Too Many Clots for Comfort

In instances of rare disease, clinical suspicion plays a critical role in preventing delays in diagnosis that can lead to unwanted complications and disease progression.

A 41-year-old woman presented to an outside medical facility with 4 days of progressive dry cough, fever of 101°F, fatigue, myalgias, and mild exertional dyspnea. After a chest x-ray showed left lower-lobe consolidation with parapneumonic effusion, she was admitted for treatment of pneumonia. Computed tomography imaging of the abdomen performed to evaluate the cause of abdominal pain and distention revealed hepatosplenomegaly and moderate ascites. Thoracentesis demonstrated exudative pleural effusion, and a left chest tube was placed for drainage. A left subclavian central venous line was placed after attempts to install a left internal jugular line failed. The abdominal distention and pain continued to worsen, however, and the patient was transferred to our hospital for further evaluation on day 10 of admission.

The patient's medical history was additionally notable for mild jaundice over the previous year, with simultaneous onset of intermittent brown-colored urine; 4 years of generalized fatigue; 4 miscarriages; and a normal birth after progesterone treatment.

To read this article in its entirety, please visit our website.

-- Bibhu D. Mohanty, MD, Carlos M. De Castro, MD

This article originally appeared in March 2012 issue of The American Journal of Medicine.

Do physicians pay attention to electronic health record notifications?

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

Primary care providers receive large numbers and types of asynchronous electronic medical alerts daily and spend an estimated 50 minutes of daily non-face-to-face time processing them.

Abstract

Background
Asynchronous electronic health record (EHR)-based alerts used to notify practitioners via an inbox-like format rather than through synchronous computer “pop-up” messages are understudied. Our objective was to create an asynchronous alert taxonomy and measure the impact of different alert types on practitioner workload.

Methods
We quantified and categorized asynchronous alerts according to the information they conveyed and conducted a time-motion analysis to assess practitioner workload. We reviewed alert information transmitted to all 47 primary care practitioners (PCPs) at a large, tertiary care Veterans Affairs facility over 4 evenly spaced 28-day periods. An interdisciplinary team used content analysis to categorize alerts according to their conveyed information. We then created an alert taxonomy and used it to calculate the mean number of alerts of each type PCPs received each day. We conducted a time-motion study of 26 PCPs while they processed their alerts. We used these data to estimate the uninterrupted time practitioners spend processing alerts each day.

Results
We extracted 295,792 asynchronously generated alerts and created a taxonomy of 33 alert types categorized under 6 major categories: Test Results, Referrals, Note-Based Communication, Order Status, Patient Status Changes, and Incomplete Task Reminders. PCPs received a mean of 56.4 alerts/day containing new information. Based on 749 observed alert processing episodes, practitioners spent an estimated average of 49 minutes/day processing their alerts.

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.

To read this article in its entirety, please visit our website.

-- Daniel R. Murphy, MD, MBA, Brian Reis, BE, Dean F. Sittig, PhD, Hardeep Singh, MD, MPH

This article originally appeared in February 2012 issue of The American Journal of Medicine.

Pregnancy and Stiff Person Syndrome

Stiff person syndrome is an uncommon disorder characterized by fluctuating, progressive muscle stiffness, contractions, rigidity, and spasm usually involving the axial muscles.1 Although the cause is unknown, it has been reported to be frequently associated with autoimmune conditions such as diabetes mellitus, pernicious anemia, thyroiditis, and vitiligo. Three different forms of stiff person syndrome are recognized: autoimmune, paraneoplastic, and idiopathic.2

The autoimmune form of the disease accounts for approximately 60% of the cases and is associated with circulating anti-glutamic acid decarboxylase antibodies.3 These antibodies target gamma aminobutyric acidergic neurons and their nerve terminals and are detectable in the serum. The other 40% rely on clinical testing and history for diagnosis4 because there are no consistent characteristic serologic or image abnormalities.

Case Report
A woman (gravida 3 para 2) at 10 weeks' gestation presented to the triage area with several days of progressive muscle stiffness, body spasms, rigidity, and disabling axial muscle pain.

To read this article in its entirety, please visit our website.

-- George Amyradakis, MD, S.J. Carlan, MD, Amanpreet Bhullar, MD, Julie Eastwood, RN

This article originally appeared in March 2012 issue of The American Journal of Medicine.

New CME Feature... CaseBook Consults: Improving Outcomes in Gout

A new continuing medical education module has been added to The American Journal of Medicine website. Check it out.

CaseBook Consults: Improving Outcomes in Gout
(iPad compatible)
Presenters: Paul P. Doghramji, MD, FAAFP, Brian F. Mandell, MD, PhD, FACR, MACP, and Rick S. Pope, MPAS, PA-C, DFAAPA

Despite the fact that gout can be diagnosed with relative certainty and that effective therapies have been available for a long time, gout is underdiagnosed and undertreated, management is less than optimal, and poor clinical outcomes are not uncommon. It is the aim of this CE activity to provide information that will assist primary care providers to improve management and clinical outcomes for their patients with gout. Specifically, the program will convey the key factors needed to confidently make a presumptive diagnosis of gout, explore the rationale, timing and duration of pharmacologic treatment of gout and hyperuricemia, discuss the importance of achieving a target SUA level of ≤6.0 mg/dL with urate lowering therapy (ULT), and provide examples of how to educate and communicate with patients to improve adherence to urate-lowering therapy and overall outcomes.

Commercial Support: This activity is supported by an educational grant from Takeda Pharmaceuticals North America, Inc.

Review and Sponsorship: This multimedia activity was peer reviewed by The American Journal of Medicine and The Journal for Nurse Practitioners and is jointly sponsored by Beth Israel Medical Center; St. Luke's and Roosevelt Hospitals and Health Education Alliance, Inc.

To log into this activity or view other CME modules, click here.

Schizophrenia for Primary Care Providers: How to Contribute to the Care of a Vulnerable Patient Population

Patients with schizophrenia represent a vulnerable population with high medical needs that are often missed or undertreated. Primary care providers have the potential to reduce health disparities experienced by this population and make a substantial difference in the overall health of these patients. This review provides primary care providers with a general understanding of the psychiatric and medical issues specific to patients with schizophrenia and a clinically practical framework for engaging and assessing this vulnerable patient population and assisting them in achieving optimal health. Initial steps in this framework include conducting a focused medical evaluation of psychosis and connecting patients with untreated psychosis to psychiatric care as promptly as possible. Given the significant contribution of cardiovascular disease to morbidity and mortality in schizophrenia, a top priority of primary care for patients with schizophrenia should be cardiovascular disease prevention and treatment through regular risk factor screening, appropriate lifestyle interventions, and other indicated therapies.

To read this article in its entirety, please visit our website.

-- Mark Viron, MD, Travis Baggett, MD, MPH, Michele Hill, MB, MRCPsych, Oliver Freudenreich, MD

This article originally appeared in March 2012 issue of The American Journal of Medicine.

What's new in AJM's March issue?

AJM Editor-in-Chief Joseph S. Alpert, MD reviews new research in the March 2012 issue of The American Journal of Medicine.

Repeat Abdominal Imaging Examinations in a Tertiary Care Hospital

The volume of repeat abdominal imaging examinations has grown by 85% over the past decade. Many factors contribute to repeat imaging, including patient age, sex, underlying disease, initial study modality, practice setting, and radiologist’s recommendation.

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 for follow-up imaging from radiology reports. Univariate and multivariate logistic regressions were fitted to determine the effect of patient age, sex, study modality, care setting, follow-up recommendations, and history of neoplasm on the primary outcome over time.

Results
Over 10 years, 245,184 abdominal imaging examinations were performed (43.2% CT, 20.6% US, 16.6% radiograph, 13.9% fluoroscopy, 5.7% MRI). The RAI rate remained unchanged (41.2% to 41.7%); unadjusted RAI volume increased from 6596 to 12,218 (P <.01). Most repeat studies (88.2%) were not preceded by a radiologist's recommendation. Practice setting, study modality, patient age, sex, underlying health condition, and radiologist's recommendations were associated with higher rate of repeat abdominal imaging examinations. Conclusions
A large proportion of abdominal imaging examinations result in a repeat study. Many factors contribute to repeat imaging, including patient age, sex, underlying disease, initial study modality, practice setting, and radiologist's recommendation.

To read this article in its entirety, please visit our website.

-- Ivan K. Ip, MD, MPH, Koenraad J. Mortele, MD, Luciano M. Prevedello, MD, Ramin Khorasani, MD, MPH

This article originally appeared in February 2012 issue of The American Journal of Medicine.

When will malpractice lawsuits be filed against armchair doctors?

Blog Commentary

Ferket and colleagues could have added to their long list a guideline from the Haute Autorité de Santé (High Authority for Health, the French agency for quality of care) which recommended in 2006 for the screening peripheral artery disease and its treatment with aspirin, despite evidence was lacking.(1,2)

This French recommendation is surprising because: a) aspirin does not have a marketing authorization for such a use; b) it was even published in the official bulletin of the French republic to enforce good clinical practices.(3)

Guidelines are generally characterized by poor methodology but the main concern is the neurotic quest of many bodies to issue recommendations for acting despite poor evidence. Only the US Preventive Services Task Force (USPSTF) dare to recommend against routine screening for peripheral arterial disease (Grade: D) as evidence was lacking.(4)

From April 1998 to October 2008, the Aspirin for Asymptomatic Atherosclerosis trial screened 28,980 men and women aged 50 to 75 years, free of clinical cardiovascular disease.(5) Of those, 3,350 with a low ankle brachial index (< or = 0.95) were entered in an intention-to-treat double-blind randomized controlled trial comparing aspirin vs placebo. Aspirin resulted in neither reduction in mortality nor reduction in cardio-vascular events but caused major hemorrhage (HR, 1.71; 95% CI, 0.99-2.97).

Five of the guidelines scrutinized by Ferket and colleagues advocated for screening.(1) This was waste of money as systematic reviews for a complex clinical topic may cost in the range of $300,000 to $350,000 or more (communication from Beth A. Collins Sharp, director, Evidence-Based Practice Centers Program, Agency for Healthcare Research and Quality, November 14, 2008). Failure to withdraw or to update these five guidelines enduringly results in inappropriate care to healthy people.

-- Alain Braillon MD, PhD, France

1 Ferket BS, Spronk S, Colkesen EB, Hunink MG. Systematic Review of Guidelines on Peripheral Artery Disease Screening. Am J Med. 2011 Nov 11 doi:10.1016/j.amjmed.2011.06.027

2 Haute Autorité de Santé. Prise en charge de l’artériopathie chronique oblitérante athéroscléreuse des membres inférieurs - Indications médicamenteuses, de revascularisation et de rééducation. April 2006 Available at http://www.has-sante.fr/portail/upload/docs/application/pdf/AOMI_fiche.pdf Accessed 20 Dec 2011.

3 Avenant à l’accord de bon usage des soins relatif à l’utilisation des antiagrégants plaquettaires NOR : SJSU0722012X Journal Officiel de la République Française. 19 December 2007 Texte 33 sur 143.

4 U.S. Preventive Services Task Force. Screening for Peripheral Arterial Disease. August 2005 current as of December 2011. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspspard.htm Accessed 20 Dec 2011.

5 Fowkes FG, Price JF, Stewart MC et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA. 2010 ;303:841-8

NOTE: Conflict of interests-- Dr Braillon, a senior tenured consultant in Public Health was sacked in Sept 2010 by the National Management Centre (French Department of Health) against the advice of the National Statutory Committee. He won a lawsuit in Sept 2011 against the Haute Autorité de Santé for breach of the Freedom of Information Act but the Haute Autorité de Santé failed to apply the judgment.(Lee SS. The power of one and saving private Braillon. Liver Int 2012;32:1)

Spontaneous Blue Finger Syndrome: A Benign Process

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.

A 46-year-old woman experienced 3 episodes of acute finger discoloration over 2 years. The first episode involved a spontaneous, nontraumatic, nonpainful purple “lump” at the base of the 4th finger. As an embolic phenomenon was suspected, transthoracic echocardiography was performed and was normal. She was discharged on aspirin 81 mg daily. The lesion resolved within several days. A second episode, 22 months later, involved the palmar aspect of the distal phalanx of her right thumb becoming spontaneously red and tender.

To read this article in its entirety, please visit our website.

-- Ido Weinberg, MD, MSc, MHA, Michael R. Jaff, DO

This article originally appeared in January 2012 issue of The American Journal of Medicine.

Unusual Enhancing Foci

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.

The patient, a hypertensive 78-year-old man, presented with fevers and increased abdominal pain 4 weeks after beginning chemotherapy for the presumed recurrence of a gastrointestinal stromal tumor. Three years previous to this presentation, he had undergone endoscopy during an evaluation for melena; the procedure had revealed a 1-cm submucosal abdominal mass that was identified by pathologic analysis as a low-grade gastrointestinal stromal tumor. The tumor had been removed by a partial gastrectomy without any further imaging studies, and because it was small and low-grade, with non-malignant surgical margins, no chemotherapy had been prescribed. The management plan had been to follow the patient by periodic abdominal imaging with computed tomography (CT).

To read this article in its entirety, please visit our website.

-- Abhishek Agarwal, MD, Meghana Bansal, MD, Rebecca E. Martin, MD

This article originally appeared in January 2012 issue of The American Journal of Medicine.

Diagnostic Imaging: Powerful, Indispensable, and Out of Control

Reality is never quite as simple as it seems. For all the good that imaging has done, it has come with significant costs: exorbitant financial costs to individual patients and society, and personal health costs to patients through over-diagnosis, over-radiation, and over-treatment.

At issue in any review of the appropriateness of imaging utilization are the various interests of the stakeholders. The primary stakeholders are the patient and the physician. Their motivation to acquire as much information as possible through imaging is laudable but is, in fact, misguided. The core of the dilemma is that our ability to diagnose subtle findings far exceeds our knowledge of what to do with the information: advanced diagnostic studies have led to an epidemic of indeterminate incidental findings that physicians and patients often find at least as troubling as the events that triggered the initial imaging study. In a sense, imaging has become too powerful: it frequently identifies subtle, questionable, unrelated, indeterminate pathology that it cannot characterize any further, leaving both stakeholders up in the air regarding what to do next. This often leads to a vicious cycle of more and more imaging and testing.

To read this article in its entirety, please visit our website.

-- Robert G. Stern, MD

This article originally appeared in February 2012 issue of The American Journal of Medicine.

Sexual Activity and Satisfaction in Healthy Community-dwelling Older Women

Do you have to have sex to be sexually satisfied? Apparently not, if you are a woman over 40.

Abstract

Background
Female sexual dysfunction is a focus of medical research, but few studies describe the prevalence and covariates of recent sexual activity and satisfaction in older community-dwelling women.

Methods
A total of 1303 older women from the Rancho Bernardo Study were mailed a questionnaire on general health, recent sexual activity, sexual satisfaction, and the Female Sexual Function Index.

Results
A total of 806 of 921 respondents (87.5%) aged 40 years or more answered questions about recent sexual activity. Their median age was 67 years; mean years since menopause was 25; most were upper-middle class; 57% had attended at least 1 year of college; and 90% reported good to excellent health. Half (49.8%) reported sexual activity within the past month with or without a partner, the majority of whom reported arousal (64.5%), lubrication (69%), and orgasm (67.1%) at least most of the time, although one third reported low, very low, or no sexual desire. Although frequency of arousal, lubrication, and orgasm decreased with age, the youngest (<55 years) and oldest (>80 years) women reported a higher frequency of orgasm satisfaction. Emotional closeness during sex was associated with more frequent arousal, lubrication, and orgasm; estrogen therapy was not. Overall, two thirds of sexually active women were moderately or very satisfied with their sex life, as were almost half of sexually inactive women.

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.

To read this article in its entirety, please visit our website.

-- Susan E. Trompeter, MD, Ricki Bettencourt, MS, Elizabeth Barrett-Connor, MD

This article originally appeared in January 2012 issue of The American Journal of Medicine.

'Imaging for the Clinician' premiers in AJM's February issue (video)

Imaging for the Clinician-- a special section in The American Journal of Medicine-- will premier in the February 2012 issue of the Journal. In this video, AJM Editor-in-chief Joseph S. Alpert, MD, discusses diagnostic testing and the February issue.

Steroid-responsive but not Rheumatologic

Presentation
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.

Over the ensuing months, she was readmitted twice more for recurrent lethargy, fevers, hypotension, and hypoxia of unknown etiology. All admissions were predated by a steroid taper. During each admission, intravenous methylprednisolone sodium succinate resulted in rapid improvement. Shortly after discharge from her third hospital admission, the patient experienced progressive lethargy, altered mental status, and fever to 104° F (40° C).

To read this article in its entirety, please visit our website.

-- Clare Kelleher, MD, Carrie Herzke, MD

This article originally appeared in December 2011 issue of The American Journal of Medicine.

A Blast from the Past

Presentation
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 embarrassing, he presented for a second opinion.

To read this article in its entirety, please visit our website.

-- Leann Silhan, MD, Robert M. Reed, MD

This article originally appeared in December 2011 issue of The American Journal of Medicine.

Pyogenic Liver Abscess as the Initial Manifestation of Underlying Hepatocellular Carcinoma

The prognosis of patients who present with pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma is poor. In regions with a high prevalence of both pyogenic liver abscess and hepatocellular carcinoma, physicians should not ignore the possibility of underlying hepatocellular carcinoma in patients with risk factors.

Abstract

Background
Pyogenic liver abscess and hepatocellular carcinoma are common in Taiwan. We investigated the frequency of, risk factors for, and prognosis of pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma over a 12-year period in Taiwan.

Methods
We extracted 32,454 patients with pyogenic liver abscess from a nationwide health registry in Taiwan during the period 1997-2008. The frequency of and risk factors for pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma were determined. The prognosis of these patients was compared with patients with hepatocellular carcinoma but without liver abscess.

Results
A total of 698 (2.15%) patients presented with liver abscess as the initial manifestation of underlying hepatocellular carcinoma during the 12-year period. Liver cirrhosis, hepatitis B virus infection, hepatitis C virus infection, and age ≥65 years were independent risk factors for liver abscess as the initial manifestation of underlying hepatocellular carcinoma. Furthermore, these patients had a lower 2-year survival rate than patients with hepatocellular carcinoma but without liver abscess (30% vs 37%; P=.004).

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.

To read this article in its entirety, please visit our website.

-- Yi-Tsung Lin, MD, Chia-Jen Liu, MD, Tzeng-Ji Chen, MD, Te-Li Chen, MD, PhD, Yi-Chen Yeh, MD, Hau-Shin Wu, MD, Chih-Peng Tseng, MD, Fu-Der Wang, MD, Cheng-Hwai Tzeng, MD, Chang-Phone Fung, MD

This article originally appeared in December 2011 issue of The American Journal of Medicine.

Anticoagulation-associated Adverse Drug Events

Most anticoagulant-associated adverse drug events (70%) are potentially preventable. Transcription errors comprise the most frequent root cause of anticoagulant-associated medication errors. In turn, medication errors are a common root cause of anticoagulant-associated adverse drug reactions.

Abstract

Purpose
Anticoagulant drugs are among the most common medications that cause adverse drug events (ADEs) in hospitalized patients. We performed a 5-year retrospective study at Brigham and Women's Hospital to determine clinical characteristics, types, root causes, and outcomes of anticoagulant-associated ADEs.

Methods
We reviewed all inpatient anticoagulant-associated ADEs, including adverse drug reactions (ADRs) and medication errors, reported at Brigham and Women's Hospital through the Safety Reporting System from May 2004 to May 2009. We also collected data about the cost associated with hospitalizations in which ADRs occurred.

Results
Of 463 anticoagulant-associated ADEs, 226 were medication errors (48.8%), 141 were ADRs (30.5%), and 96 (20.7%) involved both a medication error and ADR. Seventy percent of anticoagulant-associated ADEs were potentially preventable. Transcription errors (48%) were the most frequent root cause of anticoagulant-associated medication errors, while medication errors (40%) were a common root cause of anticoagulant-associated ADRs. Death within 30 days of anticoagulant-associated ADEs occurred in 11% of patients. After an anticoagulant-associated ADR, most hospitalization expenditures were attributable to nursing costs (mean $33,189 per ADR), followed by pharmacy costs (mean $7451 per ADR).

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.

To read this article in its entirety, please visit our website.

-- -- Gregory Piazza, MD, Thanh Nha Nguyen, PharmD, Deborah Cios, PharmD, Matthew Labreche, PharmD, Benjamin Hohlfelder, John Fanikos, RPh, MBA, Karen Fiumara, PharmD, Samuel Z. Goldhaber, MD

This article originally appeared in December 2011 issue of The American Journal of Medicine.

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

The management of hyponatremia in patients with end-stage liver disease is always a challenge for caring physicians because of limited options, poor responses, and risk of central pontine myelinolysis due to rapid correction of hyponatremia.1 Tolvaptan, an oral competitive arginine vasopressin V2-receptor antagonist, is effective for treating euvolemic or hypervolemic hyponatremia, including cirrhosis-related hyponatremia, and is well tolerated.2, 3 We describe a patient with alcoholic cirrhosis-associated hyponatremia who developed massive aquaresis after tolvaptan administration and intravenous albumin infusion.

A 40-year-old man with recently diagnosed alcoholic cirrhosis presented with a 2-day history of increasing lethargy and anasarca.

To read this article in its entirety, please visit our website.

-- --Charles Cho, MD, Joy L. Logan, MD, Yeong-Hau H. Lien, MD, PhD

This is an article in press on The American Journal of Medicine website.

Lead Intoxication Caused by Traditional Chinese Herbal Medicine

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 2000.1 Here we describe a case of lead intoxication following the use of traditional Chinese herbal medicine as an agent for maintaining health.

A 25-year-old man, a teaching assistant at a university, with no significant medical history, presented with progressive exertional dyspnea for 2 months. An intermittent pulling-like pain over his anterior subcostal region had developed 2 weeks before his admission. He reported neither bloody vomiting nor tarry or bloody stools. His physical examination was normal except for pale conjunctiva. His renal and liver function, electrolytes, gastroscopy, colonoscopy, and computed tomography were all unremarkable. Serial investigations showed hypochromic microcytic anemia (hemoglobin 8.3 g/dL). The red blood cell morphology showed anisocytosis with basophilic stippling. (Figure)

A review of his medical history found that for the past 3 months he had been taking a traditional Chinese herbal medicine known as Qushangjieyu-san powder. The diagnosis of lead intoxication was confirmed by his blood lead level (75.5 μg/dL, normal <35 μg/dL), as well as the lead content (80,309.95 μg/g, normal <5 ppm) of the Qushangjieyu-san powder. To read this article in its entirety, please visit our website.

-- --Wei-Hung Lin, MD, Ming-Cheng Wang, MD, Wei-Chun Cheng, MD, Chia Jui Yen, MD, Meng-Fu Cheng, MD, Hsiu-Chi Cheng, MD, PhD

This is an article in press on The American Journal of Medicine website.

Can Primary Care Medicine Be Saved?

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.1 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?

Some of the answers to these questions can be found in a recently published book by Frederick M. Barken, MD, a highly qualified and dedicated internist who closed his primary care internal medicine practice in upstate New York in 2007 at the age of 51.1 Barken describes in considerable detail how he built a busy, successful, and patient-centered practice, and how it unraveled during the last 3 decades, culminating in his early retirement. His book is based on his personal experiences as well as a thorough review of current literature in this area. Barken decries the devolution of his practice from a patient-friendly, personal enterprise to one in which the practice of medicine was no longer enjoyable. Among other factors, Barken feels that medical practice in the US has lost its social aspects and become progressively a pure business transaction: “Primary care is collapsing, a victim of economists' tenets of maximized efficiency, profit, and productivity. There is no heading on an accountant's financial statement for altruism, empathy, a warm smile, or other random acts of kindness that we all appreciate as patients and as people. Physician frustration, alienation, and chronic suppressed anger at such a market model of medicine have done us all, physicians and patients alike, immeasurable harm.” (1)

This entertaining but disturbing book contains many humorous clinical anecdotes that enliven the more serious report of the slow and inexorable destruction of Barken's practice. I recognized and sympathized with many of the situations that he describes.(2) Both of us are irritated by fanciful direct-to-consumer pharmaceutical advertising, polypharmacy, and polydoctoring. But these were not the major forces that led to Barken's early retirement and his concern for the survival of primary care internal medicine in the US. What he describes as the reason for the demise of his practice can be summarized in the phrase “too much hassle and too little reward.” And by reward, I mean more than economic gain. Barken loved his patient-centered practice and felt he benefited every day he was able to practice internal medicine as he had been taught during his residency. Over time, administrative and patient expectations and demands increased to the point where the reward of a day's work well done had evaporated.

The most interesting comments addressed Barken's recommendations for improving our health care system and rejuvenating primary care.

To read this article in its entirety, please visit our website.

-- -- Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine

This article originally appeared in December 2011 issue of The American Journal of Medicine.