Mark J. Lema, M.D., Ph.D. Editor

Keep Those Cards and Letters Coming

"Ventilations” and “Letters to the Editor” are two of the more entertaining columns in the NEWSLETTER. Obviously, controversial topics, highly provocative comments and clearly opinionated statements in “Ventilations” fuel the responses sent to the editor. Over these past five years, I have tried to increase the “Letters” section in order to make the ASA NEWSLETTER a members’ periodical.

I have become a victim of my “success” in that we are deluged with letters that have not been printed in timely fashion to reflect their impact about the topics in question. So, in order to clear the docket of letters being held due to previous space constraints, I am using the space allocated for my editorial to print your responses to the contents of past NEWSLETTER articles. Read on for some interesting and entertaining viewpoints by your colleagues.

– M.J.L.

Spinal Tip for Editor

Fortunately, neuraxial block is “alive and well” for the obstetric population.

I enjoyed reading the August 2002 “Ventilations” on regional anesthesia. However, a failure to acknowledge the popularity and safety of spinals in obstetrics surprised and disappointed me. Logistics also support the use of regional methods for pain control and for operative deliveries, as you know. At least part of the practice and training in regional methods will remain securely in the practice of obstetric anesthesia.

I hope your otherwise lucid article alerts members to the serious concern you addressed.

Donald H. Wallace, M.D.
Richardson, Texas

ASA’s Status Symbol in Texas

We read with great interest your review and comments about the ASA Physical Status (PS) Classification System in the September 2002 “Ventilations.” We must concur with your observation that the ASA PS Classification System is “regarded by hospitals, law firms, accrediting boards and other health care groups as a scale to predict risk.” As a further example, we would like to bring to your attention that the Texas Medicaid program uses the ASA PS classification as the determining factor to justify if a patient can be admitted for elective surgery:

“If a client is admitted for a day surgery procedure whether scheduled or emergency and has either an American Society of Anesthesiologists (ASA) Classification of Physical Status III, IV or V, … the procedure can be considered an inpatient procedure.”¹

Therefore, the Texas Medicaid program values the ASA PS class as an objective measure of the medical necessity for inpatient admission and ignores all other aspects of the medical record (including the surgeon’s documentation).

It is amazing that the ASA PS is used in many ways that it was never intended.

Amr E. Abouleish, M.D.
Nhung Nguyen, M.D.
Houston, Texas

Reference:
1. Texas Department of Health. 24.3.2.5 Day Surgery Services. 2001 Texas Medicaid Provider Procedures Manual. 2001:24-20.

ASA Physical Status Guilty Only of Success

Your “Ventilations,” “Using the ASA Physical Status Classification May Be Risky Business” (September 2002), was a truly interesting piece. I wish I had been so elegant in my letter to JAMA¹ when discussing the same subject.

As you wrote, the ASA Physical Status (PS) has been misused substantially. What was more interesting, I thought, was the original authors’ response. I have included it here:

“In Reply —We thank Dr. Rozner for his comments but disagree with his claim that the ASA score “has never been correlated with any risk for infection.” By using data from more than 84,000 operations performed at 44 U.S. hospitals participating in the National Nosocomial Infections Surveillance (NNIS) System, the Centers for Disease Control and Prevention developed a risk index that is a significantly better predictor of a surgical patient’s risk of acquiring a surgical wound infection (SWI) than the traditional wound classification system of categorizing wounds as clean, clean-contaminated, contaminated or dirty-infected.1 For each surgical procedure, a risk index score ranging from 0 to 3 was used to represent the number of risk factors present among the following: 1) whether the patient had an ASA preoperative assessment score of 3, 4 or 5; 2) an operation classified as contaminated or dirty-infected; and 3) an operation lasting over T hours, where T is defined as the 75th percentile of the distribution of the duration of surgery for the specific operative procedure performed (based on NNIS data). The SWI rates (number of infections per 100 operations) for patients with scores of 0, 1, 2 and 3 were 1.5, 2.9, 6.8 and 13.0, respectively. In comparison, the SWI rates within each of the categories of the traditional wound classification system were 2.1, 3.3, 6.4 and 7.1, respectively.

The study also found that as a single predictor of SWI risks, the ASA score was at least as good as the traditional wound classification system, i.e., the SWI rates for patients with ASA scores of 1, 2, 3, 4 and 5 were 1.5, 2.1, 3.7, 5.5 and 7.1, respectively.¹

Donald A. Goldmann, M.D.
Children’s Hospital
Boston, Massachusetts
Edited by Margaret A. Winker, M.D., Senior Editor, and Phil B. Fontanarosa, M.D., Senior Editor, Journal of the American Medical Association

Reference:
1. Culver DH, Horan TC, Gayness RP, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. Am J Med. 1991; 91 (supplement 3B):152S-157S.

Interestingly when the Joint Commission on Accreditation of Healthcare Organizations reviewers reviewed our preoperative charts in the preop center, they seemed overly concerned that we had scored an “ASA PS.” This search for the ASA PS seemed to be their main purpose in the preop center. Now I see tons of research that uses this PS as a guide to how well a patient should have done.

Marc A. Rozner, M.D., Ph.D.
Houston, Texas

Reference:
1. The American Society of Anesthesiologists Physical Status Score and Risk of perioperative infection [letter to the editor]. JAMA. 275(20):1544. [Copyrighted 1996, American Medical Association, reprinted with permission].

Judging a NEWSLETTER by Its Cover

In general, I think you do a fantastic job of editing the ASA NEWSLETTER. However, in the year 2002, I do not know any anesthesiologists who would wear their lab coats into an operating room [September 2002 cover]. This is a clear violation of Joint Commission on Accreditation of Healthcare Organizations standards and not what I would have expected on the cover of such a quality publication!

Stanley D. Knight, M.D.
Hinsdale, Illinois

Who’s on First? In This Case, Not Swan and Ganz

I thought the photographs and text accompanying the article “Cardiorespiratory Monitoring: A Pictorial Sampler” in the September 2002 NEWSLETTER were truly wonderful. The authors must have researched numerous sources to write such a report.

However, the picture of W. Ganz, M.D., and H.J.C. Swan, M.D., and the credit for introduction of the balloon-tipped flow-directed catheter to reflect right ventricular, pulmonary artery pressure and the pulmonary artery catheter thermodilution technique for cardiac output in 1970 is incorrect. These techniques were popularized but not devised by them. The first reported use of thermodilution cardiac output was its use in animals by veterinarians in 1954.¹ The first reported use of measurement of cardiac output by thermal dilution in humans was made by M.A. Branthwaite, M.D., (an anesthesiologist)² and R.D. Bradley, M.D., (an intensivist).³ This group at St. Thomas’ Hospital in London also described evaluation of pulmonary artery end-diastolic pressure as an indirect estimate of left atrial mean pressure in 1970.⁴ Since Dr. Swan and Dr. Ganz usually get the credit, I thought that the article’s authors, Leslie Rendell-Baker, M.D., and George S. Bause, M.D., would appreciate setting the historical scientific record straight.

Colin F. MacKenzie, M.B.
Baltimore, Maryland

References:
1. Fegler G. Measurement of cardiac output in anaesthetized animals by a thermo-dilution method. Quart J Exptl Physiol. 1954; 39:153-164.
2. Branthwaite MA, Bradley RD. Measurement of cardiac output by thermal dilution in man. J Appl Physiol. 1968; 24:434.
3. Bradley RD. Diagnostic right heart catheterisation with miniature catheters in severely ill patients. Lancet. 1964; 2:941-942.
4. Jenkins BS, Bradley RD, Branthwaite MA. Evaluation of pulmonary arterial end diastolic pressure as an indirect estimate of left atrial 1 mean pressure. Circulation. 1970; 42:75.

We’re Our Own Worst Enemy

As we struggle in the state of Florida for supervision over nurse anesthetists and licensure of anesthesiologist assistants (AAs), I have come to realize that the future of our specialty as a unique provider of medical care may be in jeopardy. It is our responsibility as physicians to provide a visible, engaged counter to the perception that we are at least partially replaceable by nurses and physician assistants.

What do I mean by leadership and visibility? It is demonstrating to our patients and their families, the operating room staff, hospital administrators, floor nurses and surgeon/physician colleagues that we are responsible for the anesthetic care and all its attendant medical decisions. This means doing preoperative rounds on the wards, meeting families and looking them in the eyes with the message that you will take care of their loved one. This means conducting the anesthetic — personally performing the induction and emergence, the regional anesthetic or the invasive lines, for example — not to satisfy some compliance requirement but to show who is in charge and who is truly in control. This may mean doing postoperative visits or calling outpatients in follow-up yourself, declaring to everyone your responsibility for the case.

We need to be active, readily available and eager consultants by managing intensive care unit patients, running pain control services, putting in the “tough” lines or tubes or performing the “impossible” lumbar puncture. Finally, taking responsibility for our specialty means being involved in hospital committees where our expertise can shine such as in critical care, respiratory therapy, ethics, pain management, obstetric care and pharmacy/therapeutics.

We cannot succumb to greed or laziness by abrogating more and more of our professional duties to lesser qualified individuals and in the process devaluing our services and our specialty. I have great respect for other anesthesia providers and the defined role they play, but by encouraging nurse anesthetists and AAs to perform central elements of our job, they will one day replace us. In allowing this, we will have been our own worst enemies.

Jay H. Epstein, M.D.
Pinellas Park, Florida

‘Foundations of Our Success’ Are What Made ‘Benign Sight’ of ASA Possible!

In his October 2002 “Ventilations,” Mark J. Lema,, M.D., is correct that “Anesthesiology is blessed by having three foundations (WLM, APSF, FAER) ‘under the benign sight’ of ASA.” He recognizes that “ASA gives generously to support the WLM, APSF and FAER. It is estimated that $75 per member (37,941 x $75 = $2,845,575) is donated in total to all foundations.” Furthermore, his “Please support these foundations as much as your own health” is appropriate.

Yet with a few exceptions, how many anesthesiologists or others who receive the NEWSLETTER are aware of: 1) why ASA can do so when, in 1958, it was deficit spending; 2) its early rescue of a destitute WLM; and 3) why “under benign sight” it can assure the viability of not only ASA and WLM but APSF and FAER?

Those who are inquisitive may wish to know the following:

The answers to these in their minuteness are documented in Volume VII (pages 225-288) of Careers in Anesthesiology published by the WLM. The sale of Volume I-VII of “Careers” supplements the income of the WLM, which in turn, as Dr. Lema noted, “preserves us as a specialty.”

Daniel C. Moore, M.D.
1959 ASA President
Seattle, Washington

Editor’s Note: The latest in the WLM’s series, Careers in Anesthesiology VII, includes insight and wisdom from three esteemed educators, two of whom were past ASA presidents, including Dr. Moore and Bernard V. Wetchler, M.D., and Jay Jacoby, M.D., Ph.D. The three recount memorable events from their military service and how World War II and the Korean War impacted their careers and their lives. This hardcover book is available for $45 through the WLM <wlm@ASAhq.org>.

— M.J.L.

Existential Dilemma of General Anesthesia
I always enjoy your thoughtful commentary in the NEWSLETTER. I recently viewed yet another discussion of conscious sedation versus deep sedation versus general anesthesia (GA) and have given it some thought...

The Emperor’s New Definitions:
“Signs of deep sedation may be indistinguishable from those of general anesthesia” say the posters. This passes the duck test (looks like a… talks like a… sounds like a… must be a…). We have defined conscious sedation very appropriately: maintained-responsiveness, airway and stable vital signs; no issue there. If those are not present, it must be GA? To be team players and because the Joint Commission on Accreditation of Healthcare Organizations mandates that “anesthesia” is responsible for setting policy in the institution, we have created a whole category where no space existed before!

I do not in any way deny that sedation for procedures is needed in nonoperating room settings, but does this imply that we define down standards to increase the available providers?

I cannot help but to recall an exchange told to me by one of my partners during his residency:

The attending asks: “And what are you doing there, Dr. S?” (He is holding open an airway for an unconscious patient.)

“Giving some sedation for this procedure, sir.”

“No, Dr. S., that is GA! Poorly done!”

I have come to a simple conclusion! Deep sedation is a political term! It applies to GA performed in an alternate setting by a person not trained for GA! It all makes sense then — no fancy definitions, I understand it.

Have we become them (thanks, Pogo) and have downwardly redefined standards to appear to be team players? Let’s call it what it is, provide services as needed and training to providers and stop torturing ourselves with all this hairsplitting.

Robert Forest, M.D.
Tucson, Arizona

VAM Simulator a Real Gas

Chapter one of the Anesthesia Patient Safety Foundation anesthesia machine workbook is available free of charge at the Virtual Anesthesia Machine (VAM) Web site at <www.anest.ufl.edu/vam>.

The 50-page chapter covers normal function of traditional anesthesia machines, including structured exercises designed for instructional use or self-paced learning, in conjunction with the Web-based VAM simulation. Adobe Acrobat Reader™ 5.0 or higher (a free download) is required to view or print the workbook. The read-only PDF file containing the workbook can be printed (color printer recommended) and used as a workbook. Alternatively, it may be viewed simultaneously with the VAM simulation by toggling back and forth between separate Web browser windows containing the two applications.

The VAM simulation is a free, Web-based, interactive, real-time simulation of gas flows in a traditional anesthesia machine. Instead of complex, dimensional drawings of an anesthesia machine, VAM presents a simplified mental model designed to help viewers appreciate and retain basic concepts. Gas “molecules” are made visible and are color-coded (US/ISO gas color codes). Users can adjust 30 controls and observe in real time the essential effects of their interventions on gas pressures, flows, compositions and volumes (lung, bellows and manual and scavenging bags). Machine faults can be simulated, and the simulation can be paused. Gas molecules can be made invisible as well. Online help to use the simulation is available as an animated tutorial.

The simulation features Arabic, Chinese, Dutch, English, French, German, Italian, Korean, Russian or Spanish legends. To lower distribution costs, the free materials are available only via the Web. Macromedia Shockwave™ (a free download) is required to view the simulation. Upon first access, user registration is required for all downloadable material. Instructions for offline use at teaching locations without Web access are provided at the VAM Web site.

Samsung Lampotang, Ph.D.
Gainesville, Florida

Agonizing Truths About Our Pain Skills

Recent editions of the NEWSLETTER have emphasized the anesthesiologist’s role in acute and chronic pain management. Sadly my experiences as anesthesiologist-turned-hospice-doctor indicate that neither anesthesiologists nor other physicians are particularly skilled or interested in either. Most patients leave the hospital or surgery center a few hours after surgery and are given a prescription for a handful of pills unlikely to provide a high level of comfort. Occasionally, someone will slap on a fentanyl patch without the slightest idea of what dose is appropriate and totally ignorant of the fact that stable blood levels of the drug are unlikely to be had for 12 to 24 hours. Prescriptions for oral sustained-release morphine or oxycodone or methadone are rare indeed. Prescribing adequate doses for breakthrough pain are more rare.

For the complicated patient who has had a spinal or epidural catheter placed, management at home is often even more difficult. Locating the pain doctor after office hours and weekends tends to be frustrating. Getting such a doctor to make a house call on a debilitated or dying patient is a “break out the champagne” event. The most common outcomes, in my experience, are poorly treated pain or rehospitalization — both highly unsatisfactory to the patient, family and primary care physician.

Eight years in hospice work have made a believer of me. I believe that most doctors, in all specialties, do not know how to treat pain.

J. Bruce Laubach, M.D.
Castle Rock, Colorado

We Need to Catch the Ball Before Running With It

In the business world, companies sometimes fail when their efforts expand beyond their core business in an attempt to capture a greater share of new markets. Several articles that appeared in the November 2002 ASA NEWSLETTER highlight that our specialty may be committing a similar error. Several authors suggested that anesthesiologists consider becoming hospitalists in addition to perioperative physicians. Are we to go forward into this century adding these and other goals to our training curriculum and workforce demands?

What follows is a partial list of what leads me to question the argument that we need to and should expand our mission as anesthesiologists:

• Our existing “core” subspecialties with certification (critical care, pain management) are inadequately staffed and funded and face tremendous challenges.
• The number of anesthesiologists trained has not kept pace with the number of nurse anesthetists trained.
• Departments of anesthesiology continue to change their names (at times to something that is almost difficult to say in one breath) in recognition of the expanding roles that are being assumed.
• There remains a critical shortage of anesthesia care providers throughout the country, and it is projected that this shortage will persist for years.

In addition, anesthesiologists who “merely” practice anesthesia face challenges in maintaining and upgrading their knowledge and abilities in numerous key (“core”) specialty techniques, including some very basic and vital skills such as airway and cardiovascular management. Most departments also have yet to solve numerous “core” problems that require significant resources such as the deployment of electronic data management systems and incorporation of competency assessment.

I in no way wish to diminish the accomplishments of all individuals who seek to better themselves and their patients. However, I see a specialty and a community of specialists who have yet to manage the “core” business of anesthesiology well. The specialty of anesthesiology is the perioperative care (including pain management) of the surgical patient. Doing it well remains an admirable and difficult challenge. My preference has always been to do fewer things well than many things not so well. In analogous fashion, I would like to present for consideration the notion that the specialty of anesthesiology is at risk of mismanaging its core business. As anesthesiologists and the specialty continue to diverge into new areas with inadequate resources, will we lose something along the way?

Peter L. Bailey, M.D.
Rochester, New York

Misquoted Quotable

I read with interest the letter submitted by Norm Aleks, M.D., (“Pat Yourself on the Back”) in the November ASA NEWSLETTER. Although I was quite pleased to learn that someone actually listened to something I said during their anesthesiology residency, the aphorism that Norm credits to me (“Regional anesthesia is like regional television — of variable quality but always entertaining!”) is not mine.

This pronouncement was first made by Howard Gutstein, M.D., during the first month of his anesthesiology residency. While I might have provided some inspiration as his faculty mentor, I would like to think Howard suggested this as a general axiom and did not intend it to be attending-specific.

Kenneth Drasner, M.D.
Kentfield, California

We Are Our Own Worst Aliens

The emergence of the expert witness physician is not — as you suggest in your December 2002 “Ventilations” titled “Aliens Among Us” — an interesting byproduct of the medical liability tort crisis. You do not hear of anyone suggesting that an interesting byproduct of the product liability crisis is the emergence of lawyers.

I would suggest to you that the medical liability tort crisis is a byproduct of the failure of physicians to adequately monitor ourselves. As a past president of ASA has discussed at numerous lectures, “we are our own worst enemy.”

The liability crisis has been brought about by the failure of residency programs, especially anesthesiology residencies, to properly identify residents who are clearly inferior both in ability and knowledge. Instead of confronting the issue and encouraging, even demanding, the inferior residents to seek another specialty, most programs will coddle the inferior and allow them to enter the workforce knowing they are producing a potentially deadly product.

You go on to say, “In recent years, a different breed of medical expert has metamorphosed — the plaintiff’s expert witness.” I would suggest to you that the plaintiff’s expert witness has existed for many decades and is not a recent metamorphosis.

We would not be so hasty to alienate a medical expert who was testifying in behalf of one of our family members or loved ones who has suffered at the hands of incompetence or carelessness.

Unscrupulous physicians who modify their testimony solely to suit a prosecutor’s agenda should be censured and exposed as frauds. The institution of a program to foster integrity among medical experts is certainly a worthy endeavor. ASA might even sanction a curriculum to certify a medical expert, thus ensuring professional, impartial expert testimony.

We have the ability to defuse the crisis by altering our own behavior.

Anthony M. Frasca, M.D.
Port Jefferson, New York

Editor’s Note: I believe what you stated in your letter was the point of the editorial.

— M.J.L

Defending Plaintiff’s Witnesses

I hope Mark J. Lema, M.D., Ph.D., did not really mean what he said in “Aliens Among Us,” (December “Ventilations”) referring to what he perceives to be the misconduct of anesthesiologists who dare to testify for plaintiffs. I have occasionally testified over the years in patient injury cases, successfully defending unfairly accused physicians, but also helping patients injured through negligence to be made whole by the courts, which exist to help all of us.

His statement that “defense work is good, and plaintiff’s work is bad” is just plain silly and, in my opinion, unethical. It is essential that ASA members be willing to testify truthfully in any case for which their help is requested. That and that alone is true professionalism and the ultimate in patient advocacy. Over the years, I have had the pleasure of seeing plaintiffs’ attorneys gladly follow my recommendation to drop as meritless at least 15 cases for every one in which I was willing to testify for the plaintiff.

When the plaintiffs’ bar has difficulty finding highly credible anesthesiologists to evaluate cases for them, they resort to consulting those on the fringe to whom Dr. Lema hopefully refers. Too often, those “experts” provide whatever testimony the plaintiff desires, and the lawsuit moves forward.

The equally distressing flip side of that coin are those anesthesiologists who only testify for the defense, often without sufficiently thoughtful regard to the propriety of the defendant’s actions. Dr. Lema implies that this includes most ASA officers, who testify only for defendants. To the extent that is true, it undermines our credibility as an organization and betrays our stated commitment to the best care for every patient.

All of us would best serve the interests of patients and of ASA if we objectively reviewed all cases when requested to do so within our expertise and experience.

Thomas J. Poulton, M.D.
Omaha, Nebraska

Editor’s Note: Obviously I am referring to those who are purely hired guns. I tried to explain that serving as a plaintiff’s witness against a deadly doctor provides a public service. My point is that we as an anesthesiology society should have ethical standards with some teeth.

— M.J.L.

Spread the Word: Reused Needles Are Unacceptable

Thank you for publishing the article by Elliott S. Greene, M.D., “Hepatitis C Outbreak: More Than 50 Infected by Reused Needles and Syringes” in the December 2002 ASA NEWSLETTER.

As an anesthesiologist supervising eight nurse anesthetists at a hospital in the Midwest a few years ago, I was shocked to find that most of the nurse anesthetists administered medication from the same syringe to multiple patients. Only the needle was changed between patients. They would then use the same syringe on multiple patients until it was empty, re-fill the syringe with the same medication and then repeat the process. The syringes were essentially never discarded.

This practice was not covert, but it was not noticed until close attention was paid to the actions of the nurse anesthetists when handling medications. In fact, I discovered this practice after working with these nurse anesthetists after one month. When I brought it to the attention of the other anesthesiologists in my group, some of whom had worked with these same nurse anesthetists for 10-plus years, they were shocked and had not noticed this practice themselves.

The nurse anesthetists informed me that they were taught that administering medication from a syringe to multiple patients was OK as long as the needle was changed between patients. When I informed them that this was not acceptable, they balked. I obtained the publication “Recommendations for Infection Control for the Practice of Anesthesiology” from ASA for each nurse anesthetist, held an emergency in-service with all of the nurse anesthetists, using this publication as reference, and put an end to this dangerous practice at the hospital.

Unfortunately, this experience has me convinced that this dangerous practice is ongoing at other hospitals today.

Patricia A. Roth, M.D.
San Francisco, California

Making Our Bite Bigger Than Our Bark

I read with interest “What’s New In … The Future of Anesthesiology: Let’s Act Now” (December 2002) by Ronald D. Miller, M.D., who called for a 40-year plan for ASA and the specialty of anesthesiology. Many of the concerns and suggestions are valuable and should be pursued. In my view, a long-range plan only makes sense within a structure of frequent moments of accountability; goals should be prioritized, progress should be measured, and adaptations should be implemented as the process unfolds.¹

Dr. Miller should be aware that ASA has been engaged in this activity for over a decade. In 1992, as ASA President-Elect, I convened a strategic planning group and began a long-range process in which various aspects of our Society and our specialty were subject to analysis and re-evaluation. I would agree with Dr. Miller that this effort could be more forceful and sustained. As I urged the Society in 1993,

“We must ask ourselves to identify the tyrannies of the past, those habits of thought that keep us from apprehending the truth or that reduce our ability to see tomorrow’s opportunities.

Perhaps it is time for us to convene a symposium consisting of thoughtful members of the community of anesthesiologists, including young physicians, to deliberate upon the future identity of this gifted specialty, test the conventional wisdom, revisit the assumptions upon which we have predicated our specialty’s future and broaden the dimensions of the dialogue. We should define ourselves consistent with our possibilities; then we should develop strategies that are consistent with the ensuing expectations.”²

We have lost many opportunities in the past to establish our authenticity and competence in respiratory care, critical care medicine and currently in pain management. We will lose another chance to be leaders in perioperative medicine and the arena of systems management within health care facilities.

Whether we bite off 40-year chunks or opt for the more digestible five- or 10-year plan, we should not only agree on the absolute necessity of the project, we should commit ourselves to ensuring that the process does not languish in the endless institutional byways that eat up good ideas.

Peter L. McDermott, M.D., Ph.D.
1993 ASA President
Camarillo, California

References:
1. McDermott PL. Fireflies and poison toads. ASA Newsl. 1993; 57(8):2-3.
2. McDermott PL. Tomorrow [editorial]. Anesthesiology. 1993; 79(2):209-210.