Bruegel's Landscape with the Fall of Icarus.

Ovid's Metamorphoses tells the story of Icarus - his tragic flight with man-made wings, the melting of the wax that bound them, and the ensuing fall to his death. This moment has been immortalized across the arts and through several mediums, but none are more notable than Bruegel's Landscape with the Fall of Icarus. Described as a "painter for poets," Bruegel's work served as inspiration for several writers, with this piece in particular providing the basis for ekphrastic poems by W.H. Auden and William Carlos Williams. Though each of these works has a different focus, the unifying theme is that human tragedy is too often placed on the periphery of notice. They are effective reminders to physicians and other healthcare providers about the human aspect of suffering and pain in medicine.

When I Am Asked: Lisel Mueller's Beginning in Poetry.

Why does anyone write poetry? Lisel Mueller (1924-2020) was a poet, author, and translator with a long and much-decorated career. She and her family fled Nazi Germany in the 1930s and emigrated to the United States, where she would establish herself as a writer. The poem "When I Am Asked" describes the beginning of her journey into poetry, undertaken during a period of grief after the death of her mother. Her writing would come to include nine collections of poetry and myriad accolades, including the 1981 National Book Award and the 1997 Pulitzer Prize for Poetry. Though her ouvre is filled with evocative works, this piece stands out as particularly relevant to physicians and other writers who find solace by expressing themselves through the art of poetry.

Posterior Reversible Encephalopathy Syndrome and Eclampsia in the Setting of Magnesium Toxicity: A Case Report.

Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic condition and a feared complication of eclampsia. It is evidenced by acute neurologic dysfunction secondary to cerebral edema and is typically reversible in nature. Although it is a relatively new diagnosis, an increasing amount of literature has described its occurrence, including an association with hypomagnesemia. We present a case wherein a 24-year-old parturient developed PRES and eclampsia in the setting of symptomatic hypermagnesemia, requiring management with lorazepam after seizures developed. Here we detail her clinical course, including the unique challenges of treating eclampsia and PRES in the setting of magnesium toxicity.

Oh Death, Here Is Your Sting.

Perioperative death is a harrowing experience that physicians often encounter while needing to continue life sustaining care for others. In this piece, an anesthesiology resident uses poetry to process the recent passing of one of his patients, highlighting the ways that it continues to impact the care that he provides.

The ACCRAC podcast: an innovative educational tool for trainee and staff development.

The Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast provides stimulating lectures on a broad range of educational topics within the realms of anesthesia and critical care. Though not intended as a primary learning tool, it can be used as part of a multidisciplinary developmental approach for both trainees and staff clinicians. This short commentary provides a brief overview of its contents and describes its relevance to board preparation and career-focused continuing education.

Death, Introduced.

An anesthesiology intern at Walter Reed National Military Medical Center uses poetry to describe the nuances related to an end-of-life discussion with a terminally ill patient. She was a new admission to the oncology service who had already come to grips with her impending death, but had not yet discovered its identity.

The Noncompliant Patient.

This issue's Poet's Pen is an experiential work submitted by Captain Justin C. Cordova, MD, from the Department of Anesthesiology at Walter Reed National Military Medical Center in Bethesda, Maryland. The submission was a response to an invitation for our readers to submit poems for consideration of publication. Captain Cordova's work, "Against Medical Advice," is an engaging and provocative poem that focuses on a disturbing healthcare provider challenge-attempting to deliver "best care" to patients who, for countless reasons, choose a pathway we label as noncompliance or against medical advice.

CD5+ Diffuse Large B-Cell Lymphoma With Leukemic Transformation: A Rare Case With Central Nervous System Involvement, Treated With R-CHOP and Intrathecal Methotrexate/Cytarabine.

Diffuse large B-cell lymphoma (DLBCL) is one of several subtypes of non-Hodgkin's lymphoma, and one that can present in a myriad of ways. One unique and particularly aggressive presentation is leukemic transformation with CD5 positivity, which leads to systemic symptoms, a relatively high peripheral tumor load, and higher rates of CNS involvement. The prevalence of leukemic transformation has not been determined, as published literature is limited to case reports and small case series. CD5 positivity appears to be even rarer and is only found in a small fraction of DLBCL with leukemic transformation. Treatment regimens for this presentation have not been well-established due to the rarity of the disease and paucity of literature on the subject. Our patient, a 76-year-old female with a history of previously treated stage IIIB follicular lymphoma, was found to have CD5+ DLBCL with leukemic transformation. She was treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) along with intrathecal methotrexate (IT MTX)/cytarabine after CNS involvement was diagnosed. The patient tolerated therapy well, with an objective reduction in leukocytosis and blast count. To our knowledge, this is the first such case of CD5+ DLBCL with leukemic transformation treated with dose-reduced R-CHOP and IT MTX/cytarabine. Her response to therapy indicates that this regimen could be a viable option for the treatment of this exceedingly rare disease presentation.

The "good" physician: Oslerian aphorisms in the 21st century.

On February 2, 1899, William Osler gave a lecture before the students and faculty of Albany Medical College. As a founding member of the Johns Hopkins School of Medicine, Osler had already established himself as a prominent physician and educator and would spend the rest of his career bolstering his reputation as a public speaker. This brief essay looks at four of the more salient points of this lesser-known address, discussing the ways in which he practiced his own advice and finally asserting that his contributions to medical education are still broadly relevant in the 21st century.

Does Hallux Valgus Correction Reduce the Width of the Forefoot?

Background: Hallux valgus has been associated with a widened forefoot. Most surgical procedures for the correction of hallux valgus have the potential to reduce forefoot width. Success after hallux valgus surgery is correlated with relief of toe pain in conventional shoes and improvement in the appearance of the foot. Therefore, reduction in forefoot width, referred to as metatarsal span (MS), likely correlates with both criteria and may be a reliable radiographic indicator of success after hallux valgus surgery. Methods: Preoperative and postoperative radiographs of 52 patients who underwent correction of hallux valgus with a distal Chevron osteotomy and Akin osteotomy were evaluated by 4 observers. The observers measured the hallux valgus angle (HVA), the intermetatarsal first and second angle (IMA), and the MS. Results: Preoperative HVA ranged from 14° to 48°, IMA ranged from 6° to 25°, and MS ranged from 74.2 to 110.6 mm. The average HVA improvement was 19.4°, IMA improvement was 6.7°, and MS reduction was 8.7 mm. No correlation was identified with regard to correction of the HVA or IMA to MS. Conclusion: Digital radiographic linear measurements were easily and reliably made. Therefore, linear measurements as described in this article can be used as a tool to evaluate if clinical outcomes correlate with reduction of MS. A distal Chevron with an Akin osteotomy has the potential to reduce forefoot width. Levels of Evidence: Level IV: Case series.