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IS A PUZZLEMENT!

Lawrence I. Bonchek, M.D., F.A.C.S., F.A.C.C.
Editor in Chief
Lawrence I. Bonchek, M.D., F.A.C.S., F.A.C.C.
 

In the historical narrative made famous by the movie The King and I, 19th century King Mongkut of Siam strives desperately to wrench his backward country into the modern world, in order to resist foreign domination. England and France were already subjugating Siam’s neighbors Burma and Indo-China. England had also established a colony in Hong Kong, and with the Opium Wars of 1839-42, had coerced China into allowing itself to be exploited commercially.

King Mongkut (also known as Rama IV), did manage to keep his country independent by Westernizing it, a process he started (as every moviegoer knows) by hiring Anna Leonowens as a British governess for his children. Subsequent kings in the dynasty all received a full Western education, and his grandson Rama VI became a proper English gentleman by attending Oxford and Sandhurst – the British military academy from which Churchill also graduated.

Mongkut’s inner conflict as the cultural ground shifted beneath his feet was immortalized in this excerpt from the song that gives my column its name:
 
There are times I almost think I am not sure of what I absolutely know.
Very often find confusion in conclusion I concluded long ago.
In my head are many facts that, as a student, I have studied to procure.
In my head are many facts of which, I wish I was more certain I was sure!”

I readily concede that even by the standards of this column, where my musings wander widely, this title might seem far afield. But in addition to its obvious relevance to the current world situation, it actually has quite a bit to do with medicine and JLGH.

First is the obvious point that medical knowledge is progressing so rapidly that much of what we learned as medical students is no longer “sure,” and “conclusions we concluded long ago” are now not just confusing, but downright wrong. Indeed, in our clinical practices, we must be careful to remember that we often cannot be “sure of what we absolutely know.” But even those obvious truths are not the main reason I chose the title and this excerpt from the lyrics. I did so, rather, because they provide direct links to several articles in this issue.

First is the introduction of a new section, compliments of Drs. Shashi and Fabian Baksh of our Pathology Department: a clinico-pathologic conference. Clearly, the CPC is the hallmark of “puzzlements” in the medical literature, because it presents a medical riddle and the solution. Our format doesn’t exactly follow the one used by the New England Journal in its “Case Records of the MGH,” but I feel certain you will enjoy the article Anemia And Hyperbilirubinemia – More Than Just Hemolysis. I am deeply grateful to the Drs. Baksh – as I’m sure you will be – for their initiative in developing this section for us, and I look forward to their future contributions. This article about a patient cared for by Dr. Chris Addis is a particularly fitting inaugural CPC, because [hint] it deals with a disease of historic importance that was recognized even before King Mongkut came to power.

Another type of “puzzlement” is presented by Hyperbaric Oxygen Therapy (HBO) in the article by Dr. Michael Flood, Director of our Hyperbaric and Wound Care Center. As he states in his article, “the role of HBO therapy… was controversial for a long time… most studies… were hampered by small sample size, potential sources of bias, inadequate evaluation of co-morbid conditions… and other methodological problems.” Recent randomized trials have gone far to resolve the “puzzlement” about the value of HBO therapy, but much controversy remains.

The third type of “puzzlement” is the clinical dilemma posed by the use of Gadolinium as an enhancer for MRI studies, as discussed by Dr. Paul Leslie in the current Imaging Insights. One of the problems Gadolinium can cause is described in the related article on Nephrogenic Systemic Fibrosis. This could easily have been another CPC, but since the diagnosis is relatively obscure, we chose to give it away in the title. Once again, the insight of our Pathologist Dr. Shashi Baksh was crucial. I also draw your attention to the first author of this article, James O’Connor, a college student who was a Research Intern supported by the von Hess Research Institute. You can read more about that entity in the article by Dr. Michael Horst about research at LGH.

The fourth type of “puzzlement” we traditionally offer are the CME questions. We have decided that because of space limitations, we will soon begin a trial of putting the CME questions only on our website. This may or may not become a permanent policy, but we would like to note that our bellwether, the NEJM, has the same policy.

The fifth type is the traditional Letter to the Editor, which poses a question (a “puzzlement”) to an author. We’re delighted to say that after much surprise that it has taken so long, we have received an excellent such letter, and have printed it with a response from the author, Dr. James Artuso.

I trust you will also enjoy the remaining articles in this expanded Holiday Edition, even if they aren’t “puzzlements” in the same sense.

Gina and I wish everyone, everywhere, Happy Holidays and a joyous New Year!

I conclude with another excerpt from the poetic lyrics of Oscar Hammerstein II, for no other reason than that I like them:

“When I was a boy, world was better spot.
What was so was so, what was not was not.
Now I am a man; world have changed a lot.
Some things nearly so, others nearly not.”

“IS A PUZZLEMENT!”