The American Journal of Medicine via MedWorm.com

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

(Source: The American Journal of Medicine)

Masthead

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

(Source: The American Journal of Medicine)

Clinicians' Perceptions About How They Are Valued by the Academic Medical Center

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

Academic health centers have multiple distinct yet interrelated missions related to advancing research and discovery, educating the next generation of physicians, and caring for patients with expertise and humanism. The reverence directed toward accomplishment in research at our academic health center exceeds the value directed toward clinical and educational successes, as reflected in both the culture and the promotion processes. Because promotion decisions and academic rank are heavily influenced by research success and not clinical accomplishments, distinction in the clinical care of patients is thought to be “under-rewarded and taken for granted.” Some academic health centers have established multiple tracks for promotion in an effort to balance the appreciation for all 3 parts of ...

The Reply

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

We all do better when we all do better. Foy and Majdan take issue with my thesis that income inequality in this country is a public health crisis. They argue that substantial inequality is not necessarily bad because, “in a free society inequality of earning will always exist because such patterns … . emerge from billions … of individual choices and transactions.” (Source: The American Journal of Medicine)

Systematic Reporting Bias in Meta-analyses of Trials of Aspirin for the Primary Prevention of Cardiovascular Disease

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

I read with interest the meta-analysis of trials of aspirin for the primary prevention of cardiovascular disease. After almost 1 million person-years' follow-up, >3500 deaths, and almost 4000 cardiovascular events, treatment with aspirin might have prevented 21 deaths, possibly none cardiovascular, 88 myocardial infarctions, and 13 strokes, and may have caused 387 major gastrointestinal hemorrhages. Incredibly, the authors believe this analysis should persuade people to take, rather than avoid, aspirin. If the data on mortality were true, that might just be justified. However, confidence intervals barely exclude the null effect. (Source: The American Journal of Medicine)

The Reply

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

I would like to thank Altman and Gonzalez for their interest in our paper, which documented a harmful association between chronic self-reported use of nonsteroidal anti-inflammatory drugs (NSAIDs) and adverse cardiovascular outcomes. This was due to a 2.3-fold increase in cardiovascular mortality among chronic NSAID users. Acknowledged limitations of the study were that we did not have information on the type of NSAID or indication for their use. We agree that inflammatory conditions like rheumatoid arthritis might confound this association; however, other investigations have controlled for such diseases and still documented harmful effects of NSAIDs. (Source: The American Journal of Medicine)

Aspirin and the Harmful Effect of NSAIDs

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

The article by Bavry et al reporting the recurrence of myocardial infarction after the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with established cardiovascular disease is of great interest and of relevance for clinicians working in the “real world.” Although the mechanism for the harmful effect of NSAIDs remains poorly understood, it is feasible that NSAIDs would induce an imbalance between cyclooxygenase-2 (COX-2)-derived prostacyclin (PGI2) and the COX-1-derived thromboxane (TXA2). COX-2 inhibitors do not affect TXA2 level, may increase platelets reactivity, and could exert prothrombotic effects. Aspirin decreases both COX-1-derived TXA2 and PGI2, preventing the imbalance of these 2 prostanoids. In the Bavry et al study, it is possible to suppose that some pat...

The Reply

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

We would like to thank Salamon et al for their interest in our article. They raise 2 very interesting points. The first is the distribution of medications known to affect cardiovascular mortality, such as statins, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and aspirin in our study population, and the possible impact that these variables might have on our results when included in the multivariate analysis. The distributions of baseline use of ACE inhibitors, beta-blockers, aspirin, and statins by constipation category are shown in the . The prevalence of use of these medications was slightly higher with more severe constipation, although this may be due to age—because both constipation severity and medication use increase with age. Overall, the prevalence of statin use...

Postmenopausal Women with Constipation and Cardiovascular Disease

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

This study clearly documents the distribution of the many cardiovascular risk factors, such as smoking and diabetes. Although the study does document the use of symptomatic medications such as diuretics and calcium channel blockers, it would be helpful to know the distribution of mortality-reducing medications in post-cardiovascular injury, such as angiotensin-converting enzyme inhibitors, beta-blockers, and aspirin. (Source: The American Journal of Medicine)

Rhabdomyolysis: Not a Textbook Case

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

A 21-year-old gravida 2, para 1, woman at 34 weeks' gestation with a history of iron deficiency anemia presented to the hospital with lower-extremity numbness, tingling, and weakness, resulting in falls. Vital signs were unremarkable, with the physical examination significant for diminished lower-extremity strength and intact sensation. Laboratory assessment was notable for hemoglobin of 9.5 g/dL, potassium of 2.2 mmol/L, magnesium of 1.81 mg/dL, phosphorus of 3.0 mg/dL, calcium of 8.2 mg/dL, glucose of 91 mg/dL, creatine kinase of 11,089 U/L, albumin of 1.1 g/dL, and thyroid-stimulating hormone of 2.5 mIU/L. Further laboratory evaluation revealed a mild respiratory alkalosis (pH 7.43, PaCO2 34 mm Hg, and bicarbonate 23 mmol/L), serum osmolality of 279 mOsm/kg, urine pH of 7.0, urine osmol...

Rapid Recovery from Acute Kidney Injury in a Patient with Metformin-associated Lactic Acidosis and Hypothermia

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

We describe here a hypothermic patient who recovered rapidly from acute kidney injury despite hemodynamic instability and respiratory failure. (Source: The American Journal of Medicine)

The Impact of Prior Heart Failure Hospitalizations on Long-term Mortality Differs by Baseline Risk of Death

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:01 +0100

Abstract: Background: Hospitalizations for decompensated heart failure (HF) are thought to increase long-term mortality. However, previous reports focus on newly hospitalized HF patients or clinical trial populations and do not always adjust for baseline mortality risk. We hypothesized that the number of HF hospitalizations within the prior 12 months would improve overall mortality risk stratification, particularly in otherwise “low-risk” HF inpatients. Methods: We studied 2221 HF patients admitted to 14 Michigan community hospitals during 2002-2004. We estimated 1-year mortality using the multivariable (Enhanced Feedback For Effective Cardiac Treatment [EFFECT]) model and classified patients as low (EFFECT 120). We used logistic regression and stratified Cox proportional hazard mo...

Notifications Received by Primary Care Practitioners in Electronic Health Records: A Taxonomy and Time Analysis

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Conclusions: PCPs receive a large number of EHR-based asynchronous alerts daily and spend significant time processing them. The utility of transmitting large quantities and varieties of alerts to PCPs warrants further investigation. (Source: The American Journal of Medicine)

Lifestyle Risk Factors Predict Disability and Death in Healthy Aging Adults

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Abstract: Background: Associations between modifiable health risk factors during middle age with disability and mortality in later life are critical to maximizing longevity while preserving function. Positive health effects of maintenance of normal weight, routine exercise, and nonsmoking are known for the short and intermediate term. We studied the effects of these risk factors into advanced age. Methods: A cohort of 2327 college alumnae aged 60 years or more was followed annually (1986-2005) by questionnaires addressing health risk factors, history, and Health Assessment Questionnaire disability. Mortality data were ascertained from the National Death Index. Low-, medium-, and high-risk groups were created on the basis of the number (0, 1, ≥2) of health risk factors (overweight, sm...

Concurrent Use of Warfarin and Antibiotics and the Risk of Bleeding in Older Adults

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Conclusion: Among older continuous warfarin users, exposure to antibiotic agents—particularly azole antifungals—was associated with an increased risk of bleeding. (Source: The American Journal of Medicine)

Statin Use and Musculoskeletal Pain Among Adults With and Without Arthritis

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Conclusion: In this population-based study, statin use was associated with a higher prevalence of musculoskeletal pain, particularly in the lower extremities, among individuals without arthritis. Evidence that statin use was associated with musculoskeletal pain among those with arthritis was lacking. (Source: The American Journal of Medicine)

A Combined Cardiorenal Assessment for the Prediction of Acute Kidney Injury in Lower Respiratory Tract Infections

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Conclusion: A model combining the markers BNP and NGAL is a powerful predictor of early AKI in patients with lower respiratory tract infection. (Source: The American Journal of Medicine)

Race/Ethnicity, Sleep Duration, and Diabetes Mellitus: Analysis of the National Health Interview Survey

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Conclusion: The present findings suggest that American short and long sleepers of black race may be at greater risk for diabetes independently of their sociodemographic profile or the presence of comorbid medical conditions, which have been shown to influence habitual sleep durations. Among black individuals at risk for diabetes, healthcare providers should stress the need for adequate sleep. (Source: The American Journal of Medicine)

Repeat Abdominal Imaging Examinations in a Tertiary Care Hospital

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Abstract: Background: Reducing unnecessary repeat imaging may reduce waste and costs, and improve health care quality. We aimed to quantify repeat imaging rates in patients with abdominal imaging examinations, and identify factors associated with repeat imaging. Methods: We retrospectively analyzed all diagnostic abdominal computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), fluoroscopy, and radiograph reports performed at our institution between January 1, 2000 and December 31, 2009. Primary outcome measure was the rate of repeat abdominal imaging (RAI) examinations, defined as any imaging examination of the abdomen on the same patient within 0-90 days of the first (enrollment) examination. We used natural language processing tools to extract recommendations fo...

Transient Ischemic Attacks in a 22-Year-Old

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

A frightening symptom in a 22-year-old undergraduate student signaled an uncommon chronic disease—and led to reconsideration of a previous diagnosis. In July 2010, she presented with a 2-month history of a “whooshing sound” in her right ear. She noted the sound when trying to sleep, though it did not interfere with sleeping. She denied tinnitus or headaches. For the previous 7 weeks, she had experienced right-neck tenderness and stiffness, particularly with flexion of the cervical spine. The onset of these symptoms was associated with fever and dysphagia that resolved in 1-2 days without treatment. One week prior to admission, she experienced 6-10 episodes of transient (< 1 minute) loss of vision in the right eye, as well as severe fatigue. (Source: The American Journal of Medicine)

Using the GRACE Risk Scores in Everyday Practice

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Acute coronary syndromes, a continuum of disease ranging from unstable angina to ST-elevation myocardial infarction, can pose a high degree of uncertainty and acuity on presentation. These patients have varying degrees of risk for death and adverse events. The recently released 2011 Focused Update on the American College of Cardiology and American Heart Association Guidelines for the Management of Unstable Angina and Non-ST Elevation Myocardial Infarction suggest that using a risk-stratification tool can not only help clinicians with prognostication, but also may help them decide which patients warrant higher-risk interventional strategies such as anticoagulation or cardiac catheterization. (Source: The American Journal of Medicine)

Whooping Cough in Adults: An Update on a Reemerging Infection

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

This article describes the recent epidemiologic shifts and reviews the clinical presentation, diagnosis, and treatment of pertussis. New vaccination recommendations by the Advisory Committee on Immunization Practices in response to recent outbreaks and infant deaths are highlighted. (Source: The American Journal of Medicine)

Current Views on Diagnostic Approach and Treatment of Lymphedema

The American Journal of Medicine — Mon, 23 Jan 2012 23:45:00 +0100

Abstract: Lymphedema is a chronic, progressive, and often debilitating condition. Primary lymphedema is a lymphatic malformation developing during the later stage of lymphangiogenesis. Secondary lymphedema is the result of obstruction or disruption of the lymphatic system, which can occur as a consequence of tumors, surgery, trauma, infection, inflammation, and radiation therapy. In this review, we report an update upon the diagnostic approach and the medical and surgical therapy for both primary and secondary lymphedema. (Source: The American Journal of Medicine)

The Cardiovascular Effects of Peroxisome Proliferator-activated Receptor Agonists

The American Journal of Medicine — Mon, 23 Jan 2012 23:44:59 +0100

Abstract: Although peroxisome proliferator-activated receptor agonists are prescribed to improve cardiovascular risk factors, their cardiovascular safety is controversial. We therefore reviewed the literature to identify landmark randomized controlled trials evaluating the effect of peroxisome proliferator-activated receptor gamma agonists (pioglitazone and rosiglitazone), alpha agonists (fenofibrate and gemfibrozil), and pan agonists (bezafibrate, muraglitazar, ragaglitazar, tesaglitazar, and aleglitazar) on cardiovascular outcomes. Pioglitazone may modestly reduce cardiovascular events but also may increase the risk of bladder cancer. Rosiglitazone increases the risk of myocardial infarction and has been withdrawn in European and restricted in the United States. Fibrates improve cardiov...

Sarcoidosis: Challenging Diagnostic Aspects of an Old Disease

The American Journal of Medicine — Mon, 23 Jan 2012 23:44:59 +0100

In conclusion, we strongly advise that physicians be ready to reconsider the diagnosis of sarcoidosis in the presence of atypical manifestations or persistent/progressive disease despite conventional therapy. (Source: The American Journal of Medicine)

Patient-centered Imaging

The American Journal of Medicine — Mon, 23 Jan 2012 23:44:59 +0100

SEE RELATED EDITORIAL p. 113 (Source: The American Journal of Medicine)

Diagnostic Imaging: Powerful, Indispensable, and Out of Control

The American Journal of Medicine — Mon, 23 Jan 2012 23:44:59 +0100

SEE RELATED COMMENTARY AND ARTICLE pp. 115 & 155 (Source: The American Journal of Medicine)

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

(Source: The American Journal of Medicine)

Masthead

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

(Source: The American Journal of Medicine)

Impact of Resident Workload and Handoff Training on Patient Outcomes

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

SEE RELATED EDITORIAL p. 1 (Source: The American Journal of Medicine)

Psychological Effects of Bed Bug Attacks (Cimex lectularius L.)

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Conclusions: Based upon our survey of online postings concerning such effects, an as-yet-to-be-determined proportion of individuals who experience bed bug bites develop moderate-to-severe negative emotional symptoms after infestations. These individuals should be identified in the course of their interactions with health professionals so that appropriate mental health care may be provided. (Source: The American Journal of Medicine)

The Reply

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

We thank Chatterjee for his interest in our work. Most of the theoretical background that supports the systemic use of prednisone to prevent restenosis has been previously described by our group. (Source: The American Journal of Medicine)

Regarding Immunosuppressive Therapy to Prevent Restenosis after PCI

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

We read with great interest the article by Ribichini et al about use of oral prednisone at immunosuppressive doses reducing recurrence of cardiovascular events for nondiabetic patients with elevated C-reactive protein at 1 year as well as lowering rates of target vessel revascularization and rates of restenosis. The same group had earlier reported encouraging findings with the Inhibition of Metaloprotease by Omapatarilat in a Randomized Exercise and Symptoms Study of Heart Failure (IMPRESS) study. (Source: The American Journal of Medicine)

The Reply

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

We recently published a randomized controlled clinical trial that evaluated a telephone counseling intervention, designed to help patients with peripheral arterial disease and suboptimal low-density lipoprotein cholesterol (LDL-C) levels influence their physician's cholesterol medication-prescribing practices. Intervention participants achieved significantly lower LDL-C levels at 12-month follow-up compared with an attention control condition, but not as compared with a usual care condition. Hassan et al question whether a higher proportion of participants taking rosuvastatin or a statin medication combined with ezetimibe in the intervention arm of the randomized controlled clinical trial may have influenced the trial results. In response, we performed additional analyses. The shows the pr...

When It Comes to Reducing Cholesterol, Not All Statins Are the Same

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

McDermott et al have done well to raise the issue of optimizing patient compliance with statin therapy to achieve therapeutic goals in the peripheral arterial disease population. However, their data did not differentiate between types of lipid-lowering therapy or detail the doses that may have affected the response to the intervention, although the authors did document change in dose at 12-month follow-up. (Source: The American Journal of Medicine)

The Reply

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

The goal of certification boards is not to be punitive or to cause physicians any undue stress. Rather, certification boards exist to enhance the quality of health care by certifying physicians who demonstrate the knowledge, skills and attitudes essential for excellent patient care. (Source: The American Journal of Medicine)

Common Sense and the Recertification Process

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

I strongly disagree with the authors' statement that certification is voluntary. Because some hospitals require applicants for membership on their staffs to be certified or recertified and because there is a risk that managed care organizations may use certification as a criterion for admitting physicians to their panels or for prorating their fees, many physicians consider it virtually compulsory. (Source: The American Journal of Medicine)

Surprise Under the Sleeve

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

A 69-year-old woman with hypertension and depression was admitted to the medicine service for treatment of pneumonia. On presentation, her blood pressure was 85/58 mm Hg, heart rate was 105 beats/min, temperature was 99.5°F, and arterial oxygen saturation was 88% on ambient air. On full skin examination, the patient had a large, painless, fungating mass with yellow exudate on the right shoulder (). Upper extremities were warm, pulses were present, and sensation was intact bilaterally. She had full range of motion of both shoulders and elbows. She had no palpable axillary lymph nodes. (Source: The American Journal of Medicine)

Spontaneous Blue Finger Syndrome: A Benign Process

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

While isolated acute blue discoloration of a finger may be secondary to acute ischemia or vasospasm and underlying systemic illness, some cases are neither dangerous nor signify a systemic condition. (Source: The American Journal of Medicine)

Safety of Iodinated Intravenous Contrast Medium Administration in Sickle Cell Disease

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Conclusion: Adverse events related to intravenous contrast occur in sickle cell disease patients at a rate similar to the general population, without an increase in contrast-induced nephropathy. Subjective reports of new or worsening pain crisis do not translate to objective findings. Beneficial diagnostic imaging can be performed without increased risk of serious complication in this population. (Source: The American Journal of Medicine)

Skilled Nursing Facility Referral and Hospital Readmission Rates after Heart Failure or Myocardial Infarction

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Abstract: Background: Substantial hospital-level variation in the risk of readmission after hospitalization for heart failure (HF) or acute myocardial infarction (AMI) has been reported. Prior studies have documented considerable state-level variation in rates of discharge to skilled nursing facilities (SNFs), but evaluation of hospital-level variation in SNF rates and its relationship to hospital-level readmission rates is limited. Methods: Hospital-level 30-day all-cause risk-standardized readmission rates (RSRRs) were calculated using claims data for fee-for-service Medicare patients hospitalized with a principal diagnosis of HF or AMI from 2006-2008. Medicare claims were used to calculate rates of discharge to SNF following HF-specific or AMI-specific admissions in hospitals with �...

Frailty and Respiratory Impairment in Older Persons

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Conclusion: Frailty and respiratory impairment are strongly associated with one another and substantially increase the risk of death when both are present. Establishing these associations may inform interventions designed to reverse or prevent the progression of either condition and to reduce adverse outcomes. (Source: The American Journal of Medicine)

Renal Replacement Therapies for Prevention of Radiocontrast-induced Nephropathy: A Systematic Review

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Conclusion: In this updated meta-analysis, periprocedural RRT did not decrease the incidence of RCIN compared with SMT. HD appears to actually increase RCIN risk. (Source: The American Journal of Medicine)

Declining Rates of Deceased Donor Renal Transplantation in the United States Over Successive Years of Listing

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Conclusion: There is a progressive unfavorable pattern of declining transplantation rates with each successive year of listing in patients listed for deceased donor renal transplantation. (Source: The American Journal of Medicine)

Sexual Activity and Satisfaction in Healthy Community-dwelling Older Women

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Conclusion: Half these women were sexually active, with arousal, lubrication, and orgasm maintained into old age, despite low libido in one third. Sexual satisfaction increased with age and did not require sexual activity. (Source: The American Journal of Medicine)

Drug-induced Hypertension: An Unappreciated Cause of Secondary Hypertension

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

Abstract: A myriad variety of therapeutic agents or chemical substances can induce either a transient or persistent increase in blood pressure, or interfere with the blood pressure-lowering effects of antihypertensive drugs. Some agents cause either sodium retention or extracellular volume expansion, or activate directly or indirectly the sympathetic nervous system. Other substances act directly on arteriolar smooth muscle or do not have a defined mechanism of action. Some medications that usually lower blood pressure may paradoxically increase blood pressure, or an increase in pressure may be encountered after their discontinuation. In general, drug-induced pressure increases are small and transient: however, severe hypertension involving encephalopathy, stroke, and irreversible renal fa...

The Unmet Need of Education in Genomic Medicine

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

In medicine, technological breakthroughs have, on occasion, brought about striking changes. A couple of notable examples include reperfusion therapy for acute myocardial infarction in the late 1980s, which changed the natural history for heart attack victims, and antiviral medications for the treatment of human immunodeficiency virus in the 1990s, which cleared out hospital wards of patients who were considered preterminal. These advances represent breakthroughs that have helped transform medicine. Their clinical utility drove their clinical acceptance but still required educational initiatives in specific disciplines to change practice and adopt new standards of care. They occurred at a time when broadly accessing the medical community through the Internet was not possible, and the delay ...

Optical Densities Reduce Odds of Heparin-induced Thrombocytopenia Over-diagnosis

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

SEE RELATED ARTICLE p. 44 (Source: The American Journal of Medicine)

A Bridge too Far: A Critique of the New ACGME Duty Hour Requirements

The American Journal of Medicine — Sun, 25 Dec 2011 12:07:00 +0100

SEE RELATED ARTICLE p. 104 (Source: The American Journal of Medicine)

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

(Source: The American Journal of Medicine)

Masthead

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

(Source: The American Journal of Medicine)

Renal Calculosis of Pandolfo III Malatesta (1370-1427)

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Urolithiasis is an ancient disease, whose first paleopathologic documentation dates back to the Paleolithic age. Bladder stone disease is currently endemic in rural or impoverished areas, whereas renal stone disease is mainly an affliction of the industrialized countries of the Western world. This trend well explains the prevalence of bladder stone disease in past agricultural societies, as confirmed by historical sources that report references to bladder stones but rarely mention renal colic from upper tract stones. (Source: The American Journal of Medicine)

Success in Grateful Patient Philanthropy: Insights from Experienced Physicians

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Facing challenging economic conditions, medical schools and teaching hospitals have turned increasingly to philanthropy as a way to supplement declining clinical revenues and reduced research budgets. One approach to offset these diminished returns is to commit efforts to “grateful patient” programs that concentrate on satisfying patients and their families, especially families with significant assets. Support from grateful patients is the single most important source for substantive philanthropic gifts in medicine. When patients develop strong relationships with their physician or hospital, they may become deeply invested and resolve to support them. Involvement of physician faculty members in grateful patient philanthropy may be a complex undertaking with ethical considerations as pa...

Brachial Artery Flow-mediated Dilation in Patients with Tako-Tsubo Cardiomyopathy

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Conclusions: There is a pronounced and reversible endothelial dysfunction in patients with TTC, which can impair myocardial perfusion. (Source: The American Journal of Medicine)

The Reply

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

I would like to thank Glazier for his interest in my review article and his comments. Glazier refers to a report on the use of troponin I levels in the early detection of high-dose chemotherapy-induced cardiomyopathy. A study by Cardinale et al did demonstrate a prognostic value of troponin I when measured within 3 days and again at 1 month after 703 patients received high-dose chemotherapy. For patients with 2 negative troponin test results (70%) there was no significant reduction in left ventricular ejection fraction (LVEF) and few cardiac events (1%) over a mean follow-up of 20 months. By contrast, among patients with 2 troponin test results above 0.08 ng/mL, more than 80% had at least a 15% reduction in LVEF, and a greater incidence of cardiac events (84%). Those with one positive and ...

Importance of Troponin Levels in the Early Detection of Anthracycline-associated Cardiomyopathy

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

I read with great interest Figueredo's excellent review article on chemical cardiomyopathies that was recently published in the Journal. I would, however, like to add to the author's discussion of anthracycline-induced cardiomyopathy, in particular noting the important role for measurement of troponin I levels in the early detection and subsequent management of this cardiomyopathy. (Source: The American Journal of Medicine)

The Reply

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

We fully agree with Petrie and Campbell that previous myocardial infarction is an important contributor to left ventricular systolic dysfunction, elevated B-type natriuretic peptide (BNP) levels, and mortality during follow-up. This was true in our dataset of patients with acute chest pain as well as in studies recruiting exclusively patients with myocardial infarction. In the multivariable model, this information is reflected by the variable “previous coronary artery disease,” reflecting “previous myocardial infarction” in two thirds of the patients with previous coronary artery disease. Considering “previous myocardial infarction” in the multivariable model instead of “previous coronary artery disease” resulted in similar findings about the prognostic value of BNP (). (So...

B-type Natriuretic Peptide and Chest Pain: Do Not Forget Left Ventricle Function

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

I read with interest the article by Haff et al in the Journal, entitled “B-type natriuretic peptide in the early diagnosis and risk stratification of acute chest pain.” They found that B-type natriuretic peptide (BNP) was an independent predictor of mortality over 2-year follow-up in 1075 unselected hospital admissions with acute chest pain. The authors state that BNP should be measured in all patients who present with chest pain, and thus extend the role of natriuretic peptides in risk stratification of unselected admissions with chest pain. (Source: The American Journal of Medicine)

The Perils of PowerPoint

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

In his editorial, Dr Alpert lists 5 errors that occur frequently in clinical practice and suggests 5 guidelines for correcting them. All 5 are noteworthy, but his observations on PowerPoint (Microsoft Corporation, Redmond, Wash) presentations are particularly timely. (Source: The American Journal of Medicine)

Endothelial Dysfunction Is Reversible in Helicobacter Pylori-Positive Subjects

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Conclusions: The novel finding of our study was that HP eradication can improve endothelial dysfunction. (Source: The American Journal of Medicine)

The Relationship Between Serum 25(OH)D and Parathyroid Hormone Levels

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Conclusion: Our data suggest that a 25(OH)D threshold of 50 nmol/L is sufficient for parathyroid hormone suppression and prevention of secondary hyperparathyroidism in persons with normal renal function. 25(OH)D levels greater than 75 nmol/L do not seem to be associated with additional change in parathyroid hormone levels. (Source: The American Journal of Medicine)

Pyogenic Liver Abscess as the Initial Manifestation of Underlying Hepatocellular Carcinoma

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Conclusions: The prognosis of patients who presented with pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma was poor. Physicians should not ignore the possibility of underlying hepatocellular carcinoma in patients with risk factors for the disease in regions with a high prevalence of both pyogenic liver abscess and hepatocellular carcinoma. (Source: The American Journal of Medicine)

Venous Thromboembolism Prophylaxis for Medical Service—Mostly Cancer—Patients at Hospital Discharge

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Abstract: Objective: Many hospitalized Medical Service patients remain at high risk for venous thromboembolism (VTE) after hospital discharge. Our aim was to compare the effect of the use or omission of extended pharmacologic VTE prophylaxis after hospital discharge among Medical Service patients on the incidence of symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) over the ensuing 3 months.Methods: In this case-control study, we identified a case population of 461 patients for whom parenteral pharmacological VTE prophylaxis was prescribed to continue after discharge and matched them according to age, sex, and VTE risk score to a control group of 922 patients for whom VTE prophylaxis was not continued after discharge.Results: The primary endpoint of symptomatic DVT or PE at...

Anticoagulation-associated Adverse Drug Events

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Conclusion: Most anticoagulant-associated ADEs among inpatients result from medication errors and are, therefore, potentially preventable. We observed an elevated 30-day mortality rate among patients who suffered an anticoagulant-associated ADE and high hospitalization costs following ADRs. Further quality improvement efforts to reduce anticoagulant-associated medication errors are warranted to improve patient safety and decrease health care expenditures. (Source: The American Journal of Medicine)

A Blast from the Past

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Common complaints tend to be explained by common conditions, but sometimes that assumption is wrong. A 56-year-old man presented with cough, skin lesions, and left knee pain. Five months earlier, he had developed a cough that occasionally produced blood-tinged sputum. A smoker, he was told he had bronchitis, for which he received courses of levofloxacin, inhaled bronchodilators, and inhaled corticosteroids; this was followed by a course of amoxicillin. There was no noticeable improvement, and 5 weeks prior to presentation at The University of Illinois at Chicago, his left knee became painful and swollen. At the same time, he developed skin lesions that a dermatologist diagnosed as acne; he was treated with doxycycline for 3 weeks. When his skin worsened to the point that he thought it emba...

Contrast-induced Nephropathy Risk Assessment in Real World Practice

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

A 56-year-old woman with a history of coronary artery disease with previous 3-vessel coronary artery bypass grafting, ischemic cardiomyopathy, and diabetes mellitus presented with several months of exertional chest discomfort. She was referred for cardiac catheterization after reversible inferior ischemia was demonstrated on a stress myocardial perfusion scan. The catheterization showed an occluded saphenous vein graft to the right coronary artery and focal right coronary artery stenosis. Overlapping drug-eluting stents were placed in the right coronary artery utilizing a total of 200 cc of iodixanol during both the diagnostic and interventional procedure. At baseline, her serum creatinine was 1.2 mg/dL for an estimated glomerular filtration rate of 46 mL/min/1.73 m2, and her hemoglobin wa...

Care of the Adult Hodgkin Lymphoma Survivor

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

Abstract: Of those individuals diagnosed with Hodgkin lymphoma, 85% will survive and may be affected by residual effects of their cancer and its therapy (chemotherapy, radiation therapy, stem cell transplantation). Hodgkin lymphoma survivors are at risk of developing secondary malignancies, cardiovascular disease, pulmonary disease, thyroid disease, infertility, premature menopause, chronic fatigue, and psychosocial issues. These conditions usually have a long latency and therefore present years or decades after Hodgkin lymphoma treatment, when the patient's care is being managed by a primary care provider. This review summarizes these unique potential medical and psychologic sequelae of Hodgkin lymphoma, and provides screening and management recommendations. (Source: The American Journal ...

The D-batable Parathyroid Hormone Plateau

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

SEE RELATED ARTICLE p. 1165 (Source: The American Journal of Medicine)

Can Primary Care Medicine Be Saved?

The American Journal of Medicine — Fri, 25 Nov 2011 12:06:30 +0100

The number of medical students who choose to train for a career in primary care internal medicine has been falling for decades and has now reached a critical point. If the trend is not reversed, many patients in the US will be left without access to a primary care internist. I often get desperate phone calls from my cardiology patients asking me to help them find a primary care internist who is still accepting new patients. A similar situation exists in primary care family medicine. Is the field of primary care medicine about to become extinct? And why don't more young physicians choose this satisfying career path? (Source: The American Journal of Medicine)

Lead Intoxication Caused by Traditional Chinese Herbal Medicine

The American Journal of Medicine — Fri, 25 Nov 2011 05:00:00 +0100

The total number of people using traditional Chinese herbal medicine is vast and steadily increasing in East Asian countries and Chinese society. The industrial output value of traditional Chinese herbal medicine has also continued to expand rapidly across the world since the year 2000. Here we describe a case of lead intoxication following the use of traditional Chinese herbal medicine as an agent for maintaining health. (Source: The American Journal of Medicine)

Intracerebral Hemorrhage with Thrombolytic Therapy for Acute Pulmonary Embolism

The American Journal of Medicine — Fri, 25 Nov 2011 05:00:00 +0100

Abstract: Background: Intracranial hemorrhage is one of the dreaded complications of thrombolytic therapy for acute pulmonary embolism. We identified patients with pulmonary embolism who may be at relatively high risk of intracerebral hemorrhage from those selected for thrombolytic therapy by their physicians and presumably thought to be of reasonable risk. Methods: The number of patients discharged from short-stay hospitals in the United States from 1998 to 2008 with pulmonary embolism who received thrombolytic therapy and the proportion with intracerebral hemorrhage were determined from the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Results: From 1998 to 2008, 2,237,600 patients were discharged with a diagnosis ...

Systematic Review of Guidelines on Peripheral Artery Disease Screening

The American Journal of Medicine — Mon, 14 Nov 2011 05:00:00 +0100

Conclusions: Recommendations on PAD screening vary across current guidelines, making the value of PAD screening uncertain. The variation seems to reflect lack of studies that show added value of detection of early PAD beyond expectant management and traditional risk assessment. (Source: The American Journal of Medicine)

Bugs and Battles during the American Civil War

The American Journal of Medicine — Mon, 14 Nov 2011 05:00:00 +0100

Military historians have focused on generals commanding troops in battle, but recently physicians have published research showing that bugs and germs can decide victory or defeat. In Rats, Lice and History, Hans Zinsser, MD, argues that “… soldiers have rarely won wars … typhus, with its brothers and sisters—plague, cholera, typhoid, dysentery—has decided more campaigns than Caesar, Hannibal, Napoleon, and all the inspector generals of history.” Physiologist Jared Diamond's work, Guns, Germs and Steel, explores the impact of germs in world history. He finds that nonhuman vectors like mosquitoes and fleas have caused more war deaths than humans fighting each other: “Until World War II, more victims of war died of war-borne microbes than of battle wounds.” (Source: The Americ...

Preoperative Thienopyridine Use and Outcomes after Surgery: A Systematic Review

The American Journal of Medicine — Mon, 14 Nov 2011 05:00:00 +0100

Conclusions: These data support withholding thienopyridines 5 days before cardiac surgery; there was insufficient evidence to make definitive recommendations for elective noncardiac surgery although the direction and magnitude of associations were similar. (Source: The American Journal of Medicine)

Genetics for the General Internist

The American Journal of Medicine — Mon, 14 Nov 2011 05:00:00 +0100

Abstract: The internist's goal is to determine a patient's disease risk and to implement preventative interventions. Genetic evaluation is a powerful risk assessment tool, and new interventions target previously untreatable genetic disorders. The purpose of this review is to educate the general internist about common genetic conditions affecting adult patients, with special emphasis on diagnoses with an effective intervention, including hereditary cancer syndromes and cardiovascular disorders. Basic tenets of genetic counseling, complex genetic disease, and management of adults with genetic diagnoses also are discussed. (Source: The American Journal of Medicine)

Massive Aquaresis After Tolvaptan Administration and Albumin Infusion in a Patient with Alcoholic Cirrhosis

The American Journal of Medicine — Wed, 09 Nov 2011 05:00:00 +0100

We describe a patient with alcoholic cirrhosis-associated hyponatremia who developed massive aquaresis after tolvaptan administration and intravenous albumin infusion. (Source: The American Journal of Medicine)

Thrombosis in Suspected Heparin-induced Thrombocytopenia Occurs More Often with High Antibody Levels

The American Journal of Medicine — Wed, 09 Nov 2011 05:00:00 +0100

Conclusion: Higher levels of anti-PF4/heparin antibody are associated with increased thrombosis risk among patients with clinically suspected heparin-induced thrombocytopenia and might have clinical utility for prediction of true heparin-induced thrombocytopenia and the development of thrombosis. (Source: The American Journal of Medicine)

Abdominal Pain and Heart Failure: A Grim Diagnosis

The American Journal of Medicine — Mon, 07 Nov 2011 05:00:00 +0100

In this unique case, a previously healthy middle-aged man presented with symptoms of right-sided heart failure, abdominal pain, and abdominal/lower extremity edema. A workup for the abdominal pain revealed an unexpected and grim diagnosis. (Source: The American Journal of Medicine)

Unusual Enhancing Foci

The American Journal of Medicine — Mon, 07 Nov 2011 05:00:00 +0100

Pressure to treat can discourage physicians from carrying out the careful investigations needed for correct diagnosis. Here, we describe a case in which the correct diagnosis took several years, and became apparent only after a review of patient records revealed a decade-old surgical history of laparoscopic cholecystectomy performed for acute calculous cholecystitis. (Source: The American Journal of Medicine)

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

(Source: The American Journal of Medicine)

Masthead

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

(Source: The American Journal of Medicine)

The Fundamental Need for Relative Value Metrics in Educational Innovation

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Recently, after leaving 5 years of administration and returning to the medical education arena, I had the opportunity to review several years' worth of publications in the educational literature, including the APM Perspectives of The American Journal of Medicine, Academic Medicine, and academia articles in the Annals of Internal Medicine. I was struck by the number and diversity of new topics, disciplines, and skills now advocated (and sometimes required) for physicians-in-training. More than 50 new or expanded topics have received support in the published educational literature (). At the same time, educators struggle to maintain sufficient breadth and depth in traditional aspects of medical education in an era in which discovery and technological advancement in biomedical sciences are gr...

The Reply

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Briggs et al from Mt Sinai wonder whether we withheld any clinical information that might have helped with a deeper understanding of the clinical implications of our study. We did not. As noted in our article, one of the patients who had an elevated cardiac troponin level had previous coronary artery bypass grafting and one patient had a positive stress test result. Had there been other associations, we would have reported them. To be clear, no cardiovascular comorbidities were detected in the other 6 patients with elevations by the internists who evaluated the patients before electroconvulsive therapy. (Source: The American Journal of Medicine)

Trouble Getting Started: Predictors of Primary Medication Nonadherence

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Abstract: Background: Patient nonadherence to prescribed medication is common and limits the effectiveness of treatment for many conditions. Most adherence studies evaluate behavior only among patients who have filled a first prescription. The advent of electronic prescribing (e-prescribing) systems provides the opportunity to track initial prescriptions and identify nonadherence that may have previously been undetected.Methods: We analyzed e-prescribing data and filled claims for all patients with CVS Caremark (Woonsocket, RI) drug coverage who received e-prescriptions from the iScribe e-prescribing system in calendar 2008. We matched e-prescriptions with filled claims by using data on the drug name, date of e-prescription, and date of filled claims, allowing up to 180 days for patients t...

Outcomes of Early versus Late Nephrology Referral in Chronic Kidney Disease: A Systematic Review

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Abstract: Background: As late provision of specialist care, before starting dialysis therapy, is believed to be associated with increased morbidity and mortality, a systematic review was undertaken to evaluate clinical outcomes relating to early versus late referral of patients to nephrology services.Methods: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE were searched up until September 2008 for studies of early versus late nephrology referral in adult (>18 years) patients with chronic kidney disease. Early referral was defined by the time period at which patients were referred to a nephrologist.Findings: No randomized controlled trials were found. Twenty-seven longitudinal cohort studies were included in the final review, providing data on 17,646 participan...

Risk of Thiazide-induced Hyponatremia in Patients with Hypertension

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Conclusions: Approximately 3 in 10 patients exposed to thiazides who continue to take them develop hyponatremia. (Source: The American Journal of Medicine)

Obesity Is Not Protective against Fracture in Postmenopausal Women: GLOW

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Conclusions: Our results demonstrate that obesity is not protective against fracture in postmenopausal women and is associated with increased risk of ankle and upper leg fractures. (Source: The American Journal of Medicine)

Naproxen as Prophylaxis against Atrial Fibrillation after Cardiac Surgery: The NAFARM Randomized Trial

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Conclusions: Postoperative use of naproxen did not reduce the incidence of atrial fibrillation but decreased its duration, in a limited sample of patients after CABG surgery. There was a significant increase in acute renal failure in patients receiving naproxen 275 mg twice daily. Our study does not support the routine use of naproxen after CABG surgery for the prevention of atrial fibrillation. (Source: The American Journal of Medicine)

Hypoglycemia-associated Mortality Is Not Drug-associated but Linked to Comorbidities

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Abstract: Objective: Although tight glucose control is used widely in hospitalized patients, there is concern that medication-induced hypoglycemia may worsen patient outcomes. We sought to determine if the mortality risk associated with hypoglycemia in hospitalized noncritically ill patients is linked to glucose-lowering medications (drug-associated hypoglycemia) or merely an association mediated by comorbidities (spontaneous hypoglycemia).Methods: A retrospective cohort of patients admitted to the general wards of an academic center during 2007 was studied. The in-hospital mortality risk of a hypoglycemic group (at least 1 blood glucose≤70 mg/dL) was compared with that of a normoglycemic group using survival analysis. Stratification by subgroups of patients with spontaneous and drug-ass...

Double Trouble

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Medical computing technology can be extremely helpful for clinicians and has improved outcomes for many diseases, but software can be imperfect. Recognizing the relationship between one particular idiosyncrasy of ECG interpretation software and an easily treated condition can be life-saving, as illustrated here. (Source: The American Journal of Medicine)

A Common Fungus, an Unusual (and Deadly) Infection

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

We describe a case in which an immunocompetent patient with several comorbid conditions ultimately died of an uncommon infection. A 64-year-old woman with a history of poorly controlled diabetes mellitus type II and chronic alcohol abuse was transferred to our facility for a hepatology evaluation for severe hepatic encephalopathy and fulminant liver failure. Shortly after arrival, she was intubated for airway protection, and a nasogastric tube was placed for gastric decompression. Laboratory studies and a liver biopsy performed shortly after her arrival confirmed a diagnosis of hemochromatosis, with iron deposition noted on the specimen (). (Source: The American Journal of Medicine)

Cardiac Amyloidosis: A Practical Approach to Diagnosis and Management

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Abstract: Cardiac amyloidosis, the primary determinant of prognosis in systemic amyloidoses, is characterized by infiltration of myocardium by amyloid protein resulting in cardiomyopathy and conduction disturbances. Cardiac involvement is primarily encountered in immunoglobulin (AL) and transthyretin-associated (hereditary/familial and senile) amyloidoses. Although the latter variants could be indolent, untreated AL amyloidosis with clinical cardiac involvement is a rapidly fatal disease. The management decisions of cardiac amyloidosis are based on the underlying cause. Although treatment of senile systemic amyloidosis is largely supportive, the therapeutic approaches for AL amyloidosis include chemotherapy, autologous stem cell transplantation, and, rarely, cardiac transplantation. The fa...

Oxygen Therapy for Acute Myocardial Infarction—Then and Now. A Century of Uncertainty

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Abstract: For about 100 years, inhaled oxygen has been administered to all patients suspected of having an acute myocardial infarction. The basis for this practice was the belief that oxygen supplementation raised often-deficient arterial oxygen content to improve myocardial oxygenation, thereby reducing infarct size. This assumption is conditional and not evidence-based. While such physiological changes may pertain in some patients who are hypoxemic, considerable data suggest that oxygen therapy may be detrimental in others. Acute oxygen therapy may raise blood pressure and lower cardiac index, heart rate, cardiac oxygen consumption, and blood flow in the cerebral and renal beds. Oxygen also may lower capillary density and redistribute blood in the microcirculation. Several reports now co...

Understanding Systemic Inflammation, Oral Hygiene, and Cardiovascular Disease

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

Cardiovascular diseases (CVDs) represent an escalating source of morbidity and mortality worldwide. Obesity, dyslipidemia, hypertension, cigarette smoking, and diabetes mellitus have emerged as risk factors for CVD over the preceding several decades. Despite attempts at managing these comorbidities, the incidence of CVD remains significant and there is growing interest in identification of novel risk factors. There has been ongoing emphasis on the association between periodontal disease (PD) and CVD. (Source: The American Journal of Medicine)

Death during Intensive Glycemic Therapy of Diabetes: Mechanisms and Implications

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:20 +0100

SEE RELATED ARTICLE p. 1028 (Source: The American Journal of Medicine)

Technology Is Great … Except When It Doesn't Work

The American Journal of Medicine — Sun, 23 Oct 2011 00:57:19 +0100

When Dr Joseph Alpert and I first took over The American Journal of Medicine in the fall of 2004, many of our processes were Internet-based, and many weren't. The Journal still accepted snail-mail manuscripts on paper (in triplicate) with glossy photographs and a CD or diskette back-up copy; uploading video to our website was unheard of; and the review process—a hybrid paper/e-mail system—was cumbersome at best. (Source: The American Journal of Medicine)

Study of Nonoutbreak Giardiasis: Novel Findings and Implications for Research

The American Journal of Medicine — Wed, 19 Oct 2011 04:00:00 +0100

Conclusions: The presence of intermittent diarrhea contributes to delayed health-seeking behavior and to delayed diagnosis of Giardia. More study is needed to determine if this symptom can help distinguish Giardia from other causes of infectious diarrhea. The occurrence of extraintestinal manifestations of Giardia infection does not appear to be rare, and merits further study. (Source: The American Journal of Medicine)

Patients with Acute Coronary Syndrome and Normal High-sensitivity Troponin

The American Journal of Medicine — Wed, 19 Oct 2011 04:00:00 +0100

Abstract: Background: Failure to identify patients with acute coronary syndrome (ACS) is a serious clinical problem. The incidence, characteristics, and outcome of ACS patients with normal high-sensitivity cardiac troponin T (hs-cTnT) levels at presentation are unknown.Methods: In a prospective multicenter study, hs-cTnT was determined in a blinded fashion in 1181 consecutive patients presenting with acute chest pain to the emergency department. The final diagnosis of ACS was adjudicated by 2 independent cardiologists. Patients were followed for 12 months.Results: ACS was the adjudicated diagnosis in 351 patients (30%), including 187 patients with acute myocardial infarction (AMI) and 164 patients with unstable angina (UA). At presentation, hs-cTnT was normal ( (Source: The American Journa...

Cellulitis: Definition, Etiology, and Clinical Features

The American Journal of Medicine — Wed, 19 Oct 2011 04:00:00 +0100

Abstract: Cellulitis is a common condition seen by physicians. Over the past decade, skin and soft tissue infections from community-associated methicillin-resistant Staphylococcus aureus have become increasingly common. In this article, the definition, etiology, and clinical features of cellulitis are reviewed, and the importance of differentiating cellulitis from necrotizing soft tissue infections is emphasized. Empiric antimicrobial recommendations are suggested, including the most recent recommendations from the Infectious Disease Society of America. (Source: The American Journal of Medicine)

Management of the Metabolic/Bariatric Surgery Patient

The American Journal of Medicine — Wed, 19 Oct 2011 04:00:00 +0100

Abstract: There is currently a global pandemic of obesity and obesity-engendered comorbidities; in particular, certain major chronic metabolic diseases (eg, type 2 diabetes) which markedly reduce life expectancy and quality of life. This review is predicated on the fact that management of the obese patient is a primary concern of all physicians and health care providers, and that metabolic/bariatric surgery is a highly successful therapeutic option for this disease. (Source: The American Journal of Medicine)

Steroid-responsive but not Rheumatologic

The American Journal of Medicine — Mon, 17 Oct 2011 04:00:00 +0100

An odd cluster of signs and symptoms responded to steroids, but the cause was elusive. A 75-year-old female with a history of hypertension and cerebrovascular accident presented with intermittent lethargy, fevers to 104° F (40° C), dyspnea, and a 1-week history of severe pancytopenia. Her symptoms began 4 months earlier with generalized lethargy and increasing dyspnea, prompting admission at a local hospital. Bilateral pleural effusions and a small pericardial effusion were found, and a thoracentesis identified the effusions as exudative. Cultures and cytology were negative. The patient was discharged on a steroid taper for presumed exacerbation of chronic obstructive pulmonary disease. (Source: The American Journal of Medicine)

Processes of Care and Outcomes for Community-Acquired Pneumonia

The American Journal of Medicine — Fri, 14 Oct 2011 04:00:00 +0100

Abstract: Background: Although processes of care are common proxies for health care quality, their associations with medical outcomes remain uncertain.Methods: For 2076 patients hospitalized with pneumonia from 32 emergency departments, we used multilevel logistic regression modeling to assess independent associations between patient outcomes and the performance of 4 individual processes of care (assessment of oxygenation, blood cultures, and rapid initiation [ (Source: The American Journal of Medicine)