Intracranial hemorrhage produced by spontaneous dissecting intracranial aneurysm.

Two patients with intracranial dissecting aneurysms were seen initially because of acute hemorrhage. One patient died, and a false dissecting aneurysm secondary to atherosclerosis was found at autopsy. In the other patient, the appearance of the carotid arteriogram was typical of a dissection. Because of the propensity of these aneurysms to rupture, caution is indicated in the use of anticoagulants or vasopressors in patients with evolving cerebral infarction secondary to intracranial arterial dissection.

Ocular bobbing: the myth of its localizing value.

Ocular bobbing is a distinctive eye movement disorder seen in patients with pontine dysfunction. The typical phenomenon consists of abrupt, spontaneous downward jerks of the eyes with a slow return to the midposition in association with paralysis of spontaneous and reflex horizontal eye movements. Bobbing was present in a patient with acute cerebellar hemorrhage in whom no intrapontine lesions could be demonstrated. The myth that this sign is specific for intrapontine destruction has to be abandoned.

Alexia with left homonymous hemianopia without agraphia. A case report with autopsy findings.

Unusual findings at autopsy prompted this case report of a patient with the syndrome of alexia without agraphia. The expected disconnection of the left angular gyrus from both visual cortices was not found at postmortem examination. Multiple cerebral metastases were identified, but none were present in the presumed pathways connecting the left occipital lobe and the left angular gyrus.

Heterogeneity of prenatal onset hydrocephalus: management and counseling implications.

We have evaluated 30 cases of congenital hydrocephalus, most with a presumed early prenatal onset. The ten cases delivered in 1982 were studied prospectively. In 18 of the 25 nonsurvivors, no cause was apparent and many had multiple anomalies. The heterogeneity seen in this series is discussed in relation to intrauterine treatment.

News from the future: health care summit caps decade of transformation, 1996-2005.

Many in academic medicine agree that its future will be very different from its past. Transformation, not tinkering, is needed if academic health science centers are to survive the challenges posed by federal and state budget constraints, the intense price competition of managed care, and the wide dispersion of information via the Internet. Academic medicine is like an ocean liner, stately and slow to turn from its charted course. But those who captain the huge, slow ship have seen the tip of the iceberg that looms in its path, and must turn to a new course now. The author presents a possible scenario of the future that describes new relationships among academic health centers, new roles for deans and department chairs, and a more collaborative approach to learning. In the scenario, set in the year 2002, the writer looks back on the changes of the period 1996-2005 and describes the relationships, management, priorities, and reward systems of the institutions responsible for health care, medical education, and biomedical research.

Training future leaders of academic medicine: internal programs at three academic health centers.

The authors review the need for internal programs for leadership training at academic health centers and then describe in detail three programs of this type that have operated during the 1990s: (1) the Allegheny Leadership Institute, founded by the Allegheny Health, Education and Research Foundation, Pittsburgh, Pennsylvania; (2) the Physician Executive Management Development Program (PEMDP) of Saint Louis University School of Medicine; and (3) the University of Nebraska Medical Center Leadership Institute. Educational elements common to these programs include having a small class size and participants from many areas of academic medicine and health care, focusing on educational strategies that draw on participants' experiences and training, conducting the training away from the participants' institutions, having short sessions, using faculty from both within and outside the participants' institutions, and creating strategies to reinforce learning. Lessons learned reflect the unique context of each institution; the authors list the major lessons learned by each of the three programs they surveyed (e.g., leaders of the Saint Louis University PEMDP program believe that it is important to help participants implement desired changes in their work areas once they return to work, and are investigating how to do this). The authors conclude with an extensive list of recommendations to optimize the effects of leadership development training carried out in AHCs' internal programs (e.g., "Focus on specific skills that can be learned, and link the learning experiences to real work situations in health care and higher education") and explain why they think internal leadership institutes have at least three distinct advantages over external programs.

How medical schools can maintain quality while adapting to resource constraints.

To gain a better understanding of the effects on medical schools of ongoing transformations in medical practice, science, and public expectations, the Association of American Medical Colleges (AAMC) formed the Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) in 1994. Six working groups were appointed to address different issues of importance. This article is a report of the findings and recommendations of the Working Group on Adapting to Resource Constraints. That group was charged to consider how leaders in academic medicine can respond to the challenges of external forces and the anticipated diminishing of resources, and to focus on medical schools and how they can maintain quality while reengineering to effect needed changes. The group members developed their thinking within four categories: size of the academic enterprise; organizational models and their relationships to the clinical enterprise; faculty tenure and compensation; and partnerships with capital-intensive entities. Three recommendations for action, to which the APMOMS unanimously agreed, were made to the AAMC, which has already acted upon them in ways described in the article. The group also developed a series of "ideas for consideration," which represent a range of the members' perspectives. The working group did not seek (and probably could not have obtained) unanimous agreement on many of the issues that these ideas focus upon. The ideas are presented as a series of resolutions designed to stimulate discussion and foster better-informed planning.

Extrapyramidal disorder with pineal germinoma. Case report.

Space-occupying lesions of the basal ganglia are a rare cause of extrapyramidal dysfunction in children. Metastatic pineal germinoma in both basal ganglia produced dystonia in a 12-year-old boy. The literature is reviewed. Extrapyramidal manifestations in the child are compared with previously reported cases of basal ganglia neoplasms.

Conflict management, Part 1. Conflict management checklist: a diagnostic tool for assessing conflict in organizations.

Complex interpersonal conflicts are inevitable in the high speed, high stakes, pressured work of health care. Poorly managed, conflict saps productivity, erodes trust, and spawns additional disputes. Well managed, conflict can enhance the self-confidence and self-esteem of the parties, build relationships, and engender creative solutions beyond expectations. Just as thoughtful differential diagnosis precedes optimum treatment in the doctor-patient relationship, management of conflict is greatly enhanced when preceded by careful assessment. In the first of two articles, the authors present a diagnostic approach, the Conflict Management Checklist, to increase self-awareness and decrease anxiety around conflict.

Part 2, Conflict management. Managing low-to-mid intensity conflict in the health care setting.

Physician executives face low to mid-level intensity conflicts, day-to-day issues and problems associated with pressures and changes in the health care environment. Such conflicts can be sorted on the basis of relationship, duration, and intensity. The authors apply the five major modes of conflict management--competition, avoidance, compromise, accommodation, and collaboration--to specific scenarios taken from their work in health care and suggest guidelines for managing conflicts with peers, supervisees, and authority figures. Thorough preparation and a portfolio of skills build flexibility through the conflict management process. In part 1 of this article series, the authors presented the conflict management checklist, a diagnostic tool for assessing conflict in organizations.

The future is in the present: the impact of generations.

Among the complex mix of forces that shape our futures are differences among generations. A generation is a cohort, roughly twenty-some years in duration, where the members have experienced a common formative environment and tend to react to the world in patterned fashion. The defining characteristics of five generations are discussed: Gl, Silent, Boomers, Generation X, and the millennial generation. Implications are drawn for patient preferences as dental consumers, recruitment and management of faculty and others in organizations, and the transitions of values in leadership of professional organizations.

Nonbacterial thrombotic endocarditis and nondisseminated malignancy associated with osteopetrosis.

Nonbacterial thrombotic endocarditis (NBTE) is a presentation of an occult malignancy. The clinical, laboratory and postmortem findings of a 44-year-old man with osteopetrosis and NBTE are reported. A small apical bronchogenic carcinoma was found on postmortem examination. A thorough search for malignancy should be made in patients with unexplained cerebral emboli, especially if hematologic abnormalities are present. There is presently no evidence that anticoagulation or other treatment is beneficial.

Occult pulmonary thromboembolism presenting as diffuse interstitial pneumonitis in cancer patients.

The prompt and accurate recognition of non-malignant complications is of critical importance in the care of cancer patients. Pulmonary thromboembolism is particularly important because it is common, treatable and frequently difficult to diagnose. Two patients are presented who died of recurrent pulmonary thromboemboli which were unrecognized because open lung biopsies showed diffused interstitial pneumonitis. The association of pulmonary thromboembolism and interstitial inflammation has been recognized at autopsy, and there are a number of plausible mechanisms which could link these processes. Interstitial pneumonitis should be added to the numerous protean manifestations with which pulmonary thromboembolism is associated.

Cerebral infarction due to moyamoya disease in young adults.

Moyamoya disease was diagnosed as the cause of cerebral infarction in eight young adults (seven women, one man), aged 17-40 (mean 33) years. All had angiographic abnormalities characteristic of moyamoya disease. Single-photon emission tomography showed bilateral carotid circulation hypoperfusion and posterior circulation hyperemia in all seven patients with regional cerebral blood flow studies. All seven women had used oral contraceptives before cerebral infarction. Four patients were treated medically; one died of a second cerebral infarction 9 months after diagnosis. Four patients underwent superficial temporal-to-middle cerebral artery anastomosis; they did well. Moyamoya disease should be included in the differential diagnosis of cerebral infarction as well as intracranial hemorrhage in young adults, particularly women. A possible relation between moyamoya disease and oral contraceptive use deserves investigation.

The neuropathology of malignant external otitis.

A case report of malignant external otitis is presented with particular emphasis on the neuropathological sequelae. The most striking finding was a mycotic aneurysm of the basilar artery with resultant thrombosis and brain stem infarction. Diffuse pachymeningitis was also present. The severity of the changes described in this case further point out the need for early recognition and adequate treatment of this potentially fatal disease complex.

Primary angiosarcoma of the heart.

Primary hemangioendotheliosarcoma is the least common form of sarcoma of the heart, itself an uncommon tumor. A review of most of the reported cases is presented. This study revealed that although the syndrome produced by cardiac sarcoma point to a strikingly characteristic picture, the diagnosis is almost always confused, especially with pericardial inflammatory diseases, and delayed. Successful treatment generally has not been available. This is the only case we know of that has been treated by resection utilizing cardiopulmonary bypass. The appearance of metastases in unusual locations in our patient, despite total excision of the primary, suggests tumor embolization during the bypass and the need for intra-operative chemotherapy, as well as such treatment before or after surgery.

Locked-in syndrome caused by a solitary pontine abscess.

The clinical and pathological findings in a patient with locked-in syndrome caused by a solitary pontine abscess are reported for the first time. Successful treatment of brainstem abscess rests on early and accurate diagnosis.