging the constitu- tionality of the retroactive rule. Once the liability has been determined by Medicare intermediaries, hospitals will have 180 days to appeal the decision or pay their liability.
SUMMER RESEARCH FELLOWSHIP	The M. Louise Carpenter Gloeckner, MD, Summer Research Fellowship Award Committee of the Archives and Special Collections on Women in Medicine, The Medical College of Pennsylvania, is accepting appli- cations for summer 1990 research using materials in the Archives and Special Collections at the College. The Archives houses the business and academic records of The Medical College of Pennsylvania dating from its founding in 1850 as the Female Medical College of Pennsylvania. Two grants of up to $1,500 each for four to six weeks of research in the Archives will be made to applicants selected by the Award Committee. For an application and description of the Fellowship, contact the Archives and Special Collections on Women in Medicine, The Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphia, PA 19129.

12

NEW JERSEY MEDICINE

MSNJ NEWSLETTER

MEDICARE HMOs HURT BY SKILLED NURSING FACILITIES

HCFA and Medicare HMOs are at odds over a rule that clarified when skilled nursing facilities (SNF) could accept patients. As a result of the April 1988 clarification, beneficiaries have used skilled nursing care and HMOs have incurred costs that were not anticipated. Since HCFA pay- ments to Medicare HMOs for SNF coverage are on a prospective flat rate based on expected costs for a year, HMOs have incurred substantial losses that they have not been able to recover from HCFA. This rule is expected to impact 131 Medicare HMOs in 35 states with plans in California, Florida, and Minnesota expected to suffer the greatest losses. In Minnesota, SNF costs incurred by HMOs have increased by 400 to 700 percent.

INDIRECT MEDICAL EDUCATION

The Prospective Payment Assessment Commission has released data accumulated during the fourth year of the Medicare Prospective Pay-

ADJUSTMENT men^ System (PPS) that estimates the indirect medical education (IME) factor at 3.5 percent. The Commission’s previous estimate was 4.4 per-

	cent. ProPAC attributed the decrease in the IME factor to the increased sensitivity of DRGs to the severity of illness as a result of refinements to PPS. ProPAC has urged Congress to adjust the IME factor for 1990 to 6.6 percent from its current 7.7 percent level. The Senate 1990 rec- onciliation package would reduce the indirect medical education add- on to 7.1 percent, while the House has recommended no change in the factor.
ATTRACTING AND RETAINING PHYSICIANS	A subcommittee of the House Committee on Veterans’ Affairs has charged the Department of Veterans’ Affairs with serious deficiencies in salary levels, research opportunities, and work environment in its efforts to recruit and retain physicians. The subcommittee also charged the Department with failure to adjust salaries to reward long-term service. The subcommittee concluded that the deficiencies can be remedied and recommended using bonus pay incentives as a way for recruiting and retaining physicians from specialties experiencing acute labor shortages.
SUPPLEMENTARY MEDICAL INSURANCE PREMIUMS	Monthly premiums for enrollees, age 65 and over, in the Medicare Sup- plementary Medical Insurance (SMI) Program for calendar year 1990 will be $29 compared to the 1989 monthly premium of $27.90. Monthly premiums for disabled enrollees in the SMI Program will increase from $34.30 in 1989 to $44.10 in 1990.
HCFA ADMINISTRATOR DECISION	The HCFA administrator has upheld a Provider Reimbursement Review Board decision that found a hospital operating a 46-bed facility that closed and subsequently opened as a new 120-bed facility was not enti- tled to be classified as a new hospital under the Medicare Prospective Payment System (PPS). The administrator noted that the provider did not file separate cost reports for the old and new facilities, carried over its old provider number, and failed to request status as a new hospital until well after its first year of PPS had ended.
GRAMM-RUDMAN TRIGGERED	As a result of the Senate not being able to get the budget finalized in time, the Gramm-Rudman balanced budget law went into effect on October 16, 1989. Medicare payments to hospitals, doctors, and other providers will drop approximately 2.1 percent. The payment reduction will apply to community and migrant facilities, Indian health facilities, and veteran medical care.

PHYSICIAN CARE A new quality-assurance program is being tested by Private Healthcare MONITORED Systems, a Massachusetts-based preferred provider organization (PPO)

VOL. 87— NUMBER 1 JANUARY 1990

13

	owned by 17 insurance companies. Using data furnished by physicians, patients, and insurers, the program will review physicians’ care by 13 different quality screens that identify frequent hospital readmissions and the use of outdated procedures. Private Healthcare Systems operates 40 individual PPO networks in 26 states, and has approximately 1.1 million enrollees and 30,000 participating physicians.
INVESTEGATIONAL NEW DRUG TREATMENTS	Princeton Biomedical Research is conducting studies that may be of interest to the patients of Medical Society members. These are investiga- tional new drug treatments for depression, anxiety, age-associated mem- ory difficulties, and Alzheimer’s disease. The memory testing, available in ten sites nationwide, involves state of the art computerized testing simulating real-life situations. The programs are free to qualifying indi- viduals. For further information, contact Dr. Apter at 609/921-3555.
NEW POSITION FOR LANCIANO	Ralph C. Lanciano, Jr, DO, of Haddonfield, was appointed chairman of the Eye Section f of the Camden County Medical Society. He also was appointed to the Board of Governors of the New Jersey Academy of Ophthal- mology. Dr. Lanciano is a clinical assistant j Ml professor at the University of Pennsylvania’s \ jMs X Department of Ophthalmology, Scheie Eye B'*r - ,» Institute. In addition, he serves as a clinical Jl associate professor at UMDNJ-School of Os- Jw teopathic Medicine. Dr. Lanciano is a section head at Kennedy Me- morial Hospital University Medical Center, Stratford Division, and is attending ophthalmologist for the New Jersey State Police.
CHILDHOOD ITP INVESTIGATION	The New Jersey Pediatric Hematology/Oncology Network (NJPHON) is conducting a study to compare the efficacy of treatment modality, total monetary cost differential, emotional cost differential, and lymphocyte function differences in children with newly diagnosed acute ITP (idiopathic thrombocytopenic purpura). Children eligible for study will be prospectively randomized to steroid treatment versus in- travenous gammaglobulin (IVIG) versus (in select cases) observation alone. Total costs (financial and emotional) will be assessed at varying times via questionnaire. Lymphocyte function tests will be performed four times during the first six months of treatment/observation. The cost of the IVIG and lymphocyte function testing is being underwritten by a grant; call NJPHON for more information.
HEALTH RESEARCH FELLOWSHIPS	The Advanced Research Fellowship Program is sponsored by the Gov- ernor’s Council on the Prevention of Mental Retardation and De- velopmental Disabilities. Each fellow will receive $25,000 a year and the award is renewable for one year. Applications are due February 2, 1990. The purpose of the program is to encourage researchers in their efforts to learn more about the causes of mental retardation and developmental disabilities. Candidates must have been awarded a PhD or MD to be qualified for consideration. Candidates also must document their accep- tance for postdoctoral training under the supervision of an appropriate mentor at a nonprofit research institution in New Jersey. For infor- mation, call the Office for Prevention of Mental Retardation and De- velopmental Disabilities at 609/984-3351 or write to Dr. Deborah Cohen, Director, Office for Prevention of MR/DD, CN 700, 222 South Warren Street, Trenton, NJ 08625.
FINI	“Appreciating what you have instead of being miserable about what you don’t have, is so difficult for the human mind to comprehend.”

14

NEW JERSEY MEDICINE

PRESIDENT’S

PAGE

POLITICAL

EFFECTIVENESS

COMMUNICATING.

SELECTING ISSUES AND NARROWING FOCUS.

DEALING ACTIVELY, VIGOROUSLY, AND HONESTLY.

BEING FIRM, YET FLEXIBLE.

NEVER MAKING ENEMIES.

In the November issue of NEW JERSEY MEDICINE, I wrote about political action and its importance in our program of political effective- ness— effectiveness in dealing with health policy and public policy that impacts upon our profession and our patients. I appreciate the enthusiastic comments and support this article generated. However, “political action” is but one phase in our coordinated program of politi- cal effectiveness. Other activities include the following:

We have an ongoing program of discussion with our legislative leaders. We do not approach our legislators only when we have a problem or a request. We discuss our priorities, and our perceptions of the health needs of New Jersey. And, we listen to their perceptions, their ideas, and their advice as to what is politically practical.

We will not be effective if we try to deal with the hundreds of bills peripherally affecting our profession, in any given legislative session. We always are able to identify the major general issues that require our focus, attention, and major efforts. We will not ignore other or peripheral issues, but we will not forget our major objectives.

Our major issues require the efforts of the leadership of MSNJ, our lobbyists, and our key contacts. These efforts are coordinated through the MSNJ office, for maximum effectiveness. Our discussions with legis- lators must be strong, but never less than completely honest if we are to maintain our credibility.

We will take an unyielding stand on essential issues. But, we also under- stand the political process, and the need to participate in the process of negotiation that often occurs as legislation is formed. We are not willing to stand aside from this. This process can make the “inevitable” a little less onerous; and can help us to achieve at least part of the “impossible.”

We work hard at achieving generally good relationships with as many legislators as possible. This does not mean that they will do our bidding; it usually means, however, that our point of view will be heard and considered. There is a pattern of shifting alliances with virtually every bill. No single legislator supports us on every issue. Similarly, there is no legislator in New Jersey who opposes us on every issue. We cannot afford to designate as an “enemy” a legislator who opposes us on an important issue; that legislator’s vote may be the one that we need on a subsequent issue. Every senator and assemblyman is likely to oppose us some of the time, and occasionally be an adversary; we always seek the opportunity to continue our conversations with these legislators, and to hope that they will be our proponents on a subsequent issue.

This is our program. We follow these steps, and maintain a coordinated program, always remembering our major goals, and the need to be working toward these goals on a daily basis. □

VOL. 87— NUMBER 1 JANUARY 1990

17

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LEVOXINE® (Levothyroxine Sodium Tablets, USP) For oral administration

The following is a brief summary. Before prescribing, please consult package insert

INDICATIONS AND USAGE:

LEVOXINE (L-thyroxine) tablets are indicated as replacement or supplemental therapy for diminished or absent thyroid function, resulting from functional deficiency, primary atrophy, from partial or complete absence of the gland or from the effects of surgery, radiation or antithyroid agents. Therapy must be maintained continuously to control the symptoms of hypothyroidism.

CONTRAINDICATIONS:

L-thyroxine therapy is contraindicated in thyrotoxicosis, acute myocardial infarction and uncorrected adrenal insufficiency.

WARNINGS:

Drugs with thyroid hormone activity, alone or together with other therapeutic agents have been used for the treatment of obesity. In euthyroid patients doses within the range of daily hormonal requirements are ineffective for weight reductioa Larger doses may produce serious or even life-threatening manifestations of toxicity, particularly when given in as- sociation with sympathomimetic amines such as those used for anorectic effects

PRECAUTIONS:

Caution must be exercised in the administration of this drug to patients with cardiovas- cular disease. Development of chest pains or other aggravation of the cardiovascular dis- ease requires a reduction of dosage

Patients on thyroid preparations and parents of children on thyroid therapy should be informed that replacement therapy is to be taken essentially for life They should im- mediately report during the course of therapy any signs or symptoms of thyroid hormone toxicity, eg, chest pains, increased pulse rate, palpitations, excessive sweating, heat intolerance, nervousness, or any other unusual event In case of concomitant diabetes mellitus the daily dosage of antidiabetic medication may need readjustment In case of concomitant oral anticoagulant therapy, the prothrombin time should be measured fre- quently to determine if the dosage of oral anticoagulants is to be readjusted.

Partial loss of hair may be experienced by children in the first few months of thyroid therapy, but this is usually a transient phenomenon and later recovery is usually the rule

Drug Interactions — In patients with diabetes mellitus addition of thyroid hormone therapy may cause an increase in the required dosage of insulin or oral hypoglycemic agents

Patients stabilized on oral anticoagulants who are found to require thyroid replace ment therapy should be watched very closely when therapy is started.

Cholestyramine binds both T4 and T3 in the intestine, thus impairing absorption of these thyroid hormones Four to five hours should elapse between administration of cholestyramine and thyroid hormones

Estrogens tend to increase serum thyroxine-binding globulin (TBg). Patients without a functioning thyroid gland who are on thyroid replacement therapy may need to increase their thyroid dose if estrogens or estrogen-containing oral contraceptives are given. Drug/ Laboratory Test Interactions — The following drugs or moieties are known to inter- fere with laboratory tests performed on patients taking thyroid hormone: androgens cor- ticosteroids estrogens oral contraceptives containing estrogens iodine-containing preparations and the numerous preparations containing salicylates Carcinogenesis, Mutagenesis And Impairment ol Fertility — A reported apparent as- sociation between prolonged thyroid therapy and breast cancer has not been confirmed. No confirmatory long-term studies in animals have been performed to evaluate car- cinogenic potential, mutagenicity, or impairment of fertility in either males or females Pregnancy-Category A— The clinical experience to date does not indicate any adverse effect on fetuses when thyroid hormones are administered to pregnant women Nursing Mothers — Minimal amounts of thyroid hormones are excreted in human milk Thyroid is not associated with serious adverse reactions and does not have a known tumorigenic potential. However, caution should be exercised when thyroid is adminis- tered to a nursing womaa

Pediatric Use — The incidence of congenital hypothyroidism is relatively high. Routine determinations of serum (T4) and/or TSH is strongly advised in neonates in view of the deleterious effects of thyroid deficiency on growth and development

ADVERSE REACTIONS:

Adverse reactions are due to overdosage and are those of induced hyperthyroidism. OVERDOSAGE — Excessive dosage of thyroid medication may result in symptoms of hyperthyroidism, which may not appear for one to three weeks after the dosage regimen is begun. The most common signs and symptoms of overdosage are weight loss, palpita- tion, nervousness diarrhea or abdominal cramps sweating tachycardia cardiac arrhy- thmias angina pectoris tremors headache insomnia intolerance to heat and fever. If symptoms of overdosage appear, discontinue medication for several days and reinstitute treatment at a lower dosage level

Complications as a result of the induced hypermetabolic state may include cardiac failure and death due to arrhythmia or failure

Dosage should be reduced or therapy temporarily discontinued if signs and symptoms of overdosage appear.

Treatment of acute massive thyroid hormone overdosage is aimed at reducing gas- trointestinal absorption of the drugs and counteracting central and peripheral effects, mainly those of increased sympathetic activity. Measures to control fever, hypoglycemia, or fluid loss should be instituted if needed.

DOSAGE FORMS AVAILABLE:

LEVOXINE (L-thyroxine) tablets are supplied as oval, color coded, potency marked tablets in 11 strengths: 12 Vi meg (0.0125 mg) - maroon, 25 meg (0.025 mg) - orange, 50 meg (0.05 mg) - white, 75 meg (0.075 mg) - purple 100 meg (0.1 mg) -yellow, 112 meg (0.112 mg) - rose 125 meg (0.125 mg) - brown, 150 meg (0.15 mg) - blue, 175 meg (0.175 mg) -turquoise, 200 meg (0.2 mg) -pink and 300 meg (0.3 mg) - green in bottles of 100 and 1000, and unit dose in cartons of 100 (10 strips of 10 tablets), 200 meg and 500 meg injectable (see injectable package insert).

18

NEW JERSEY MEDICINE

A NEW BROOM?

EDITOR’S

DESK

Dr. Burton J. Lee III, personal friend of George Bush, now is the phy- sician to the president of the United States. In that role, he has the potential to influence greatly the health care delivery system in the nation and to change markedly the patient-physician-hospital rela- tionships.

An interview of Dr. Lee by Dennis L. Breo in the November 17, 1989, issue of the Journal of the American Medical Association is an eye- opener and deserves your careful reading.

Dr. Lee, who spent all his professional life in a salaried position at Memorial Sloan-Kettering Cancer Center in New York City, has made it clear that he intends to expand the activities of the White House physician “so that when I leave here eight years from now — it is one of the premier health policy positions in the nation.”

He believes that medical resources should be rationed, that “some phy- sicians tend” to overtreat the patient and to overdo procedures. “We’re never going to get a handle on medical costs unless we take the piecework out of medicine, especially the procedures performed in the surgical sub- specialties.” “It’s a tremendous conflict of interest for a surgeon’s income to depend upon how many procedures he does.” “Of course, I can’t say that I am for putting all physicians on salary, but if I were the president or the chairman of a House or Senate subcomxiiittee on health, I’d have to look at it, sure.”

Somehow this anticapitalistic, socialistic approach brings to mind a debate reported years ago about the virtues of fee-for-service medicine versus the salaried type. Dr. Francis D. Moore of Boston espoused the first point of view and Dr. George Crile, Jr, of Cleveland espoused the latter point of view. Both were eloquent in presenting their arguments, no blood was spilled and no clear-cut decision was reached, but both agreed that members of the most-honored profession could be relied on, by-and-large, to do the right thing. It is most unfortunate that Dr. Lee feels otherwise.

Perhaps Dr. Lee, unknowingly — to be kind — is refueling the town-gown conflagration that should have fizzled out years ago. Today, even the family doctor is residency trained. Would he have this caring physician relegated to triage? Would he have the patient shipped to a specialty hospital away from the family and community support he cherishes? (The recent failure of the Oral Roberts Medical School and Hospital occurred, at least in part, because patients’ strong desires to be treated at home were not recognized.)

Is the LMD again to become the object of derision and snide comment? Are community hospitals worthless? Should all rural hospitals be closed?

An entire career spent on salary in a medical center is not exactly comparable to being in the trenches, no matter how caring the hospital- based physician. Memorial Sloan-Kettering Cancer Center is a magnifi-

VOL. 87— NUMBER 1 JANUARY 1990

21

EDITOR’S DESK

cent institution, brilliantly staffed and buttressed by support systems that are the envy of most other centers. Medicine cannot be practiced only at that level, now or in the foreseeable future. We would surely bankrupt the country if we tried.

So please, Dr. Lee, temper your experiences with the evaluations of others. Those of us who belong to “organized medicine” do have our patients’ interests first and foremost, but hope that changes will not make sacrificial lambs of well-meaning physicians. Even your erstwhile colleague, Dr. Murray Brennan, chairman of the Department of Surgery at Memorial Sloan-Kettering Cancer Center said, “The requirements of bureaucracy — filling out paperwork — are demoralizing. Even worse, it makes it impossible to do what we should be doing — spending more time with the patient, instead of defensive paper management.” In your review of health care costs, try to remember Henry Clay’s advice, “Statistics are no substitute for judgment.” And if you feel that taking care of your patients took “a lot out of you,” visualize how many of us are suffering and struggling without the support system you enjoyed, especially those that took a large part of bureaucracy off your back. If only the rest of us could be so lucky. □

JOURNAL With the tremendous increase in research being performed in New Jer- ARTICLES sey, the Committee on Publication voted to increase the documentation on research published in NEW JERSEY MEDICINE. Beginning with this issue of our journal, all articles will include the date the article was received and the date of acceptance by NEW JERSEY MEDICINE. The Committee believes this policy will give authors more appropriate credit for their original research and provide for timeliness of reporting of the work being done in New Jersey.

LETTERS TO Letters to the editor are welcome. Communications should be sent to THE EDITOR NEW JERSEY MEDICINE, MSNJ, Two Princess Road, Lawrenceville, NJ 08648.

22

NEW JERSEY MEDICINE

BOOK

REVIEWS

ATLAS OF Marcos V. Goycoolea, MD. W. B. Saunders Company. This extremely OTOLOGIC SURGERY well-written book is an atlas of otologic surgery. The text graphically

displays the usual surgical procedures performed in otology. The draw- ings and pictures are absolutely superb and the descriptions are excel- lent. This atlas, obviously, belongs on the shelf of every otolaryngologist. But, more than that, any medical student interested in ear surgery would find the text a great help in understanding the procedures of this special- ty. This book can be utilized by anyone wanting a fuller understanding of ear surgery. It is a superb atlas. □ Harold Arlen, MD

I EMERGENCY MEDICINE. George R. Schwartz, MD, Nicholas Bircher, MD, Barbara K. Hanke, THE ESSENTIAL UPDATE MD, et al. Philadelphia, PA, W.B. Saunders Company, 1989. Over the

years, I have written a number of book reviews, in part to keep up with newly published material. Frequently, however, the books I have re- viewed have not been strikingly relevant, but Emergency Medicine. The Essential Update is an exception; it is more than a textbook.

By their nature, medical textbooks cannot remain on the cutting edge of advances. This is a problem in the area of emergency and acute care medicine where change happens quickly and across a broad spectrum of medical specialties. This book accomplishes what it promises to do — namely, to provide a “cutting-edge” update that can supplement any textbook of emergency medicine as well as textbooks of internal medi- cine, surgery, and family practice. In fact, it does offer essential and focused information which can be lifesaving. Since I am a practicing emergency physician, I have found this book to contain concise, relevant, and practical information to assist me in the care of my patients. The fact that it is not a weighty, medical tome means the reader is able to digest more of its information than a typical medical textbook.

It is a pure coincidence that I personally know two of the six editors of this fine book. I have not had conversations with either one of them about this matter. They have not asked me to speak kindly of their book. Nonetheless, the book deserves to be spoken about in a kind fashion and, more importantly, the book deserves to be in the library of every practic- ing emergency physician. □ James E. George, MD, JD

SOCIAL SIGNIFICANCE Barry D. McPherson, PhD, James E. Curtis, MA, John W. Loy, PhD.

Qp SPORT Champaign, IL, Human Kinetics Books, 1989. This book is a textbook for psychology students; yet it makes very interesting reading for anyone who has more than a passing interest in sports. The authors discuss a variety of topics dealing with the social, economic, political, and legal aspects of sports, and how these various entities react with each other and with such other factors such as race relations, women’s liberation, social interaction, class structure, subcultures, and age-related ac- tivities. Included in the book is a wealth of historical background ma- terial relative to the previously mentioned topics and, hence, the book is a valuable reference in this regard. I recommend it as a book to read for those concerned about sports medicine or for those physicians with an interest just in sports per se. □ Christine E. Haycock, MD

VOL. 87— NUMBER 1 JANUARY 1990

25

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26

NEW JERSEY MEDICINE

Medication Errors: 1 977 to 1 988

Experience in Medical Malpractice Claims

SUZANNE L. KUEHM, MPH

MICHAEL

The Risk Prevention Department of the Medi- cal Inter-Insurance Exchange of New Jersey (MIIENJ), a physician-owned carrier, was established on February 1, 1983, by its Board of Governors. Two of the objectives of the Department are to decrease patient injury and to reduce medical malpractice claims with its attendant emotional and economic stresses. It appears that medication error is one area where risk prevention efforts could make a significant contribution towards meeting these goals. Therefore, it seems beneficial to analyze all cases where indemnity was paid due to a medication error.

PROCEDURE

All cases identified previously as having a medi- cation error as a significant cause of the suit and closed with a payment to the plaintiff during the period of February 1, 1977, through December 31, 1988, were reviewed. There was a total of 337 files reviewed, inclusive of all specialties. In 57 percent of these files, medication error was the primary cause of the suit and, in the remaining files, it was an important factor. Total indemnity paid was $30,144,636, an average of $89,450 per file. Thirty- four distinct performance errors were identified, and

Ms. Kuehm is a loss analyst, Risk Prevention Depart- ment, Medical Inter-Insurance Exchange of New Jersey (MIIENJ), and Dr. Doyle is chairman of the claims com- mittee of MIIENJ and a member of the Board of Under- writers. Requests for reprints may be addressed to Dr. Doyle, MIIENJ, Two Princess Road, Lawrenceville, NJ I 08648.

. DOYLE, MD

there were between one and five of these per- formance errors in each of the 337 files analyzed. Only those actions which indicate a trend are re- ported here. The actions are organized into nine categories: allergic reaction; error in writing the prescription; communication failure; administration of excessive dose of medication; prescription of con- traindicated medication; failure to monitor drugs for toxic levels; treatment with antibiotics; prescription of medication to treat symptoms; and generic drugs.

TRENDS

A. Allergic Reaction (indemnity paid, $1,063,657). There were 34 files involving allergic reactions. These cases resulted in six deaths, one profoundly brain-damaged patient (permanent coma), and 14 anaphylactic reactions with elec- trocardiogram (EKG) changes, hypotension, respir- atory difficulty, cyanosis, and facial edema resulting in hospitalization. In 5 files, the extent of the reac- tion was not specified, and the reactions in the re- maining files consisted of gastrointestinal hemor- rhage, cellulitis, and conjunctivitis. The deaths were due to the administration of penicillin (4 files), am- picillin (1 file), and ibuprofen (Motrin®) (1 file). Sodium thiopental (Pentothal®) was the cause of the severe brain damage in 1 file. Of all the allergic reactions, 16 were due to an allergy to penicillin and the administration of ampicillin (5 files), penicillin (6 files), bacampicillin hydrochloride (Spectrobid®) (2 files), oxicillin (1 file), amoxicillin (1 file), and ampicillin trihydrate (Principen®) (1 file). In 5 files, there was an allergy to acetylsalicylic acid (aspirin), and the physicians prescribed ibuprofen (Motrin®),

VOL. 87— NUMBER 1 JANUARY 1990

27

ascriptin, Darvon® compound, and Percodan®. The latter three drugs all contain acetylsalicylic acid (aspirin), and ibuprofen (Motrin®) is contrain- dicated for persons who have a history of allergy to acetylsalicylic acid (aspirin). In each of these events there was an indicator that should have alerted the physician against prescribing the drug. The following are examples.

1. The specific allergy was noted in the patient’s office record or hospital chart, but the insured either never reviewed the office chart before prescribing the medication; admitted to overlooking the entry in the record; or failed to read the discharge summary of a previous hospitalization.

Example: A patient gave a history of an allergy to penicillin. The physician prescribed ampicillin. The patient developed a rash and difficulty in

breathing requiring hospitalization. This was the second time this patient required hospitalization for an allergic reaction to ampicillin.

2. Some physicians stated that they were not “told forcefully enough, so the information didn’t stick.” Other physicians admitted that they had not questioned the patient regarding allergies. There also were some instances when a pharmacist had called to notify the physician that the patient was allergic to the prescribed medication and was told by the physician to “give the drug anyway,” believ- ing that it was still the best choice for the condition.

Example: A patient gave a history of allergy to penicillin. The same patient was given intravenous oxicillin preoperatively after induction, but before an incision was made. The patient developed a rash on the face and extremities, hypotension, and EKG

Medication Errors by Specialty. The named specialty within each sphere had the greatest number of suits within the specific error category (February 1, 1977, to December 31, 1988).

28

NEW JERSEY MEDICINE

changes indicative of cardiac ischemia which necessitated aborting the procedure.

Example: A patient related that his father died from a reaction to sodium thiopental (Pentothal®). The patient was given sodium thiopental (Pen- tothal®) and, subsequently, developed a laryngo- spasm resulting in anoxic brain damage and per- manent coma.

3. Office staff also have been responsible for pa- tient injuries.

Example: The insured ordered a computed axial tomographic (CAT) scan and wrote “no dye” be- cause of the patient’s history of allergy to iodine. In addition, the patient verbally told the receptionist the same warning. The receptionist filled out the request form incorrectly, stating “use dye.” The radiologist never saw the original request. The pa- tient suffered anaphylactic shock requiring emer- gency hospital treatment with oxygen and in- travenous steroids.

Example: An office staff member recopied patient information from part 1 to part 2 of a patient’s chart and neglected to write down the patient’s allergies on the second part.

4. There also is some indication that allergic reac- tions occurred because the insureds were not aware of the drug components of the medication or the drug manufacturers’ warnings associated with the medication.

Example: The patient gave a history of previous allergic reaction to acetylsalicylic acid (aspirin). The insured prescribed ibuprofen (Motrin®). The patient developed an anaphylactic reaction with cardiopul- monary arrest, resulting in coma and death. Phy- sicians’ Desk Reference states, “Do not prescribe for patients who have a known sensitivity to

acetylsalicylic acid (aspirin).”

★ Allergic reactions to prescribed medications have caused patient deaths and morbidity. In an effort to reduce the incidence of these claims and subsequent damages:

1. Do heed patient warnings of known or

suspected allergies.

2. Indicate all allergies in bold lettering in the patient record. Ideally, this should be in the front of the chart where it will not be overlooked easily.

3. Question the patient regarding allergy to medi- cations including over-the-counter (OTC) medi- cations. If this is not possible, consult previous hos- pital records or prior treating physicians.

4. Be aware of the composition of drugs before prescribing medication.

5. Educate the office staff regarding the impor- tance of allergy notations on charts and forms.

6. Radiologists should insist on seeing the original request for diagnostic imaging, especially when dye could be used.

7. If there is a need to prescribe a drug to which a patient is allergic, such as an antibiotic which would be life saving, consult first with a board certified allergist.

B. Error in Writing the Prescription (indemni- ty paid, $419,111). While this “error” did not appear frequently (six files), the damages and the potential for damage were great. It also is an error which easily is preventable and, therefore, merits inclusion. The following are examples from these files.

Example: A pediatrician wrote a prescription for phenytoin suspension (Dilantin® Suspension) taking into consideration the patient’s age, weight, and serum phenytoin level. The insured did not specify pediatric suspension. The prescription was filled with adult-strength phenytoin (Dilantin®), which is greater than four times the pediatric stength. (Dilantin® Pediatric provides 30 mg of medication in 5 ml dose; adult strength, in contrast, contains 125 mg in 5 ml.)

Example: A 20-year-old with leukemia was hospi- talized for induction chemotherapy and discharged to continue consolidation treatment with cytarabine (Cytosar-U®) at home. The pharmacist filled the prescription with cyclophosphamide (Cytoxan®). The patient took this drug for five days. This took the patient out of remission, and she died two months later. The pharmacist paid 3/4 of the indem- nity, the insured paid 1/4 of the indemnity.

Example: A patient hospitalized for atrial

fibrillation was discharged with a prescription for digoxin (Lanoxin®). The patient returned 24 hours later in digoxin toxicity. The physician had intended to prescribe 0.25 mg od but had written “4 tabs per day.” Two tablets (0.125 mg per tablet) per day would have equaled 0.25 mg.

Example: An office nurse administered an injec- tion of lorazepam 10 mg (Ativan®) instead of lorazepam 1 mg (Ativan®). The office nurse read the 1.0 mg as 10 mg.

★ It does not take long to recognize errors such as these can occur easily with both written and ver- bal orders. A few simple guidelines should help to minimize the chances of these errors occurring:

1. Never place a zero after a decimal; at times, the decimal may not be seen. (The U.S. Pharma- copea has requested drug companies to follow this guide in their labelling.)

2. Always use a zero before a decimal; decimals get lost on lines.

3. Use a fraction instead of a decimal between two numbers.

4. When writing prescriptions be careful of drugs that look alike, such as adriamycin versus acromycin or Cytosar® versus Cytoxin®.

5. Be careful of drugs that sound alike, especially when giving verbal orders to pharmacists, such as

VOL. 87— NUMBER 1 JANUARY 1990

29

Zantac® or Xanax®; and seldane or feldene.

6. As a safeguard against misinterpretation of both written and verbal prescriptions include the diagnosis or the reason for the drug for wheezing; give the strength 500 mg not two tablets of the dose; include directions for taking medication; and re- quest the pharmacist to place warnings on the label.

(These suggestions were made by Michael R. Cohen, MS, RPh, clinical assistant professor, School of Pharmacy, Temple University, and assistant edi- tor of Hospital Pharmacy.)

C. Communication Failure (indemnity paid, $1,215,878). There were 19 files where patient in- juries occurred (including three deaths and one inci- dent of loss of sight) as a direct consequence of the physicians: failing to communicate to another phy- sician; failing to review the chart; failing to com- municate effectively with a pharmacist; failing to communicate clearly with office staff; and failing to communicate effectively with an answering service. The following examples elaborate these points.

Example: During a presurgical interview, an anesthesiologist learned the patient had hepatitis several years earlier and decided, because of this, the patient should receive a narcotic anesthesia. A sec- ond anesthesiologist failed to read the note made by the interviewing anesthesiologist and gave halothane without any problems occurring. One week later the patient again had surgery. The patient again was given halothane because it was assumed that the patient was given the narcotic anesthesia previously. This resulted in the patient’s death due to halothane hepatitis.

Example: The physician telephoned a prescrip- tion to the pharmacist for novocolchine (Col- chicine®). He ordered 1 pill every 15 minutes until pain subsided, not to exceed 6 to 10 pills in 24 hours. The pharmacist omitted the limiting number in the directions for taking the drug. The patient took 35 pills in 24 hours resulting in renal failure and requir- ing renal dialysis. The pharmacist stated that he was not advised of the limit by the physician.

Example: A patient was being unsuccessfully treated with a variety of antibiotics for a post- operative infection. The physician requested an in- fectious disease consultation. The requested special- ist never arrived to see the patient. After a lengthy hospitalization, the patient was discharged with no residual effects. A jury, however, faulted the insured for not following up on obtaining the consultation since he had documented his need for assistance in antibiotic management of this patient. The jury awarded the plaintiff $67,000.

Example: A patient on long-term maintenance with warfarin sodium (Coumadin®) was notified by the laboratory to contact his physician regarding his prothrombin time results. (The test result indicated

the bleeding time was too prolonged.) The patient telephoned the insured’s office and was told by the answering service to call back in one week, since the physician was on vacation. The patient complied, but by that time he had lost the sight in one eye due to a vitreous hemorrhage. A physician is respon- sible for giving sufficient instructions to the answering service. In this instance, the covering physician was not given the patient’s telephone number by the answering service. From the earlier discussions, it is apparent that communication fail- ures also resulted in allergic reactions and some er- roneous prescriptions.

★ Breakdown in communication among pro- fessionals has caused medication errors which re- sulted in patient injury and death and led to success- ful medical malpractice suits. There are files where medical peer reviewers opined that the physicians did not deviate from the standard of care, but juries decided in favor of the plaintiff because they be- lieved the physician had a duty to followup on a communication breakdown.

Decreased Awareness of Pharmacokinetics of Drugs. The broad category of decreased awareness of pharmacokinetics of drugs is composed of a va- riety of behaviors, including prescribing a dose of medication which is: too large; too potent for the presenting symptoms; a lower dose than required; administered by an improper route, contraindicated because of patient history or other concurrently prescribed medications; not monitored for toxic levels or adverse reactions; and lacking in proper instructions for administration. It appears that the best single explanation for these would be a less than desirable pharmacological awareness of the drugs prescribed. There were 152 files in this category. We will discuss only the most significant of these.

D. Administration of Excessive Dose of Medi- cation (indemnity paid, $12,350,445). There were 57 files in this category, with 16 deaths, 11 patients with permanent injury, and 3 patients with brain injuries. (This category does not include over- medication due to a failure to monitor blood levels with resulting toxic levels of a drug being obtained.) Some case examples representative of these files fol- low.

Example: A three-year-old child with breathing difficulty was sedated with meperidine hydro- chloride (Demerol®), promethazine hydrochloride (Phenergran®), and chlorpromazine hydrochloride (Thorazine®) for an electroencephalogram. The child never aroused. He vomited and aspirated, and then died. The peer reviewer opined that the dose was appropriate for a normal child, but not for one with breathing difficulty.

Example: A patient was treated for arthritis with high doses of steroids. The patient developed pan-

30

NEW JERSEY MEDICINE

creatitis, gastritis, peritonitis, an abdominal abscess, and generalized sepsis before dying.

Example: Nine consecutive doses of Mannitol® were given to a patient prior to undergoing cataract surgery. The patient developed an electrolyte im- balance secondary to the Mannitol®, suffered a cardiac arrest, and died. The peer reviewer and de- fense expert opined that an inordinate amount of Mannitol® had been given.

★ Patients received an overdose of medication be- cause physicians: failed to consider patients’ indi- vidual requirements at the time of prescribing the drug, and were unfamiliar with pharmacodynamics of the drugs prescribed.

E. Prescription of Contraindicated Medication by Patient’s History or Due to Noncompatability of Several Prescribed Drugs (indemnity paid, $5,774,346). There were 51 files in this combined category. There were 12 patient deaths, and 6 pa- tients suffered severe brain damage. The majority of drugs which were contraindicated by patient’s his- tory were the anti-inflammatory drugs, both steroid and nonsteroidal, and medications which contain acetylsalicylic acid (aspirin). Typically, the patient had a low hemoglobin and hematocrit (that could be an indicator of active bleeding) or the patient gave a history of ulcer disease. After taking these drugs, the patients developed severe gastrointestinal hemorrhage requiring hospitalization, many trans- fusions, and sometimes surgery.

Example: A patient gave a history of bleeding from acetylsalicylic acid (aspirin) ingestion and having a gastrectomy 15 years earlier. The physician prescribed naproxen (Naprosyn®), and the patient developed a near-fatal gastric hemorrhage.

Example: A patient, who already was taking bronchodilators for asthma, was treated with pin- dolol (Visken®) for hypertension. This drug, like all beta-blockers, must be used with extreme caution in patients who have asthma. This patient died im- mediately after taking this drug.

In all 51 files, either one or several of the following behaviors were seen: the physician failed to take a complete history; the physician ignored the patient’s complaints associated with taking the medication; or the physician disregarded the patient’s medical history.

When the cases involving the prescription of two noncompatible drugs were analyzed, the drugs that appeared more than once were Actifed® and the combination of an anticoagulant with an anti-in- flammatory medication. Commonly, the physicians never ascertained the present medications the pa- tients were taking. For example, an orthopedist prescribed an anti-inflammatory drug without de- termining that the patient was taking warfarin so- dium (Coumadin®), prescribed by an internist.

In some cases, the physician was not familiar with the pharmacodynamics of the drugs involved. For example, a patient was taking phenelzine dihydro- gen sulfate (Nardil®). The patient saw her family practitioner for complaints of a cold. She relayed that she had previous reactions from the combina- tion of other drugs with phenelzine dihydrogen sulfate (Nardil®). She was reassured that Actifed® was safe to use with phenelzine dihydrogen sulfate (Nardil®) which is an monoamine oxidase (MAO) inhibitor. Within 24 hours after taking Actifed®, she became comatose and remains dependent upon a caretaker for activities of daily living. (Sym- pathomimetics, of which Actifed® is only one exam- ple, are contraindicated with MAO inhibitors.)

★ It is imperative to thoroughly question patients regarding all medications they are taking. Also, a thorough awareness of pharmacodynamics of drugs prescribed is necessary to insure patient safety, es- pecially in view of the number of medications many patients are taking at any one time.

F. Failure To Monitor Drugs for Toxic Levels or Adverse Reactions (indemnity paid, $2,036,471). There were 39 files in this category. The drugs which were found more frequently were gen- tamicin, warfarin sodium (Coumadin®), heparin so- dium (Heparin®), the nonsteroidal anti-inflam- matory group, and the digitalis derivatives. In every one of these cases, there was a failure or delay to obtain blood tests to monitor the patient’s response to the drug. When the patient did offer complaints indicative of a toxic level or adverse reaction to the medication, the physician either failed or delayed in discontinuing the drug or checking the serum level of the drug. The patient damages were severe: five deaths, five patients with severe brain damage, and seven patients with total or severe hearing loss. The other patients had life-threatening events or prolonged hospitalization and recovery.

Example: An eight-month-old child was treated with gentamycin for nine days. No blood tests were done to monitor serum levels of the drug. The child is bilaterally deaf, with little chance of speech de- velopment, because of the age at which the hearing loss occurred.

Example: Warfarin sodium 25 mg (Coumadin®) was prescribed for a patient based upon a one-week- old blood test. The physician ignored the patient’s complaints of side effects, resulting in a severe hemorrhage from the esophagus, necessitating many transfusions.

Example: Five days after being discharged from the hospital, a patient, who had been taking digoxin, suffered a cardiac arrest and died. The patient’s digoxin level was 7; toxicity level is 2.5. During the patient’s hospitalization, there had been no monitor- ing of the serum digoxin level.

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★ There is evidence that it is difficult to defend a medication error when a patient injury occurs be- cause the physician failed to follow the manufac- turer’s recommendation for performing periodic blood tests to access the serum level of the drug. This especially is true with gentamycin, warfarin sodium (Coumadin®), heparin sodium (Heparin®), digitox- in, and digoxin. It is of equal importance, when prescribing nonsteroidal anti-inflammatory drugs, to evaluate periodically the patient for adverse reac- tions.

G. Treatment with Antibiotics (indemnity paid, $5,867,802). There were 73 files involving inap- propriate use of antibiotics. Of the 21 specialties represented in these 337 files, this performance error was found in 11 specialties. The actions consisted of failure to order a culture and sensitivity test; treat- ment with the wrong antibiotic; failure to re-evalu- ate when the infection did not respond to the prescribed antibiotic; failure to prescribe an anti-

biotic; and prescribing a lower dose than required.

In those files where a culture and sensitivity test was not performed, physicians stated the reasons for choosing the antibiotics were: “It usually was suc- cessful before,” or “It is the routine antibiotic used in these cases.” In each of these 15 files, the bacteria was not sensitive or was resistant to the prescribed antibiotic. The patients were treated inappropriate- ly over a period of time and the majority of them suffered loss of limbs or digits. In other files, phy- sicians prescribed antibiotics to treat presumed sys- temic infections (often by telephone diagnosis) before obtaining a blood culture. One patient had meningitis and, because of the wrong antibiotic ther- apy, suffered severe residual brain damage. In another example, there was a delay in diagnosing subacute bacterial endocarditis. Initial blood cul- tures were negative (false negative) due to prior long-term and inappropriate antibiotic treatment. This patient required surgery for mitral valve re-

Table. Additional reference materials for drug information.

• Drug Facts and Comparisons. This text contains objective drug information to facilitate comparison of prescription and over-the-counter drugs. The infor- mation is organized by therapeutic use with groups and subgroups to facilitate comparison of drugs with similar uses. One physician reviewer found the section on “pa- tient information” very desirable. This section reminds the physician what the patient should be told about the prescribed drug. This reference contains complete de- scriptive information on all drugs, regardless of current marketability (i.e. how long they have been available). Often PDR does not include detailed descriptions on older drugs. As drugs become available in generic form, they may disappear from future editions of PDR. This reference combines information which is pertinent to the physician from the drug package insert, current text- books, and many professional journals. The editorial panel for Drug Facts and Comparisons consists of rep- resentatives of medicine and pharmacy from some of the most respected universities. The hardbound version of this reference is updated yearly; the looseleaf version is updated monthly. (Facts and Comparisons, 111 West Port Plaza, Suite 423, St. Louis, MO 63146-3098.)

• Drug Information for the Health Care Pro- fessional. Published by the U.S. Pharmacopoeial Con- vention, Inc., this publication has several advantages: it is indexed by indications for use for easy reference to drugs used in the treatment, prevention, or diagnosis of disease. Along with Drug Facts and Comparisons, it in- cludes unlabeled accepted uses. Among its organiza- tional categories there is one, “Precautions To Con- sider,” which includes drug interactions, diagnostic inter- ference, and medical problems/contraindications. It in- cludes a section on patient consultation including “Before Use,” “Proper Use,” “Precautions,” and “Side/Adverse Effects— those needing medical attention and those that do not need medical attention.” The stan- dards (strength, quality, and purity) for drugs published in USP are recognized as official by the federal govern- ment and are enforceable by the FDA.

• Advice for the Patient. USP-DI also publishes this

drug information in lay language. This text contains drug information prepared specifically for the consumer. It is sold only to health care professionals as a reference for the patient which may be placed in the physician’s wait- ing room. Permission is given to photocopy monographs for patients if no charge is made to the patient for the / monographs. Each drug monograph contains proper use I directions and precautions to be observed among other topics. Also available are these same monographs print- ed as single-page leaflets on an assortment of 80 drugs. These are similar to the AMA Patient Medication Instruc- tion sheets which use the USP database. Sections in- clude “Uses of This Medicine,” “Before Using This Medi- cine,” “Proper Use of This Medicine,” “Precautions While Using This Medicine,” "Side Effects of This Medicine,” and “Discontinuing This Medicine.” These now are avail- able for 83 drugs through USP. (They no longer are to be ordered from the AMA.) These leaflets would be es- pecially useful when prescribing such drugs as an- ticoagulants, diuretics, nonsteroidal anti-inflammatories, and digitalis preparations. (For more information write: USP, 12601 Twinbrook Parkway, Rockville, MD 20852.)

• Drug Evaluations. This book is prepared by the professional staff of the American Medical Association, Department of Drugs, providing physicians and other health care professionals with unbiased information on the clinical use of drugs. It has been published for 20 years and it is updated every 3 years. It is available at a discounted price as a benefit of membership of the AMA.

• DUET (Drug Use Education Tool). These are pamphlets for a variety of drugs published by the Ameri- can Academy of Family Practice. Available to members, this is one example of drug information available through specialty societies.

• Medifile Cards. These are blank cards which allow physicians to list all medications, including dosage. The patient carries this card, to be shown to other treating physicians or emergency personnel. These biank cards are available from the Medical Society of New Jersey at no charge.

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placement and repair of mycotic cerebral aneurysm.

There were 26 files where the wrong antibiotic was given. There is the possibility that the wrong anti- biotic may have been given because a culture and sensitivity test was not done, but this was not stated in these cases. What specifically was seen in these files either was a failure to followup on a culture and sensitivity report after ordered and obtained, or a failure to order the antibiotic which the culture and sensitivity report recommended. There were three patient deaths, one patient with severe brain dam- age, eight amputations, three cases of chronic os- teomyelitis, and sterility of two teenage females as a sequalae to these infections.

There were 26 files where there was a failure to give antibiotics. In the majority of these files the patients had come to the emergency room for treat- ment of a laceration, or were patients with diabetes mellitus and being treated for foot ulcers or had incurred postoperative infections. There were six pa- tient deaths, five above-the-knee amputations, three amputated fingers, one partial amputation of the sternum, and five other patients requiring additional surgeries and facing permanent partial disability.

Example: A 49-year-old patient was discharged from the hospital following coronary artery bypass surgery with a prescription for an antibiotic to treat persistent drainage from the incision. The patient was monitored by his internist. After five weeks of antibiotic therapy, there was no change in the con- dition of the draining incision, and the internist re- ferred the patient back to the surgeon. The surgeon discontinued all antibiotics. The patient continued to be seen by the surgeon monthly for one year. The drainage from the incision persisted. No antibiotic was prescribed during this 12-month period. The patient eventually sought treatment from another physician who diagnosed osteomyelitis of the ster- num. A partial sternectomy was performed; in ad- dition, the patient required intravenous antibiotic therapy for several weeks.

★ There is additional morbidity and mortality from infections when physicians neglect to obtain culture and sensitivity tests from draining wounds and then fail to treat the infection with the ap- propriate antibiotic. When an apparent systemic in- fection is treated with antibiotics before obtaining a blood culture, the blood culture may yield a false negative result, leading to a delay in diagnosis and treatment. There were cases where there was no re- evaluation when the patient’s infection did not re- spond to the prescribed antibiotic. Of the total 73 files, there were only 2 files where an infectious dis- ease specialist had been consulted.

H. Prescription of Medication To Treat Symp- toms (indemnity paid, $3,397,105). There were 39 files in this category. In the majority of these cases,

physicians prescribed medication to alleviate pa- tients’ complaints of pain. In each of these cases, with the symptom of pain absent or diminished through medication, the physician failed or delayed in diagnosing the patient’s condition. In many of the 39 files, the prescription of medication masked the patient’s condition and made the diagnosis more difficult. In this category, there were 16 patient deaths, 1 severely brain-damaged patient, and 2 pa- tients whose future health is threatened. A few ex- amples are presented for clarification.

Example: A three-month-old hospitalized infant was treated with acetaminophen (Tylenol®) for a temperature of 105°C. The physician suspected meningitis but did not continue with a diagnostic workup because the infant’s temperature responded to the acetaminophen (Tylenol®). The physician thought that the infant was better; however, the child became worse later the same evening and died.

Example: A 19-year-old was treated with Per- codan® in an emergency room. He was misdiagnosed as having gastroenteritis. He actually had acute myocarditis and pericarditis. The Percodan® masked his symptoms and he died two days later.

Example: A 35-year-old was treated with

meperidine hydrochloride (Demerol®), hydroxyzine pamoate (Vistaril®), Combid® spansules, and Don- natal®. The patient had a ruptured appendix and peritonitis, but the analgesics had masked the pain and made the diagnosis more difficult.

★ In an attempt to alleviate patient discomfort, physicians have increased patient morbidity and mortality through the practice of prescribing medi- cation to eradicate symptoms before establishing a diagnosis. By removing these clues to the patient’s condition, the physicians found it more difficult to make a correct and timely diagnosis.

I. Generic Drugs (indemnity paid, $21,000). The issue of generic drugs is included here not be- cause it reflects a trend, but to report that the prescription of generic drugs or the substitution for generic drugs produced only one claim. There was only one file involving a generic drug; the following is a summary of that incident.

A patient being treated for hypertension had a prescription for hydroflumethiazide (Diucardin®) filled through a mail-order pharmacy. The phar- macy erroneously filled the prescription with bishydroxycoumarin (Dicumarol®), an anticoagu- lant, labeled as hydroflumethiazide (Diucardin®). The patient developed retroperitoneal hemorrhage and required hospitalizations over a period of two months before the problem was identified. The pa- tient had notified the physician that the pills did not look the same as the previous pills. The physician stated that he had no way of identifying the pills because they were generic. When the patient men-

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tioned this a second time, and the physician could not find a cause for the coagulopathy, the physican sent a sample of the pills to the pharmaceutical company for identification. A jury found the insured 10 percent liable ($21,000 of the total $215,000 ver- dict). An article written in Medical Economics, on May 25, 1987, entitled “Generics Are Giving Me A Cheap Headache,” describes a similar situation.

SUMMARY

MIIENJ has paid $30,144,636 in indemnity from 1977 through 1988 for medical malpractice suits aris- ing from medication errors. A review of these files revealed that patients incurred death and serious morbidity, and that several specific behavior errors accounted for the majority of patient injury. Among the damages that occurred during that time period were 88 deaths, 15 patients with profound brain damage, 15 patients who alleged that they had be- come addicted to medications prescribed for pain, 10 patients who required amputations of limbs, and 12 patients who suffered some degree of hearing loss or decreased visual acuity. The predominant categories where insureds incurred difficulty were in disregarding patient allergies to specific drugs (acetylsalicylic acid (aspirin), penicillin and its de- rivatives); prescribing drugs without consideration of the patient’s medical history; failing to monitor therapy with anticoagulants, nonsteroidal anti-in- flammatory drugs, digitalis derivatives, theophyl- line, and aminoglycoside antibiotics; antibiotic ther- apy; and errors in the writing of prescriptions.

In order to reduce the number of patient injuries and accompanying medical malpractice suits from medication errors, the following suggestions are of- fered:

1. Heed the patient’s warning regarding drug allergies and prescribe a substitute drug, es- pecially if the drug is aspirin or penicillin (and derivatives) or if the patient gives a history of having asthma. If the patient gives a history of aspirin sensitivity, make certain the drug you are prescribing does not contain aspirin as one of its components. Often physicians stated that they were not aware that aspirin was contained in the drug they prescribed for patients with a documented al- lergy to aspirin. Question all patients regarding al- lergy to the drug you are considering prescribing. Ask if the patient has ever taken the drug before and if he/she has had any problems related to taking the drug.

2. Maintain in the front of the patient’s office record a current listing of all drugs which the patient is taking and include the date prescribed, refill dates, and date the drug was discontinued.

Also, include on this medication sheet drugs other physicians are prescribing and over-the-counter

drugs the patient admits to taking. Indicate on the top of this sheet, along with the patient’s name, a diagnosis, past medical history, and drug allergies. This may reduce the incidence of prescribing drugs that are contraindicated by the patient’s history, prescribing drugs to which the patient is allergic, and prescribing an excessive amount of tranquil- izers, hypnotics, and narcotics. It also may prompt the physician to re-evaluate the effectiveness of a drug and either consider a different diagnosis or a different drug.

A stamp, “Blood Test Needed,” could be used to remind the physician of the need to monitor such drugs as diuretics, anticoagulants, digitalis prep- arations, nonsteroidal anti-inflammatory products, anticonvulsants, and certain antibiotics (aminogly- cosides such as gentamycin, tobramycin, and amikacin which have been known to cause ototoxici- ty, neurotoxicity, and nephrotoxicity). This may help to prevent the fatalities and severe morbidity associated with toxic levels and blood-altering properties of these drugs.

3. When antibiotic therapy is being considered to treat a draining wound or cavity, choose the antibiotic based on the result of a culture and sensitivity test. Whenever possible, consult with an infectious disease specialist for treatment of the un- usual, severe, or nonresponding infection.

4. Make it a habit to consult a good reference before prescribing a drug for a patient. The vol- ume of new drugs and the existing older drugs avail- able for patient treatment is colossal. No one can retain in his memory all the information necessary to ensure patient safety and the desired therapeutic effect. It is of interest that many of the severe medi- cation errors involved the more common and older drugs. In addition to the Physicians’ Desk Reference (PDR) which is provided at no cost to physicians by the drug companies, consideration should be given to additional resources (Table). Often PDR lacks information on older drugs.

5. Consider the hospital or community phar- macist as a consultant. Updated drug reference materials such as Drug Facts and Comparisons, USP-DI, and Facts And Comparisons’ Drug Inter- actions are kept in pharmacies and pharmacy de- partments. Education for pharmacists now empha- sizes their role as a provider of drug information. Clinical pharmacists with the degree of doctor of pharmacy (PharmD) are being found in increasing numbers in New Jersey hospitals. They are gradu- ates of six or seven years of pharmacy training and have completed at least one year of residency. The pharmacist can be considered a source of infor- mation. ■

Submitted May 1989; Accepted August 1989

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I

The Contemporary Alcoholic

NORMAN S. MILLER, MD MARK S. GOLD, MD

The contemporary alcoholic is younger and addicted to more drugs than ever before. The alcoholic under the age of 30 years old is addicted to marijuana, cocaine, benzodiazepines, barbiturates, and other drugs.

The use of drugs other than alcohol by al- coholics has been sufficiently prevalent for clinicians and researchers to record in the past. Alcoholics are using more drugs than ever before.1'7 The importance of identifying drug use and addiction in alcoholic populations is crucial to clinical diagnosis, prognosis, and treatment. The formulation of research models for the etiology and natural history of abuse and addiction to alcohol must consider other drug use and addiction.

The contemporary alcoholic reflects a departure from the traditional alcoholic in pattern and fre- quency of other drugs used. Today’s alcoholic is

younger, usually starts with alcohol as the first drug, and progresses to other drug use rapidly and intense- ly. Most alcoholics under the age of 30 use at least one other drug, typically multiple drugs. The use of the other drugs frequently is addictive and some- times has indistinguishable consequences from an alcohol addiction.3,1

Conversely, the majority of the drug addicts who are addicted initially to a drug other than alcohol later will develop an alcohol addiction. For these drug addicts, alcohol usually is not the drug of choice, but is used as an adjunct for the effects of a drug or as a substitute for a drug.4'5

Dr. Miller is affiliated with Cornell University Medical Col- lege. Dr. Gold is associated with Fair Oaks Hospital, Summit. Requests for reprints may be addressed to Dr. Miller, The New York Hospital/Cornell Medical Center, 21 Bloomingdale Road, White Plains, NY 10605.

PREVALENCE OF USE

An arbitrary cut-off between young and old al- coholics is made at 30 years of age to illustrate the epidemiology of drug use among alcoholics. The in-

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cidence of drug use by alcoholics decreases as age increases and reflects the pattern of drug use that began in the 1960s among the younger popula- tion.3'6 A complete, and often cited, reference that illustrates the frequency of alcohol and drug use in young populations is a monitoring survey conducted annually since 1975 by the National Institute on Drug Abuse (NIDA). A nationally representative sample of high school seniors who are enrolled at the time of the survey is polled.

The lifetime use by high school seniors in 1986 of alcohol was 91 percent; marijuana, 51 percent; co- caine, 17 percent; other stimulants, 23 percent; and tranquilizers, 11 percent. The use in the most recent month for the same drugs was 85 percent, 38 percent, 13 percent, 13 percent, and 6 percent, respectively. Another national survey by NIDA samples house- holds in the United States for drug use in all ages. Although similar figures are obtained for the young, the inverse relationship between age and other drug use among alcoholics is illustrated in this survey. Among the adults 26 years of age and older, the lifetime prevalence in 1985 for alcohol use was 90 percent; marijuana, 27 percent; cocaine, 10 percent; other stimulants, 8 percent; hallucinogens, 6 per- cent; and sedatives/tranquilizers, 12 percent.5

The Drug Abuse Warning Network (DAWN), re- cording visits to emergency rooms in the United States, has found that alcohol used with other drugs was cited more frequently than drugs used alone. This combination of alcohol and drugs accounted for 24 percent of all drug-related episodes in the emer- gency rooms for all ages, excluding those episodes related to alcohol alone, for which data were not collected.6

A national accounting of youths with alcohol and drug problems in the National Youth Poly-drug Study (NYPS) revealed that the mean number of drugs regularly used by the alcoholic youths was 4.4. Marijuana and alcohol were the most frequently used drugs on a regular basis, 86 percent and 80 percent, respectively, of the sample of 2,750 youths. Amphetamines had the third highest prevalence at 45 percent, followed by hashish, barbiturates, hal- lucinogens, and phencyclindim (PCP) at 42 percent, 40 percent, 40 percent, and 32 percent, respectively.7

From 1930 through 1970, alcoholics’ use of other drugs has been reported with regular frequency. As many as 46 percent of 1,340 alcoholic patients (of all ages in 17 New York alcoholism rehabilitation units) used drugs, often addictively, during the 30 days before entering treatment. The drugs most frequent- ly used were minor tranquilizers, marijuana, seda- tives, amphetamines, hallucinogens, and narcotics. Approximately 20 percent of the patients reported using two or more drugs in addition to alcohol. A comprehensive review examining 15,447 cases in 46

studies found 3,046 alcoholics who also were ad- dicted to another drug, a 20 percent rate of drug addiction among alcoholics. Some of today’s drugs were reported in the literature from the 1930s through the 1960s, i.e. barbiturates, opiates, benzodiazepines, organic solvents, and marijuana.8,9

In recent, large-scale studies of inpatient popu- lations of adult and adolescent alcoholics and drug addicts in various treatment facilities, the number of cocaine addicts with the additional diagnosis of alcohol dependence was in the 70 to 90 percent range.10,11 Similar studies of methadone and heroin addicts show rates of alcohol dependence between 50 and 75 percent.12,13 Approximately 80 to 90 percent of cannabis addicts also are addicted to alcohol.10,11 The prevalence of poly-drug use and addiction that includes alcohol is the rule for the contemporary drug addict. The mono-drug user and addict is a vanishing species in American culture.12'14

PATTERNS OF USE

Many studies that examine alcoholics separately from drug addicts indicate that alcohol is the first drug used, often addictively, by both the alcoholic whose primary drug of choice is alcohol and the drug f addict whose primary drug of choice is marijuana or 1 another drug other than alcohol.15 Summarizing i available studies, alcoholics over the age of 30 typi- I cally began drinking in adolescence and progressed s to alcohol dependence in their 20s. A certain propor- t tion began using cannabis (10 to 20 percent) in their ( adolescence. Another 10 percent began use of stimu- ( lants, including cocaine, amphetamines, and or- j ( ganic solvents, while 20 percent began use of i ( sedative/hypnotics, predominately benzodiazepines, i barbiturates, and meprobamates. Around 50 percent ] may continue their alcohol dependence without sig- nificant use of drugs in addition to alcohol.8,9,14,16,17

The alcoholic under the age of 30 has developed a different pattern. Over 80 percent of these al- coholics are addicted to at least one other drug, often more than one drug. A triad of alcohol, marijuana, and cocaine addiction is a regular occurrence among younger alcoholics being admitted currently to inpa- tient and outpatient facilities.18 Typically, the younger alcoholic begins using alcohol in early teenage years, around 13 to 15, progressing to addic- tive use of alcohol by 15 to 16 years of age. A year or two after the onset of alcohol use, other drugs are tried, some addictively, that include marijuana and cocaine, followed by hallucinogens, benzodia- zepines, and barbiturates. The pattern of cocaine use is changing dramatically, most notably by an earlier age of onset of use and high addiction rates. The skillful marketing techniques for the cheaper form of cocaine, “crack,” have lured younger indi- viduals to repetitive and often addictive use.6,7,10,11,17

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© Susan J. Freeman

DIAGNOSIS

The dependence syndrome as defined in DSM-III- R is used to diagnose alcohol and drug dependence by utilizing the criteria of addiction, tolerance, and dependence. Investigations into the utility of the DSM-III-R criteria for diagnosis of the “dependence syndrome” also have confirmed these trends of mul- tiple drug use that are occurring among alcoholics. Clusters of signs and symptoms conform to the criteria for a common dependence syndrome for al- cohol and drugs, particularly, alcohol, opiates, and cocaine.19

The prevalence of multiple drug use by contem- porary alcohol and drug addicts poses difficulties in accurate diagnosis. The identification of only alcohol use in a patient often is tenuous and misleading. Because denial is a part of the addictive process, an under-reporting and underestimation of other drug use is to be expected in a clinical interview, es- pecially if only the alcoholic is interviewed. Cor- roborative sources increase the likelihood of obtain- ing a more accurate estimate of the total pattern and amount of alcohol and other drug use. These ad- ditional sources may be family, employer, legal agencies, and urine and blood testing for drugs.20

Information needed for diagnosis is difficult to obtain from the alcoholic, sometimes in even the most obvious cases. The criteria for addiction, in- cluding preoccupation, compulsive use, and relapse to alcohol and drugs, are boldly denied by many alcoholics and drug addicts who are actively using, and under the influence of, alcohol and drugs. Ques- tions regarding the development of tolerance and dependence to alcohol and drugs are equally difficult to have answered adequately. Persistent pursuit of

the patient by subsequent interviews and a knowl- edge of the natural history of alcohol and drug use and addiction often will yield satisfying results when trying to fully understand the clinical dynamics of the alcoholic.20

Multiple drug use will determine the clinical pres- entation of the acute and chronic intoxication syn- dromes in the alcoholic. A mixture of signs and symptoms produced by alcohol and drugs may con- fuse the clinical picture and make the diagnosis of a specific type of intoxication difficult. Psychiatric syndromes that are produced by alcohol and, par- ticularly, by drugs, in the acute and chronic periods of intoxication, are not easily differentiated from psychiatric syndromes from other etiologies.

TREATMENT

The complete knowledge of all drug use in the alcoholic has important implications in the treat- ment of drug and alcohol withdrawal in the acute detoxification period, as well as in relapse preven- tion. Different drugs, including alcohol, may require individualized detoxification schemes because cross tolerance and dependence do not exist for all the drugs. The physiological withdrawal from alcohol is treated with benzodiazepines, whereas the anergia, depression, and craving seen in cocaine withdrawal are treated by bromocriptine.21,22 The persistent de- lusional and hallucinatory symptoms from PCP are ameliorated by neuroleptic medication. The withdrawal syndrome from opiates is treated either with clonidine or methadone.23,24 Furthermore, the protracted withdrawal from hallucinogens and other stimulants in the alcoholic may require prolonged pharmacological intervention and supportive care.

The nonpharmacological modalities for long-term

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treatment of alcohol dependence are affected by other drug use. Individualized education and sup- port are indicated for specific drugs such as cocaine and opiates. However, the principles of the abstinence-based treatment program that includes Alcoholics Anonymous will work for the alcoholic who has additional drug addictions. The similarities among the alcohol and multiple drug addictions are greater than the differences, so that recovery by poly-drug alcoholics in self-help groups such as Al- coholics Anonymous (AA) and Narcotics Anony- mous (NA) is not only possible, but is more the rule than the exception. Even individual psychotherapy should involve the core of both alcohol and drug addiction and their combined effects on the mind and behavior.

The risk of relapse to the drug of choice, whether it be cocaine, opiates, marijuana, or alcohol, is heightened by the use of any drug, including alcohol. The need to abstain from all drugs, including al- cohol, is necessary, with few exceptions.1015'1719

GENETICS

The theoretical implications are interesting to consider, especially because of the genetic studies of the recent decades. Twin, adoption, familial, and high-risk studies have demonstrated a significant genetic predisposition to alcoholism. Identical twins are more concordant for alcoholism than fraternal twins. The biological parent of an adoptee is a more important determinant of alcoholism than the foster parent who reared the adoptee. Alcoholism runs in families. More than 50 percent of alcoholics have a family history of alcoholism. A child of an alcoholic is more likely to have certain neurophysiological and behavioral manifestations in common with other off- spring of alcoholics than with matched controls without an alcoholic parent.25

Corresponding studies for the prevalence of al- cohol dependence in the families of cocaine and opiate addicts and other drug users have been per- formed. In one study, the rate of diagnosis of alcohol dependence in first- or second-degree relatives in the families of 263 cocaine addicts was greater than 50 percent; more than 132 cocaine addicts had at least one relative with alcohol dependence by DSM-III- R criteria.26

Opiate addicts with a parental history of al- coholism more frequently were diagnosed with con- current alcoholism. In one study, opiate addicts (n = 638) had at least one parent with alcohol de- pendence in 21.3 percent of the families. Opiate ad- dicts with the diagnosis of alcohol dependence (n = 216) had a 27.0 percent rate of parental al- coholism, and opiate addicts (n = 422) without pa- rental alcohol dependence had a 12.5 percent rate of alcohol dependence in their families. Among the

opiate addicts with alcohol dependence, those with parental alcoholism had more severe problems with alcohol.27

A study of young alcohol users revealed a higher rate of alcohol-related problems and drug use if a family history of alcoholism was present in first- and second-degree relatives. Young alcohol users without, or with fewer, relatives with alcoholism had a lower rate of alcohol-related problems and drug use.28

These findings compare favorably with the famil- ial studies of alcoholism. Alcoholics have at least a 50 percent probability for a positive family history of alcoholism. The high rate of alcohol dependence among cocaine and opiate addicts and drug users and their families suggests a generalized vulner- ability that may have a genetic contribution to al- cohol and drug abuse. The genetic predisposition to alcoholism may overlap or share transmission with cocaine, opiates, and other addictions.

THE NEUROBIOLOGY OF ADDICTION

The concurrence of alcohol and drug addiction provides further theoretical considerations for a neu- robiological basis for addiction. The loss of control that underlies all the criteria for addictive behavior is manifested by a drive to pursue, use, and resort to alcohol and drugs repetitively and spontaneously. The substrate for the mechanisms for the drive in addiction reside in the limbic system.29 The limbic structures include the amygdalae and septal areas for mood, the hippocampi for memory association, and the drive states for hunger, libido, and thirst. The reward center also is represented among the limbic structures in the lateral hypothalamus.30

The important features of addiction are subserved by the functions in the limbic system. Alcohol and drugs profoundly alter mood and drive states. An association between alcohol and drugs and the drive states may be reinforced by the reward center and recorded in memory by the hippocampi. The drive states may entrain the use of alcohol and drugs in a fashion similar to their autonomous control over their other functions. The pursuit and use of drugs and alcohol become as easily stimulated and spon- taneous as eating, drinking, and sexual behavior.31

Cocaine may activate the limbic system through stimulation of the dopamine transmission.32 The re- ward system consists of neurons located in the lateral hypothalamus that traverse the median fore- brain bundle to synapse on dopamine-containing neurons in the ventral tegmentum. These dopamine neurons send fibers into the nucleus accumbens (mesolimbic pathway) and the limbic cortex (mesocortical pathway). Neurons with opiate recep- tors for endorphins and enkephalins are located on the dopamine neurons in the ventral tegmentum.

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NEW JERSEY MEDICINE

Alcohol appears to have a widespread effect on many of the neurotransmitter systems in the limbic system and reward system. All of the drugs of addiction, including alcohol, affect mood, libido, memory, and appetite. These drugs also may stimulate the mesolimbic area that may be responsible for halluci- nations and delusions. All the drugs suppress frontal lobe function to produce impairment in judgment and insight characteristic of these addictions.3031 SUMMARY

Multiple drug use occurs in alcoholics in an age- dependent relationship. The younger the onset of alcoholism, the more likely is additional drug use. Drugs used by alcoholics, in decreasing order of fre-

quency, are marijuana, cocaine, and other stimu- lants, phencyclidine, benzodiazepines, barbiturates, and hallucinogens. Evaluation of intoxication and treatment or detoxification in alcoholics should always include consideration of other drugs. Mul- tiple drug use in alcoholics does not preclude the short- or long-term treatment that traditionally is available for alcoholics, such as programmatic treat- ment and AA and NA and psychotherapy. The ex- istence of poly-drug addiction in alcoholics and of alcohol dependence in families of drug addicts and alcoholics suggest a common genetic vulnerability to alcoholism and drug addiction. ■

Submitted: April 1989; Accepted: June 1989

REFERENCES

1. Sokolow L, Welte J, Hynes G, Lyons J: Multiple substance abuse by alcoholics. Br J Addict 76:147-158, 1981.

2. Mirin SM, Weiss RD, Michael J: Alcohol abuse in patients dependent on other drugs. Psychiatr Ann 12:430-433, 1982.

3. Refroe CL, Messinger TA: Street drug analysis. An 11-year perspective on illicit drug alteration. Sem Adoles- cent Med 1:247-257, 1985.

4. Jekel JF, Allen DF: Trends in drug abuse in the mid-1980s. Yale J Biol Med 60:45-52, 1987.

5. Clayton RR: The epidemiology of alcohol and drug abuse among adolescents. Adv Alcohol Subst Abuse 4:69-87, 1985.

6. Meltzer HF, Kreek MJ: Multiple drug abuse pat- terns and medical consequence, in Psychopharmacology: The Third Generation of Prognosis. New York, NY, Raven Press, pp. 1597-1604, 1987.

7. Santo Y, Farley EC, Friedman AS: Highlights from the National Youth Poly-drug Study, in, Drug Abuse Pat- terns among Young Poly-drug Abusers and Urban Ap- palachian Youths. U.S. Dept, of Health and Human Ser- vices, Publication No. 80-1002, 1-16, 1980.

8. Freed EX: Drug abuse by alcoholics: A review. Int J Addict 8:451-473, 1973.

9. Sokolow L, Welte J, Hynes G, Lyons J: Multiple substance abuse by alcoholics. Br J Addict 76:147-158, 1981.

10. Miller NS, Gold MS: The diagnosis of alcohol de- pendence and cannabis dependence among cocaine ad- dicts (submitted for publication), 1988.

11. Miller NS, Millman RB, Keskinen S: The preva- lence of alcohol dependence among cocaine addicts in an inpatient population (submitted for publication), 1988.

12. Liebson F, Bigelow G, Flainer R: Alcoholism among methadone patients. A specific treatment method. Am J Psychiatry 130:483-485, 1973.

13. Birrhari B: Alcoholism and methadone mainte- nance. Am J Drug Alcohol Abuse 1:79-87, 1974.

14. Carrol JFX, Santo Y, Hannigan PC: Description of the total client sample, analysis of substance use patterns and individual program descriptions, chapter III, in, Gardner SE, National Drug/Alcohol Collaborative Project Issues in Multiple Substance Abuse. Research Monograph Services, NIDA DHEW Publication No. (ADM) 80-957, 1980.

15. Gold MS: Drugs of Abuse: A Comprehensive Series for Clinicians. Vol. 1. Marijuana. New York, NY, Plenum

Medical Book Company, 1989.

16. Kanaia J, Kofoed L: Drug use by alcoholics in out- patient treatment. Am J Drug Alcohol Abuse 10:529-534, 1984.

17. Smith DE: Cocaine-alcohol abuse: Epidemiological, diagnostic, and treatment considerations. J Psychoactive Drugs 18:117-129, 1986.

18. Gold MS: The Facts About Drugs and Alcohol. New York, NY, Bantam Books, 1987.

19. Kosten TR, Rounsaville BJ, Babor TF, et al.: Substance-use disorders in DSM-III-R evidence for the dependence syndrome across different psychoactive substance. Br J Psychiatry 151:834-843, 1987.

20. Miller NS: A primer of the treatment process for alcoholism and drug addiction. Psychiatry Letter 5:30-37, 1987.

21. Extein IL, Gold MS: The treatment of cocaine ad- dicts: Bromocriptine or desipramine. Psychiatr Ann 18:535-537, 1988.

22. Dackis CA, Gold MS: Bromocriptine as treatment of cocaine abuse. Lancet 1:1151-1152, 1985.

23. Miller NS, Gold MS, Millman RB: PCP: A danger- ous drug. Am Fam Pract 38:215-218, 1988.

24. Tennant F: Clinical diagnosis and treatment of postdrug impairment syndrome. Psychiatry Letter 6:47-51, 1988.

25. Goodwin DW: Alcoholism and genetics: The sins of the fathers. Arch Gen Psychiatry 42:171-174, 1985.

26. Miller NS, Gold MS, Belkin BM, Klahr AL: Family history and diagnosis of alcohol dependence in cocaine dependents (in press), 1988.

27. Kosten TR, Rounsaville BJ, Kleber HD: Parental alcoholism in opioid addicts. J Nerv Mental Dis 173:461-468, 1985.

28. Schuckit MA, Sweeney S: Substance use and men- tal health problems among sons of alcoholics and controls. J Studies Alcohol 48:528-534, 1987.

29. Gold MS, Dackis CA: New insights and treatments: Narcotics and cocaine addiction. Clin Ther 7:6-21, 1985.

30. Lader M: The psychopharmacology of addiction. New York, NY, Oxford University Press, 1988.

31. Miller NS, Dackis CA, Gold MS: The relationship of addiction, tolerance, and dependence: A neurochemical approach. J Substance Abuse Treatment 4:197-207, 1987.

32. Dackis CA, Gold MS: New concepts in cocaine ad- diction: The dopamine depletion hypothesis. Neu-

roscience Biobehavioral Rev 9:469-477, 1985.

VOL. 87— NUMBER 1 JANUARY 1990

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NEW JERSEY MEDICINE

Whipple Operation Revisited

DAVID A. SPAIN, MD RALPH S. GRECO, MD

The Whipple procedure traditionally is associated with an operative mortality of 20 to 25 percent. /As a result, percutaneous and endoscopic techniques have been advocated to alleviate symptoms in patients with periampullary carcinoma. Now, dramatic reductions in operative mortality rates have been reported. Since radical pancreaticoduodenectomy is the only treatment for cure, a re-evaluation of the role of this procedure is warranted.

Modern pancreatic surgery began in 1935 when Whipple introduced a two-stage radical pancreaticoduodenectomy for the treatment of carcinoma of the ampulla of Vater.1 This was modified to a single-stage procedure by Trimble in 1941. 2 At that time, the fear of a pan- creatic-intestinal anastomosis was so great that the pancreatic duct was simply ligated. This led to pan- creatic fistula formation in up to 70 percent of pa- tients.3 During the next 30 to 40 years, despite ad- vances in surgical techniques, septic complications from leakage of the pancreatic-jejunal anastomosis were frequent. The high operative morbidity and mortality rates and poor long-term survival in periampullary cancers caused surgeons in the 1960s and 1970s to call for abandonment of this procedure. In 1970, Crile reported that survival in patients with

Dr. Spain is a resident in general surgery and Dr. Greco is professor and chief, Division of General Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick. Requests for reprints may be addressed to Dr. Greco, UMDNJ-Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, CN 19, New Brunswick, NJ 08903-0019.

biliary bypass was greater than those with resection.4 However, this study was limited to patients with adenocarcinoma of the head of the pancreas and a palpable mass, and, therefore, does not apply to all patients with periampullary tumors.

Radical pancreaticoduodenectomy offers the only chance for cure in patients with periampullary cancers, which now are the fourth leading cause of death from cancer.5 Despite advances in diagnostic capabilities, it often is difficult to distinguish the origin of the four tumors found in the periampullary region: pancreatic, ampullary, common bile duct, and duodenal. Five-year survival rates vary drastically depending on the site of origin, from as low as 3 percent for pancreatic cancer to as high as 60 percent for ampullary cancer,6'8 but laparotomy may be the only way to identify a more favorable lesion. In order to justify the more frequent use of this procedure, morbidity and mortality rates must be decreased. Recent reports from Johns Hopkins University, UCLA Medical Center, and other in- stitutions have reported operative mortality rates as low as 1 to 6 percent, well below the oft-quoted 25 percent.79 These reports and experience with a re-

VOL. 87— NUMBER 1 JANUARY 1990

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cent patient prompted us to review radical pan- creaticoduodenectomy at Robert Wood Johnson University Hospital. Unfortunately, the traditional view that the Whipple procedure carries a prohibitive mortality has remained with many in- ternists, gastroenterologists, radiologists, and sur- geons. A nonoperative approach using percutaneous or endoscopic techniques to alleviate symptoms has

Table 1. Presenting signs and symptoms. Number Percent
Jaundice	11	92
Bilirubinuria	7	58
Diarrhea/Acholic Stool	7	58
Weight Loss	6	50
Abdominal Pain	4	33
Pruritis	4	33
Abnormal liver function tests	1	8.3

been advocated for an ever-increasing number of patients. A case report illustrates the limitations of the nonoperative approach and the advantages of an aggressive surgical attitude towards patients with periampullary tumors.

CASE REPORT

A 59-year-old white female, with a history of asthma and atrial arrhythmias, was seen initially at another hospital for vague right upper quadrant ab- dominal pain associated with anorexia and weak- ness. A diagnosis of biliary colic was made, and when her symptoms subsided, she was discharged from the emergency room. She felt well for two weeks and then noticed the gradual onset of jaundice and a 15- pound weight loss. She was admitted to the hospital for evaluation. A computed tomography (CT) scan of the abdomen was performed and reported to show an extensive mass in the head of the pancreas, which was felt to be unresectable. An endoscopic retro- grade cholangiopancreatography (ERCP) was at- tempted, but the ampulla could not be identified. A large mass impinging on the second portion of the duodenum was found. A biopsy was positive for adenocarcinoma. She was transferred to the Robert Wood Johnson University Hospital Surgical Service for evaluation.

Physical examination revealed an icteric woman with normal vital signs. Her lungs were clear and the cardiac rhythm regular. The abdomen was soft with slight right upper quadrant tenderness. A 6 cm gall- bladder was palpable in the right upper quadrant. The liver span was 8 cm. The rectal examination was normal and the stool negative for blood.

Laboratory data were significant for a total bilirubin of 8.0 mg percent with a direct of 6.0 mg

percent, and elevation of all liver enzymes including an alkaline phosphatase of 640 U/L (normal 0 to 75 U/L). A visceral arteriogram revealed a right hepatic artery originating from the superior mesenteric ar- tery and displacement of the superior mesenteric vessels by the tumor mass. Encasement of a minor inferior pancreaticoduodenal artery branch was seen as well.

Table 2. Operative data.

	1980-1988 (n = 12)	1980-1984 (n — 6)	1985-1988 (n = 6)
Operative Time	8 hr 14 m	9 hr 20 m	7 hr 8 m
Estimated Blood	2010 cc	2400 cc	1620 cc
Loss
Intraoperative	3.9 units	4.6 units	3.3 units
Transfusions
Morbidity	58.3%	66.7%	50.0%
Mortality	0%	0%	0%

At this point, the impression was that the patient had a pancreatic head cancer that appeared unre- sectable. Physicians involved in her care offered sev- eral treatment modalities to the patient, including percutaneous biliary drainage. We strongly felt this patient should have an exploratory laparotomy and possible radical pancreaticoduodenectomy, as this offered the only chance for cure. The patient agreed and underwent a Whipple procedure with an opera- tive time of four hours and 14 minutes. Estimated blood loss was 500 cc and no transfusions were re- quired. Pathologic examination of the specimen re- vealed a well-differentiated adenocarcinoma of the ampulla of Vater (Figure). The margins were free of tumor and all nodes were negative. The patient’s postoperative course was uneventful and she was discharged on postoperative day 10.

RESULTS

Twelve patients have undergone elective radical pancreaticoduodenectomy at Robert Wood Johnson University Hospital from 1980 to 1988. All were per- formed for carcinoma. There were 9 males and 3 females with an average age of 62 years (range 54 to 73 years). The oldest patient now is 76 years old and alive and well without evidence of disease. Pre- senting signs and symptoms are listed in Table 1. The average duration prior to presentation was 5 weeks (range 1 to 12 w'eeks). Seven patients had pancreatic tumors and 3 patients had negative nodes. There were 2 patients with ampullary and 1 patient with common bile duct cancer, all with negative nodes. Both patients with primary duodenal cancer had positive nodes.

Operative data for all patients are presented in Table 2. The cases are divided into two time periods

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NEW JERSEY MEDICINE

Figure. Gross pathology specimen revealing a 5 x 5 cm mass of the ampulla of Vater. The probe is through the common bile duct.

VOL. 87— NUMBER 1 JANUARY 1990

43

for comparison. There were no perioperative deaths in either group and all patients were discharged home. During the last four years, operative time, estimated blood loss, and the number of intra- operative transfusions all have decreased. Morbidity remained high at 50 percent but decreased from 66.7 percent for the previous time period. Five patients had no complications and were discharged between 10 and 24 days. Three patients (33 percent) had the major complication of an anastomotic leak with intra-abdominal abscess: two patients were drained percutaneously and one patient required a second laparotomy. Three patients developed postoperative diabetes mellitus, but easily were controlled with modest doses of insulin.

DISCUSSION

The Whipple procedure remains one of the most complex and difficult intra-abdominal operations performed. Historically, the operative mortality rates have been 20 to 25 percent.10 Because of this and the poor long-term prognosis for pancreatic cancer, there has been a great hesitancy to subject patients to this procedure. Recent developments in endoscopy and interventional radiology have provided nonoperative methods to alleviate symp- toms in patients with periampullary cancers. This philosophy, however, ignores the well-documented decrease in operative mortality rates to 3 to 10 per- cent.7911 Grace and Longmire from UCLA had an operative mortality rate of 6 percent in 96 patients, and this had further decreased to 2 percent in the last five years of their study.7 In 1984, Trede reported an operative mortality of 1.1 percent in 91 con- secutive patients and found that the resectability rate also had increased from 5 to 21 percent during the study.11 Advances in perioperative care, includ- ing intensive care unit monitoring and total parent- eral nutrition, and improved treatment of peri- operative complications through interventional

radiology may account for these changes. Cameron believes the most important reason for the decline is that more patients are being sent to experienced pancreatic surgeons at regional centers.12

Overall survival in pancreatic cancer appears to be increasing, although the reasons for this are un- clear.9 Cameron reported an actual five-year survival of 19 percent in all patients with pancreatic cancer undergoing a Whipple procedure; however, lymph node involvement was critical.12 Five-year actuarial survival was 1 percent in node positive patients, and 48 percent in those with negative nodes. Three of our patients fall into the latter category. In 1986, the UCLA Medical Center reported a five-year actuarial survival after resection of 52 percent in common bile duct cancer, 60 percent in duodenal cancer and 62 percent in ampullary cancer.7 Therefore, 6 of 12 pa- tients in our study would be expected to have a 40 to 60 percent chance of surviving five years. In par- ticular, the patient presented would have been poor- ly served with a nonoperative approach or simple biliary bypass.

Clearly, the prevailing attitude toward radical pancreaticoduodenectomy must be re-evaluated. Furthermore, nonoperative approaches must be re- evaluated as well, with specific regard to the quality of survival. There is one point upon which all specialists dealing with this problem agree: patients who are denied operations will die of their disease. Patients now may be offered a potentially curable operation with an acceptable mortality. Although complications still are common and the overall prog- nosis is variable, we must not become pessimistic. Radical pancreaticoduodenectomy offers the only chance to cure these patients. An aggressive surgical approach should be undertaken in all patients with periampullary lesions unless there is unequivocal evidence of metastatic disease. ■

Submitted: May 1989; Accepted: July 1989

REFERENCES

1. Whipple AO, Parsons WB, Mullins CR: Treatment of carcinoma of the ampulla of Vater. Ann Surg 102:763-779, 1935.

2. Trimble IR, Parsons JW, Sherman CP: A one-stage operation for the cure of carcinoma of the ampulla of Vater and head of the pancreas. Surg Gynecol Obstet 73:711-727, 1941.

3. Papachristou DN, D’Agistino H, Fortner JG: Liga- tion of the pancreatic duct in pancreatectomy. Br J Surg 67:260-262, 1980.

4. Crile G Jr: The advantage of bypass operation over radical pancreaticoduodenectomy in the treatment of pan- creatic carcinoma. Surg Gynecol Obstet 130:1049-1053, 1970.

5. Silverberg E: American Cancer Society. Cancer Statistics 36:9-16, 1986.

6. Connolly MM, Dawson PJ, Michelassi F, et ah: Survival in 1001 patients with carcinoma of the pancreas.

Ann Surg 206:366-373, 1987.

7. Grace PA, Pitt HA, Tompkins RK, et ah: Decreased morbidity and mortality after pancreaticoduodenectomy. Am J Surg 151:141-149, 1986.

8. Hayes DH, Bolton JS, Willis GW, Bowen JC: Carcinoma of the ampulla of Vater. Ann Surg 206:572-577,

1987.

9. Crist DW, Sitzman JV, Cameron JL: Improved hos- pital morbidity and mortality after the Whipple procedure. Ann Surg 206:358-365, 1987.

10. Shapiro TM: Adenocarcinoma of the pancreas: A statistical analysis of biliary bypass versus Whipple resec- tion in good risk patients. Ann Surg 182:715-721, 1976.

11. Trede M: The surgical treatment of pancreatic carcinoma. Surgery 97:28-35, 1985.

12. Cameron JL: Current status of the Whipple oper- ation for periampullary carcinoma. Surgical Rounds 77-87,

1988.

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MEDICAL HISTORY

Thomas Jefferson University

Tradition and Heritage

MORRIS H. SAFFRON, MD

This ponderous and unwieldly volume (edited by Frederick B. Wagner, Jr, MD, Lea and Febiger, Philadelphia and London, 1989) contains the most detailed account of any medical school in the United States. Written and in large part edited by a Jefferson professor of surgery who also is University historian, the work is a composite by many hands, including specialists in various fields as well as collateral administrators. This essay will concern itself primarily with the 19th century history of the school as it relates to the development of medical education in this country.

Jefferson College, the first literary institution founded west of the Alleghenies, was chartered in 1802 during the administration of our third president who showed his pleasure at the name by donating books and money to the school. As a result, a tenuous relationship with the University of Virginia seems to have persisted for a considerable period of time. However, it was not until 1824 that a medical school located in Philadelphia was engrafted on the parent college. Two years later, despite strenuous efforts on the part of the University of Pennsylvania to prevent such a move, the state Legislature authorized the new school to grant the medical degree. The animus between the two schools per- sisted for many years and as late as the 1830s, it was stated that “the faculty of the University of Penn- sylvania could take no notice of anything that emanated from the Jefferson School.” The prime

Dr. Saffron is archivist/historian of the Medical Society of New Jersey, and a member of the Editorial Board of NEW JERSEY MEDICINE. Requests for reprints may be addressed to Dr. Saffron, Medical Society of New Jersey, Two Princess Road, Lawrenceville, NJ 08648.

mover in the stirring events connected with the foun- dation of Jefferson was the surgeon George McClellan, himself a Pennsylvania graduate. He was assisted by three other faculty members, one of whom was the noted John Eberle, an early pedia- trician whose Treatise on the Practice of Medicine ran through no less than six editions.

The 1830s, the so-called Jacksonian era, witnessed a general lowering of educational standards with the concomitant rise of a number of poorly organized proprietary medical schools, many of which ex- perienced a rapid demise. Jefferson itself suffered from many vicissitudes, including a difficulty in re- taining faculty members as well as financial prob- lems before reaching a period of relative calm. Among the prominent teachers of these early days were: botanist William P. C. Barton, professor of materia medica, whose Flora of North America is highly regarded and Nathan R. Smith, a surgeon who already had founded two medical schools in Vermont and at Dartmouth before coming to Jef- ferson. Another transient faculty member was the remarkable medical pioneer, Daniel Drake, who taught at several schools and was the founder of two others in Ohio. He is noted as author of the classic Diseases of the Interior Valley of North Am erica, the first textbook on the subject. Still another peri- patetic who touched base at Jefferson was the Scotsman Grenville S. Pattison, a famous anatomist who soon wandered off to help found the medical school at New York University.

At this period, the class of 1835 produced two graduates whose names still are revered in the his- tory of medicine: Carlos J. Finlay, the Cuban phy- sician who apparently was the first to attribute the

VOL. 87— NUMBER 1 JANUARY 1990

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MEDICAL HISTORY

cause of malaria to the bite of a mosquito, and J. Marion Sims, whose skill in the repair of vesico- vaginal fistulae brought him the title, father of American gynecology, and a statue in New York’s Central Park. Somewhat later, another famous graduate was Edward R. Squibb, who devised a method of freeing ether from its impurities and went on to establish the famous pharmaceutical house which still bears his name.

The year 1838 saw the final separation of Jefferson Medical School from the parent college. The ensuing year was one of turmoil and dissension ending with the dismissal of the founding father, George McClellan, and the selection of a basically new fac- ulty. Prominent among the appointees were Robley Dunglison, professor of medicine, and Charles D. Meigs, professor of obstetrics and gynecology. Both of these men were prolific writers and their numer- ous publications helped bring increased recognition to the “second” Philadelphia school. Indeed, it was the highly cultured Meigs who obtained a somewhat dubious notoriety for himself by his vigorous opposi- tion to the Holmes-Semmelweiss theory of post- partum contagion induced by the uncleanliness of the obstetrician. A rigorous traditionalist, Meigs later opposed the use of anesthesia during child- birth. In 1847, at the founders meeting of the Ameri- can Medical Association, it was a Jefferson professor of medicine, Nathaniel Chapman, who was named first president by acclamation.

We now are approaching the antebellum period and the arrival from Louisville of Samuel D. Gross as professor of surgery. Gross succeeded Thomas D. Mutter whose name is perpetuated in the famous anatomical museum now housed in the College of Physicians of Philadelphia. During his long and pro- ductive tenure (1856-1882), Gross became recog- nized as dean of surgery in America, and the numer- ous accolades he received on his many trips here and abroad naturally brought permanent lustre to the institution which he represented. The famous paint- ing by Thomas Eakins, “The Gross Clinic,” is rec- ognized as a masterpiece of American painting. In- cidentally, the connection between the artist, who insisted on emphasizing the value of anatomical studies to his pupils, and the nearby medical school was very close, with the result that the numerous portraits of faculty members done by Eakins remain among Jefferson’s most prized possessions.

The Civil War brought a period of hardship to Jefferson as many southern students withdrew to join the Confederate forces. Gross immediately produced a “Manual of Military Surgery” which promptly was pirated by the southerners and soon became a veritable vade mecum for medical officers on both sides of the struggle. By the end of the war, Jefferson had become firmly established as a leading

school of medicine in this country. Among the notables on the faculty we can mention only a few: John W. Brinton, a founder of the Army Medical Museum and collaborator with William H. Ham- mond in the publication of the voluminous, Medical and Surgical History of the War of the Rebellion; William W. Keen, a prolific writer on anatomy and surgery noted for performing the first successful op eration for brain tumor; and John P. da Costa whose work on surgery went through ten editions. In other fields, we may mention the unrelated though equally famous clinician, Jacob M. da Costa, whose Medical Diagnosis long held supremacy in the field; Jacob da Silva Solis-Cohen, a pioneer in the specialty of laryngology; Hobart A. Hare, whose work on thera- peutics was reprinted no less than 21 times; and S. Weir Mitchell, often called the father of neurology in this country, who is equally revered for his eminence in the field of the American novel.

Jefferson sailed through the Flexner probe of 1910 to 1911 with flying colors, and as we approach recent times, the names of faculty leaders in medicine be- come ever more frequent: Elmer H. Funk who ex- panded Trudeau’s sanatorium treatment for tu- berculosis; Martin E. Rehfuss, the gastroenterologist whose name is linked with his tube for gastric analysis; Charles E. Sajous and Francis X. Dercum, pioneers in the development of the science of en- docrinology; Jay F. Schamberg, the dermatologist who collaborated in the manufacture of arsphenamine when this substance could not be ob- tained from Germany during World War I; George E. de Schweinitz, famous ophthalmologist whose Diseases of the Eye, first published in 1892, ran through ten editions; and Chevalier Jackson, an in- novator in the field of bronchoscopy who improved instruments used in removing foreign objects from the food and air passages.

As previously indicated, the latter half of this vol- ume is concerned with the development of the vari- ous specialties. Written in each instance by the cur- rent head of the department, these introductory ac- counts should prove of considerable interest to fu- ture scholars. Unfortunately, in the case of the older disciplines such as surgery and medicine, there is a noticeable degree of overlapping and repetition which occasionally mar this otherwise splendid work. At times, identical photographs are repro- duced. A number of portraits seems to be legion and in the case of Samuel D. Gross, I counted no less than four, with two duplicates of the sword carried by his son during the Civil War. In spite of such laudable, if frequently overwhelming, efforts to at- tain absolute completeness, this book certainly will prove to be a landmark in the field, and one which future institutional historians will wish to explore and emulate. ■

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CASE REPORT

Malignant Fibrous Histiocytoma

Induced by Thorium

MARK T. DIMARCANGELO, DO ERIBERTO T. DAVID, MD KOSON KURODA, MD

Thorium dioxide is a deleterious substance that was employed as a vascular contrast medium during the early 20th century. Our report entails a unique neoplastic complication of thorium administration.

We report the interesting and unusual his- tory of a patient exposed to the contrast medium, thorium dioxide, during the sec- ond decade of her life. The patient then developed an extraosseous malignant fibrous histiocytoma of her lower extremity during the sixth decade of life.

The authors are affiliated with the Department of Diagnostic Radiology and Nuclear Medicine, Cooper Hospital/University Medical Center, Camden. Requests for reprints may be addressed to Dr. DiMarcangelo, Cooper Hospital/University Medical Center, 1 Cooper Plaza, Camden, NJ 08103.

To our knowledge, this is the first report of this rare, latent complication of thorium exposure.

CASE REPORT

A 57-year-old woman was admitted to Cooper Hospital/University Medical Center, Camden, in November 1987, with a mass involving the right thigh, accompanied by edema of the entire lower extremity. At age 11, the patient sustained a severe laceration to the right thigh, that was repaired surgically. At age 14, she developed painful right lower leg varicosities. She underwent a venogram

VOL. 87— NUMBER 1 JANUARY 1990

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CASE REPORT

with thorotrast (thorium dioxide), at which time there was soft tissue extravasation of the thorotrast into the right thigh and pelvis. The patient could not recall the site of the contrast injection. She subse- quently had two venous ligation procedures to treat the varicosities.

Six years prior to the present admission, the pa- tient had a frontal meningioma excised. Approx- imately 24 months before this admission, a mass developed in the right thigh, that was diagnosed as a malignant fibrous histiocytoma (MFH). The neoplasm was resected and followed by radiation therapy (6500 rads) to the surgical bed.

Within 24 months, the thigh mass recurred and outpatient chemotherapy with Adriamycin® and Methotrexate® was initiated. The tumor, however, was refractory to this therapy, necessitating hospi- talization.

On this admission, the plain film examination of the abdomen and abdominal computed tomography (CT) imaging demonstrated sequestration of thorotrast within the spleen and the lymph nodes (Figures 1 and 2). As might be expected, the spleen was noted to be diminished in size secondary to

Figure 1. The plain abdominal radiograph shows thorotrast within the spleen (arrow) and multiple lymph nodes (ar- rowheads).

radiation-induced atrophy. Radiographic examin- ation of the right hemipelvis and thigh demon- strated thorotrast within the musculature and adja- cent soft tissues as well as within regional lymph nodes (Figure 3). Arteriography, preliminary to sur- gery, revealed tumor blush within the right thigh mass (Figure 4).

A total right lower extremity amputation (right hip disarticulation) was done. Surgical recovery was uneventful and there was no evidence of other neoplastic process at the time of discharge. A third primary neoplasm has been discovered in the upper lobe of the right lung; histology has yet to be estab- lished, but it is thought to be a carcinoma.

PATHOLOGICAL FINDINGS

Gross pathological analysis of the amputated thigh revealed an oval, circumscribed, rubbery, white and pale gray tumor measuring 14 x 11 x 6 cm. The mass involved the skeletal musculature and extended into the subcutaneous fat. Osseous in- volvement was not found, but there was impinge- ment upon the femoral vessels and evidence of cen- tral tumor necrosis. The microscopic examination again demonstrated findings consistent with malig- nant fibrous histiocytoma of the storiform pleomorphic variety. Thorotrast granules were pres- ent in the microscopic sections.

DISCUSSION

Thorium dioxide (thorotrast) is a radioactive substance that predominantly emits alpha particles. This agent was utilized as a contrast medium after its introduction in 1928.' Thorium-232, present in thorotrast, has a biological half life of 400 years and, when introduced into the body, it is sequestered by the reticuloendothelial system. The alpha particles are responsible for high radiation dosage to these

Figure 2. Computed tomogram of the upper abdomen confirms i the presence of thorotrast ih the spleen (arrow) and lymph nodes (small arrowheads). Radiopaque contrast is present within the stomach (large arrowhead).

48

NEW JERSEY MEDICINE

CASE REPORT

Figure 3. Plain film of the right hemipelvis and upper thigh depicts thorium within the soft tissues and lymph nodes.

tissues and can culminate in carcinogenesis. After the first report in 1947 of neoplasia related to thorotrast administration,2 the angiographic use of this deleterious material was abandoned. Many papers since have described the malignancies as- sociated with thorotrast. The types of tumors cited in the literature include various hepatic and splenic lesions,1 meningioma,3 4 leukemia/ lung carcinoma,5 renal cell carcinoma,6 mesotheliomas, and sarcomas of the bone and soft tissues of the neck.7 No reports were found of thorium-induced MFH of the lower extremity. It is interesting to note that, although MFH usually is osseous in origin, this patient’s

Figure 4. Arteriogram reveals smooth narrowing of the proxi- mal portion of the superficial femoral artery secondary to adja- cent mass effect (arrow). Tumor blush and neovascularity also are present (arrowheads).

neoplasm was totally extraosseous in location.

A thigh malignancy occurring in an area where there had been thorotrast deposition 21 years earlier is consistent with thorotrast-induced neoplasia. As systemic thorotrastosis was noted on radiography and CT of the abdomen, it is probable that the three primary neoplasms in this patient (meningioma, MFH, and lung carcinoma) can be attributed to the administration of thorium dioxide. ■

Submitted: April 1989;

Accepted: September 1989

REFERENCES

1. Levy D, Rindsberg S, Friedman A, et al.: Thorotrast- induced hepatosplenic neoplasia: CT identification. Am J Roent 146:997-1004, 1986.

2. Kaplan A, Teng S, Koo A: CT Recognition of thorotrast-induced intracranial and lumbar arachnoiditis. Am J Neuro Rad 5:323-325, 1984.

3. Kyle R, Oler A, Lasser E, Rosomoff H: Meningioma induced by thorium dioxide. N Engl J Med 268:80-82, 1963.

4. Boggs D, Kaplan S: Cytobiologic and clinical aspects

in a patient with chronic neutrophilic leukemia after

thorotrast exposure. Am J Med 81:905-910, 1986.

5. Sadahira Y, Mori M, Nakamoto S, et al.: Lung cancer in a thorotrast-administered patient. Acta Pathol Jpn, 35:1467-1473, 1985.

6. Kauzlaric D, Barmeir E, Lusieti P, et al.: Renal carcinoma after retrograde pyelography with thorotrast. Am J Roent 148:897-898, 1987.

7. Silpananta P, Illescas F, Sheldon H: Multiple malig- nant neoplasms 40 years after angiography with thorotrast. Can Med Assoc J 128:289-292, 1983.

VOL. 87— NUMBER 1 JANUARY 1990

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NEW JERSEY MEDICINE

'iclorian 72. Shops On

HOUSING APPLICATION

224th ANNUAL MEETING MEDICAL SOCIETY OF NEW JERSEY MAY 6-9, 1990

Select the hotel of your choice. Mail the entire form with one night’s deposit to that hotel.

THE SANDS HOTEL, CASINO & COUNTRY CLUB (Headquarters Hotel)

INDIANA AVE. AT BRIGHTON PARK, P.O. BOX 28, ATLANTIC CITY, NJ 08404 RESERVATION DEPARTMENT 1-800-257-8580

(Please Print)

Name

Address

City State Zip

Home Phone Business Phone

Sharing With

Date of Arrival Time

Date of Departure Time

A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money order payable to the SANDS or complete the following:

American Express No. Expiration Date

SCHEDULE OF RATES SUBJECT TO 12% TAX

□ SINGLE $75.00 □ One-Bedroom Suite $225.00 □ Two-Bedroom Suite $300.00

□ DOUBLE $75.00 (Reservations must be received prior to April 6, 1990)

Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.

PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.

□ Check if Official Delegate County

CLARIDGE CASINO HOTEL

INDIANA AVE. AT THE BOARDWALK, P.O. 448, ATLANTIC CITY, NJ 08404 RESERVATION DEPARTMENT (609) 340-3434 NJ ONLY 1-800-582-7676

(Please Print)

Name

Address

City State Zip

Home Phone Business Phone

Sharing With

Date of Arrival Time

Date of Departure Time

A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money order payable to the CLARIDGE or complete the following:

Card # Type Exp. Date

SCHEDULE OF RATES SUBJECT TO 12% TAX

□ SINGLE $75.00 □ One-Bedroom Suite $225.00 □ Two-Bedroom Suite $300.00

□ DOUBLE $75.00 (Reservations must be received prior to April 5, 1990)

Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.

PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.

□ Check if Official Delegate County

VOL. 87— NUMBER 1 JANUARY 1990

51

NOTEBOOK

■ TRUSTEES’ REPORT ■

A regular meeting of the Board of Trustees was held on November 19, 1989, at the executive offices of the Medical Society of New Jersey. Detailed minutes are on file with the secretary of your county so- ciety. A summary of significant ac- tions follows:

Frank R. Begen, MD . . . Noted that a contribution was made to the MSNJ Medical Student Loan Fund in memory of Doctor Begen, and received unanimously the fol- lowing memorial resolution:

Whereas, the Almighty has chosen to call from us our beloved colleague, Frank R. Begen, MD; and

Whereas, as a fellow and officer of this Society, Doctor Begen served its mem- bers and the people of New Jersey; and

Whereas, he demonstrated the at- tributes of a concerned caring father, husband, and physician, and will be missed by all; now therefore be it

Resolved, that the Medical Society of New Jersey expresses its profound sor- row at the death of Dr. Begen and ex- tends its sympathy to his family; and be it further

Resolved, that this Resolution be spread upon the minutes of this meet- ing, and a copy t hereof presented to his family in heartfelt sympathy.

Report of the President . . .

(1) Conference of Presidents . . .

Reported that the Conference was well attended, and will continue to be used as a forum for updating the leadership of the physician com- munity on current issues of the So- ciety.

(2) Medical Books for China In-

ternational Foundation . . . Will encourage membership to partici- pate in this project to collect used medical books for China.

(3) JEMPAC . . . Noted that Drs. Anthony P. Caggiano and Hormoz M. Minoui will serve with Dr. Hirsch on the Nominating Com- mittee as Dr. Ryan will not seek reappointment as chairman; and, noted that a number of trustees have joined JEMPAC.

(4) President’s Page . . . Noted that Dr. Hirsch, in his column in the December 1989 issue of NEW JERSEY MEDICINE, responded to a letter that expressed a con- trary viewpoint about political ac- tion.

(5) Unified Membership in AMA

. . . Heard Dr. Hirsch’s comments on the MSNJ policy that AMA membership should be encouraged but that it should be voluntary.

(6) AMA Physicians’ Assistance Program . . . Noted that a resolu- tion is being introduced calling for the AMA to continue funding and maintaining an impaired physi- cians’ program.

(7) AMA Interim Meeting . . .

Unanimously carried the request to formulate a resolution calling for the AMA to begin, at an ap- propriate point, to hold interim meetings in Washington, DC.

(8) News Media Items . . . Noted three news items: availability of copies of Mr. Maressa’s response to the editorial entitled, “The E.T. Answer to Doctor Bills”; commen- dation for the recent MSNJ ad- vertisement, “Doctor’s Medicare Fees”; and referred to the Council on Public Relations a public rela- tions campaign for the elderly to have their personal physician re-

view their medications, as done by Essex County Medical Society.

(9) Immunizations for Children . . . Requested the Essex County Medical Society to send their con- cerns regarding immunization schedules to the New Jersey Academy of Pediatrics for review and report.

(10) AIDS Legislation . . . Re- ferred a letter from Congressman William Dannemeyer (seeking en- dorsement of the Public Health Response to AIDS Act of 1989 es- tablishing certain eligibility re- quirements in the program of grants to the states for counseling and testing with respect to AIDS and for other purposes) to the Task Force on AIDS for consideration and report.

(11) AMA Leadership Con- ferences . . . Noted that ten mem- bers will attend this Conference to be held on February 24-26, 1990, in Phoenix, Arizona.

Report of Executive Director . . ,

(1) MSNJ Paid Memberships

. . . Noted that as of October 1989, paid memberships were 7,457, and observed that as the effects of the special assessment begin to de- cline, membership again will as- sume a favorable trend. Also, noted the list of 314 members who did not pay the special assessment will be published in NEW JER- SEY MEDICINE.

(2) Financial Statements . . . Re- viewed and approved the financial statements for the months of Sep- tember and October 1989.

(3) State Board of Medical Examiners . . . Noted two signifi- cant changes in N.J.A.C. 13:34-6.5: if the patient or a subse-

52

NEW JERSEY MEDICINE

quent treating health care pro- fessional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the licensee shall provide a transcrip- tion at no cost to the patient; and the licensee shall not refuse to provide a professional treatment record on the grounds that the pa- tient owes the licensee an unpaid balance, if the record is needed by another health care professional for the purpose of rendering care.

(4) Medicare Transition . . . Filed a request with SBME regard- ing the refusal of HCFA to honor SBME’s major surgery rule (defin- ing a procedure in which an open- ing is made into any of the major body cavities as major surgery re- quiring an assisting physician); and noted that the Pennsylvania Blue Shield Provider 800 line will be discontinued as of December 31, 1989, but MSNJ will submit a re- quest that the line be re-estab- lished.

(5) Litigation Reports . . . Re- viewed the following litigation: in- terrogatories have been served and notices of deposition are being prepared and a case management conference has been scheduled in the suit against the insurance com- missioner over his failure to fund the Medical Malpractice Re- insurance Association deficit in a fair and lawful practice; request has been Filed with the EPA for a stay of their fee collection format (members have been advised to complete the registration form but not to pay the fee); heard that SBME will file a brief challenging the Board of Physical Therapy in two areas: the right of the therapist to examine a patient without a prior physician referral and the right of the therapist to alter a physician prescription without the physician’s approval; awaiting a trial date for in re Sinha involving a medial licensure action; and MSNJ versus PRO case is pending in federal district court, and a trial date in June appears likely.

(6) Membership Directory . . .

Noted that the supplement to the Directory has been published and distributed.

Specialty Reports . . . Received reports from Stanley S. Bergen, Jr, MD (UMDNJ); Michael B. Grossman, DO (State Board of Medical Examiners); and the New Jersey Hospital Association.

Academy of Medicine of New Jersey . . . Noted that Dr. Leighton E. Cluff is the recipient of the Edward J. Ill Award and Arline Schwartzman is the recipi- ent of the Citizen Award for 1990.

Task Force on AIDS . . . Ap- proved the following recommen- dations:

That the Board of Trustees submit a letter to the Governor’s office request- ing that a strong, centralized inter- agency task force (with physician membership) be established to ag- gressively attack the burgeoning AIDS epidemic in New Jersey.

That the Medical Society of New Jer- sey, through the Council on Legis- lation, develop legislation requiring compulsory HIV testing and counsel- ing for all existing prisoners.

Unfinished Business: S-3429 — Commissioner of Health . . .

Voted to actively oppose S-3429 (this bill deletes the requirement for a medical license to be held by the commissioner of health).

New Business: New Jersey

Physicians in Home Care Awards Program . . . Voted to de- cline endorsement of this program, as MSNJ has not specifically en- dorsed other awards in the past.

Correspondence . . . Received a letter from David I. Knowlton, act- ing commissioner of health, re- sponding to concerns raised by the Committee on Medical Aspects of Sports in light of the issue covered by A-1734 (the bill requires ran- dom drug testing of school athletes

before participation in events); and referred the letter addressing the issue of the need for uniform criteria among state-certified utilization review organizations from Commissioner of Health Molly Coye to the Committee on Utilization Review Systems for its review. □

■Ml UMDNJ NOTES H

The University of Medicine and Dentistry of New Jersey (UMDNJ) broke ground October 26 at its Newark campus for a $55 million medical office complex and park- ing garage. The eight-level medical office complex will allow UMDNJ to expand clinical services and educational programs. The build- ing and adjacent 1,031-car parking facility will occupy the Bergen Street- 12th Avenue corner of the campus.

The medical office complex will house the faculty practice services of UMDNJ-New Jersey Medical School and UMDNJ-New Jersey Dental School. Some 300 faculty physicians and dentists will pro- vide a wide range of health-care services from the facility.

Designed as a full-service am- bulatory care facility, the medical office complex will provide a com- prehensive array of outpatient ser- vices including a same-day surgery center, imaging center, and re- habilitation unit. In addition, the complex will consolidate several services and features on the New- ark campus, including: quarters for The Eye Institute of New Jer- sey; quarters for the Stone Center of New Jersey, a lithotripsy (kidney stone therapy) unit run jointly by UMDNJ and Saint Barnabas Medical Center, Liv- ingston, a UMDNJ affiliate; a Uni- versity Center comprising a con- ference facility, and dining and fit- ness centers open to UMDNJ fac- ulty, staff, and students; the Em- ployee/Student Health Center; and space for complementary com- mercial opportunities, such as a coffee shop, newsstand, and phar-

VOL. 87— NUMBER 1 JANUARY 1990

53

macy/medical equipment shop.

For the first time, New Jersey students can receive doctoral level training in public health without leaving the state. Doctoral degrees in public health now are offered through two new programs jointly administered by UMDNJ and Rutgers, the State University of New Jersey. The doctor of philos-

ophy (PhD) program in public health is for students interested in academic careers furthering basic knowledge and theory on the health effects of environmental and occupational conditions. The doctor of public health (Dr PH) program trains students to apply their knowledge to specific prob- lems such as setting priorities for

cancer research or providing health services for hazardous substance workers.

UMDNJ has received a new fed- eral grant of almost $1.6 million to launch the state’s first federally funded regional AIDS Education and Training Center. One of only 15 in the nation, the Center will provide comprehensive training programs consisting of courses and workshops aimed at all segments of the health care professions.

The Center is funded by a three- year $1,586,784 grant from the Health Resources and Services Ad- ministration of the Department of Health and Human Services. Ad- ministered by UMDNJ’s Office of Continuing Education, it is an out- growth of UMDNJ’s Center for AIDS Education, established in 1988 to centralize education pro- grams and attract funding to create a statewide resource.

An innovative peer-mentoring program to smooth the way for first-year minority group dental students has been started at UMDNJ-New Jersey Dental School, Newark. This year, 22 black and Hispanic freshmen have been teamed with upperclass stu- dent-mentors in the Peer Initiative Program. The student mentors guide the freshmen in such areas as obtaining tutors and working out study plans for difficult courses. They also provide general infor- mation about dental education and the dental school. The Peer Initiative Program is believed to be one of the first of its kind at a den- tal school in the nation.

Congratulations to: Dr. Donald Louria, a leading public health ex- pert at UMDNJ, who received the major public health award of the New Jersey Public Health Associa- tion; and William R. Walsh, Jr, executive vice-president of finance and treasurer of the Robert Wood Johnson Foundation, who received the 1989 Distinguished Service Award from the Melvin H. Motolinsky Research Foundation. □ Stanley S. Bergen, Jr, MD

1990 MSNJ ANNUAL MEETING

Saturday, May 5, 1990

3:30 p.m. Board of Trustees’ Meeting

7:00 p.m. Officers’ Cocktail Reception and Dinner

Sunday, May 6, 1990

8:00 a.m. Registration Opens 8:00 a.m. Message Center Opens 10:00 a.m. Educational Program 11:00 a.m. Exhibits Open 1:00 p.m. House of Delegates 3:30 p.m. Reference Committee Meetings

Monday, May 7, 1990

8:00 a.m. Registration Opens

8:00 a.m. Message Center Opens

8:30 a.m. Exhibits Open

9:00 a.m. House of Delegates (Election)

12:00 noon Golden Merit Award Ceremony and Reception 1 :00 p.m. Professional Liability Program (MIIENJ)

2:45 p.m. Reference Committee Meetings 5:00 p.m. JEMPAC Political Forum 5:45 p.m. JEMPAC Wine and Cheese Reception 6:30 p.m. Somerset County Medical Society

Tuesday, May 8, 1990

8:00 a.m. Registration Opens

8:00 a.m. Message Center Opens

8:30 a.m. Exhibits Open

9:00 a.m. House of Delegates

1:30 p.m. House of Delegates

2:00 p.m. Exhibits Close

6:30 p.m. Inaugural Reception and Dinner

Wednesday, May 9, 1990

8:00 a.m. Registration Opens 8:00 a.m. Message Center Opens 8:30 a.m. General Session 1 .00 p.m. Board of Trustees’ Meeting

54

NEW JERSEY MEDICINE

^■MSNJ AUXILIARY M

One of the major accomplish- ments of the American Medical Association Auxiliary (AMAA) is its longstanding commitment to health education, particularly its sponsorship of juvenile/adolescent health and drug abuse programs.

The MSNJ Auxiliary recently presented a health symposium, “Protect Their Future.” The session, attended by educators from high schools and colleges across the state, included dis- cussions on helmet safety, head in- jury and trauma, and anabolic steroid abuse.

Barbara Repetti, from the As- sociation of Retired Citizens in Union County, and Pat Cone, RN, from the University of Medicine and Dentistry of New Jersey, both addressed the issue of head trauma caused by bicycle accidents and the necessity for cyclists of all ages to wear safety helmets.

According to Mrs. Repetti, a bicyclist is injured four times each hour of each day and nearly 1,300 die yearly. Children under 15 years of age account for 600 of all bicycle deaths. Of these deaths, 75 percent are caused by head injury. Bicycle injuries account for more than one- half million emergency room vic- tims. One third of all victims of bicycling accidents treated in emergency rooms have head in- juries, as do two-thirds of all pa- tients with bicycle injuries ad- mitted to the hospital. Even in a minor accident, a child has a 50/50 chance of hitting his head. Each year 6,000 children are hospi- talized due to bike-car accidents. And because bicycle riding is so popular — 111 million riders in the United States — injuries are in- creasing.

Ronald D. Grossman, MD, phy- sician for the United States Olym- pic Medical Committee and a member of the drug testing crew, and Pat Croce, PT, trainer for the Philadelphia Flyers and the 76ers, spoke on anabolic steroid abuse.

Anabolic steroids, derivatives of the male hormone, testosterone, increase protein synthesis, which combined with proper diet and training, produce an increase in body mass, lean muscle tissue, and overall strength.

Dr. Grossman warned the au- dience that anabolic steroids have filtered down to junior high, high school, and college sports. He emphasized that children must learn the real and potential risks involved; for example, anabolic steroids affect the body’s normal hormonal balance and cause dangerous side effects ranging from impotence and sterility, to liver cancer, heart disease, psy- chosis, and death. There also is pervasive psychological and physi- cal addiction to anabolic steroids. Teachers can identify students using anabolic steroids in several ways: rapid weight gain — 15 to 30 pounds in one or two months; development of acne, particularly on the back; great behavioral changes — overtly hostile, ready to explode, even to hurt someone.

Pat Croce continued the dis- cussion, including information on the aspects of fitness and the side effects of steroid use. He cautioned that using drugs to improve ath- letic performance undermines one of the most basic notions of sports — the value of honesty, hard work, and discipline. To stop drug abuse in sports, he emphasized the need for drug testing, appropriate education, and laws designating anabolic steroids as controlled substances. □ Marion Geib

■■AMNJ UPDATE ■■■

The Board of Trustees of the Academy of Medicine of New Jer- sey has named the 1990 recipients of the awards presented at the Academy’s Annual Awards Dinner on Wednesday, May 23, 1990, held at the Chanticler in Short Hills.

Leighton E. Cluff, MD, of Princeton, will receive the Edward J. Ill Award “presented annually

to that physician of New Jersey who merits recognition by the Academy for distinguished service as a leader in the medical pro- fession.” Recent recipients have included Drs. James Todd, Arthur Krosnick, Leon Smith, Alfred Alessi, Stanley Bergen, Palma For- mica, Paul Hirsch, Richard Rey- nolds, Ervin Moss, and James Oleske.

Dr. Cluff is president of the Rob- ert Wood Johnson Foundation. His leadership of that Foundation has been instrumental in maintaining and advancing its position of pre- eminence in the advancement of the health of this country through support of highly focused and imaginative projects. Many of these projects strike to the very core of the problems of health care delivery to underserved popu- lations and the problems of the in- terface between the practice of medicine and the changing social fabric of our society.

The Academy’s Citizen’s Award is “presented annually to that citizen or group of citizens of New Jersey who merit recognition by the Academy for distinguished ser- vice in the interest of the health and welfare of the community at large.” The 1990 Citizen’s Award has been granted to Arline Schwartzman of Highland Park. Recent recipients include Richard J. Hughes, former governor of New Jersey; Alan Sagner, past-chair- man of the Port Authority of New York and New Jersey; Drs. Herman and Anne Somers; Con- gressman James Courter; Malcolm Borg, publisher of the Bergen Rec- ord; Mary Strong of the Citizens’ Committee on Biomedical Ethics; Assemblyman Chuck Hardwick; and attorney Paul Armstrong.

Mrs. Schwartzman exhibits the spirit of effective volunteerism. She has served as president of the Auxiliary of the Robert Wood Johnson University Hospital and has served on their Board of Trustees (and its predecessor) since 1965. For the past five years,

VOL. 87— NUMBER 1 JANUARY 1990

55

she has been the chairperson of the Professional Affairs Committee which has dealt with all aspects of medicine, ethics, and the regu- lation of hospital practice. She is truly dedicated to making New Jersey a better place to live for its residents and giving those resi- dents a better chance to be healthy.

We are pleased to announce that Lewis Coriell, MD, a member of the Medical Society of New Jersey, was selected by an academy of prestigious New Jerseyans to re- ceive the Clara Barton Medical Service Award. The award was presented at the Fourth Annual Governor’s Jersey Pride Awards Program held on Thursday, Janu- ary 4, 1990, at Princeton’s

McCarter Theatre. The award is sponsored by the Academy and the American Red Cross. This project is part of a major statewide effort by Governor Kean to improve the image of New Jersey and to rec- ognize New Jerseyans who have ac- complished many great and im- portant advances in a wide variety of fields. A total of 11 specific fields was recognized at the formal cere- mony. □ Frederick B. Cohen, MD, President

I LEGISLATIVE BULLETIN!

The accompanying list presents, for your information and reference, the official position of the Medical Society of New Jersey regarding bills currently in the Legislature. As further bills of medical interest are introduced, they will be con- sidered by the Society and sup- plemental bulletins will be sup- plied, indicating the Society’s po- sition.

Positions. The Society has adopted the following regular range of official positions concern- ing proposed legislation:

ACTIVE SUPPORT: All out support for the measure.

ACTIVE OPPOSITION: All out opposition for the measure.

CONDITIONAL APPROV-

AL: To indicate that the approval of the Society is conditional, sub- ject to elimination of the un- satisfactory elements of the bill that are pointed out.

APPROVAL: Commended as satisfactory, but not actively sup- ported.

DISAPPROVAL: Rejected as unsatisfactory, but not actively op- posed.

NO ACTION: Considered, but not regarded as significant or rel- evant to the proper interest of the Society.

Senate/Assembly (Active)

S-722-Codey — Mental Health Cov- erage. Requires health insurers (hospi- tal service corporations) to provide coverage for mental illnesses. Active Support.

S-723-Codey — Mental Health Cov- erage. Requires health insurers (medi- cal service corporations) to provide coverage for mental illnesses. Active Support.

S-724-Codey — Mental Health Cov- erage. Requires health insurers (com- mercial group health) to provide cov- erage for mental illnesses. Active Sup- port.

S-725-Codey — Mental Health Cov- erage. Requires health insurers (com- mercial individual health) to provide coverage for mental illnesses. Active Support.

S-726-Codey — Mental Health Cov- erage. Requires health insurers (HMOs) to provide coverage for men- tal illnesses. Active Support.

S-727-Codey — Mental Health Cov- erage. Requires health insurers (health service corporations) to provide coverage for mental illnesses. Active Support.

S-3440-Codey — Generic Substitu- tion/Prescription Blank Change.

Changes prescription forms to facili- tate use of generic drugs. Active Op- position, filling out the new prescrip- tion format would require more time for physicians, the probability of for- getting to write the required words to override generics was greater when using a blank form and, therefore, the new format would not be in the best interest of patients.

S-3494-Zane — Unemployment Compensation and Disability Ben-

efits. Exempts physicians who are in- dependent contractors from employ- ment and disability taxes. Clarifies an ambiguity in the current law. Active Support.

S-3549-Lynch — Optometric Use of Drugs. Permits optometrists to use drugs for diagnostic and treatment purposes. Active Opposition, op- tometrists are not medical doctors and, therefore, should not be given the man- date, via legislation, to administer drugs. If the wrong medication is prescribed, what appears to be a simple problem could develop into a destructive process of the eye in a very short period of time. The bill is short- sighted in attempting to provide less expensive care to the general public to the detriment of their health.

A-4259-Naples — Medical Records. Would require that records be “furnished upon request to the patient and/or his duly authorized representa- tive immediately.” Active Opposi- tion, this situation is adequately cov- ered under existing regulation and could not be implemented in the form stated in the bill.

Senate/Assembly (Monitor)

S-2939-Van Wagner — Emergency Services. Appropriates $1.5 million to the Department of Health to be used for EMS training and equipment. Ap- proved.

S-3104-Lipman — AIDS. Makes AIDS or HIV sensitivity reportable to the Department of Health and provides for confidentiality. Action Deferred, pending review of the Task Force on AIDS of the Assembly amendments to S-3104.

S-3236-Rice — AIDS. Requires that persons convicted for using controlled dangerous substances shall be tested for AIDS and HIV sensitivity. Action Deferred, pending reconsideration of the Task Force on AIDS about this legislation.

S-3261-Bassano — Drug Testing Student Athletes. Requires school boards to establish random drug test- ing programs for student athletes. Tes- ting would be done at school board ex- pense. Disapproved, the issue of drug abuse in the school extends beyond the scope of the student athlete. This bill therefore, would send the wrong message and ignore the need to educate and test beyond the athlete population.

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NEW JERSEY MEDICINE

S-3320-Ambrosio — Health Care Directives. Establishes procedures for the execution of advance directives for health care. The advance directives in- volve designation of a health care rep- resentative and a statement of per- sonal wishes in the event of loss of de- cision-making capacity. Action De- ferred, pending review of the Senate Committee amendments by the Com- mittee on Biomedial Ethics.

S-3327-Codey — Infection Control Education. Requires institutions which educate allied health pro- fessionals to incorporate infection pre- vention and control as part of their program. No Action.

S-3346-Codey — Laboratory Direc- tor’s Licensing. Adds “diagnostic lab- oratory immunology” to the list of specialty licenses. No Action.

S-3389-Paterniti — Health Needs Study (same as A-2987). Requires the commissioner of health to conduct a study of the health needs of low income persons over the age of 60. Disap- proved, this study is unnecessary; there is a wealth of information on this topic available through federal and academic sources.

S-3429-Ewing — Commissioner of Health (same as A-4142). Deletes the requirement of a medical license to be commissioner of health. Conditional Approval, pending amendment of the bill to create a position of physician general and also to include an MSNJ representative on the Health Care Ad- ministration Board.

S-3433-D’Amico — Medical Waste. Increases the categories of regulated medical waste to include — wastes from surgery or autopsy that were in contact with infectious agents, including soiled dressings, sponges, drapes, lavage tubes, drainage sets, underpads, and surgical gloves; laboratory wastes from medical, pathological, pharma- ceutical, or other research, com- mercial, or industrial laboratories that were in contact with infectious agents, including slides and cover slips, dis- posable gloves, laboratory coats, and aprons; dialysis wastes that were in contact with the blood of patients undergoing hemodialysis, including contaminated disposable equipment and supplies such as tubing, filters, disposable sheets, towels, gloves, aprons, and laboratory coats; dis- carded medical equipment and parts that were in contact with infectious

agents; biological waste and discarded materials contaminated with blood, excretion, exudates, or secretion from human beings or animals who are isolated to protect others from com- municable diseases. Disapproved, w/ Active Opposition if the bill moves, until the current law is effectively im- plemented.

S-3463-Contillo — HIV Testing for Certain Defendants. Mandates HIV testing when any criminal commits an offense that results in a victim or third party exchanging body fluids or a nee- dle stick if there is probable cause to believe the defendant is an IV drug user. Action Deferred, pending further information from the Task Force on AIDS with the following rec- ommendation that the bill be amended to read “that any person who is charged with a criminal offense that results in the victim or a third party exchanging body fluids should be tested for HIV positivity.”

S-3479-Zimmer — Hospital Un- compensated Care Charges. Requires hospitals to itemize uncompensated care costs on patient bills. No Action.

S-3546-Feldman — Sexually Abused Children. Requires the com- missioner of human services to estab- lish two regional treatment centers for sexually abused children. The regional centers would be networked into com- munity-based model programs and a research institute at one of the schools of higher education. No Action.

S-3565-Ewing — HIV Testing of Newborns. Requires that all newborns be tested for HIV sensitivity. Action Deferred, pending further information from the Task Force on AIDS with the following recommendations: 1. Con- sider HIV testing of mother. 2. Con- sider the possibility of HIV testing of

all prenatal patients. 3. Consider false negative and false positive readings and what should be done in these in- stances.

A-955-Kern — Artificial Insemina- tion. Statutorily regulates artificial in- semination, requires certain forms of consent, data gathering, and record- keeping. No Action, the Council directed that correspondence be ad- dressed to the sponsor of the bill rec- ommending that it be written in con- formance with the American Fertility Society Guidelines.

A-1456-Kline — Organ Trans- plants. Prohibits organ transplants unless the tissues are HIV negative. Approved.

A-2938-Ogden — Communicable Disease. Requires health