Letters To The Editor

“MANAGEMENT OF WOUND COMPLICATIONS FOLLOWING OBSTETRIC ANAL SPHINCTER INJURY (OASIS)”

ROBERT L. BARBIERI, MD, AND JEANNINE M. MIRANNE, MD, MS (EDITORIAL; DECEMBER 2016)

Delivering clinician should be seated

Indeed, obstetric anal sphincter injuries (OASIS),¹ with their short- and long-term consequences, merit clinical attention, as spotlighted in Dr. Barbieri and Dr. Miranne’s article. An issue not discussed is the position of the obstetrician.

In our practice, we sit down to perform a vaginal delivery, as taught by Soranus of Ephesus.² We strive to be at the bedside sooner than when the nurse calls “she is crowning.” This allows communication with the woman, attending nurse, and support person(s), as well as for a brief review of recent estimated fetal weight, length of the second stage, position of the presenting part, degree of flexion, presence of caput, and other last-minute details. Sitting down in front of the outlet permits uninterrupted visual evaluation of the distention of the soft perineal tissues. All traditional maneuvers are performed comfortably from the sitting position: the vertex is controlled by hands-on, and a quick reach with the nonpredominant hand searches for a loop of cord or a small part procidentia to resolve it. The patient is coached either for the next bearing-down effort or to not push to allow for gradual, controlled delivery of the fetal shoulder girdle. We avoid use of the fetal head for traction and move to facilitate “shrugging” with reduction of the bisacromial to facilitate delivery.

In our experience, the sitting position is ideal to observe uninterruptedly the tension of the perineal body during vertex and shoulders delivery, without having to flex and rotate our back and neck in repeatedly nonergonomic positions.

If an obstetrician of above-average height stands for the delivery, the obstetric bed should be elevated to fit her or his reach. Should shoulder dystocia occur, an assistant will stand on a chair and hover over the maternal abdomen to provide suprapubic pressure (indeed, an indelible memory for any parturient and her family). From the sitting position, exploration of the birth canal and repair of any injury, if necessary, can be conducted without technical impediments.

These simple steps have provided our patients and ourselves with clinical and professional satisfaction with minimal OASIS events as shown by others.³ Ironically, if we successfully avoid perineal injuries, our young trainees may require simulation training to learn this tedious repair procedure. In our geographic practice area, a new “collaborative” expects the frequency of episiotomy to be less than 4.6%. Third- and 4th-degree spontaneous or procedure-related perineal injuries still are used to measure quality of care despite demonstrated reasons for this parameter to be a noncredible metric.

Federico G. Mariona, MD
Dearborn, Michigan

Dr. Barbieri responds

I agree with Dr. Mariona that in some cases the fetal head delivers without causing a 3rd- or 4th-degree laceration, but then the delivery of the posterior shoulder causes a severe perineal injury. Dr. Mariona’s clinical pearl is that the delivering clinician should be seated, carefully observe the delivery of the shoulders, and facilitate fetal shrugging by gently reducing the bisacromial diameter as the posterior shoulder transitions over the perineal body.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“MANAGEMENT OF WOUND COMPLICATIONS FOLLOWING OBSTETRIC ANAL SPHINCTER INJURY (OASIS)”

ROBERT L. BARBIERI, MD, AND JEANNINE M. MIRANNE, MD, MS (EDITORIAL; DECEMBER 2016)

Delivering clinician should be seated

Indeed, obstetric anal sphincter injuries (OASIS),¹ with their short- and long-term consequences, merit clinical attention, as spotlighted in Dr. Barbieri and Dr. Miranne’s article. An issue not discussed is the position of the obstetrician.

In our practice, we sit down to perform a vaginal delivery, as taught by Soranus of Ephesus.² We strive to be at the bedside sooner than when the nurse calls “she is crowning.” This allows communication with the woman, attending nurse, and support person(s), as well as for a brief review of recent estimated fetal weight, length of the second stage, position of the presenting part, degree of flexion, presence of caput, and other last-minute details. Sitting down in front of the outlet permits uninterrupted visual evaluation of the distention of the soft perineal tissues. All traditional maneuvers are performed comfortably from the sitting position: the vertex is controlled by hands-on, and a quick reach with the nonpredominant hand searches for a loop of cord or a small part procidentia to resolve it. The patient is coached either for the next bearing-down effort or to not push to allow for gradual, controlled delivery of the fetal shoulder girdle. We avoid use of the fetal head for traction and move to facilitate “shrugging” with reduction of the bisacromial to facilitate delivery.

In our experience, the sitting position is ideal to observe uninterruptedly the tension of the perineal body during vertex and shoulders delivery, without having to flex and rotate our back and neck in repeatedly nonergonomic positions.

If an obstetrician of above-average height stands for the delivery, the obstetric bed should be elevated to fit her or his reach. Should shoulder dystocia occur, an assistant will stand on a chair and hover over the maternal abdomen to provide suprapubic pressure (indeed, an indelible memory for any parturient and her family). From the sitting position, exploration of the birth canal and repair of any injury, if necessary, can be conducted without technical impediments.

These simple steps have provided our patients and ourselves with clinical and professional satisfaction with minimal OASIS events as shown by others.³ Ironically, if we successfully avoid perineal injuries, our young trainees may require simulation training to learn this tedious repair procedure. In our geographic practice area, a new “collaborative” expects the frequency of episiotomy to be less than 4.6%. Third- and 4th-degree spontaneous or procedure-related perineal injuries still are used to measure quality of care despite demonstrated reasons for this parameter to be a noncredible metric.

Federico G. Mariona, MD
Dearborn, Michigan

Dr. Barbieri responds

I agree with Dr. Mariona that in some cases the fetal head delivers without causing a 3rd- or 4th-degree laceration, but then the delivery of the posterior shoulder causes a severe perineal injury. Dr. Mariona’s clinical pearl is that the delivering clinician should be seated, carefully observe the delivery of the shoulders, and facilitate fetal shrugging by gently reducing the bisacromial diameter as the posterior shoulder transitions over the perineal body.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“MANAGEMENT OF WOUND COMPLICATIONS FOLLOWING OBSTETRIC ANAL SPHINCTER INJURY (OASIS)”

ROBERT L. BARBIERI, MD, AND JEANNINE M. MIRANNE, MD, MS (EDITORIAL; DECEMBER 2016)

Delivering clinician should be seated

Indeed, obstetric anal sphincter injuries (OASIS),¹ with their short- and long-term consequences, merit clinical attention, as spotlighted in Dr. Barbieri and Dr. Miranne’s article. An issue not discussed is the position of the obstetrician.

In our practice, we sit down to perform a vaginal delivery, as taught by Soranus of Ephesus.² We strive to be at the bedside sooner than when the nurse calls “she is crowning.” This allows communication with the woman, attending nurse, and support person(s), as well as for a brief review of recent estimated fetal weight, length of the second stage, position of the presenting part, degree of flexion, presence of caput, and other last-minute details. Sitting down in front of the outlet permits uninterrupted visual evaluation of the distention of the soft perineal tissues. All traditional maneuvers are performed comfortably from the sitting position: the vertex is controlled by hands-on, and a quick reach with the nonpredominant hand searches for a loop of cord or a small part procidentia to resolve it. The patient is coached either for the next bearing-down effort or to not push to allow for gradual, controlled delivery of the fetal shoulder girdle. We avoid use of the fetal head for traction and move to facilitate “shrugging” with reduction of the bisacromial to facilitate delivery.

In our experience, the sitting position is ideal to observe uninterruptedly the tension of the perineal body during vertex and shoulders delivery, without having to flex and rotate our back and neck in repeatedly nonergonomic positions.

If an obstetrician of above-average height stands for the delivery, the obstetric bed should be elevated to fit her or his reach. Should shoulder dystocia occur, an assistant will stand on a chair and hover over the maternal abdomen to provide suprapubic pressure (indeed, an indelible memory for any parturient and her family). From the sitting position, exploration of the birth canal and repair of any injury, if necessary, can be conducted without technical impediments.

These simple steps have provided our patients and ourselves with clinical and professional satisfaction with minimal OASIS events as shown by others.³ Ironically, if we successfully avoid perineal injuries, our young trainees may require simulation training to learn this tedious repair procedure. In our geographic practice area, a new “collaborative” expects the frequency of episiotomy to be less than 4.6%. Third- and 4th-degree spontaneous or procedure-related perineal injuries still are used to measure quality of care despite demonstrated reasons for this parameter to be a noncredible metric.

Federico G. Mariona, MD
Dearborn, Michigan

Dr. Barbieri responds

I agree with Dr. Mariona that in some cases the fetal head delivers without causing a 3rd- or 4th-degree laceration, but then the delivery of the posterior shoulder causes a severe perineal injury. Dr. Mariona’s clinical pearl is that the delivering clinician should be seated, carefully observe the delivery of the shoulders, and facilitate fetal shrugging by gently reducing the bisacromial diameter as the posterior shoulder transitions over the perineal body.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“SHOULDER DYSTOCIA: TAKING THE FEAR OUT OF MANAGEMENT”

JOHN T. REPKE, MD, AND RONALD T. BURKMAN, MD (WEB EXCLUSIVE; APRIL 2016)

Montgomery maneuver for shoulder dystocia

In managing shoulder dystocia, my maneuver is to use my elbow to maximize mechanical advantage when applying suprapubic pressure to push the trapped shoulder down. It works well and is more efficient than having a nurse standing off to the side.

J.S. Montgomery, MD
Cypress, Texas

Dr. Barbieri responds

I thank Dr. Montgomery for sharing his maneuver for dislodging the trapped anterior shoulder by using his elbow to apply suprapubic pressure. There is vast knowledge and experience in our clinical community, and sharing insights is helpful to all our readers.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“SHOULDER DYSTOCIA: TAKING THE FEAR OUT OF MANAGEMENT”

JOHN T. REPKE, MD, AND RONALD T. BURKMAN, MD (WEB EXCLUSIVE; APRIL 2016)

Montgomery maneuver for shoulder dystocia

In managing shoulder dystocia, my maneuver is to use my elbow to maximize mechanical advantage when applying suprapubic pressure to push the trapped shoulder down. It works well and is more efficient than having a nurse standing off to the side.

J.S. Montgomery, MD
Cypress, Texas

Dr. Barbieri responds

I thank Dr. Montgomery for sharing his maneuver for dislodging the trapped anterior shoulder by using his elbow to apply suprapubic pressure. There is vast knowledge and experience in our clinical community, and sharing insights is helpful to all our readers.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“SHOULDER DYSTOCIA: TAKING THE FEAR OUT OF MANAGEMENT”

JOHN T. REPKE, MD, AND RONALD T. BURKMAN, MD (WEB EXCLUSIVE; APRIL 2016)

Montgomery maneuver for shoulder dystocia

In managing shoulder dystocia, my maneuver is to use my elbow to maximize mechanical advantage when applying suprapubic pressure to push the trapped shoulder down. It works well and is more efficient than having a nurse standing off to the side.

J.S. Montgomery, MD
Cypress, Texas

Dr. Barbieri responds

I thank Dr. Montgomery for sharing his maneuver for dislodging the trapped anterior shoulder by using his elbow to apply suprapubic pressure. There is vast knowledge and experience in our clinical community, and sharing insights is helpful to all our readers.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“LONG-ACTING REVERSIBLE CONTRACEPTIVES AND ACNE IN ADOLESCENTS”

ROBERT L. BARBIERI, MD, AND ANDREA H. ROE, MD (EDITORIAL; JANUARY 2017)

Manage acne with spironolactone for women on LARC

Dr. Barbieri’s editorial with Dr. Roe addressed the very important theme of proactively talking about acne before a patient starts long-acting reversible contraception (LARC), especially when switching from a birth control pill that had controlled the acne to a levonorgestrel intrauterine device (LNG-IUD). It missed the mark, however, in not mentioning a very important presenting feature of adolescent polycystic ovary syndrome (PCOS)—cystic acne. I highly recommend obtaining baseline testosterone levels and using spironolactone, 50 to 200 mg daily, to treat acne while on LARC, especially an LNG-IUD. I learned this trick a few years ago from a Canadian endocrinologist.

John Lewis, MD

Waterbury, Connecticut

Dr. Barbieri responds

I thank Dr. Lewis for the important clinical pearl to use spironolactone to prevent and treat acne when inserting a progestin-releasing LARC in an adolescent or young woman. Spironolactone blocks testosterone action in the pilosebaceous unit, thereby decreasing sebum production and reducing acne activity. I frequently use spironolactone in my practice, especially for women with PCOS who have hirsutism and acne (see my editorial on page 8 of this issue). However, authors of a recent systematic review reported that there is minimal evidence from clinical trials to support the use of spironolactone to treat acne vulgaris.¹

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“LONG-ACTING REVERSIBLE CONTRACEPTIVES AND ACNE IN ADOLESCENTS”

ROBERT L. BARBIERI, MD, AND ANDREA H. ROE, MD (EDITORIAL; JANUARY 2017)

Manage acne with spironolactone for women on LARC

Dr. Barbieri’s editorial with Dr. Roe addressed the very important theme of proactively talking about acne before a patient starts long-acting reversible contraception (LARC), especially when switching from a birth control pill that had controlled the acne to a levonorgestrel intrauterine device (LNG-IUD). It missed the mark, however, in not mentioning a very important presenting feature of adolescent polycystic ovary syndrome (PCOS)—cystic acne. I highly recommend obtaining baseline testosterone levels and using spironolactone, 50 to 200 mg daily, to treat acne while on LARC, especially an LNG-IUD. I learned this trick a few years ago from a Canadian endocrinologist.

John Lewis, MD

Waterbury, Connecticut

Dr. Barbieri responds

I thank Dr. Lewis for the important clinical pearl to use spironolactone to prevent and treat acne when inserting a progestin-releasing LARC in an adolescent or young woman. Spironolactone blocks testosterone action in the pilosebaceous unit, thereby decreasing sebum production and reducing acne activity. I frequently use spironolactone in my practice, especially for women with PCOS who have hirsutism and acne (see my editorial on page 8 of this issue). However, authors of a recent systematic review reported that there is minimal evidence from clinical trials to support the use of spironolactone to treat acne vulgaris.¹

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“LONG-ACTING REVERSIBLE CONTRACEPTIVES AND ACNE IN ADOLESCENTS”

ROBERT L. BARBIERI, MD, AND ANDREA H. ROE, MD (EDITORIAL; JANUARY 2017)

Manage acne with spironolactone for women on LARC

Dr. Barbieri’s editorial with Dr. Roe addressed the very important theme of proactively talking about acne before a patient starts long-acting reversible contraception (LARC), especially when switching from a birth control pill that had controlled the acne to a levonorgestrel intrauterine device (LNG-IUD). It missed the mark, however, in not mentioning a very important presenting feature of adolescent polycystic ovary syndrome (PCOS)—cystic acne. I highly recommend obtaining baseline testosterone levels and using spironolactone, 50 to 200 mg daily, to treat acne while on LARC, especially an LNG-IUD. I learned this trick a few years ago from a Canadian endocrinologist.

John Lewis, MD

Waterbury, Connecticut

Dr. Barbieri responds

I thank Dr. Lewis for the important clinical pearl to use spironolactone to prevent and treat acne when inserting a progestin-releasing LARC in an adolescent or young woman. Spironolactone blocks testosterone action in the pilosebaceous unit, thereby decreasing sebum production and reducing acne activity. I frequently use spironolactone in my practice, especially for women with PCOS who have hirsutism and acne (see my editorial on page 8 of this issue). However, authors of a recent systematic review reported that there is minimal evidence from clinical trials to support the use of spironolactone to treat acne vulgaris.¹

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

To the Editor: We read with great interest the article by Drs. Cawcutt and Wilson on caring for international patients.¹ They provide an overview of the challenges of delivering medical care for these patients (eg, cultural differences) and the likely benefits from such interactions (eg, gaining cultural knowledge). Having practiced medicine in 3 different continents and experienced working in various medical centers caring for international patients, we would like to offer a slightly different viewpoint.

First, gaining cultural knowledge should be regarded as a prerequisite for healthcare workers involved in the care of international patients, rather than the expected benefit and consequence of such encounters. Healthcare workers with some knowledge of an international patient’s culture are best able to serve that patient.² Indeed, unless knowledge of cultural differences is obtained before such interactions, there is a significant risk of stereotyping by amplifying the sense of “otherness,” which is unfortunately too often mistaken for cultural sensitivity. The perception of the stereotypes and prejudices during the second stage of cultural adaptation (ie, irritation, hostility) often stems from the host’s lack of cultural knowledge. Table 1 of their article clearly reflects such risk: the authors have tried to exemplify the concepts they discussed through a number of real-life scenarios. But indeed some of those cases (eg, the man from Saudi Arabia) could be interpreted more as examples of stereotyping than cultural sensitivity.

Second, the authors do not mention requests by family members of international patients for nondisclosure of serious medical diagnoses, one we have frequently received from family members from different cultural backgrounds. These requests represent another challenge of caring for these patients as they counter our obligation for full disclosure and the patients’ right to know in order to be able to make informed decisions regarding their medical care.³

To the Editor: We read with great interest the article by Drs. Cawcutt and Wilson on caring for international patients.¹ They provide an overview of the challenges of delivering medical care for these patients (eg, cultural differences) and the likely benefits from such interactions (eg, gaining cultural knowledge). Having practiced medicine in 3 different continents and experienced working in various medical centers caring for international patients, we would like to offer a slightly different viewpoint.

First, gaining cultural knowledge should be regarded as a prerequisite for healthcare workers involved in the care of international patients, rather than the expected benefit and consequence of such encounters. Healthcare workers with some knowledge of an international patient’s culture are best able to serve that patient.² Indeed, unless knowledge of cultural differences is obtained before such interactions, there is a significant risk of stereotyping by amplifying the sense of “otherness,” which is unfortunately too often mistaken for cultural sensitivity. The perception of the stereotypes and prejudices during the second stage of cultural adaptation (ie, irritation, hostility) often stems from the host’s lack of cultural knowledge. Table 1 of their article clearly reflects such risk: the authors have tried to exemplify the concepts they discussed through a number of real-life scenarios. But indeed some of those cases (eg, the man from Saudi Arabia) could be interpreted more as examples of stereotyping than cultural sensitivity.

Second, the authors do not mention requests by family members of international patients for nondisclosure of serious medical diagnoses, one we have frequently received from family members from different cultural backgrounds. These requests represent another challenge of caring for these patients as they counter our obligation for full disclosure and the patients’ right to know in order to be able to make informed decisions regarding their medical care.³

To the Editor: We read with great interest the article by Drs. Cawcutt and Wilson on caring for international patients.¹ They provide an overview of the challenges of delivering medical care for these patients (eg, cultural differences) and the likely benefits from such interactions (eg, gaining cultural knowledge). Having practiced medicine in 3 different continents and experienced working in various medical centers caring for international patients, we would like to offer a slightly different viewpoint.

First, gaining cultural knowledge should be regarded as a prerequisite for healthcare workers involved in the care of international patients, rather than the expected benefit and consequence of such encounters. Healthcare workers with some knowledge of an international patient’s culture are best able to serve that patient.² Indeed, unless knowledge of cultural differences is obtained before such interactions, there is a significant risk of stereotyping by amplifying the sense of “otherness,” which is unfortunately too often mistaken for cultural sensitivity. The perception of the stereotypes and prejudices during the second stage of cultural adaptation (ie, irritation, hostility) often stems from the host’s lack of cultural knowledge. Table 1 of their article clearly reflects such risk: the authors have tried to exemplify the concepts they discussed through a number of real-life scenarios. But indeed some of those cases (eg, the man from Saudi Arabia) could be interpreted more as examples of stereotyping than cultural sensitivity.

Second, the authors do not mention requests by family members of international patients for nondisclosure of serious medical diagnoses, one we have frequently received from family members from different cultural backgrounds. These requests represent another challenge of caring for these patients as they counter our obligation for full disclosure and the patients’ right to know in order to be able to make informed decisions regarding their medical care.³

In Reply: We appreciate the comments, and we fully agree about the dangers of blurring sensitivity and stereotyping in medicine. We also recognize that health providers working around the world have distinct backgrounds and unique perspectives, which serve to enrich the discussion.

We agree that gaining cultural knowledge should be a prerequisite for healthcare workers. However, healthcare providers may not uniformly have the opportunity, time, or resources for this training. Additionally, providers working in large group practices including referral and academic medical centers often do not have control over scheduling of patient appointments. Therefore, rather than prohibiting the evaluations of international patients, we advocate for the utilization of a few guiding and common principles to optimize a mutually beneficial patient care experience. Despite inherent inadequacies and potential prejudices, healthcare providers do learn through patient encounters. Within this learning environment, mistakes will be made, but there are also opportunities for further self-improvement.

We agree there is a fine line between sensitivity and stereotyping, along with common misunderstandings regarding patient labeling. Identifying the geographic homeland of a patient could be misconstrued as intent to stereotype patients. However, numerous infectious diseases and many noncommunicable syndromes are disproportionately represented within select countries. Thus, we feel the identification of a patient’s homeland along with ethnicity, age, gender, and pertinent socioeconomic details can be done respectfully and remain an important collective part of the active medical history and serve to optimize care for each patient. Within medical education, we often find ourselves generalizing patient presentations and symptom profiles. 

Yet we must recognize that the generalized concepts cannot apply to everyone. Medicine remains a profession of humility—both in our willingness to consider additional diagnoses and in our openness to care for patients of different backgrounds. With this humility, we hope to avoid the pitfalls of patient stereotyping, misjudgments, and misunderstandings.

Finally, the nondisclosure of serious medical diagnoses at the request of family members can be a tricky issue. It can be most difficult to balance unique wishes of a family with the ethics of accurate patient communication and compliance with legal statutes and medical center policies. We advocate a team approach with family members of international patients as a way to avoid breaches in medical ethics or breaks in mutual family trust. 

In Reply: We appreciate the comments, and we fully agree about the dangers of blurring sensitivity and stereotyping in medicine. We also recognize that health providers working around the world have distinct backgrounds and unique perspectives, which serve to enrich the discussion.

We agree that gaining cultural knowledge should be a prerequisite for healthcare workers. However, healthcare providers may not uniformly have the opportunity, time, or resources for this training. Additionally, providers working in large group practices including referral and academic medical centers often do not have control over scheduling of patient appointments. Therefore, rather than prohibiting the evaluations of international patients, we advocate for the utilization of a few guiding and common principles to optimize a mutually beneficial patient care experience. Despite inherent inadequacies and potential prejudices, healthcare providers do learn through patient encounters. Within this learning environment, mistakes will be made, but there are also opportunities for further self-improvement.

We agree there is a fine line between sensitivity and stereotyping, along with common misunderstandings regarding patient labeling. Identifying the geographic homeland of a patient could be misconstrued as intent to stereotype patients. However, numerous infectious diseases and many noncommunicable syndromes are disproportionately represented within select countries. Thus, we feel the identification of a patient’s homeland along with ethnicity, age, gender, and pertinent socioeconomic details can be done respectfully and remain an important collective part of the active medical history and serve to optimize care for each patient. Within medical education, we often find ourselves generalizing patient presentations and symptom profiles. 

Yet we must recognize that the generalized concepts cannot apply to everyone. Medicine remains a profession of humility—both in our willingness to consider additional diagnoses and in our openness to care for patients of different backgrounds. With this humility, we hope to avoid the pitfalls of patient stereotyping, misjudgments, and misunderstandings.

Finally, the nondisclosure of serious medical diagnoses at the request of family members can be a tricky issue. It can be most difficult to balance unique wishes of a family with the ethics of accurate patient communication and compliance with legal statutes and medical center policies. We advocate a team approach with family members of international patients as a way to avoid breaches in medical ethics or breaks in mutual family trust. 

In Reply: We appreciate the comments, and we fully agree about the dangers of blurring sensitivity and stereotyping in medicine. We also recognize that health providers working around the world have distinct backgrounds and unique perspectives, which serve to enrich the discussion.

We agree that gaining cultural knowledge should be a prerequisite for healthcare workers. However, healthcare providers may not uniformly have the opportunity, time, or resources for this training. Additionally, providers working in large group practices including referral and academic medical centers often do not have control over scheduling of patient appointments. Therefore, rather than prohibiting the evaluations of international patients, we advocate for the utilization of a few guiding and common principles to optimize a mutually beneficial patient care experience. Despite inherent inadequacies and potential prejudices, healthcare providers do learn through patient encounters. Within this learning environment, mistakes will be made, but there are also opportunities for further self-improvement.

We agree there is a fine line between sensitivity and stereotyping, along with common misunderstandings regarding patient labeling. Identifying the geographic homeland of a patient could be misconstrued as intent to stereotype patients. However, numerous infectious diseases and many noncommunicable syndromes are disproportionately represented within select countries. Thus, we feel the identification of a patient’s homeland along with ethnicity, age, gender, and pertinent socioeconomic details can be done respectfully and remain an important collective part of the active medical history and serve to optimize care for each patient. Within medical education, we often find ourselves generalizing patient presentations and symptom profiles. 

Yet we must recognize that the generalized concepts cannot apply to everyone. Medicine remains a profession of humility—both in our willingness to consider additional diagnoses and in our openness to care for patients of different backgrounds. With this humility, we hope to avoid the pitfalls of patient stereotyping, misjudgments, and misunderstandings.

Finally, the nondisclosure of serious medical diagnoses at the request of family members can be a tricky issue. It can be most difficult to balance unique wishes of a family with the ethics of accurate patient communication and compliance with legal statutes and medical center policies. We advocate a team approach with family members of international patients as a way to avoid breaches in medical ethics or breaks in mutual family trust. 

To the Editor: In their article “A patient with altered mental status and an acid-base disturbance,”¹ Drs. Shylaja Mani and Gregory W. Rutecki state that 5-oxoproline or pyroglutamic acidosis is associated with an elevated osmol gap. This is not the case. The cited reference by Tan et al² describes a patient who most likely had ketoacidosis, perhaps complicated by isopropyl alcohol ingestion.

Those disorders can certainly generate an osmol gap. Although pyroglutamic acidosis was mentioned in the differential diagnosis of that case, that condition was never documented. The accumulation of 5-oxoproline or pyroglutamic acid should not elevate the serum osmolality or generate an osmol gap.

To the Editor: In their article “A patient with altered mental status and an acid-base disturbance,”¹ Drs. Shylaja Mani and Gregory W. Rutecki state that 5-oxoproline or pyroglutamic acidosis is associated with an elevated osmol gap. This is not the case. The cited reference by Tan et al² describes a patient who most likely had ketoacidosis, perhaps complicated by isopropyl alcohol ingestion.

Those disorders can certainly generate an osmol gap. Although pyroglutamic acidosis was mentioned in the differential diagnosis of that case, that condition was never documented. The accumulation of 5-oxoproline or pyroglutamic acid should not elevate the serum osmolality or generate an osmol gap.

To the Editor: In their article “A patient with altered mental status and an acid-base disturbance,”¹ Drs. Shylaja Mani and Gregory W. Rutecki state that 5-oxoproline or pyroglutamic acidosis is associated with an elevated osmol gap. This is not the case. The cited reference by Tan et al² describes a patient who most likely had ketoacidosis, perhaps complicated by isopropyl alcohol ingestion.

Those disorders can certainly generate an osmol gap. Although pyroglutamic acidosis was mentioned in the differential diagnosis of that case, that condition was never documented. The accumulation of 5-oxoproline or pyroglutamic acid should not elevate the serum osmolality or generate an osmol gap.

In Reply: We thank Dr. Emmett for his insightful comment. He is correct that in the case reported by Tan et al the elevated osmol gap was not a direct result of the patient’s presumed acetaminophen ingestion but more likely another unidentified toxic ingestion. The online version of our article has been modified accordingly (also see page 214 of this issue).

In Reply: We thank Dr. Emmett for his insightful comment. He is correct that in the case reported by Tan et al the elevated osmol gap was not a direct result of the patient’s presumed acetaminophen ingestion but more likely another unidentified toxic ingestion. The online version of our article has been modified accordingly (also see page 214 of this issue).

In Reply: We thank Dr. Emmett for his insightful comment. He is correct that in the case reported by Tan et al the elevated osmol gap was not a direct result of the patient’s presumed acetaminophen ingestion but more likely another unidentified toxic ingestion. The online version of our article has been modified accordingly (also see page 214 of this issue).