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Back to the Future: Clinical Vignettes and the Measurement of Physician Performance

John Norcini, PhD
[+] Article and Author Information

From Foundation for Advancement of International Medical Education and Research, Philadelphia, PA 19104.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: John Norcini, PhD, Foundation for Advancement of International Medical Education and Research, 3624 Market Street, Philadelphia, PA 19104; e-mail, jnorcini@faimer.org.


Ann Intern Med. 2004;141(10):813-814. doi:10.7326/0003-4819-141-10-200411160-00014
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The past 2 decades have seen many efforts to improve the quality of health care. These efforts have relied on a series of methods devised by workers in the field of quality management science and, in some cases, used successfully in industry for more than 50 years (12).

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Genetic Basis of High-Altitude Diseases
Posted on December 6, 2004
Matiram Pun
Institute of Medicine, Kathmandu, Nepal
Conflict of Interest: None Declared

Dear Editor,

The article "The Physiologic Basis of High-Altitude Disease" is an excellent piece of review of its type by the current icon of Respiratory Physiology John B. West. The article has nicely elaborated the High Altitude Diseases Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE). The Chronic Mountain Sickness, Sub acute Mountain Sickness and Retinal Haemrrhages1 have also been included that has really been overshadowed by the acute problems. However, I humbly think the following points have not been adequately highlighted.

1. There should have been more about the focal neurological deficits, which have been important to diagnose the high altitude problems, and many other sub clinical diseases that manifest in high altitude. 2. The next thing is the genetic basis of High Altitude Illness especially HAPE. He should have elaborated about the involvement of Vascular Endothelial Growth Factors (VEGF) in the HACE and HAPE2. Is there any role of angiotensin-1 [AT1]-converting enzyme [ACE], tyrosine hydroxylase, serotonin transporter [5-HTT], and endothelial NO synthase [eNOS] genes in the pathogenesis of HAPE3? How about the association between genetic polymorphism and HAPE? 3. The prescription of Gingko biloba for the prevention of remains questionable. The use of Gingko biloba in various diseases seems vague e.g. intellectual improvement4 and this now has entered into the field of Mountain Medicine. The prevention of high altitude illness trial (PHAIT) group has found not only this is ineffective in the prevention of AMS but also reduces the efficacy of Acetazolamide (if taken simultaneously) and causes headache (one of the principal symptom of AMS) as its side effects5.

Refereces: 1. West, JB. The Physiologic Basis of High-Altitude Diseases. Annals of Internal Medicine 2004; 141: 789-800 2. Hanaoka M, Droma Y, Naramoto A, Honda T, Kobayashi T, Kubo K. Vascular endothelial growth factor in patients with high-altitude pulmonary edema. J Appl Physiol 2003; 94:1836-1840 3. Mortimer H, Patel S, Peacock AJ. The genetic basis of high-altitude pulmonary oedema; Pharmacology & Therapeutics 2004; 101: 183-192 4. CD ROM. Mosby's Drug Consult 2002 5. Gertsch JH, Basnyat B, Johnson EW, Onopa J, Holck S. Randomised, controlled trial of ginko biloba and acetazolamide for the prevention of acute mountain sickness:the prevention of high altitude illness trial ( PHAIT). BMJ 2004; 328:797-799.

Conflict of Interest:

None declared

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