I discovered B2M amyloid in 2 hemodialysis patients during the late 1970’s and early 1980’s who sequentially broke both femoral necks. We were doing home hemodialysis on 75 VA patients, who lived an average of 220 miles away. One of them had a cystic knee lesion, which we biopsied. It was Congo red positive. A light bulb went off in my brain. All of the femoral neck tissue from both patients at joint replacement, misread as increased connective tissue, was full of amyloid. Workup for AA and AL was negative. The patient later died of lung cancer. At autopsy we scooped the amyloid out of a large humeral lesion. When sequenced in NYC, its subunit was intact B2M. To my knowledge, this has not been repeated.In the early days of dialysis he was in Vietnam with Army and used dialysis for battlefield injuries, Stone again:
I was sent to the Third Field Hospital in Saigon from 1968-69, where we dialyzed battle casualties and falciparum malaria cases of AKI. I had completed a basic science nephrology fellowship at Cornell from 1965-67 and had never done dialysis before. We saved a lot of them using the old coil dialyzers.
One of his former fellows described him as, "One of those guys who can describe a case of almost anything you can imagine, across all of internal medicine."
Dr. Stone has created the Rules of Stone, bits of wisdom that should guide doctors through the uncertainties of diagnosis and treatment.
Rules of Stone
- Anything can do anything. (WJS clarified: is for people who say things like a stroke alone cannot give you a high fever)
- Anything can do nothing. (WJS clarified: is for those doubters who say a patient on prednisone will have a tender abdomen if he has perforated an ulcer or a diverticulum)
- Nothing can do anything. (WJS clarified: refers to self-inflicted illness; e.g. IV injectors of dissolved pain pills can have multisystem disease)
- Nothing works every time.
- No lab or diagnostic test is perfect.
- No disease is always predictable.
- Just because you can do something doesn't mean you should do something.
- A patient known to have x,y, and z doesn't necessarily have x, y, and z.
- A person with an illness similar to a previous one probably has it again.
- No list is complete.
- The more drugs there are for a disease the less likely they are to benefit it.
- There are no uninteresting patients (just disinterested physicians).
- Four drugs are more toxic then two.
- Always guess 20% if you don't know the real answer.
- No drug has been proven useless until it has been tried in scleroderma and ALS.
- Just because you failed to diagnose the cause of X in the past doesn't mean you shouldn't try again.
- Orneriness is best treated as an outpatient.
- If an older doctor writes an axiom or a diagram on a piece of paper, ask if you can have it.
- Common but unrelated diseases co-exist at least 1% of the time.
- If asked when you last played basketball, be able to answer with a day of the week.
- Before addressing non-compliance with diet and medicine #1, doctors add medicine #2.
- In a sick patient without a diagnosis, get invasive early.
- You cannot learn medicine at home, so the new residency hours rules make no sense. A cadre of doctors with inadequate experience is being created.