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Two of the features in our Winter issue came in for kudos. One was on ethical dilemmas generated by 21st-century technology, and the other one detailed what was learned about diabetes thanks to advances of the 19th century.

Conversation starter
I am a senior at Hanover High School and found your Winter 2008 cover article, "On the Other Hand", to be thoroughly engaging. It greatly contributed to my understanding of medical ethics.

The article says only 20% of U.S. adults have signed advance directives. I believe in time this number will improve. And I agree that more ethics education would benefit doctors—and would also help patients understand a subject that applies to many parts of our lives.

I'd like to add that the ethical scenarios about patients and doctors facing difficult decisions inspired some of the best conversations among my friends and family. I look forward to future articles that promote discussion. If one of the goals of Dartmouth Medicine is to educate the public, this article was a true success.

Caroline Dodge
Hanover, N.H.

Archival investigation
I enjoyed the article "Diabetes Detectives" by Dr. Lee Witters and three undergraduates in the Winter 2008 Dartmouth Medicine. I was a history major and love medicine, so it appealed to both sides of my intellectual curiosity. It was also nice to see that there are others who enjoy searching through Dartmouth's archives.

I even sent a copy of the article to my grandfather, a vascular surgeon; he wrote back that he had fairly close ties with Hitchcock many years ago and that the chief of vascular surgery there had been a friend of his.

Lauren Kaufman, DC '07
New York, N.Y.

On a tear
Thanks for the play, "Stroke," in your Fall 2008 issue. I suffered a stroke just as Chin Woon Ping did on New Year's Eve 2005. Her play is the first time someone's said what it's like being me. I cried buckets as I read it, but they were tears of a good kind.

We're always glad to hear from readers about matters pertaining to medicine at Dartmouth or to the contents of past issues of Dartmouth Medicine. Letters to the editor may be sent to DartMed@Dartmouth.edu. Letters may be edited for clarity, length, or the appropriateness of the subject matter.

I can't say any more because my language isn't good enough—but thank you.

Graeme Walker
Bishopstoke, England

Noting a distinction
I am writing about a recent article [in the Winter 2008 issue] titled "Studying a 'spoonful of sugar' in the ICU." It concerned an excellent study, published by Renda Wiener in the Journal of the American Medical Association, that has stimulated a great deal of discussion in our institution as well as nationally.

Two features in this issue—including the cover story—prompted letters.

The article talked about the Dartmouth researchers "calling for a reevaluation of tight-glucose-control guidelines" and concluded with a quote that this was going to "fall out of favor."

My concern is that this article is widely available at DHMC and will be read by patients and their families but did not provide enough information to distinguish the intensive diabetes care in the ICU studied by Dr. Wiener from the excellent diabetes care we provide to all patients at DHMC.

We have a commitment to excellent diabetes control delivered by staff and, if needed, by a glucose management service. Patients with diabetes at DHMC see a great deal of attention paid to blood sugar control, in accord with recommendations from multiple published experts and guidelines from large societies. Our glucose control targets are not the ones evaluated in Dr. Wiener's study; indeed, the ICU here has adopted less tight targets in response to the type of data cited by Dr. Wiener.

I suggest that these types of articles contain a paragraph or two from the relevant service at DHMC to clarify their relationship to the care provided here.

Richard Comi, M.D.
Chief of Endocrinology, DHMC

We appreciate Comi's thoughtful input about communicating the subtleties of medicine.

The article in question tried to make it clear that the study applied to the care of patients in ICUs, not to diabetes care generally. And as in all our research stories, we aimed to describe the main finding, mention important details about the study's design, and touch on any limitations noted in the paper about the finding. At the same time, we try to keep stories interesting, readable, and pertinent to the magazine's diverse, nationwide readership.

But there is always more that can be said on any subject, so we welcome follow-up on points like this. It's a good reminder for us about the importance of emphasizing the complexity of medicine, and it conveys to our readers how many nuances there are to clinical medicine and biomedical research.

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