The American Journal of Medicine Blog

When will malpractice lawsuits be filed against armchair doctors?

2012-02-03T04:00:00.001-07:00

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

2012-02-01T04:00:00.000-07:00

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

2012-01-30T04:00:00.001-07:00

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

2012-01-27T03:30:00.000-07:00

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

2012-01-25T04:00:00.000-07:00

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)

2012-01-23T14:14:00.001-07:00

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

2011-12-21T04:00:00.000-07:00

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

2011-12-19T14:39:00.001-07:00

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

2011-12-15T10:45:00.000-07:00

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

2011-12-08T04:00:00.001-07:00

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

2011-12-06T04:00:00.000-07:00

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

2011-11-30T04:00:00.002-07:00

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?

2011-11-29T13:28:00.002-07:00

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.

Technology Is Great … Except When It Doesn't Work

2011-11-28T11:36:00.004-07:00

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.

In the summer of 2005, our Internet-based manuscript submission system (http://ees.elsevier.com/ajm) launched, and the Journal tossed out its paper processes.

Obviously, online journal publishing has continued to evolve since 2005. The American Journal of Medicine—like most other academic journals—now requires far more background information (ie, conflict of interest statements, funding sources, and statements about data access and authorship) in addition to the manuscript and supporting tables and figures.

This additional documentation and the level of complexity built into the submission process can cause consternation on the part of authors.

As the title of this article states … Technology Is Great … Except When It Doesn't Work. To help potential authors navigate the Journal's online submission system more smoothly, we offer these 10 tips.

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

-- -- Pamela J. Powers, MPH, AJM managing Editor

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

AJM's December 2011 issue is online

2011-11-23T11:56:00.000-07:00

AJM Editor-in-chief Joseph S. Alpert, MD, reviews the December 2011 issue, now online at amjmed.com.

A Rare Shock

2011-11-17T04:00:00.002-07:00

In this case, a patient with no history of coronary artery disease presented with cardiogenic shock and eosinophilia. Her history of adult-onset asthma proved key to the eventual diagnosis.

The patient, a 71-year-old woman, was transferred to our coronary intensive care unit from a local hospital emergency department for a non-ST-segment-elevation myocardial infarction and cardiogenic shock. She had visited the emergency department reporting dyspnea on exertion, orthopnea, lightheadedness, and a several-month history of worsening productive cough, weight loss, and fatigue. Previous antibiotic therapy had not improved her condition. The patient also had a history of Graves thyrotoxicosis, for which she had undergone radioiodine thyroid ablation therapy 10 years previously, adult-onset asthma, allergic sinusitis, nasal polyps, and persistent eosinophilia.

On the patient's arrival at the emergency department, her temperature was 38°C; heart rate, 112 beats/min; blood pressure, 80/33 mm Hg; respiratory rate, 24 breaths/min; O2 saturation (on room air), 88%. She was started on intravenous dobutamine and epinephrine infusions and placed on O2 (6 L/min). Although her blood pressure and O2 saturation improved, a chest radiograph demonstrated bilateral pulmonary edema, and an electrocardiogram showed loss of anterior forces, left atrial delay, and ST segment depression (Figure 1). A chest computed tomography (CT) scan was negative for pulmonary embolism but revealed diffuse, small pulmonary nodules and interstitial and alveolar edema. As that point, the patient was transferred to our coronary intensive care unit.

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

-- -- Omeed Zardkoohi, MD, Robert Hobbs, MD, Carmela D. Tan, MD

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

Lessons from My First Patient

2011-11-14T04:00:00.001-07:00

Lying in front of me, motionless, was the red-haired woman whose brain had been ravaged by glioblastoma multiforme. What did I know about her other than that she had brain cancer? Was she a grandmother? Did she like to travel? Did she have hobbies? I told myself that I had just been too busy to learn about such things, but the truth is that I just wasn't interested. I was too focused on the procedures I had to learn. I knew she had undergone extensive chemotherapy and radiation treatment. Did she have other medical problems? I couldn't remember clearly.

While I was pondering these questions, our professor entered the lab and told us that the patient had written us a letter. I began to read:

Esteemed friends,

One wonders how much time will have passed at the point when you are reading this letter. Two weeks? Two months? Two years? One year ago, I thought I had all the time in the world. I was beginning to think of retirement and 20 years to spend with my two sons and their families. I've always wanted to visit the Grand Canyon, too. It looks like those may be dreams to go unfulfilled.

I suppose I should start with an introduction.

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

-- -- Lt Brent W. Lacey, MD

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

Antimicrobial Use and Risk for Recurrent Clostridium difficile Infection

2011-11-10T04:00:00.001-07:00

Antimicrobial therapy after an episode of Clostridium difficile is common and significantly increases the risk of recurrent disease. The added risk associated with antimicrobial exposure (regardless of duration) should be considered if such therapy is contemplated.

Abstract

Background
Although antimicrobial use during and immediately after Clostridium difficile infection (CDI) is discouraged, the frequency and consequences of such use are poorly defined. We sought to determine the frequency of non-CDI antimicrobial therapy during and after treatment for CDI, and the association of such therapy with recurrent disease.

Methods
Retrospective review of all CDI cases at a Veterans Affairs medical center from 2004-2006. Outcomes were non-CDI antimicrobial use during and within 30 days after completing CDI treatment, and recurrent CDI.

Results
From 2004 to 2006, new-onset CDI occurred in 249 unique patients. No follow-up information was available for 3 patients, leaving 246 as study subjects. Of these, 141 (57%) received non-CDI antimicrobials, including 61 (25%) who received non-CDI antimicrobials during CDI treatment, and 80 (33%) who received non-CDI antimicrobial therapy after CDI treatment. With adjustment for age, disease severity, duration of CDI treatment, and recent hospital or intensive-care unit stay, receipt of non-CDI antimicrobials after CDI treatment was significantly associated with recurrent CDI (odds ratio [OR] 3.02; 95% confidence interval [CI], 1.66-5.52), compared with no antimicrobial use. Antimicrobial use during CDI treatment was not associated with recurrent CDI (OR 0.79; 95% CI, 0.40-1.52). Neither number of antimicrobial courses nor antimicrobial days was associated with recurrence.

Conclusions
Non-CDI antimicrobial therapy after an episode of CDI is common and is associated with a 3-fold increase in the odds of recurrent disease. The added risk associated with antimicrobial exposure (regardless of duration) should be considered if such therapy is contemplated.

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

-- -- Dimitri M. Drekonja, MD, MS, William H. Amundson, BA, Douglas D. DeCarolis, PharmD, Michael A. Kuskowski, PhD, Frank A. Lederle, MD, James R. Johnson, MD

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

A Common Fungus, an Unusual (and Deadly) Infection

2011-11-07T15:32:00.002-07:00

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.

Within 24 hours of the placement of the nasogastric tube, the patient developed a small area of necrosis at the right nare. Despite immediate removal of the tube, the necrotic area rapidly worsened. (Figure)

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

-- -- Susanna Tan, MD, Paul Aronowitz, MD

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

Face to Face or Cyberspace: Are Online Meetings Better?

2011-11-07T04:00:00.002-07:00

Software engineers and accountants would have us believe that Internet-based meetings are equally as good as face-to-face meetings, but are they really? There is no argument that cyberspace meetings are cheaper, but do they improve communication or hinder it?

Before a recent meeting held for the associate and subspecialty editors of The American Journal of Medicine, a number of us discussed why it was necessary to bring our participants physically to the meeting in Arizona, since it involved considerable expense as well as time away from work. Some argued that a virtual meeting in cyberspace would be just as effective and much less costly. Later, considering the pros and cons of a face-to-face meeting, I did an Internet search seeking information on the advantages and disadvantages of face-to-face meetings. There was a wealth of material on the topic with arguments both pro and con for face-to-face encounters.1, 2, 3 The most detailed piece was written by Richard D. Arvey, a professor in the business school of the National University of Singapore.1 He argued that face-to-face encounters were important for a number of reasons, including the opportunity for participants to engage each other directly and thereby develop important exchange relationships resulting in transparency and trust. Other positive features cited were the ability to evaluate and judge the integrity and competence of the other participants, as well as to engage in sideline conversations. Of course, Arvey also emphasized that preliminary work for the face-to-face meeting would almost always involve a considerable amount of time and preparation using electronic communication.

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 November 2011 issue of The American Journal of Medicine.

Obesity Is Not Protective against Fracture in Postmenopausal Women: GLOW

2011-11-03T14:29:00.002-07:00

The results of this study demonstrate that obesity is not protective against fracture in postmenopausal women and is associated with increased risk of ankle and upper leg fractures. These findings have major public health implications in view of the rapidly rising incidence of obesity.

Abstract

Objective
To investigate the prevalence and incidence of clinical fractures in obese, postmenopausal women enrolled in the Global Longitudinal study of Osteoporosis in Women (GLOW).

Methods
This was a multinational, prospective, observational, population-based study carried out by 723 physician practices at 17 sites in 10 countries. A total of 60,393 women aged ≥55 years were included. Data were collected using self-administered questionnaires that covered domains that included patient characteristics, fracture history, risk factors for fracture, and anti-osteoporosis medications.

Results
Body mass index (BMI) and fracture history were available at baseline and at 1 and 2 years in 44,534 women, 23.4% of whom were obese (BMI ≥30 kg/m2). Fracture prevalence in obese women at baseline was 222 per 1000 and incidence at 2 years was 61.7 per 1000, similar to rates in nonobese women (227 and 66.0 per 1000, respectively). Fractures in obese women accounted for 23% and 22% of all previous and incident fractures, respectively. The risk of incident ankle and upper leg fractures was significantly higher in obese than in nonobese women, while the risk of wrist fracture was significantly lower. Obese women with fracture were more likely to have experienced early menopause and to report 2 or more falls in the past year. Self-reported asthma, emphysema, and type 1 diabetes were all significantly more common in obese than nonobese women with incident fracture. At 2 years, 27% of obese women with incident fracture were receiving bone protective therapy, compared with 41% of nonobese and 57% of underweight women.

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.

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

-- -- Juliet E. Compston, MD, Nelson B. Watts, MD, Roland Chapurlat, MD, PhD, Cyrus Cooper, MD, Steven Boonen, MD, PhD, Susan Greenspan, MD, Johannes Pfeilschifter, MD, Stuart Silverman, MD, Adolfo Díez-Pérez, MD, PhD, Robert Lindsay, MD, PhD, Kenneth G. Saag, MD, J. Coen Netelenbos, MD, PhD, Stephen Gehlbach, MD, Frederick H. Hooven, PhD, Julie Flahive, MS, Jonathan D. Adachi, MD, Maurizio Rossini, MD, Andrea Z. LaCroix, PhD, Christian Roux, MD, PhD, Philip N. Sambrook, MD, Ethel S. Siris, MD, Glow Investigators

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

AJM Editor-in-Chief previews the November 2011 issue (video)

2011-10-20T11:11:00.000-07:00

AJM Editor-in-Chief Joseph S. Alpert, MD, previews the November 2011 issue of The Journal, which is now available on our website.

Severe Circadian Hypertension in a Young Man

2011-10-18T15:19:00.001-07:00

A 19-year-old white man with no prior health problems presented at an employment physical examination with markedly elevated blood pressures of 234/132 mm Hg. The primary doctor initiated treatment with the alpha-beta blocker, labetalol, 200 mg daily and amlodipine, 10 mg daily. The young man denied neurologic or cardiac symptoms and there was no history of drugs of abuse or use of tobacco or alcohol. His family history was unremarkable for secondary forms of hypertension or cardiovascular disease.

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

-- -- Patrick Campbell, MD, Kanwar P. Singh, MD, Gregory Schuchard, MD, Koyal Jain, MD, William B. White, MD

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

30 Articles in Press available on AJM website

2011-10-07T04:00:00.001-07:00

The American Journal of Medicine regularly publishes accepted and corrected manuscripts on our website in advance of the actual publication date. There are currently 30 case reports, clinical research studies, and other types of articles on AJM's website.

Check out Dr. Joseph S. Alpert's video about articles in press above and related articles here.

Incremental Weight Loss Improves Cardiometabolic Risk in Extremely Obese Adults

2011-10-05T04:00:00.001-07:00

Very obese adults can improve their cardiometabolic risk under primary care weight management. In this study, weigh loss correlated significantly with improvements in fasting plasma glucose, triglycerides, high and low-density lipoprotein cholesterol, uric acid, alanine aminotransferase, lactate dehydrogenase and high-sensitivity C-reactive protein.

Abstract

Objective
Excessively obese adults often acquire many metabolic disorders that put them at high risk for developing type 2 diabetes mellitus and cardiovascular disease. We investigated the hypothesis that cardiometabolic risk in a primary care cohort of 208 excessively obese adults (body mass index 40-60 kg/m2, 48 with type 2 diabetes mellitus) would deteriorate with additional weight gain and improve incrementally beginning with 5% weight reduction.

Methods
Further analysis of the Louisiana Obese Subjects Study of excessively obese patients enrolled and followed during 2005-2008 is reported.

Results
Weight loss correlated significantly with improvements in fasting plasma glucose, triglycerides, high- and low-density lipoprotein cholesterol, uric acid, alanine aminotransferase, lactate dehydrogenase, and high-sensitivity C-reactive protein. Most parameters deteriorated with weight gain and progressively improved with 5% or more weight loss. Except for low-density lipoprotein cholesterol, all risk factors significantly improved with≥20% loss of body weight. Among patients who had not been diagnosed with type 2 diabetes mellitus and had normoglycemia at baseline, median fasting plasma glucose increased significantly (13%) with stable or gained weight at 1 year, but did not change significantly with reduced weight. Although glucose levels did not change significantly in patients with type 2 diabetes mellitus who gained weight, a decline beginning after 5% weight reduction culminated in 25% glucose reduction with≥20% weight loss. Resting blood pressure declined independently of weight change.

Conclusion
Very obese adults can improve their cardiometabolic risk under primary care weight management. Incremental success may help motivate further therapeutic weight reduction.

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

-- -- William D. Johnson, PhD, Meghan M. Brashear, MPH, Alok K. Gupta, MD, Jennifer C. Rood, PhD, Donna H. Ryan, MD

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

Weight and Weight Change—Think About the Context

2011-10-03T04:00:00.003-07:00

While obesity has been linked to multiple risk factors for cardiovascular disease and risk for type 2 diabetes and its complications, several epidemiologic studies have suggested that patients with excess weight may not have higher rates of (cardiovascular) mortality. Two articles in this issue of The American Journal of Medicine and one in the September issue demonstrate how the question of an “obesity paradox” can be very tricky to answer.

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

-- -- Stuart R. Chipkin, MD, diabetes and metabolism specialty editor, The American Journal of Medicine

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

Here are links to the three research studies referenced in Dr. Chipkin's editorial.

Incremental Weight Loss Improves Cardiometabolic Risk in Extremely Obese Adults

The Obesity Paradox and Weight Loss

Weight and Mortality Following Heart Failure Hospitalization among Diabetic Patients

An Enlarging Ulcer

2011-09-30T04:00:00.001-07:00

Presentation
A patient's incision would not heal, despite antibiotic therapy and debridement; finally the cause was identified after much testing and consultation with 2 teams. The odyssey began when an obese 73-year-old woman was admitted to the surgical service for ventral hernia repair and panniculectomy. Surgery was uneventful, but her postoperative course was complicated by wound breakdown and painful necrotic-appearing skin at the surgical site. Cultures from the wound were sent, and she was placed on broad-spectrum antibiotics.

Despite 2 weeks of antibiotic therapy, the patient had no clinical response and was taken back to the operating room for debridement of the wound. (By this time, the first set of cultures proved negative.) Non-vital tissue was removed, and intraoperative cultures were sent. She returned to the floor with an open horizontal wound, which extended down to the level of the fascia and across her entire abdomen. The defect was loosely packed with gauze with the ultimate goal of healing via secondary intention or with a future surgical procedure.

Within days of debridement, the tissue at the wound edges began to look necrotic again, with devitalized areas giving way to shallow ulceration continuous with the wound bed. The patient had intermittent low-grade fevers, and blood cultures were drawn. She continued on intravenous ampicillin/sulbactam, 1.5 g every 6 hours, with a recommendation from the infectious diseases consultant to complete a 14-day course. At that time, the dermatology consult service was contacted.

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

-- -- Robert Micheletti, MD, Nicole Fett, MD

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

The Importance of Being Elderly—Some Thoughts on the Care of Geriatric Patients

2011-09-29T13:50:00.001-07:00

As the American population progressively ages, the number of elderly who suffer from a variety of serious illnesses is increasing. These days, it is not uncommon for me to be caring for a number of patients 80 years old or older in our coronary care unit. The evident and potential frailty of these individuals can make their care complex.1 The medical literature in recent years has had many reports on differences in disease presentation, therapeutic strategies, and outcomes for geriatric patients. The editors of The American Journal of Medicine are acutely cognizant of the demographic changes in the US and the effect that the graying of our population is having on medical practice. Because of the increasing importance of geriatrics for the daily practice of internal medicine and its subspecialties, the Journal's editors have decided to direct more attention to topics related to the care of the elderly. Consequently, we have promoted Michael W. Rich, MD from Subspecialty Editor for geriatrics to Associate Editor, with geriatrics as his focus.

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 October 2011 issue of The American Journal of Medicine.

AJM Editor-in-Chief previews the October 2011 issue (video)

2011-09-29T04:00:00.001-07:00

What's new in AJM's October issue? Check out Dr. Joseph S. Alpert's video preview or check out our website.

Two new CME courses on AJM website

2011-09-27T15:13:00.001-07:00

Two new continuing medical education (CME) courses have been uploaded to The American Journal of Medicine's website recently.

Managing Chronic Pain with Nonopioid Analgesics: A Multidisciplinary Consult
Presenters: Daniel Clauw, MD, and Bill H. McCarberg, MD

Determining pain mechanism is important in selecting treatment for chronic musculoskeletal pain states. While broad classifications (nociceptive, neuropathic, etc.) provide a framework, any combination of mechanisms may be present in a chronic pain patient. Growing evidence shows that pain states traditionally considered to be nociceptive (osteoarthritis, low back pain), may also involve elements of augmented central nervous system pain processing, and certain nonopioid analgesics, specifically certain SNRIs, can be effective in treating these conditions. Besides identification of biological pain mechanisms, chronic pain management also requires assessment of psychological and sociocultural factors that influence pain chronicity and patient prognosis. A multimodal/multidisciplinary approach incorporating pharmacologic and nonpharmacologic therapy is important to improve outcomes in chronic pain patients.

Commercial Support: This activity is supported by an educational grant from Lilly USA, LLC. For further information concerning Lilly grant funding visit www.lillygrantoffice.com.
Review and Sponsorship: This multimedia activity was peer reviewed by The American Journal of Medicine and jointly sponsored by Purdue University College of Pharmacy and Health Education Alliance, Inc.

Invasive Mycoses: Evolving Challenges and Opportunities in Antifungal Therapy
A Case-based Discussion
Presenters: Michael A. Pfaller, MD, Luis Ostrosky-Zeichner, MD, FACP, FIDSA, Dimitrios P. Kontoyiannis, MD, ScD, FACP, FIDSA, John R. Perfect, MD

The diagnosis and management of invasive fungal infections remain a clinical challenge. Both the frequency of infections and resistance to antifungal agents continue to increase despite the introduction of new antifungal agents. While early diagnosis and intervention are essential for favorable outcomes, diagnoses of invasive mycoses is often difficult as current diagnostic methods are not sensitive or specific enough and may not be readily available to clinicians. In addition, the underlying disease of the host is a major contributor to the final clinical outcome and often may complicate the effective management of the mycosis.

The improvements in antifungal susceptibility testing methods to detect emerging resistance patterns coupled with molecular characterization of resistance mechanisms provide useful adjuncts to optimize the efficacy of antifungal therapy. The clinician’s familiarity with the latest diagnostic markers and techniques along with emerging data and safety and efficacy of antifungal agents will help guide clinical decisions.

Commercial Support: This activity is supported by an educational grant from Merck.
Review and Sponsorship: This multimedia activity was peer reviewed by The American Journal of Medicine and is jointly sponsored by Post Graduate Institute for Medicine and Global Education Exchange.

For a list of all CME courses on our website, check this link.

Hydroxycitric Acid Dietary Supplement-Related Herbal Nephropathy

2011-09-13T13:27:00.001-07:00

Herbal preparations are unregulated and widely used because of public perception of being “harmless” and “natural.” Hydroxycitric acid, an extract from the herb garcinia cambogia, is a popular weight-loss supplement used for centuries in Asia. Its effect on weight loss, although being demonstrated in animal studies, may be effective on humans, but with harmful consequences. This is the first report of acute kidney injury caused by an herbal product containing hydroxycitric acid.

Case Presentation
A 38-year-old obese woman presented to the emergency department for treatment of abdominal pain, nausea, and vomiting of 3 days duration. Her medical history was significant for gastroesophageal reflux. The patient said she generally took no medication, but she had begun taking ranitidine 150 mg/d a few days previously and used an “occasional” hydrocodone/acetaminophen 5/500 tablet to ameliorate her abdominal pain. She denied use of nonsteroidal anti-inflammatory drugs and did not initially disclose her hydroxycitric acid herbal supplement use (500 mg/d 5 days per week for 1 year) until directly questioned by the admitting physician.

The patient's positive findings were a hypertensive state of 145/76 mm Hg, an elevated creatinine level of 5.8 mg/dL (compared with a baseline of 0.79 mg/dL), and a fractional excretion of sodium greater than 4. Negative laboratory results were anti-nuclear and anti-neutrophil cell antibodies, C3, C4, and serum protein electrophoresis. Renal artery ultrasound was normal.

After the supplement was discontinued, her creatinine increased to 6.2 mg/dL (glomerular filtration rate of 8 mL/min) over the next day, necessitating nephrology to institute hemodialysis. Consequently, her renal function sufficiently improved, so no renal biopsy was performed. She was discharged on day 7 with a creatinine level of 1.6 mg/dL and glomerular filtration rate of 38 mL/min.

The temporal relationship of her symptoms, the prolonged use of hydroxycitric acid, the absence of other nephrotoxic agents except ranitidine, and the improvement of renal function after cessation of hydroxycitric acid support the impression of acute renal failure secondary to herbal nephropathy.

To read this article in its entirety, please visit our website. It is currently an article in press.

-- -- Janette W. Li, MD, Paula Bordelon, DO

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

Reversible Nutritional Hypogonadism in a 22-Year-Old Man

2011-09-07T14:32:00.001-07:00

Editor's Note: There is such as thing as working out and dieting too much...

A 22-year-old man presented with lack of libido and erectile dysfunction of 4 years duration for evaluation. Past medical history was remarkable for fat restriction with regular engagement in body-building exercises. Physical examination was normal without any signs of hypogonadism. Laboratory work-up showed low total and high-density lipoprotein cholesterol with low total and bioavailable testosterone concentrations (Table). Gonadotropin levels were within normal ranges. Sperm analysis showed a low amount of live spermatozoids, 88% of which had severe morphological impairment with head defects. Brain magnetic resonance imaging was normal. Testosterone treatment was recommended. The patient insisted on nutritional consultation before hormone therapy initiation. Food records confirmed a very low fat intake: 2260 calories, 170 g protein, 350 g carbohydrates, and<20 g fat daily. Body composition demonstrated 4% body fat...

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

-- -- Aviva Shemesh, RD, MsC, Ronit Endevelt, RD, PhD, Yishai Levy, MD

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

Weight and Mortality Following Heart Failure Hospitalization among Diabetic Patients

2011-09-01T14:21:00.000-07:00

In overweight/obese individuals at increased cardiovascular risk, Mediterranean diets modify most cardiovascular risk factors more efficiently than low-fat diets and show a lasting benefit for 2 years after the beginning of the diet.

Abstract

Background
Type 2 diabetes is an important risk factor for heart failure and is common among patients with heart failure. The impact of weight on prognosis after hospitalization for acute heart failure among patients with diabetes is unknown. The objective of this study was to examine all-cause mortality in relation to weight status among patients with type 2 diabetes hospitalized for decompensated heart failure.

Methods
The Worcester Heart Failure Study included adults admitted with acute heart failure to all metropolitan Worcester medical centers in 1995 and 2000. The weight status of 1644 patients with diabetes (history of type 2 diabetes in medical record or admission serum glucose ≥200 mg/dL) was categorized using body mass index calculated from height and weight at admission. Survival status was ascertained at 1 and 5 years after hospital admission.

Results
Sixty-five percent of patients were overweight or obese and 3% were underweight. Underweight patients had 50% higher odds of all-cause mortality within 5 years of hospitalization for acute heart failure than normal weight patients. Class I and II obesity were associated with 20% and 40% lower odds of dying. Overweight and Class III obesity were not associated with mortality. Results were similar for mortality within 1 year of hospitalization for acute heart failure.

Conclusions
The mechanisms underlying the association between weight status and mortality are not fully understood. Additional research is needed to explore the effects of body composition, recent weight changes, and prognosis after hospitalization for heart failure among patients with diabetes.

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

-- -- Molly E. Waring, PhD, Jane S. Saczynski, PhD, David McManus, MD, Michael Zacharias, DO, Darleen Lessard, MS, Joel M. Gore, MD, Robert J. Goldberg, PhD

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

The Impact of the Aging Population on Coronary Heart Disease in the United States

2011-08-31T11:37:00.000-07:00

Absolute coronary heart disease incidence is projected to increase by 26%, prevalence by 47%, mortality by 56%, and costs by 41%, due to the aging of the U.S. population from 2010-2040. Focusing on Health People 2010/2020 goals for risk factor control could offset some of the projected increase.

Abstract

Background
The demographic shift toward an older population in the United States will result in a higher burden of coronary heart disease, but the increase has not been quantified in detail. We sought to estimate the impact of the aging US population on coronary heart disease.

Methods
We used the Coronary Heart Disease Policy Model, a Markov model of the US population between 35 and 84 years of age, and US Census projections to model the age structure of the population between 2010 and 2040.

Results
Assuming no substantive changes in risks factors or treatments, incident coronary heart disease is projected to increase by approximately 26%, from 981,000 in 2010 to 1,234,000 in 2040, and prevalent coronary heart disease by 47%, from 11.7 million to 17.3 million. Mortality will be affected strongly by the aging population; annual coronary heart disease deaths are projected to increase by 56% over the next 30 years, from 392,000 to 610,000. Coronary heart disease-related health care costs are projected to rise by 41% from $126.2 billion in 2010 to $177.5 billion in 2040 in the United States. It may be possible to offset the increase in disease burden through achievement of Healthy People 2010/2020 objectives or interventions that substantially reduce obesity, blood pressure, or cholesterol levels in the population.

Conclusions
Without considerable changes in risk factors or treatments, the aging of the US population will result in a sizeable increase in coronary heart disease incidence, prevalence, mortality, and costs. Health care stakeholders need to plan for the future age-related health care demands of coronary heart disease.

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

-- -- Michelle C. Odden, PhD, Pamela G. Coxson, PhD, Andrew Moran, MD, MPH, James M. Lightwood, PhD, Lee Goldman, MD, MPH, Kirsten Bibbins-Domingo, PhD, MD

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

Choosing a Physician

2011-08-30T10:37:00.000-07:00

How do patients choose a new physician?

From personal referrals to diplomas on the wall to communication styles to what the doctor is wearing-- patients use many types of information to make a decision about a new physician.

A recent article in the LA Times discusses the doctor-shopping process and quoted a 2005 American Journal of Medicine study about physician dress. From the LA Times....

In a 2005 study published in the American Journal of Medicine, 400 men and women were presented with pictures of physicians in four different styles of dress. When asked what style they preferred, 3/4 of the study participants said they preferred their doctors in professional attire, complete with white coat. Less than 5% want to see a physician dressed casually. They also reported that they'd be more likely to share their problems with a doctor who was dressed professionally.

The bottom line: Finding a good doctor is no easy feat. It often requires looking beyond the diplomas to the person who earned them.

To read What to wear today? Effect of doctor’s attire on the trust and confidence of patients by Rehman et al, click here.

The Ten Most Annoying Things That Happen During My Work Day—and Perhaps in Yours as Well

2011-08-29T04:00:00.001-07:00

Last month I enumerated 10 things that I enjoy most during my work day. In this issue I will list the 10 most annoying items that can occur during my daily routine. However, let me say from the outset that despite these unpleasant events, the positive features of the day far outweigh the negative ones. As always, I look forward to receiving comments from readers on our blog.

Irritation Number 1: Form letters from insurance companies suggesting alternative medications for me to prescribe for my patients. I cannot imagine that a functionary sitting at a desk in an insurance company office, someone who has had no contact with my patient, could possibly have anything interesting or valuable to say to me concerning the carefully considered therapeutic program that I have ordered for my patients. I have never found even one of these letters useful. They are a waste of paper and postage. And what is more, they never add to a fund of useful knowledge about the product. I am always open to learning more, but these letters fail to accomplish even the most basic rule of communication.

Irritation Number 2: Direct-to-consumer advertisements on television for various drugs that the announcer suggests should be “discussed with your doctor.” These ads are frequently misleading in their implications, and physicians have too little time now to spend with patients. Conversations about drug advertisements on television only shorten the really important time that needs to be spent discussing the patient's clinical condition and therapeutic options. Not once in the many years that these commercial messages have been advertised have I written a prescription as a result of these conversations. Patients are invariably taking similar agents already or the drug is contraindicated.

Irritation Number 3: The need to remember or, at least, maintain a constantly changing list of passwords to gain access to various clinical and nonclinical websites. Our hospital and university are constantly requesting changes in these passwords. Although I understand the need for security, there seems to be very little thought behind how to manage this process so that the busy clinician can get to the most important function they fulfill: taking care of patients. I look forward to the day when retinal or fingerprint scans will become the norm for these security measures.

Irritation Number 4: Requiring multiple signatures on various hospital and practice documents. Many of you must also be asked to sign the many orders, statements, and communications that pass across our desks. I have found that electronic signing takes even longer than doing this activity manually. All we can do, I guess, is to hope that some technical advance will obviate the need to sign my name continuously.

Irritation Number 5: Patients who lie to me. These lies often involve the use of illegal street drugs. Of course, the lie becomes immediately evident when we run urine or blood toxicology screening tests. Perhaps I should tell patients up front that we always discover when such agents have been used, and so the best policy is to be truthful right from the beginning of our interaction. These lies, whether based on drug use or not, often prevent me from giving the best medical care as quickly as possible.

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 the September 2011 issue of The American Journal of Medicine.

People Were Staring...

2011-08-26T04:00:00.001-07:00

Sometimes, a patient minimizes the symptoms of his or her illness, while at other times a condition can be glaringly evident and frankly observable to all. Both of these seemingly opposite situations occurred simultaneously in this case of a rare skin condition.

A 27-year-old man with a medical history of atopic dermatitis presented with a progressively disseminating non-pruritic rash that had been present for 3 days. The rash had begun on the left cheek and had spread quickly to involve the rest of the face and body. The patient had no other complaints, and the rash was not painful or irritating, but the fact that “people were staring” when he went to the grocery store bothered him so much that he sought medical care at our emergency department.

To read this article in its entirety and learn why people were staring, please visit our website.

-- Maryrose Laguio, MD, Glynis Scott, MD, Mary Gail Mercurio, MD, Peter Mariuz, MD

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

Black Hairy Tongue: If You're Tongue Looks Like This, Brush It More Often

2011-08-24T13:22:00.000-07:00

A 62-year-old man, known for alcohol and tobacco abuse, was diagnosed with laryngeal squamous cell carcinoma in 2008. He underwent curative radiotherapy (70 Gy), delivered to the laryngeal and oropharyngeal area as well as the neck. Follow-up 4 months after this treatment showed recurrence, for which we performed total laryngectomy and bilateral neck dissection.

Eight months after surgery he was doing well and presented no recurrence, but physical examination showed thick black hairy lesions on the back of his tongue (Figure). These lesions had appeared and quickly evolved 4 weeks before the consultation, with no associated symptoms such as pain, dysphagia, or dysgeusia. The patient had not received antibiotics in the last months. Bacterial and fungal cultures of tongue swab were negative. Basic blood tests showed no particularity. Thus, we diagnosed the patient with black hairy tongue.

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

-- Lluís Nisa, MD, Roland Giger, MD

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

AJM Editor-in-Chief previews the September issue (video)

2011-08-20T04:00:00.000-07:00

What new research will be featured in the September 2011 issue of The American Journal of Medicine? Click on this video update by Editor-in-Chief Joseph S. Alpert, MD, and find out.

Elsevier Health Careers: A Comprehensive Collection of Resources

2011-08-19T10:42:00.000-07:00

Elsevier Health Careers has the biggest collection of healthcare and medical jobs listings from all around the world. Search for your next healthcare job by specialty or discover available medical jobs within a geographic region. Also check out the website's free CME and other career advancement resources... here.

Attributable Risk Estimate of Severe Psoriasis on Major Cardiovascular Events

2011-08-15T11:21:00.000-07:00

Patients with severe psoriasis have an additional 6.2% absolute risk of major adverse cardiac events compared to the general population. This finding could have important therapeutic implications for cardiovascular risk stratification and prevention in patients with severe psoriasis.

Abstract

Background
Recent studies suggest that psoriasis, particularly if severe, may be a risk factor for major adverse cardiac events, such as myocardial infarction, stroke, and mortality from cardiovascular disease. We compared the risk of major adverse cardiac events between patients with psoriasis and the general population and estimated the attributable risk of severe psoriasis.

Methods
We performed a cohort study in the General Practice Research Database. Severe psoriasis was defined as receiving a psoriasis diagnosis and systemic therapy (N=3603). Up to 4 patients without psoriasis were selected from the same practices and start dates for each patient with psoriasis (N=14,330).

Results
Severe psoriasis was a risk factor for major adverse cardiac events (hazard ratio 1.53; 95% confidence interval, 1.26-1.85) after adjusting for age, gender, diabetes, hypertension, tobacco use, and hyperlipidemia. After fully adjusted analysis, severe psoriasis conferred an additional 6.2% absolute risk of 10-year major adverse cardiac events.

Conclusion
Severe psoriasis confers an additional 6.2% absolute risk of a 10-year rate of major adverse cardiac events compared with the general population. This potentially has important therapeutic implications for cardiovascular risk stratification and prevention in patients with severe psoriasis. Future prospective studies are needed to validate these findings.

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

-- Nehal N. Mehta, MD, MSCE, FAHA, YiDing Yu, BA, Rebecca Pinnelas, BS, Parasuram Krishnamoorthy, MD, Daniel B. Shin, BA, Andrea B. Troxel, ScD, Joel M. Gelfand, MD, MSCE

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

The Third Dimension: Newly-posted Article in Press (video)

2011-08-10T11:22:00.000-07:00

A 37-year-old man with bipolar disorder and active polysubstance abuse presented with 4 days of fever, chills, drenching sweats, and generalized fatigue. He reported daily inhalational use of both heroin and cocaine and also had a dental extraction in recent weeks. Vital signs were significant for a fever of 41.67°C (101.7°F). Active rigors were noted on initial assessment. Examination of the mouth revealed no evidence of active dental infection, cardiac examination was without murmur, and no cutaneous stigmata of infective endocarditis or active intravenous drug use were present. Laboratory testing was unremarkable. Electrocardiogram was normal...

This case study is currently an article in press on The American Journal of Medicine's website. Check out the rest of this article here and other newly-published articles in press here.

Illicit Drug, Ischemic Bowel

2011-08-08T13:00:00.001-07:00

In the young adult or middle-aged patient with abdominal pain and bloody diarrhea, a history of cocaine abuse is an important consideration in the differential diagnosis, as illustrated in this case.

A 44-year-old male construction worker presented to our general medicine clinic reporting 1 year of recurrent, sharp, left-sided abdominal pain associated with frequent loose stools. For a few days before presentation, he had been unable to sleep because of the pain. The painful episodes were associated with some rectal bleeding and a documented weight loss of 40 lb but no nausea, vomiting, abdominal distension, food intolerance, or change in appetite. The patient denied urinary problems (hematuria, frequency, urgency, dysuria) and fever. His medical and surgical history were unremarkable except for an appendectomy 15 years previously; he had never had a colonoscopy. His social history was significant for smoking (20 pack-years) and occasional alcohol use. He denied use of illicit drugs.

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

-- Khaldoon Shaheen, MD, M. Chadi Alraies, MD, Houssam Marwany, MD, Emmanuel Elueze, MD, PhD

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

Should the Routine Physical Examination Include Squat Maneuvers?

2011-08-02T04:00:00.000-07:00

Few primary care physicians or even cardiologists ask patients to squat routinely as part of the physical examination despite evidence that squatting is a quick and simple means of augmenting the cardiac examination.(1, 2, 3, 4) Characteristic hemodynamic changes may occur when patients squat or stand upright from a squatting position; squatting increases left ventricular preload and afterload, whereas rapid standing from a squatting position decreases left ventricular volume by diminishing venous return.(1, 2, 3) These hemodynamic changes manifest in clinically noticeable changes that may be observed on the routine cardiac examination. A 1988 study of the diagnostic accuracy of bedside maneuvers in the evaluation of patients with systolic murmurs found that the intensity and duration of murmurs changed for many patients, especially those with obstructive hypertrophic cardiomyopathy, after they performed a series of squats and subsequently stood upright.3

In addition to improving detection of some murmurs, squat maneuvers may be a useful way of adding important clinical information to the patient-physician encounter. Squatting can unmask inappropriate post-exercise heart rate or rhythm changes after brief exertion. Musculoskeletal problems ranging from balance disorders to myopathies may be identified if patients experience difficulty with performing squats. Specifically, screening for myopathies may be particularly relevant in those being followed on statin therapy, whereas fall risk assessment would be warranted in those on warfarin anticoagulation therapy.

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

-- Nona Ahankoob, Moulin Chokshi, Matthew Feinstein, Neil J. Stone, MD

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

Constipation and Risk of Cardiovascular Disease among Postmenopausal Women

2011-08-01T10:45:00.000-07:00

In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Since constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.

Abstract

Background
Constipation is common in Western societies, accounting for 2.5 million physician visits/year in the US. Because many factors predisposing to constipation also are risk factors for cardiovascular disease, we hypothesized that constipation may be associated with increased risk of cardiovascular events.

Methods
We conducted a secondary analysis in 93,676 women enrolled in the observational arm of the Women's Health Initiative. Constipation was evaluated at baseline by a self-administered questionnaire. Estimates of the risk of cardiovascular events (cumulative end point including mortality from coronary heart disease, myocardial infarction, angina, coronary revascularization, stroke, and transient ischemic attack) were derived from Cox proportional hazards models adjusted for demographics, risk factors, and other clinical variables (median follow-up 6.9 years).

Results
The analysis included 73,047 women. Constipation was associated with increased age, African American and Hispanic descent, smoking, diabetes, high cholesterol, family history of myocardial infarction, hypertension, obesity, lower physical activity levels, lower fiber intake, and depression. Women with moderate and severe constipation experienced more cardiovascular events (14.2 and 19.1 events/1000 person-years, respectively) compared with women with no constipation (9.6/1000 person-years). After adjustment for demographics, risk factors, dietary factors, medications, frailty, and other psychological variables, constipation was no longer associated with an increased risk of cardiovascular events except for the severe constipation group, which had a 23% higher risk of cardiovascular events.

Conclusion
In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Because constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.

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

-- Elena Salmoirago-Blotcher, MD, Sybil Crawford, PhD, Elizabeth Jackson, MD, Judith Ockene, PhD, Ira Ockene, MD

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

July 30, 2011: The 46th Anniversary of Medicare

2011-07-28T16:21:00.020-07:00

Blog Commentary

Forth-six years ago on July 30, President Lyndon B. Johnson signed the Social Security Act of 1965 into law and created Medicare and Medicaid. Enacting universal, single-payer healthcare for the country's elderly and indigent was a long struggle that began during Harry Truman's presidency.

Medicare and Medicaid were part of Johnson’s Great Society, which had two primary goals: to eliminate poverty and to eliminate racial injustice. After his landslide victory over Barry Goldwater in 1964, Johnson and his Democratic Congress enacted forward-thinking reforms that were reminiscent of the New Deal and began the full-on War on Poverty, which reduced the poverty rate significantly over the subsequent 10 years. Many important Great Society programs– aimed at improving labor conditions, healthcare, and education for poor and working class Americans– are still in existence: Medicare, Medicaid, food stamps, student loans for college, work study, and Head Start. These programs were strengthened under Republican Presidents Richard Nixon and Gerald Ford.

Today, there are forces on the right who would redesign Medicare, while there are equally vocal forces on the left who would extend Medicare to all Americans in order to provide universal healthcare coverage.

Testosterone Deficiency: A Comprehensive Review

2011-07-27T12:16:00.000-07:00

Testosterone Deficiency is a highly prevalent and under-diagnosed condition associated both with aging and common medical comorbidities, including metabolic syndrome and cardiovascular disease. Early evidence suggests that testosterone replacement therapy may reverse early diabetes and improve overall male health. A comprehensive review of testosterone deficiency was published in the July issue of The American Journal of Medicine.

Abstract
Testosterone deficiency (TD) afflicts approximately 30% of men aged 40-79 years, with an increase in prevalence strongly associated with aging and common medical conditions including obesity, diabetes, and hypertension. A strong relationship is noted between TD and metabolic syndrome, although the relationship is not certain to be causal. Repletion of testosterone (T) in T-deficient men with these comorbidities may indeed reverse or delay their progression. While T repletion has been largely thought of in a sexual realm, we discuss its potential role in general men's health concerns: metabolic, body composition, and all-cause mortality through the use of a single clinical vignette. This review examines a host of studies, with practical recommendations for diagnosis of TD and T repletion in middle-aged and older men, including an analysis of treatment modalities and areas of concerns and uncertainty.

Case Study Example
A 52-year-old man of Caucasian descent presented with erectile dysfunction (ED), diminished libido, and fatigue. He took no medications and was otherwise healthy. He was 5 feet, 7 inches tall (170 cm) and weighed 217 pounds (98 kg), with a body mass index of 34 kg/m2 and a waist circumference of 43 inches (109.2 cm). His blood pressure was 135/80 mm Hg. Laboratory values were all normal except for serum total testosterone of 270 ng/dL (9.37 nmol/L) (normal reference range 300-1000 ng/dL [10.4-34.7 nmol/L]) and fasting serum glucose of 110 mg/dL (6.1mmol/L) (normal 67-99 mg/dL [3.7-5.5mmol/L]), indicating a component of metabolic syndrome (MetS).1 What are the diagnostic, prognostic, and therapeutic issues in a man with symptomatic testosterone deficiency associated with the metabolic syndrome?

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

-- Abdulmaged M. Traish, MBA, PhD, Martin M. Miner, MD, Abraham Morgentaler, MD, Michael Zitzmann, MD

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

The 10 Things I Like Best About My Job

2011-07-27T04:00:00.001-07:00

I love going to work each day. Many things make work a pleasure, while others are best described as “irritating.” In the end, the positive items far outweigh the negative ones. This editorial will outline the 10 things that make my work days pleasant but, unlike the Letterman list, ranked in the order of their importance. Next month I will describe the 10 irritants that accompany my job. I would be happy to hear from others about the positive or negative events in their daily work routine.

Number 1: Personal interactions before, during, and after work with family members and friends. E-mail makes it possible to stay in touch with family and friends with rapid communications that do not interfere with the usually hectic work schedule.

Number 2: Because I work at a university hospital, I have contact throughout the day with young, enthusiastic, and knowledgeable students, residents, and fellows. Every one of these interactions, usually involving patient care but, at times, related to manuscript preparation, is a sheer delight. These contacts convince me that the next generation of physicians will grow and increase our profession's contributions to society in the future.

Number 3: I am often the attending physician of record on our coronary care unit, cardiology consult, and internal medicine ward services. It is no surprise that many of our patients are critically ill. The recovery of a patient whose life was in real jeopardy brings a moment of joy into my life and the lives of the trainees with whom I work.

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 the August 2011 issue of The American Journal of Medicine.

Chronic Pain Management: New interactive CME activities on AJM website

2011-07-26T11:17:00.000-07:00

A new interactive continuing medical education (CME) activity with patient case videos has been posted on The American Journal of Medicine's website: Comprehensive Chronic Pain Management: Improving Physical and Psychological Function.

Here is the CME program description:

Using a unique, highly interactive, video patient case teaching format, this activity is intended to provide clinicians who manage patients with chronic pain with new insights and expand their understanding to achieve the goals of effective pain management -- reduction of pain, improvement in function, and restoration of psychological health-- utilizing a multidisciplinary (pharmacological and nonpharmacological) approach. Participants will have multiple “interactive” opportunities to reinforce their own best practices or recognize potential gaps in their clinical practice and will receive information to help them accurately assess the severity of pain, evaluate biopsychosocial factors that impact treatment, and develop strategies to meet the goals of therapy and improve patient outcomes.

This CME activity was originally presented on Saturday, March 26, 2011, in National Harbor, Maryland, and was adapted for release on July 21, 2011. Content was developed by faculty. The symposium was supported by an educational grant from PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.

The symposium was an official independent satellite symposium held in conjunction with the American Academy of Pain Medicine’s 27th Annual Meeting.

Click here to register and find out more about the program

An Unusual Complication of Crack Abuse

2011-07-22T13:14:00.003-07:00

Blog Feature

Crack cocaine abuse is highly prevalent in the United States. Though physical withdrawal occurs rarely, the compulsion to smoke crack is powerful. In this case, a patient attempted to smoke crack through her tracheostomy and aspirated her glass crack pipe.

Case Report: A 50 year-old woman presented to the Emergency Department (ED) complaining of dyspnea for two hours. She had a history of laryngeal cancer and tracheostomy several years prior but because of longstanding discomfort at the tracheostomy site, she did not have a tracheostomy tube in place. She had a history of polysubstance abuse and was enrolled in a drug treatment program where she received methadone and psychosocial support. Urine toxicology reports at the program were intermittently positive for cocaine. In the ED she reported that an object had fallen into her tracheostomy. On physical examination the patient was tachypneic and agitated. Her lungs were clear to auscultation. Her oxygen saturation was 78% on room air. Chest radiography revealed a tubular radiodensity overlying the region of the carina and right mainstem bronchus. Bronchoscopy was performed urgently and a glass tube 3.2 cm in length was removed from the right mainstem bronchus. The tube was the size and shape of a pipe used to smoke crack cocaine [circled in the above image]. Copious secretions had accumulated behind the obstruction, but no injury to the airways was observed. The patient recovered uneventfully and continued intermittent crack abuse until just prior to her death three years later. She died due to a recurrence of her laryngeal cancer.

Discussion
Cocaine, including crack, is the second most commonly abused non-prescription illicit drug with 1.9 million Americans reporting use in the past month (1). Cocaine is associated with more emergency department visits than any other illicit drug (2). Cocaine abuse can lead dysfunction of multiple organ systems. For example, injecting cocaine can lead to skin and soft tissue infections as well as transmission of viral hepatitis and HIV. Smoking crack increases risk of pulmonary infections and chronic pulmonary disease. By any route, cocaine can cause myocardial infarction, cardiac arrhythmia and seizure.

Cocaine is highly addictive. Few psychosocial interventions have proved effective in treating cocaine abuse. Though multiple medications have been tried, none have proved effective in treating cocaine abuse in randomized controlled trials Cocaine vaccine is currently being investigated as a tool to prevent relapse among prior cocaine users.
Amongst poor urban populations, cocaine is most frequently smoked in the form of crack, the least expensive form of cocaine. Crack is commonly smoked from a glass pipe (“stem”) with a steel wool filter. Oral injuries such as burns and lacerations are common among crack abusers and can be routes of viral infection when smoking paraphernalia is shared. Tracheal and esophageal aspiration of smoking paraphernalia are rare sequelae of crack abuse. Published reports include cases of aspiration of bagged cocaine by a “body packer” (3), aspiration and ingestion of a steel wool filter (4) and ingestion of a crack pipe (5).

This unusual case graphically illustrates the tremendous compulsion to smoke crack, even in the face of extreme risk. Given the morbidity associated with cocaine abuse, efforts to prevent cocaine abuse as well as identify and treat patients who abuse cocaine are warranted.

-- Melissa Stein, MD
Albert Einstein College of Medicine/Montefiore Medical Center

References
1. Substance Abuse and Mental Health Services Administration. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.

2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network,2007: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD, 2010.

3. Cobaugh DJ, Schneider SM, Benitez JG, Donahoe MP. Cocaine balloon aspiration: successful removal with bronchoscopy. Am J Emerg Med. 1997; 15(5):544-6.

4. Moettus A, Tandberg. Brillo crack pad aspiration and ingestion. J Emerg Med. 1998; 16(6):861-3.

5. Young J, Beech D, Offodile R. Foreign body ingestion and management: “I swallowed a crack pipe”. Am Surg. 2007; 73(11):1144-6.

AJM Editor-in-Chief previews the August issue (video)

2011-07-20T04:00:00.001-07:00

What new research will be included in the August 2011 issue of The American Journal of Medicine, check out this video clip with Dr. Joseph S. Alpert, editor-in-chief.

Treating Patients High on Bath Salts: A Growing Problem

2011-07-19T13:27:00.002-07:00

Emergency rooms and poison control centers across the country are seeing increasing numbers of people high on bath salts. Yes... bath salts.

Sold legally in head shops and convenience stores, the bath salts are advertised as a bathing product, but people are snorting, injecting, or smoking them to get high. The problem is that users can become psychotic, violent, and dangerous to themselves and others under the influence of bath salts. Further compounding the problem, doctors are not clear how to treat these patients when they arrive in the emergency rooms, the compounds may not show up on drug screening tests, and the negative effects can be long-lasting. Ingesting bath salts is very dangerous.

Recently, the New York Times published a story about the bath salts, which are legal in many states. According to the Times, between January and June 2011, there were 3,470 calls to poison control centers about bath salts-- up from 303 calls in 2010.

On The American Journal of Medicine website, the case study Bath Salts as a "Legal High" appears as an article in press. From the article by Smith et al...

Abuse of bath salts is a new trend in the US for those trying to obtain “legal highs.” A study in the United Kingdom found 1308 products for sale, in the form of pills, smoking materials, and single plant material/extracts.(1)

Our case illustrates the clinical presentation after using bath salts as a “legal high.” Drug screens will usually be negative, and poison control centers may not have knowledge of these compounds. Internet sites listed components of “Cristalius” to include: creatine, caffeine, “herbal blends,” hoodia, and sodium sesquicarbonate (the bath salt component). These products are advertised for bathing and not for human consumption and are found by many names, including “Ivory Wave,” “Vanilla Sky,” “Snow,” and “Hurricane Charlie.” The drugs are usually snorted, but may be ingested, injected, or smoked. (2, 3)

The full story can be found here.

Effect of Aspirin on Mortality in the Primary Prevention of Cardiovascular Disease

2011-07-14T10:38:00.000-07:00

In patients without a history of cardiovascular disease, aspirin prevents deaths as well as myocardial infarction and ischemic stroke but increases hemorrhagic stroke and major bleeding when used in primary prevention of cardiovascular disease.

Abstract

Objective
The lack of a mortality benefit of aspirin in prior meta-analyses of primary prevention trials of cardiovascular disease has contributed to uncertainty about the balance of benefits and risks of aspirin in primary prevention. We performed an updated meta-analysis of randomized controlled trials of aspirin to obtain best estimates of the effect of aspirin on mortality in primary prevention.

Methods
Eligible articles were identified by searches of electronic databases and reference lists. Outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, and bleeding. Data were pooled from individual trials using the DerSimonian-Laird random-effects model, and results are presented as relative risk (RR) and 95% confidence intervals (CIs).

Results
Nine randomized controlled trials enrolling 100,076 participants were included. Aspirin reduced all-cause mortality (RR 0.94; 95% CI, 0.88-1.00), myocardial infarction (RR 0.83; 95% CI, 0.69-1.00), ischemic stroke (RR 0.86; 95% CI, 0.75-0.98), and the composite of myocardial infarction, stroke, or cardiovascular death (RR 0.88; 95% CI, 0.83-0.94), but did not reduce cardiovascular mortality (RR 0.96; 95% CI, 0.84-1.09). Aspirin increased the risk of hemorrhagic stroke (RR 1.36; 95% CI, 1.01-1.82), major bleeding (RR 1.66; 95% CI, 1.41-1.95), and gastrointestinal bleeding (RR 1.37; 95% CI, 1.15-1.62). A lack of availability of patient-level data precluded exploration of benefits and risks of aspirin in key subgroups.

Conclusion
Aspirin prevents deaths, myocardial infarction, and ischemic stroke, and increases hemorrhagic stroke and major bleeding when used in the primary prevention of cardiovascular disease.

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

-- Nina Raju, MD, MsC, Magdalena Sobieraj-Teague, MBBS, Jack Hirsh, MD, Martin O'Donnell, MD, PhD, John Eikelboom, MD, MsC

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

The DRESS Syndrome: A Literature Review

2011-07-12T04:00:00.001-07:00

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a potential life-threatening syndrome including severe eruption, fever, hypereosinophilia and internal organ involvement. Although 50 drugs can induce DRESS, the main culprit drugs are carbamazepine and allopurinol.

Abstract
The Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) is a severe adverse drug-induced reaction. Diagnosing DRESS is challenging due to the diversity of cutaneous eruption and organs involved. We used the RegiSCAR scoring system that grades DRESS cases as “no,” “possible,” “probable,” or “definite” to classify cases reported in the literature. We also analyzed the clinical course and treatments of the cases. A total of 44 drugs were associated with the 172 cases reported between January 1997 and May 2009 in PubMed and MEDLINE. The most frequently reported drug was carbamazepine, and the vast majority of cases were classified as “probable/definite” DRESS cases. Hypereosinophilia, liver involvement, fever, and lymphadenopathy were significantly associated with “probable/definite” DRESS cases, whereas skin rash was described in almost all of the cases, including “possible cases.” Culprit drug withdrawal and corticosteroids constituted the mainstay of DRESS treatment. The outcome was death in 9 cases. However, no predictive factors for serious cases were found. This better knowledge of DRESS may contribute to improve the diagnosis and management of this syndrome in clinical practice.

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

-- Patrice Cacoub, MD, PhD, Philippe Musette, MD, PhD, Vincent Descamps, MD, PhD, Olivier Meyer, MD, PhD, Chris Speirs, MD, Laetitia Finzi, MD, PhD, Jean Claude Roujeau, MD

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

Should the Affordable Care Act of 2010 Be Repealed? Another viewpoint from an AJM reader

2011-07-11T13:13:00.006-07:00

Blog Commentary

In the July 2011 issue, The American Journal of Medicine published Should the Affordable Care Act of 2010 Be Repealed? by James E. Dalen, MD, MPH, AJM associate editor and Dean Emeritus of the University of Arizona College of Medicine, in the Journal and on this blog. AJM has received several e-mails and a few phone calls (pro and con) related to this article. Here is one commentary that takes issue with Dalen's commentary supporting the Affordable Care Act.

Should the Affordable Care Act of 2010 Be Repealed? A Fuller Picture

Dr. Dalen’s commentary in the July 2011(1) issue simply repeats the longstanding arguments supporting the Patient Protection and Affordable Care Act (PPACA), without shedding any new light on it since its passage in March of 2010. I take issue with his one-sided view of the law and its subsequent impact, and supply responses to contentions while describing some underpinnings of the opposition.

The Politics of Passage
Table 1 (below) delineates the votes of the health care bill, beginning with the initial version crafted from three House committees and passed on November 7, 2009.(2) Then, on December 24, 2009, the Senate passed its version on a party-line vote.(3) Because the Senate bill differed from that of the House, it needed to return there for ultimate approval. After much politicking, and the inability to alter anything, it was ultimately brought to the floor late Sunday evening on March 21, 2010, and narrowly saved the President from scathing defeat.(4) Table 1 also shows Medicare’s passage for comparison.(5)

After claiming that Americans would watch the health care debate occur on C-SPAN, in the most transparent government, President Obama failed to deliver on either. Most Americans did not envision back-room deals tantamount to bribery to secure votes, or accounting gimmicks to seemingly keep the price tag below the $1 trillion ceiling. They did not expect to hear Nancy Pelosi (D-CA) tell them that they needed to pass it to find out what was in it 6 or have no time to actually digest the monstrosity before rendering a well-read opinion. And they certainly did not expect a vote on an issue that consumes nearly 20% of our GDP to occur in such a clearly partisan fashion on Christmas Eve or late one Sunday night. The ends do not justify the means.

The World’s Best Health Care System
The commentary resurrects the issue of health outcomes by solely touting those statistics that satisfy the author’s premise. Some noteworthy others – according to the WHO’s 2010 World Health Statistics, the USA ranks as the 3rd lowest (best) country in those under age 5 who are underweight. To immunization rates, the Americas have the lowest incidence of measles and mumps in the world, a significantly higher percentage of neonates protected at birth against neonatal tetanus compared to our European colleagues, and the highest rates of hepatitis B vaccination among 1-year olds in the world. Further, according to the Organization for Economic Co-operation and Development (OECD) Health Care Quality Indicators Project, the US has the highest five-year relative survival rates in the world for breast cancer, and the third highest rate for colorectal cancer.(7)

The Americas have 23 physicians and 55 nursing and midwifery personnel per 10,000 population compared to 33 and 68, respectively, for the European region. Perhaps some statistics touted by others as better are simply a result of a larger healthcare workforce, thereby increasing access to care.(8)

The Uninsured
Dr. Dalen writes “22% of our citizens were uninsured or had inadequate health insurance in 2007,” and then lists “50+ million uninsured Americans” in table 3. Not all uninsured people in this country are in-fact American, or even legal residents. According to 2005 census data, 45.8 million people were uninsured. While non-citizens represented 7% of the population, they accounted for 21% of this group, or more than 9.5M individuals. Further, 20% (9.16M) were uninsured for less than 3 months. And, 28% (12.8M) were above 300% of the federal poverty line (FPL). [Federal Poverty Level chart] At that level, single coverage premiums would account for 2% of annual income and premiums for a family of four would amount to 4.7%. This leaves a legitimate number of 14.2M US citizens making less than 300% of the FPL who were uninsured for more than 3 months – 5% of all US inhabitants.(9)

In the description of table 3, it states that “all uninsured Americans will certainly benefit by receiving coverage.” Yet under the section on ACA and the uninsured, the figure is “95% of legal US residents…” Based on a population of 300 million, this 5% disparity accounts for some 15 million people and does not satisfy the claim of insuring everyone, as originally billed in the run-up to the bill’s final passage.

Does Coverage Equal Access?
Dr. Dalen claims that by expanding coverage to the uninsured, “the US would finally…[ensure] that nearly all of its citizens have access to health care.” He makes the colossal mistake of equating coverage to access. The nation’s current physician shortage already results in delays to access. Add to this some 30 million newly-insured patients, and the delay simply becomes longer. Coverage does not equal access. Just look at Massachusetts.(10, 11)

The Devil is in the Details
The paper purports that nearly everyone stands to benefit from the government’s attempt at healthcare overhaul. It conveniently neglects to highlight what needs to be replaced, or simply repealed. (1) The 1099 tax reporting requirement under PPACA for all vendors receiving more the $600 was repealed earlier this year. (2) CMS recently disseminated its proposed rule regarding accountable care organizations (ACOs). When most of the institutions it touted as successful examples publicly stated their resistance, CMS promulgated new rules to entice participation. Still far from making any significant impact on the nation’s healthcare expenditures, ACOs will not likely meet their January 1, 2012 implementation target date because of inherent design flaws. (3) The independent payment advisory board (IPAB) is being attacked at present with bills in both houses of Congress calling for repeal. In bipartisan fashion, it appears likely that this will be eliminated. (4) Above all else is the individual mandate, currently under legal attack. The Supreme Court will rule on its constitutionality.

There appear to be aspects of the law that may benefit patients, namely insurance industry reforms. But these come at a cost, one that will certainly be borne by those insured in the nature of higher premiums.

While obvious is the massive expansion of entitlement programs (read government takeover), glaringly missing from PPACA is meaningful tort reform and a fix to the sustainable growth rate (SGR). Physicians who care for Medicare beneficiaries continue to be shackled to this failed reimbursement calculation. Faced with a nearly 30% cut in reimbursement rates on January 1, 2012, some physicians have stopped accepting Medicare patients, while others have opted to retire early or leave medicine altogether because they cannot run their business under the constant threat of disastrous cuts. Combine the increased number of newly-insured patients clamoring for access, the growth of the baby boomer population, and a decreasing supply of physicians, and a perfect storm is brewing leading to an incredible gap between supply and demand.

The PPACA should be repealed and replaced with a real attempt at addressing our nation’s issues, without exceptions for unions, bribes for lawmakers, or back-room deals in the middle of the night in a strictly partisan fashion. The Democrats had a golden opportunity to put everything on the table, but squandered it to save face for the President. This came at a price, one that was only partially paid in November of 2010, but whose debt will be fulfilled next November.

-- Joshua D. Lenchus, DO, RPh
University of Miami Miller School of Medicine

References
1. Dalen JE. Should the affordable care act of 2010 be repealed? Am J Med. 2011;124(7):575-577.

2. H.R.3962 – Affordable Health Care for America Act. Available at: http://www.opencongress.org/bill/111-h3962/show. Accessed June 21, 2011.

3. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396#position. Accessed June 21, 2011.

4. H.R.3590 – Patient Protection and Affordable Care Act. Available at: http://clerk.house.gov/evs/2010/roll165.xml. Accessed June 21, 2011.

5. H.R.6675 – The Social Security Amendments of 1965. Available at: http://www.ssa.gov/history/tally65.html. Accessed June 21, 2011.

6. Roff P. Pelosi: Pass Health Reform So You Can Find Out What’s In It. US News and World Report, March 9, 2010. Available at: http://www.usnews.com/opinion/blogs/peter-roff/2010/03/09/pelosi-pass-health-reform-so-you-can-find-out-whats-in-it. Accessed June 23, 2011.

7. Organisation for Economic Co-operation and Development (OECD). Health care quality indicators. Available at: http://www.oecd.org/document/34/0,3746,en_2649_37407_37088930_1_1_1_37407,00.html. Accessed June 22, 2011.

8. World Health Organization (WHO). World health statistics 2010. Available at: http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf. Accessed June 21, 2011.

9. U.S. Department of Health and Human Services. Overview of the uninsured in the United States: An analysis of the 2007 current population survey. Available at: http://aspe.hhs.gov/health/reports/07/uninsured/report.pdf. Accessed June 22, 2011.

10. Access to Massachusetts health care still tight. GazetteNet.com, Daily Hampshire Gazette. 2010 Nov 16. Available at: http://www.gazettenet.com/2010/11/16/report-health-access-still-tight. Accessed June 22, 2011.

11. Massachusetts Medical Society. 2011 Patient access to health care study: A survey of Massachusetts physicians’ offices. Available at: http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&CONTENTID=54336&TEMPLATE=/CM/ContentDisplay.cfm. Accessed June 22, 2011.

Better Health: Can Physical Exams Save Healthcare Costs?

2011-07-07T04:00:00.010-07:00

The Better Health blog recently posted an interesting story about really seeing your patients during the physical exam: Can Physical Exams Save Healthcare Costs?

The American Journal of Medicine has published many research articles and commentaries about the art of physical examination. In addition, the Journal's Physical Findings section is a regular feature, which occurs several times a year. These articles focus on physical exam skills and specific physical traits that can give physicians significant clues regarding underlying disease. Here are links to some recent Physical Findings articles published by AJM.

Ludwig's Angina

Stop, You're Making Me Blush

Muehrcke's Lines

Nailing the Diagnosis!

For other Physical Findings articles, check out the Journal's website.

Terry's Nails: A Window to Systemic Diseases

2011-07-05T04:00:00.002-07:00

Despite the enormous involvement of imaging tools in medicine, a focused physical examination still plays a pivotal role in all medical fields. During and after taking history, a detailed inspection and examination of the patient will direct to further key diagnostic tools. A wealth of information can be gained from shaking hands and examining the hands at the same time. This part of the examination, and in particular the examination of the nails, is often neglected, although it is simple to notice if the hands are warm and well perfused or sweaty and to examine the color of the nails. In some cases, nail shapes are directive for the diagnosis, such as clubbed fingers in pulmonary or cardiovascular disorders. This short report describes 2 patients with different systemic diseases but developing similar nail changes. The early recognition of this nail abnormality could have led to earlier treatment.

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

-- Amir M. Nia, MS, Stefan Ederer, MS, Kristina M. Dahlem, MS, Natig Gassanov, MD, Fikret Er, MD

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

Harmful Effects of NSAIDs among Patients with Hypertension and Coronary Artery Disease

2011-06-30T11:44:00.000-07:00

There is limited information regarding the safety of chronic non-steroidal anti-inflammatory drugs (NSAIDs) in hypertensive patients with coronary artery disease. This research study found that among hypertensive patients with coronary artery disease, chronic self-reported NSAID use over a mean of 2.7 years was associated with a 47% increase in the first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.

Abstract

Background
There is limited information about the safety of chronic nonsteroidal anti-inflammatory drugs (NSAIDs) in hypertensive patients with coronary artery disease.

Methods
This was a post hoc analysis from the INternational VErapamil Trandolapril STudy (INVEST), which enrolled patients with hypertension and coronary artery disease. At each visit, patients were asked by the local site investigator if they were currently taking NSAIDs. Patients who reported NSAID use at every visit were defined as chronic NSAID users, while all others (occasional or never users) were defined as nonchronic NSAID users. The primary composite outcome was all-cause death, nonfatal myocardial infarction, or nonfatal stroke. Cox regression was used to construct a multivariate analysis for the primary outcome.

Results
There were 882 chronic NSAID users and 21,694 nonchronic NSAID users (n = 14,408 for never users and n=7286 for intermittent users). At a mean follow-up of 2.7 years, the primary outcome occurred at a rate of 4.4 events per 100 patient-years in the chronic NSAID group, versus 3.7 events per 100 patient-years in the nonchronic NSAID group (adjusted hazard ratio [HR] 1.47; 95% confidence interval [CI], 1.19-1.82; P=.0003). This was due to an increase in cardiovascular mortality (adjusted HR 2.26; 95% CI, 1.70-3.01; P<.0001).Conclusion
Among hypertensive patients with coronary artery disease, chronic self-reported use of NSAIDs was associated with an increased risk of adverse events during long-term follow-up.

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

-- Anthony A. Bavry, MD, MPH, Asma Khaliq, MD, Yan Gong, PhD, Eileen M. Handberg, PhD, Rhonda M. Cooper-DeHoff, PharmD, MS, Carl J. Pepine, MD

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

Should the Affordable Care Act of 2010 Be Repealed?

2011-06-29T04:00:00.000-07:00

Most Republicans in the 112th Congress pledged to repeal the Affordable Care Act of 2010. When Speaker of the House John Boehner was asked why the Republicans want to repeal the Affordable Care Act, he replied: “because ‘Obamacare’ would destroy the best health care delivery system in the world” (NBC News, January 6, 2011).(1)

Does the US Have the Best Health Care Delivery System in the World? Do All Americans Have Access to It?
There are many reasons why one would expect the US to have the best health care delivery system in the world. We have a well-educated population with a high standard of living. We have well-trained health professionals and well-equipped hospitals and clinics. And most of all, we spend far more on health care than any country in the world!(2)

If we have the world's best health care system, it follows that we would have the world's best health care outcomes. We don't! We lag behind other industrial nations in life expectancy, infant mortality, maternal mortality, and immunization rates.2 In 2000, the World Health Organization ranked our health care system as the 37th best among 119 nations. We ranked #17 of 17 industrial nations.(3)

Why We Don't Have the World's Best Health Care System: The Uninsured
The reason that we do not fare well in these health outcomes is that many of our citizens do not have access to ongoing primary and preventive care. To have access to ongoing preventive care, one must have adequate health insurance. In our country, up to 22% of our citizens were uninsured or had inadequate health insurance in 2007.(4) Those without adequate insurance can seek help for emergencies in our hospitals' overcrowded emergency rooms—but where do they go for ongoing preventive care?

The uninsured at greatest risk are those with chronic conditions. Nearly 40% of our population have a chronic condition such as diabetes, hypertension, asthma, or heart disease.5 These conditions require ongoing physician care and nearly always require prescription drugs.

Multiple studies document that patients with chronic conditions who are uninsured are less likely to have a usual source of health care, do not see a physician at least once a year, and have an unmet need for prescription drugs for their condition.(5)

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

-- James E. Dalen, MD, MPH

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

Please 'Like' Us...

2011-06-28T16:16:00.001-07:00

The American Journal of Medicine now has a facebook page. If you are one of the millions of people on facebook, please "like" us.

http://www.facebook.com/pages/American-Journal-of-Medicine/175370475858922?sk=wall

Cardiovascular Risk Factors in Patients with Lichen Planus

2011-06-27T12:06:00.000-07:00

When this research group analyzed metabolic syndrome parameters, they found a significantly higher prevalence of dyslipidemia in lichen planus patients. Chronic inflammation in patients with lichen planus may explain the association with dyslipidemia.

Abstract

Background
Chronic inflammation was found to play an important role in the development of cardiovascular risk factors. Recently a case-control study found that lichen planus was associated with dyslipidemia in a large series of patients. However, no data were presented about lipid values, glucose levels, or blood pressure.

Objective
The objective of this case-control study was to evaluate cardiovascular risk factors included in Adult Treatment Panel III criteria for metabolic syndrome in men and women with lichen planus and in healthy controls.

Patients and Methods
This case-control study included 200 patients, 100 with lichen planus (50 men and 50 women) and 100 controls consecutively admitted to the outpatient clinic in Dermatology departments in Granada, Spain.

Results
Analysis of metabolic syndrome parameters revealed a higher significant prevalence of dyslipidemia in patients with lichen planus. No significant differences were observed in glucose levels, abdominal obesity, or blood pressure. Elevated levels of C-reactive protein, erythrocyte sedimentation rate, and fibrinogen were noted in patients with lichen planus. Adjusted odds ratio for dyslipidemia in patients with lichen planus was 2.85 (95% confidence interval, 1.33-5.09; P=.001).

Conclusion
Chronic inflammation in patients with lichen planus may explain the association with dyslipidemia. Lipid levels screening in men or women with lichen planus may be useful to detect individuals at risk and start preventive treatment against the development of cardiovascular disease.

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

-- Salvador Arias-Santiago, PhD, Agustín Buendía-Eisman, PhD, José Aneiros-Fernández, MD, María Sierra Girón-Prieto, MD, María Teresa Gutiérrez-Salmerón, PhD, Valentín García Mellado, PhD, Ramón Naranjo-Sintes, PhD

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

AJM Editor-in-Chief previews the July issue (video)

2011-06-23T11:20:00.002-07:00

The July 2011 issue of The American Journal of Medicine is live online at http://amjmed.com. For a preview of important research in this issue, check out this video with Editor-in-Chief Joseph S. Alpert, MD.

Web of Confusion

2011-06-08T04:00:00.001-07:00

The occurrence of a late-stage complication in a patient with early disease, reminds us that any illness can take an unpredictable course. A 63-year-old man presented with complaints of fatigue and rash. He had been in his usual state of health until approximately 2 months prior, when he developed decreased visual acuity in his right eye. He was seen by a local ophthalmologist, who diagnosed nonarteritic ischemic optic neuritis and prescribed a daily aspirin. Soon thereafter, the patient noticed that he was having trouble moving about his house and working, and he felt as if he needed to sit and rest often. Additionally, he admitted to night sweats and a 15-lb weight loss. Upon questioning, he also reported that he had developed a nonpruritic rash on his legs and torso. He denied headache, joint pain, myalgia, morning stiffness, jaw claudication, weakness, cough, or shortness of breath. He took no medications other than a daily adult aspirin.

On examination, the patient exhibited livedo reticularis involving his lower limbs, buttocks, and lower torso circumferentially.

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

-- Craig G. Gunderson, MD, Daniel G. Federman, MD

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

HITECH, Electronic Health Records, and Facebook: A Health Information Trifecta

2011-06-06T04:00:00.001-07:00

In enacting the Health Information Technology for Economic and Clinical Health (HITECH) Act, the Obama administration has devoted unparalleled resources to incentivize “the adoption and meaningful use of health information technology.” One important reason for this revolutionary legislation is the notion that information technology can improve health safety, quality, and efficiency. The vehicle of this transformation, electronic health record systems, promises a singular, standardized and universally accessible source of information, enabling data sharing across entities vested in patient care. Electronic health records facilitate abstraction of large quantities of information for research or quality improvement, modernize billing processes, and impact patient care by both reducing complications during hospitalization and lowering readmission rates. They also can serve important roles in the monitoring, measuring, and reporting of quality, safety, and efficiency. (1, 2, 3)

Despite these tangible benefits, perhaps the strongest support for the HITECH Act comes from the burgeoning health care information-exchange crisis. To state it bluntly, physicians simply communicate poorly. For example, many primary care physicians fail to receive crucial discharge information from their physician counterparts in the hospital. Patients thus frequently fail to understand medication changes or follow-up plans, lack insight as to when or whom to call for help, and do not have access to vital data after discharge as a result of poor information relay.(4) Even perilous (and preventable) events such as hospital readmissions or medical errors have been associated with a lack of/poor physician communication.(5) In ratifying HITECH, we pin our hopes on technology to streamline these deficits, promote transparency, and homogenize the quality of our documentation. Is this a sensible decision?

Paradoxically, technology may widen the chasm of health information exchange. For instance, almost all major electronic record systems restrict access to providers at a site or health system, insulating accredited caregivers while isolating outsiders. Every electronic health record also employs proprietary technology, alienating providers operating on different platforms despite their common connection to patients. Electronic systems remain provider-oriented and arguably exclude the most important stakeholder, the patient, from data-sharing. Finally, no uniform standard exists to ensure that all electronic health record systems—irrespective of vendor, hospital size, provider, or location—have the ability to share information with each other. In sum, we may stand precariously poised on the edge of an electronic catastrophe.

Is there a way to transform the noble intent of HITECH into a reality that avoids these pitfalls? One revolutionary approach is to take the focus off electronic health records and instead, consider shifting the responsibility of health care communication from providers to patients. The online networking giant, Facebook, provides a conceptual outline for precisely such a schema.

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

-- Vineet Chopra, MD, FACP, FHM, Laurence F. McMahon Jr., MD, MPH

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

Cardiovascular Screening with Electrocardiography and Echocardiography in Collegiate Athletes

2011-06-02T04:00:00.000-07:00

Current guidelines for pre-participation screening of competitive athletes in the US include a comprehensive history and physical examination. In this study, researchers screened athletes according to the guidelines and used electrocardiography and echocardiography to further screen people who appeared to be at increased risk for heart conditions.

Abstract

Background
Current guidelines for preparticipation screening of competitive athletes in the US include a comprehensive history and physical examination. The objective of this study was to determine the incremental value of electrocardiography and echocardiography added to a screening program consisting of history and physical examination in college athletes.

Methods
Competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead electrocardiography, and 2-dimensional echocardiography. Electrocardiograms (ECGs) were classified as normal, mildly abnormal, or distinctly abnormal according to previously published criteria. Eligibility for competition was determined using criteria from the 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities.

Results
In 964 consecutive athletes, ECGs were classified as abnormal in 334 (35%), of which 95 (10%) were distinctly abnormal. Distinct ECG abnormalities were more common in men than women (15% vs 6%, P<.001) as well as black compared with white athletes (18% vs 8%, P<.001). Echocardiographic and electrocardiographic findings initially resulted in exclusion of 9 athletes from competition, including 1 for long QT syndrome and 1 for aortic root dilatation; 7 athletes with Wolff-Parkinson-White patterns were ultimately cleared for participation. (Four received further evaluation and treatment, and 3 were determined to not need treatment.) After multivariable adjustment, black race was a statistically significant predictor of distinctly abnormal ECGs (relative risk 1.82, 95% confidence interval, 1.22-2.73; P=.01).Conclusions
Distinctly abnormal ECGs were found in 10% of athletes and were most common in black men. Noninvasive screening using both electrocardiography and echocardiography resulted in identification of 9 athletes with important cardiovascular conditions, 2 of whom were excluded from competition. These findings offer a framework for performing preparticipation screening for competitive collegiate athletes.

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

-- Anthony Magalski, MD, Marcia McCoy, RN, MSN, Michael Zabel, MD, Lawrence M. Magee, MD, Joseph Goeke, MD, Michael L. Main, MD, Linda Bunten, RN, BSN, Kimberly J. Reid, MS, Brian M. Ramza, MD, PhD

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

How Is Being the Editor-in-Chief of a Medical Journal like Organizing Games in the Colosseum of Ancient Rome?

2011-06-01T11:24:00.001-07:00

A recent article in Smithsonian magazine described the infrastructure and operation of the Colosseum in ancient Rome, as well as the nature of the entertainment furnished in the arena.(1) I have referred to this monthly magazine in previous editorials because it regularly publishes a number of fascinating pieces. This month, I learned something particularly interesting: The Latin title of the person who sponsored the Roman games translates into “the editor.” The editor of the games underwrote the performances financially and usually dictated the types of entertainment displayed. It is common knowledge that many of these spectacles involved bloody events, including battles with wild animals, skirmishes between gladiators, and executions.

I felt a moment of personal irony when comparing my own role as the editor of The American Journal of Medicine (AJM) with that of the ancient Roman editors of the Colosseum. I do not sponsor the journal financially, nor are there bloody events contained within each issue. However, some might argue that a number of our pathologic and dermatologic images verge on gory! Having given some thought to other differences between my own job and that of my Roman predecessors, I have listed 11 tasks performed by editors of medical journals. I suspect that at least some of them also were undertaken by the editors responsible for events in the Colosseum.

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 the June 2011 issue of The American Journal of Medicine.

AJM Editor-in-Chief previews the June issue (video)

2011-05-24T07:00:00.001-07:00

Mastectomy without Anesthesia: The Cases of Abigail Adams Smith and Fanny Burney

2011-05-16T04:00:00.002-07:00

Elizabeth Edwards (1949-2010) survived breast cancer for 6 years. She had the benefits of modern medical science, including anesthesia and painkillers. Despite her disease, Edwards published 2 bestsellers and shared upbeat messages on Facebook about her fate. Two hundred years ago, before the discovery of anesthesia by ether and painkilling pharmaceuticals, the odds of dying from illness and infection were much worse; nevertheless, some breast cancer patients dared to submit to surgery. The stories of 2 such women—Abigail Adams Smith (1765-1813), first-born child of John and Abigail Adams, and British novelist Fanny (Frances) Burney (1752-1840)—have been well-documented, and offer inspiration to breast cancer victims as well as insight into the history of surgery.(1)

When Abigail Adams Smith, or “Nabby,” at age 46, noticed a lump in her breast, she decided to leave her family's farm in upstate New York and move back to her parents' home in Quincy, Massachusetts. She consulted with doctors Tufts and Rush, informing them her tumor was moving. Rush responded by mail to her father with this advice: “Her time of life calls for expedition in this business, for tumors such as hers tend much more rapidly to cancer after 45 than in more early life.” She must have a mastectomy.

Several Boston surgeons journeyed to Quincy, among them John Collins Warren, of Ether Dome fame. In November 1811, they performed a mastectomy on their patient in a bedroom of her parents' home.

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

-- Helle Mathiasen, CandMag, PhD, AJM Specialty Editor

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

Long-Term Use of Aspirin and the Risk of Gastrointestinal Bleeding

2011-05-09T04:00:00.007-07:00

Regular aspirin use has been associated with gastrointestinal bleeding, but many people take aspirin for heart disease prevention. How can they minimize their GI bleeding risk?

Abstract

Background
In short-term trials, aspirin is associated with gastrointestinal bleeding. However, the effect of dose and duration of aspirin use on risk remains unclear.

Methods
We conducted a prospective study of 87,680 women enrolled in the Nurses' Health Study in 1990 who provided biennial data on aspirin use. We examined the relative risk (RR) of major gastrointestinal bleeding requiring hospitalization or blood transfusion.

Results
During a 24-year follow-up, 1537 women reported a major gastrointestinal bleeding. Among women who used aspirin regularly (≥2 standard [325 mg] tablets/week), the multivariate RR of gastrointestinal bleeding was 1.43 (95% confidence interval [CI], 1.29-1.59) when compared with nonregular users. Compared with women who denied any aspirin use, the multivariate RRs of gastrointestinal bleeding were 1.03 (95% CI, 0.85-1.24) for women who used 0.5 to 1.5 standard aspirin tablets/week, 1.30 (95% CI, 1.07-1.58) for women who used 2 to 5 tablets/week, 1.77 (95% CI, 1.44-2.18) for women who used 6 to 14 tablets/week, and 2.24 (95% CI, 1.66-3.03) for women who used more than 14 tablets/week (Ptrend<.001). Similar dose-response relationships were observed among short-term users (≤5 years; Ptrend<.001) and long-term users (>5 years; Ptrend<.001). In contrast, after adjustments were made for dose, increasing duration of use did not confer a greater risk of bleeding (Ptrend = .28).

Conclusion
Regular aspirin use is associated with gastrointestinal bleeding. Risk seems more strongly related to dose than duration of aspirin use. Efforts to minimize adverse effects of aspirin therapy should emphasize using the lowest effective dose among both short- and long-term users.

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

-- Edward S. Huang, MD, MPH, Lisa L. Strate, MD, MPH, Wendy W. Ho, MD, MPH, Salina S. Lee, MD, Andrew T. Chan, MD, MPH

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

May 2011: New articles in press posted on AJM's website

2011-05-06T04:00:00.005-07:00

Several new articles in press were uploaded to The American Journal of Medicine's website this week -- along with the new May 2011 issue.

Here are links to some of the new case studies now online...

Elephantiasic Thyroid Dermopathy

Bath Salts as a “Legal High”

Hydroxycitric Acid Dietary Supplement-Related Herbal Nephropathy

Some Simple Rules for Effective Communication in Clinical Teaching and Practice Environments

2011-05-05T04:00:00.000-07:00

“It is still not enough for language to have clarity and content … it must also have a goal and an imperative. Otherwise from language we descend to chatter, from chatter to babble, and from babble to confusion.”

René Daumal, French writer and poet, 1908-1944

Effective communication in clinical practice and teaching is, in my opinion, one of the most important skills that physicians in academic and community practice should strive to acquire. During my many years in medicine, I have often witnessed serious failures in effective communication between physicians and patients and among physicians speaking to each other. The commonest failure in communicating information is the result of inattentive or inaccurate listening. When an individual fails to comprehend what is being said either explicitly or implicitly, misunderstandings may result that require prolonged discussion and negotiation before resolution is achieved. We can all agree that confusion often results when careful listening is not exercised. So, how does one learn to listen effectively? This essay lists examples of a few communication failures with guidelines that I try to follow to improve my own communication skills in what I say or write.

Effective listening requires a conscious effort by the listener in order to understand what the speaker is trying to communicate. This kind of listening requires complete and focused attention on the part of the listener. It requires an expenditure of energy; it will not occur if the listener is distracted by other thoughts or by a handheld device such as a smart phone. When I am trying to communicate with someone, and they are scanning through messages on the screen of their handheld device, it irritates me because I feel that they are not focusing their attention on what is being said. In addition to being downright discourteous, listening is not occurring. The simple guideline to follow here is to focus one's attention actively and consciously on what is being said. This is the first of 5 communication failures with corrective guidelines that will be discussed in this editorial. Each failure interferes with effective communication and understanding.

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 the May 2011 issue of The American Journal of Medicine.

The Green Cerebrospinal Fluid

2011-05-04T04:00:00.001-07:00

Presentation
A sample of cerebrospinal fluid from a 52-year-old-woman told an interesting tale. The patient reported a 1-week history of worsening headache, shortness of breath, and fatigue but denied any fever, chest pain, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, abdominal pain, or diarrhea. She had experienced a subarachnoid hemorrhage 7 months earlier, and at that time, she had required several ventricular shunts for persistent hydrocephalus. When she was admitted to the Rush University Medical Center, she had a functioning ventriculopleural shunt. The original device was inserted 4 months before her current illness but replaced 2 months later at the same site after it malfunctioned.

Assessment
On admission, the patient was afebrile and had normal vital signs. Her conjunctivae were not pale, and her cardiac examination results were unremarkable. Breath sounds were decreased in the left lung field, but the patient's extremities were free of edema. A neurologic examination indicated she was alert and oriented without any signs of meningitis.

A chest radiograph showed a left-sided pleural effusion; this was the same side where the current shunt had been placed. Because of concern for a malfunctioning shunt and possible central nervous system infection, the patient underwent shunt externalization with external ventricular drain attachment. Cerebrospinal fluid collected directly from the shunt catheter was sent for examination on a daily basis throughout her hospital course. Of note, the sample color was consistently green (Figure). Initially, the cerebrospinal fluid showed 10,000 red blood cells/μL and 40 white blood cells/μL (corrected, 38 white blood cells/μL) with 58% monocytes and 14% neutrophils. Cerebrospinal fluid glucose and total protein were normal at 87 mg/dL (simultaneous peripheral blood glucose, 117 mg/dL) and 10.1 mg/dL, respectively. Gram stain showed gram-negative rods.

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

-- Gerome Escota, MD, James Como, MD, Harold Kessler, MD

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

Compression-only CPR (video)

2011-04-27T13:35:00.005-07:00

A research group from The University of Arizona's Sarver Heart Center developed and tested compression-only CPR. A new commentary by this group appears in the May 2011 issue of The American Journal of Medicine. To learn how to perform compression-only CPR check out this video.

AJM Editor-in-Chief previews the May issue (video)

2011-04-20T07:00:00.003-07:00

New articles in press posted on AJM's website

2011-04-19T10:59:00.000-07:00

Three new articles in press were posted on The American Journal of Medicine's website this week. All three are currently available for free.

Painless Horner's Syndrome Through Occupational Exposure, June 2011 issue

Dysgeusia: An Atypical and Neglected Psychiatric Symptom Induced by Fibrillary Astrocytoma, June 2011 issue

Elephantiasic Thyroid Dermopathy, September 2011 issue

Ryan's Medicare overhaul: Would it increase the rate of medical bankruptcy?

2011-04-18T07:53:00.006-07:00

Blog Commentary

With no Democratic support, the US House of Representatives passed Rep. Paul Ryan's much-ballyhoo'd 2012 budget proposal on Friday, April 15.

Rather than go into great detail regarding Ryan's Path to Prosperity, I'm going to focus on one piece that could be financially devastating for many Americans-- his plan to remake Medicare into a voucher system for anyone currently under 55 years of age. This is a financially dangerous idea.

A group of Harvard researchers has released multiple studies showing that medical costs contribute to more bankruptcies in the US than any other factor. Reporting in The American Journal of Medicine in 2009...

Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors, the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001.[Emphasis added.]

In other words, patients were almost 2.5 times more likely to go bankrupt because of medical bills in 2007 than in 2001 (when this group conducted its first landmark medical bankruptcy study). And 75% of these bankruptcies were among people who had health insurance.

Fast forward to 2011, the same Harvard research group revealed new data regarding medical bankruptcies in the State of Massachusetts. (You'll remember that Massachusetts passed healthcare reform several years ago under then Governor Mitt Romney. The Massachusetts plan requires people to buy health insurance; this plan was the blueprint for the much-maligned Affordable Care Act [AKA Obamacare].) What they found was that even though healthcare reform provided widespread coverage in Massachusetts, it didn't significantly reduce the number of people going bankrupt due to medical bills. From The American Journal of Medicine blog...

Despite broad insurance coverage in Massachusetts after reform, bankruptcy filings due to medical costs did not decrease significantly between 2007 and 2009. There is a web of causality behind this finding. Although only 11% of Massachusetts debtors remained uninsured, there was widespread underinsurance, leaving people with high out-of-pocket costs in deductibles, co-pays, and uncovered services. In addition, many debtors lost their jobs due to illness or experienced reduced income due to illness. In cascading events, loss of income led to loss of housing in many cases. [Emphasis added.]

So, what's this got to do with Ryan's voucher system? A lot! For everyone who is currently under 55, Ryan proposes to change Medicare to a voucher system. Everyone would receive an annual allowance-- $15,000/year is what Rachel Maddow reported but real numbers are hard to obtain. This allowance would be a set amount and would not increase at the rate of inflation. During the year, any medical costs over that annual allowance amount would be paid out of pocket by the individual.

The Congressional Budget Office estimates that Ryan's plan may help save the government money, but seniors could end up paying an additional $12,510 each per year. This figure assumes no major changes in health status; anyone who has the misfortune to contract a serious illness, has a major accident, or needs an expensive surgery would, of course, pay much more than that.

The bottomline is people are going bankrupt at an increasing rate due to medical bills, and even with healthcare reform in Massachusetts, people are still going bankrupt because many people are buying inadequate insurance (AKA what they can afford). Given these realities, if the government forces people to pay all medical costs after a certain dollar figure has been reached, there could be an astronomical increase in bankruptcies in the US-- especially if the feds choose a ridiculously low allowance figure.

-- Pamela J. Powers, MPH, AJM Managing Editor

The Perils of Video Games

2011-04-08T08:00:00.001-07:00

Disc Jockey Tenosynovitis

A healthy 25-year-old, left-hand dominant woman presented to clinic experiencing progressively worsening pain for 2 weeks in her right thumb. The pain was intense on waking and increased when grasping objects or shaking hands. She denied trauma and said she had not previously experienced thumb pain while working as a beautician for the past 3 years. The patient reported that 1 month earlier she began playing the video game “DJ Hero” during most nights of the week for several hours at a time...

In the video game “DJ Hero,” players use a simulated turntable to repetitively and quickly move their right wrist back and forth (radial and ulnar deviation) while pushing 3 colored buttons with the right hand to match the beat of the music identified by colored icons on the screen. The motion is designed to simulate the “scratching” of a vinyl record on a turntable that some disc jockeys have performed over the past few decades.

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

-- Allan L. Suttle, MD, Erik A. Wallace, MD

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

Tort Reform: Liability Protection Removed from Connecticut's New Healthcare Plan

2011-04-05T12:59:00.003-07:00

Blog Commentary

A recent editorial in The American Journal of Medicine-- The 800-Pound Gorilla in the Healthcare Living Room-- resulted in a minor tidal wave of physician comments about the cost of defensive medicine in the US and the addition of tort reform to the Affordable Care Act when it is revised. Here are just a few of the many comments AJM received.

As practicing physicians, we're are never afforded the luxury of making any mistakes...period. A mistake, or percieved mistake, is magnified tremendously in the hair salons and country clubs and can do great harm to a physician's credibility, particularly in smaller towns. So, until the public learns to accept clinical judgement and the inherent occasional misdiagnosis, there will be very little change in the way we physiscians practice.

I recently cared for a patient during rounds as a hospitalist who had been admitted with numerous vague complains in the past year, this time headache. Review of her chart showed over 30 CT scans of various parts in the preceding year, including 2 of her brain in the past week, all negative. It is time we stop worrying about losing our careers to a frivolous lawsuit and spend more time caring for the health of our patients. Not only it is costly to society and to the patient, but unnecessary tests can also be harmful.

From the beginning of med school, we hear about lawsuits. Fear is rampant. Every Dr I know practices defensive medicine. The costs are astronomical. I have seen thousands of examples.

I wish to divert attention to another commentary in the same journal, "On the Critical List: The U.S. Institution of Medicine". Another organization setting the "rules of the game" as deliniated in this article can be the legal profession.

Ironically, as physicians debated defensive medicine on AJM's blog, trial lawyers in Connecticut successfully removed liability protection from that state's new healthcare plan for the indigent. From the Hartford Courant...

...a key provision of the plan was that doctors, in return for following the new procedures and ordering fewer tests, would be protected from malpractice suits if the outcome of a case was not favorable for the patient. However, with backing from the Connecticut Trial Lawyers Association, that provision was removed from the SustiNet bill two weeks ago.

According to the newspaper, cardiologists are fighting back against the lack of malpractice protection in Connecticut's plan.

Cardiologists are considered a particularly important group for the new best-use procedures because they tend to order a battery of expensive tests when patients show signs of heart trouble. If specialists like them failed to participate in the SustiNet program, cutting medical costs could be more difficult.

On Tuesday, the Connecticut chapter of the American College of Cardiology withdrew its support for the bill and said that it would circulate an open letter to House Speaker Christopher G. Donovan and Gov. Dannel P. Malloy saying that it could not support the bill without the malpractice protection.

At Better Health, a community of blogging doctors, one physician predicts doctors will begin to "play hardball" over malpractice reform.

As screws continue to get tightened on doctors’ ability to order tests thanks to third-party oversight bodies, look for more physicians to play hardball about liability limits at both the state AND national levels.

Doctors are being forced to do do their part to control health care costs as a result of our increasingly government-controlled health care initiatives. It’s high time for the trial lawyers’ to do the same. And there’s already precedent to doing so: just look to the legal protections military doctors enjoy when caring for their members. While legal recourse still exists in the military, the challenge of suing the government on behalf of their employees thwarts frivolous claims.

What is playing out now in Connecticut foreshadows what will happen if and when tort reform is addressed at the national level.

-- Pamela J. Powers, MPH, AJM Managing Editor

Role Modeling: A Personal Anecdote

2011-04-05T08:00:00.001-07:00

The term “role model” refers to someone who is a colleague, often an older and more experienced individual, commonly imitated by younger colleagues. This interaction usually occurs in a professional setting. A role model can also be a mentor, a topic on which I have written in another editorial.1 In thinking about this topic recently, I was struck by how much of my own professional behavior was and still is modeled after traits that I found admirable in various individuals from my early educational and professional life.

You also may find it interesting that this term first appeared in Robert K. Merton's socialization research of medical students.2 Merton suggested that students compare themselves with individuals or reference groups of people who occupied the social role to which they themselves aspired. As for me, I am convinced that role modeling begins in early childhood. For instance, our 2.5-year-old granddaughter says, “I do it” about something and then attempts to imitate how my daughter, my wife, or I have performed some activity. My wife and I are convinced that we ourselves imitate the hard-working and serious demeanor of our parents, who lived through the great economic depression of the 1930s. My university and medical school teachers or career mentors served as role models for professional behaviors I still practice. Let me give you some specific examples. During my undergraduate years at Yale University, I consciously wished to imitate the style and substance of 3 individuals. The characteristics I admired have become part of my own daily work personality.

The first of these role models was Charles Garside, an assistant professor of European history who lectured to a vast class in the first semester of a European history survey course. Professor Garside was one of the most charismatic and inspiring speakers that I had ever seen up to that time in my life. As a result of his highly effective teaching skills, my roommate and I made great efforts to assimilate the huge amount of material that this course covered. His lectures were so exciting that we literally felt like we were “walking on air” when we left the classroom...

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

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

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

The Consequences of Requesting “Dispense as Written”

2011-04-01T08:00:00.001-07:00

Almost 5% of all prescriptions are designated as "dispense as written" and request a brand name drug, rather than a generic drug. Dispense as written requests for chronic prescriptions have been associated with a 50% - 60% greater odds that patients will not fill the prescription.

Abstract

Background
All US states have adopted generic substitution laws to reduce medication costs. However, physicians may override these regulations by prescribing branded drugs and requesting that they are dispensed as written. Patients also can make these requests. Little is known about the frequency and correlates of dispense as written requests or their association with medication filling.

Methods
We identified beneficiaries of a large pharmacy benefits manager who submitted a prescription claim from any pharmacy in January 2009. We categorized claims as a physician-assigned dispense as written, patient-assigned dispense as written, or no dispense as written. We described rates of these requests and used generalized estimating equations to evaluate physician, patient, treatment, and pharmacy characteristics associated with dispense as written requests. We also used generalized estimating equations to assess the relationship between dispense as written designation and rates prescriptions are not filled by patients.

Results
Our sample included 5.6 million prescriptions for more than 2 million patients. More than 2.7% were designated as dispense as written by physicians, and 2.0% were designated as dispense as written by patients. Substantial variation in dispense as written requests were seen by medication class, patient and physician age, and geographic region. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). When chronic prescriptions were initiated, physician dispense as written (odds ratio 1.50, P<;.001) and patient dispense as written (odds ratio 1.60, P<;.001) were associated with greater odds that patients did not fill the prescription.Conclusion
Dispense as written requests were common and associated with decreased rates of prescription filling. Options to reduce rates of dispense as written requests may reduce costs and improve medication adherence.

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

-- William H. Shrank, MD, MSHS, Joshua N. Liberman, PhD, Michael A. Fischer, MD, MPH, Jerry Avorn, MD, Elaine Kilabuk, BA, Andrew Chang, MPH, Aaron S. Kesselheim, MD, JD, Troyen A. Brennan, MD, JD, Niteesh K. Choudhry, MD, PhD

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

Stop, You're Making Me Blush

2011-03-31T10:01:00.003-07:00

The physical examination is vital in assessing a patient's presenting symptom, especially when the symptom is dermatologic in nature. However, if the dermatologic examination shows no abnormality on presentation, further measures must be completed to illicit such symptoms. In our patient, this involved provoking the physical examination finding through exercise.

Case Presentation
A 26-year-old woman with a medical history of asthma and hypothyroidism presented to her primary physician for what she described as an unusual rash on the left side of her face for the past 18 months. She described asymmetric erythema and sweating involving the left forehead, cheek, and chin that would appear intermittently and were often exacerbated by warm showers or exercise. These episodes lasted for 30 minutes to a few hours and had been increasing in duration and degree of erythema during this 18-month interval. She denied pruritus, pain, or visual changes. She denied alcohol, illicit drug, or tobacco use. There was no family history of autoimmune, connective tissue, or malignant disorders, or a history of similar symptoms.

Assessment
Dermatologic examination initially revealed no apparent erythema or skin lesions. After provocation with exercise on a treadmill, her examination revealed a confluent erythema, without separate patches or papules noted over the distribution of the left hemiface (Figure 1). This erythema ended sharply in the midline of her face. On neurologic examination, cranial nerves were intact. Specifically, there was no facial droop, lid lag, decreased sensation, or pupillary changes.

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

-- Kellee Oller, MD, Kimberley Cao, MD, Jim Parkerson, DO, Jose Lezama, MD

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

AJM Editor previews April 2011 issue (video)

2011-03-29T11:14:00.001-07:00

Editor-in-Chief Joseph S. Alpert, MD, previews research in the April issue of the American Journal of Medicine, now available online.

The 800-Pound Gorilla in the Healthcare Living Room

2011-03-21T10:40:00.000-07:00

During my many years of academic medical administration, I learned that a successful decision where there were opposing factions was often one in which no one party was particularly happy with the outcome. This observation is probably true for most political compromises, including the recently enacted Obama healthcare reform act. On the left of the political spectrum, many advocates, including myself, were dissatisfied that the resulting law did not provide all Americans with universal healthcare coverage. At the other end of the political rainbow, conservatives were unhappy with the provision that required individuals to buy health insurance. However, in my view the most important deficit in our new healthcare legislation was the failure to address the 800-pound gorilla sitting squarely in the middle of the US healthcare system: the need for tort reform. The current medical liability environment in the United States has resulted in the widespread practice of defensive medicine, which in turn has led to staggering volumes of unnecessary diagnostic testing, often accompanied by both potential clinical complications and gigantically inflated healthcare costs.

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

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

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

Not a Graves' Situation

2011-03-15T10:45:00.001-07:00

To physicians, it appeared that the patient surely had Graves' disease, but this was not the case. Several months before his admission to the Endocrinology Department, a 48-year-old man developed rapidly growing eyelid swelling, the feeling of having sand in his eyes, redness of the conjunctivae, diplopia, and photophobia. He worked as a driver, so the symptoms kept him from his job, and made other everyday activities truly difficult. Neither a family nor personal history revealed any thyroid disease.

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

-- Marek Ruchala, MD, PhD, Ewelina Szczepanek, MD, PhD, Mariusz Puszczewicz, MD, PhD, Piotr Sosnowski, MD, PhD, Jerzy Sowinski, MD, PhD

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

CME Opportunity
For more information about Graves' Disease, check out this Continuing Medical Education link on the American Journal of Medicine's website.

A Textbook Case: Making the Transition to the Online Universe

2011-03-14T16:38:00.004-07:00

Blog Commentary

Last year, one of Oxford University’s great medical legends received a long awaited transplant. Long the close confidant and trusted aide to generations of doctors and medical students, it had now become impersonal, grossly overweight, and unwieldy. Oxford University Press’s Textbook of Medicine, 5th Edition, first published in 1983, long regarded as perhaps the most comprehensive medical reference in publication and an emissary for evidence-based medicine around the world, was launched as a complete online edition. (1) The project, five years in the making, brought the entirety of its massive twenty-five pound, three-volume, six thousand page print edition to the web, complete with all of the text, figures and illustrations. Though available to hospitals, universities and individuals as a paid subscription, the move to an online edition offered an unexpected benefit: inexpensive and even free access for more than 3,500 institutions in less-developed countries sponsored by the U.K.’s Wellcome Trust. (2)

Oxford’s initiative, following a trend established by many medical publishers in recent years, reflects not just a gesture of altruism to third world countries but also a matter of contemporary professional and economic necessity. Since at least 2600 B.C., when Imhotep is said to have written his first papyrus on ancient Egyptian medicine (3), heralding the age when medical knowledge could be shared and adopted by others, clinicians have attempted to codify the practice of medicine onto the printed page. For more than 4500 years, the tradition of the paperbound medical text thrived, surviving the destruction of the Alexandria library in Egypt, the austere anti-intellectualism of the middle ages, and even the emergence of the new broadcast media of the late 20th century. But as the practice of medicine enters the second decade of the new millennium, the bound medical textbook, so symbolic of the scholarly traditions that form the basis of our craft, is facing extinction. The emergence of electronic media, from online peer-reviewed information resources, medical web portals and search engines, to personal smart phones and tablet computers has now supplanted the hardbound textbook for many health providers.

In an informal January, 2011 survey of internal medicine housestaff I conducted at my institution, only 15% had consulted a hardbound textbook in the last month, preferring instead to reference online resources such as “Up to Date,” “Harrison’s Online, “ and “Emedicine.” Less than half (47%) had reviewed a printed reference of any kind, underscoring the waning popularity of the softbound handbook or pocket guide. The migration that medical publications are making online reflects a societal shift away from the printed page, especially in basic education. In President Obama’s January, 2010, State of the Union Address (4), the president announced an initiative to extend broadband wireless coverage to 98% of Americans, so that virtually anywhere in our country, he asserted, “…a student…can take classes with a digital textbook.” Already, secondary school systems have initiated pilot online textbook programs (5), and some states are proposing the elimination of printed textbooks in their entirety. (6)

The transition away from the printed textbook is likely to have mixed consequences for the health care provider. No longer will a clinical question or controversial medical decision between clinicians be resolvable via an obsolescent, forlorn text in the corner of a nurse’s station. Many resourceful clinicians now consider even a newly published hardbound volume to be out of date, questioning the validity of any reference source which is not updated continuously. In an era where every question seems to be answerable via an online query, use of the search engine may have even superseded Pub med or Medline, with sometimes dubious results. In a recent Harris-Interactive poll (7), only a slim majority of Americans, 52%, think that vaccines don't cause autism, a stunning finding at least partially attributable to online misinformation.

In fact, it has always been the immutability and permanence of the printed page which has always added certainty to textbook-based medical decisions. In the transition to online resources, some not always peer-reviewed, medical reference information may become less credible and less durable in a rapidly changing online world. For less technologically adroit clinicians, adaptation to electronic media may present formidable obstacles to reaching the information they once felt comfortable obtaining.

Yet the online transition is likely to have far more positive than negative consequences. In a struggling economy, online reference sources are far more cost effective to produce and distribute, and for subscribers, often more affordable to obtain. In many medical facilities equipped with an electronic medical record, online medical references can be integrated with desktop, mobile or handheld devices at the point of care, permitting instantaneous access to evidence-based information critical to medical decision making. In fact, the growth of the evidence-based medicine (EBM) movement is likely to have been fueled over the last decade by the rapid growth of online medical resources. For many providers, the availability of medical blogs, email listservs, podcasts, online access to full text medical journals and even social networking sites (e.g., Facebook and Twitter) ensure that no major medical advance, clinical trial, drug recall or outbreak can escape our awareness. In less developed countries, where medical reference resources can be limited to antiquated or donated textbooks, programs such as the U.K.’s Wellcome Trust initiative offer resource-challenged providers with access that can level the playing field of medical information with wealthy countries, a development that is likely to be crucial to improving the quality of medical training and care in the third world. In the U.S., health information companies have also increasingly begun to acknowledge the promise of the new online frontier. Both Emedicine and Up-to-Date, among the most popular of the online peer-reviewed sites, began as struggling start-up firms a decade or more ago, attracted an sizable user base, and then were ultimately acquired by large multimedia conglomerates. (8) (9) For traditional publishers, almost every major hardbound text now coexists with an online edition, many enhanced for portable devices.

Like audiophiles who still extol the tonality, sonic imperfection, and nostalgia of the vinyl LP in an age of digital music downloads, there will always be those who cherish the great joy inherent in un-wrapping a new-edition hardbound text, resting its weighty spine on one’s lap, and thumbing through its unwrinkled and carefully typeset pages. Although classic medical textbooks may never completely disappear, they may be relegated to the novelty of display cases. The transformation of medical information to the online universe will continue to affect the discipline of medicine in many ways and may even alter the foundation of what it means to be a physician. For if healthcare providers can now have access to a portal that can instantly provide them with unlimited online knowledge, updated constantly, and personalized to their patient’s individual needs, at what point could the physician, like an out of print textbook, also become obsolete? It seems unlikely that this will happen anytime soon, one might think, because it is not what we know that endears us most to our patients. “The art of medicine,” the 16th century Renaissance physician Paracelsus once wrote, “cannot be inherited, nor can it be copied from books.” (10)

-- Richard L. Oehler, MD, FACP, FIDSA
Associate Professor of Medicine, Division of Infectious Diseases and International Medicine, University of South Florida College of Medicine, Tampa, FL

References:
1. Oxford Textbook of Medicine, Online edition. http://otm.oxfordmedicine.com/about.dtl. Accessed 2/2/2011.

2. Moisse K. A medical classic gets a 21st century makeover, going online and low cost. Scientific American [http://bit.ly/dpVuEk. Accessed February 2, 2010.

3. Breasted JH, ed The Edwin Smith Surgical Papyrus: published in facsimile and hieroglyphic transliteration with translation and commentary on two volumes. Chicago: University of Chicago Press; 1991; No. 3-4.

4. Obama's Second State of the Union Text. New York Times [http://nyti.ms/eGE1ol.

5. Hobbs H. Fairfax County schools to try out online textbooks for a year. The Washington Post [http://wapo.st/a0Ckwa.

6. Shannon K. Governor: Texas should move to online textbooks. Business Week [http://bit.ly/ciS2iA. Accessed 02/02/2011.

7. Gardner A. Nearly half of Americans still suspect autism link. USA Today [http://usat.ly/eXN4ou.

8. Emedicine.com. http://emedicine.medscape.com.

9. Uptodate.com. http://www.uptodate.com. Accessed 02/03/2011.

10. Jacobi J, ed Paracelsus, Selected Writings. New York: Pantheon books; 1951.

On the Critical List: The US Institution of Medicine

2011-03-09T16:27:00.001-07:00

United States' medicine, once regarded as the best in the world, is in a sorry state of health. The US ranks lowest on almost every dimension of health system performance relative to other major westernized nations.(1) It not only lags well behind Japan, Western Europe, and Australasia – it even falls behind Poland, the Czech Republic, and Slovakia.(2) Twice as many Americans die before the age of 60, as compared with Europeans3; infant mortality in the US is double that of many countries in Europe, and life expectancy at birth is lower(3); Japan has over 3 times as many acute care hospital beds,(4) and Greece has over twice as many doctors.(4) America has a health care system that is, frankly, third-rate.

To add insult to injury, the US has by far the most expensive health care system in the world. We spend $7,290 per capita on health care annually, more than double the Organisation for Economic Co-operation and Development average. The UK by contrast spends $2,992 and ranks second in international comparisons.(1)

To explain why we have the most expensive health care system in the world and yet one of the lowest performing, we need to take a perspective that focuses on the US institution of medicine as a whole. We expose the hidden rules by which this institution operates and discuss how its powerful organizations shape, control and perpetuate this ailing system.

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

-- Salinder Supri, PhD, Karen Malone, MA (Distinction)

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

Medical Bankruptcy in Massachusetts: Has Health Reform Made a Difference?

2011-03-09T16:26:00.001-07:00

Health insurance coverage rates for Massachusetts debtors were higher in 2009 than in 2007 (89.0% vs 84.1%) and significantly higher than the national average in 2007 (89.0% vs 69.7%). Despite broad insurance coverage in Massachusetts after reform, bankruptcy filings due to medical costs did not decrease significantly between 2007 and 2009. There is a web of causality behind this finding. Although only 11% of Massachusetts debtors remained uninsured, there was widespread underinsurance, leaving people with high out-of-pocket costs in deductibles, co-pays, and uncovered services. In addition, many debtors lost their jobs due to illness or experienced reduced income due to illness. In cascading events, loss of income led to loss of housing in many cases.

Abstract

Background
Massachusetts' recent health reform has decreased the number of uninsured, but no study has examined medical bankruptcy rates before and after the reform was implemented.

Methods
In 2009, we surveyed 199 Massachusetts bankruptcy filers regarding medical antecedents of their financial collapse using the same questions as in a 2007 survey of 2314 debtors nationwide, including 44 in Massachusetts. We designated bankruptcies as “medical” based on debtors' stated reasons for filing, income loss due to illness, and the magnitude of their medical debts.

Results
In 2009, illness and medical bills contributed to 52.9% of Massachusetts bankruptcies, versus 59.3% of the bankruptcies in the state in 2007 (P=.44) and 62.1% nationally in 2007 (P<.02). Between 2007 and 2009, total bankruptcy filings in Massachusetts increased 51%, an increase that was somewhat less than the national norm. (The Massachusetts increase was lower than in 54 of the 93 other bankruptcy districts.) Overall, the total number of medical bankruptcies in Massachusetts increased by more than one third during that period. In 2009, 89% of debtors and all their dependents had health insurance at the time of filing, whereas one quarter of bankrupt families had experienced a recent lapse in coverage.Conclusion
Massachusetts' health reform has not decreased the number of medical bankruptcies, although the medical bankruptcy rate in the state was lower than the national rate both before and after the reform.

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

-- David U. Himmelstein, MD, Deborah Thorne, PhD, Steffie Woolhandler, MD, MPH

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

Is healthcare reform working in Massachusetts?

2011-03-08T09:00:00.001-07:00

The US Affordable Care Act of 2010 was based, at least in part, on healthcare reform in Massachusetts, but is that system working?

To learn the answer to that question, check the March issue of The American Journal of Medicine for a new research study by the Harvard group who revealed that medical costs are the single biggest contributor to bankruptcy in the US.

The March issue will appear posted on AJM's website this week.

Fainting with HIV

2011-02-28T11:37:00.000-07:00

Presentation
When a man with untreated human immunodeficiency virus (HIV) infection presented with recurrent episodes of syncope, magnetic resonance imaging (MRI) yielded a novel etiology.

The patient, a 51-year-old Puerto Rican man, presented to our clinic with cough, hemoptysis, night sweats, and recurrent syncopal episodes. He described intermittent episodes of fainting, increasing in frequency, for 3 months prior to presentation. In the previous week alone, he had suffered 3 such episodes. His daughter, who had witnessed several of the fainting episodes, had called for emergency medical services after his most recent episode, which had resulted in a fall. She reported that the syncopal episodes were accompanied by convulsions during and after loss of consciousness and by a period of confusion after regain of consciousness. The episodes were not accompanied by bowel or bladder incontinence.

The patient had been diagnosed with HIV in 1994 but had no history of acquired immune deficiency syndrome (AIDS)-defining illnesses. He had discontinued his antiretroviral therapy in 2003 because of pill burden. His medical history was otherwise significant for a severe burn to the lumbar spine, which had left him paraplegic and wheelchair-bound at baseline.

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

-- Brian Hollenbeck, MD, Samir Dalia, MD, Kelly McGarry, MD

This article originally appeared in the September 2010 issue of The American Journal of Medicine.

Stimulating the interest for conflicting scientific debates

2011-02-25T13:48:00.004-07:00

Blog Commentary

The conflict of interest issue is now a crisis of credibility for the medical profession, despite early warnings; it requires a comprehensive framework.(1) Therefore, I am seriously puzzled by some editors’ naïve pledge for reporting “potential” conflict of interest.(2)

The International Committee of Medical Journal Editors never investigated the reasons why it failed for so long to implement an efficient policy. Chimonas et al confirmed that current journal disclosure practices do not yield consistent information regarding authors’ industry ties.(3) Their proposal to use company data to move to a system of full, verifiable transparency is in fact irrelevant. Secrecy "needs" some transparency to give public trust and to maintain preferred hierarchies of power.

Will editors and reviewers succeed if someone wants to mask a conflict? Companies repeatedly cope with regulations which ought to grant for transparency. In 2004, the Sarbanes–Oxley Act (2002) failed to prevent many major affairs (eg. Enron, Vivendi-Universal). In 2008, the new regulation did not prevent even more serious affairs (eg. Lehman Brothers Holdings was certified by the US Securities and Exchange Commission). Moreover, for a long time, consultancy fees have been just the tip of the conflict of interest iceberg. As early as mild 90’s, I observed some doctors engaged in insider trading schemes. Only those who are too voracious are caught.(4)

The bottom line for an article is simple: Is there scientific evidence -- regardless of any conflict-- or not? This means that scientific controversies must be possible. The editor must accept for publication responses to promote controversies and not hide himself behind the excuse of “the lack of space”. Among the editors, I must cite Joseph S. Alpert, MD, from the Green Journal, who dared to disclose serious breaches in scientific ethics and in evidence that many hid.(5,6)

Lastly, I propose to add at the end of each conflict of interest statement “Neither the editor and the reviewers, nor the institution where the work was performed seriously investigated the authors’ conflict of interest.”

Interest for conflict: Alain Braillon was recently sacked for whistleblowing.(HealthWatch, october 2010, issue 79, p3-7 available at http://href.fr/healthwatch_oct10.pdf)

-- Alain Braillon MD, PhD

1 Fava GA. Unmasking special interest groups: the key to addressing conflicts of interest in medicine. Psychother Psychosom. 2010;79:203-7.
2 Fontanarosa PB, Flanagin A, DeAngelis CD. Implementation of the ICMJE form for reporting potential conflicts of interest. JAMA. 2010 6;304:1496.
3 Chimonas S, Frosch Z, Rothman DJ. From Disclosure to transparency: The use of Company payment data. Arch Intern Med. 2010 Sep 13 . [Epub ahead of print] PMID: 20837820
4 United States Attorney's Office. Manhattan U.S. Attorney charges French doctor for insider trading securities fraud allegedly illegal inside tips at time of fatality and other problems in clinical drug trial allow hedge fund to avoid $30 Million in trading lLosses. November 2, 2010. available at http://newyork.fbi.gov/dojpressrel/pressrel10/nyfo110210a.htm
5 Braillon A, Nguyen-Khac E. Hepatocellular carcinoma: a pledge for evidence-based medicine. Am J Med. 2008;121:e7.
6 Braillon A. Sciensationalism. Am J Med. 2010 ; 124 :e13

AJM Editor-in-Chief previews the March issue (video)

2011-02-21T08:00:00.005-07:00

The March 2011 issue of The American Journal of Medicine will have a collection of articles focusing on healthcare reform--including new research from the Harvard team that published the seminal article on the link between bankruptcy and medical bills.

For a preview of AJM's March issue, check out Dr. Joseph Alpert's video, above.

Featured diagnostic images, clinical research studies, and editorials are available for free on the AJM website. Here is a link to our home page.

Ludwig's Angina

2011-02-10T08:00:00.009-07:00

A previously healthy 33-year-old man, with a history of type 1 diabetes mellitus, underwent left lower molar extraction. Two days later, he presented to the emergency department with swelling in the left submandibular area and was subsequently treated with meperidine, codeine, and penicillin G. Two days later, after an unsuccessful resolution, he returned with bilateral submandibular swelling and difficulty swallowing and breathing.

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

-- Nicholas Costain, BSc, Thomas J. Marrie, MD

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

It Is Only the Ignorant Who Despise Education

2011-02-08T08:00:00.002-07:00

“It is only the ignorant who despise education.”

Publius Cyrus, Latin Poet, 43-85 AD

Recently, my spouse and I celebrated a milestone birthday and anniversary by traveling on safari in East Africa. Besides the abundant and fascinating wildlife, we spent a considerable amount of time discussing with our guides and drivers the current demographic, cultural, and educational aspects of their respective countries, Kenya and Tanzania. These conversations, taken with a fair amount of background reading, led to the comments in this editorial. Our African colleagues were convinced that a key element required to improve the quality of life for the average person in their societies must involve widespread, universal education. Without this, critical measures in public health, food production, and good governmental practices would not be accomplished.

As I thought about their comments, it became clear to me that they were right. The future economic and physical health of the citizenry in Africa demands widespread education of the population. Ignorance in this magnificent continent has led to much unnecessary pain, misery, and death already.

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

-- Joseph S. Alpert, MD, AJM editor-in-chief

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

Do you need one more reason to quit smoking?

2011-02-07T08:00:00.002-07:00

Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis

Smoking cessation before any type of surgery reduced risks of complications, including wound healing and pulmonary complications. Longer periods of cessation prior to surgery had a significantly larger reduction in complications.

Abstract
Objective
We aimed to review randomized trials and observational evidence to establish the effect of preoperative smoking cessation on postoperative complications and to determine if there is an optimal cessation period before surgery.

Methods
We conducted a systematic review of all randomized trials evaluating the effect of smoking cessation on postoperative complications and all observational studies evaluating the risk of complications among past smokers compared with current smokers. We searched independently, in duplicate, 10 electronic databases and the bibliographies of relevant reviews. We conducted a meta-analysis of randomized trials using a random effects model and performed a meta-regression to examine the impact of time, in weeks, on the magnitude of effect. For observational studies, we pooled proportions of past smokers in comparison with current smokers.

Results
We included 6 randomized trials and 15 observational studies. We pooled the 6 randomized trials and demonstrated a relative risk reduction of 41% (95% confidence interval [CI], 15-59, P = .01) for prevention of postoperative complications. We found that each week of cessation increases the magnitude of effect by 19%. Trials of at least 4 weeks' smoking cessation had a significantly larger treatment effect than shorter trials (P = .04). Observational studies demonstrated important effects of smoking cessation on decreasing total complications (relative risk [RR] 0.76, 95% CI, 0.69-0.84, P < .0001, I2 = 15%). This also was observed for reduced wound healing complications (RR 0.73, 95% CI, 0.61-0.87, P = .0006, I2 = 0%) and pulmonary complications (RR 0.81, 95% CI, 0.70-0.93, P = .003, I2 = 7%). Observational studies examining duration of cessation demonstrated that longer periods of cessation, compared with shorter periods, had an average reduction in total complications of 20% (RR 0.80, 95% CI, 3-33, P = .02, I2 = 68%). Conclusion Longer periods of smoking cessation decrease the incidence of postoperative complications. To read this article in its entirety, please visit our website.

-- Edward Mills, PhD, MSc, Oghenowede Eyawo, MPH, Ian Lockhart, DLitt et Phil, Steven Kelly, MSc, Ping Wu, MBBS, MSc, Jon O. Ebbert, MD, MS

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

Medical Education Today: Is Science Enough?

2011-02-04T15:51:00.003-07:00

Blog Commentary

Educational trends swing back and forth like a pendulum. What is in vogue today, may not be in 10 or 20 years.

Twenty years ago, would-be medical students focused on the sciences in their baccalaureate education. Today, we see medical schools valuing students with a broader education and offering alternative educational opportunities to medical students. From the Wall Street Journal...

Medical schools are placing a growing emphasis on the humanities, including courses in writing, art and literature. The programs aim to teach students "right-brain" insights and skills they won't learn dissecting cadavers or studying pathology slides.

Why branch out into writing, humanities, art, or music? The goal of offering young doctors expanded educational experiences is to improve their communication skills, help them be more empathic, and make them well-rounded individuals.Again, from the Wall Street Journal...

Schools hope the programs help to turn out a new generation of physicians better able to listen attentively to patients, show emotion and provide sensitive personal care...

"Emotional reasoning and clinical empathy isn't about be-nice-to-the-patient. It's about understanding the significance of illness and how it takes place in the context of their life, and any physician or caregiver who doesn't have a sense of that cannot be effective," says Felice Aull, founding editor of the literature, arts and medicine database at New York University...

"We ask about chest pain and shortness of breath, but the discussion rarely gets to what is going on in their lives and their experience of being a patient," says Paul Gross, a family medicine physician at Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx, N.Y. Dr. Gross holds a monthly session in narrative medicine, which encourages writing stories about patients to understand all the factors that affect them. He also edits a medical literary journal called "Pulse: Voices from the Heart of Medicine."

Re-visioning Flexner: Educating Physicians to Be Clinical Scientists and Humanists by Doukas et al focused on the role of liberal arts in medical education in The American Journal of Medicine's December 2010 issue. Referring to the 1910 Flexner Report on medical education, Doukas et al write:

Scientific study and thinking were not sufficient to make a capable physician; however, as Flexner well understood, the physician must have “insight and sympathy on a varied and enlarging cultural experience…scientific progress has greatly modified his ethical responsibility.” (1) The physician should be “culturally experienced,” and possess humanistic skills to serve the social good. (1)

A “broader more liberal arts education” provided the basis for these skills. (2) In the report, the college-based development of reflective, abstract thinking was cited as necessary before the secondary stage of medical education. (1) In his other writings, Flexner insisted that liberal arts education should be tailored toward each student's future profession of choice and include both science and humanities to prepare a physician to fully develop the necessary skills. (2, 4, 5, 6)

Under the direction of Editor-in-chief Joseph S. Alpert, MD, and Specialty Editor Helle Mathiasen, Cand mag, PhD, AJM has promoted the role of humanities in medicine. The Journal's Medical Humanities Perspectives section appears several times a year in both the print and online versions. If you are a physician who enjoys writing prose, you may consider submitting a Medical Humanities Perspectives article to be considered for publication.

-- Pamela J. Powers, MPH, AJM Managing Editor

1- Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching (Bulletin No. 4). Boston, Mass: Updyke; 1910.

2- Zelenka MH. Educational philosophy of Abraham Flexner: creating cogency in medical education. Lewiston, NY: Edwin Mellen Press; 2008.

3- Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355:1339–1344.

4- Flexner A. Purpose in the American college. School and Society. 1925;22:729–736.

5- Flexner A. The problem of college pedagogy. Atl Mon. 1909;103:838–844.

6- Flexner A. The American college: a criticism. New York, NY: The Century Co; 1908.

AJM Editor-in-Chief previews the February issue (video)

2011-02-04T14:30:00.001-07:00

What's coming up in The American Journal of Medicine's February 2011 issue? Check out Dr. Joseph Alpert's video for a preview.

Featured diagnostic images, clinical research studies, and editorials are available for free on the AJM website. Here is a link to the home page.

Patterns of Care and Outcomes After Computed Tomography Scans for Headache

2011-01-28T11:49:00.000-07:00

Due to the potential risk of cancer from exposure to ionizing radiation, efforts should be made to avoid CT scanning for headache when the likelihood of serious illness is low. Evidence-based decision rules that identify which patients with headache do not require neuroimaging may decrease the use of CT scans in situations of little benefit.

Abstract

Background
Concerns exist about potential overuse of computed tomography (CT) scans for headache in ambulatory care.

Methods
We sought to examine health services use, brain tumor diagnosis, and death during the year after CT scanning for headache by linking records of an audit of 3930 outpatient CT brain scans performed in 2005 in Ontario, Canada, to administrative databases.

Results
Of 623 patients receiving CT scans for a sole indication of headache, few (2.1%) scans contained findings potentially causing their headache. For most patients, the index CT scan was the only one received over an 11-year period. However, 28.4% of patients received 1 or more CT brain scans during the preceding decade and 6.7% received 1 or more CT brain scans during the subsequent year. Of the 473 patients (75.9%) whose index scan was ordered by a primary care physician, most (80.3%) did not see a specialist during follow-up. One patient with an indeterminate finding on the index scan was diagnosed with a malignant brain tumor (0.2%), and 6 patients (1.0%) died during follow-up. Among the 4 deaths in which the cause could be determined, none were due to central nervous system causes.

Conclusion
Because of the potential risk of cancer from exposure to ionizing radiation, efforts should be made to avoid CT scanning for headache when the likelihood of serious illness is low. Evidence-based decision rules that identify which patients with headache do not require neuroimaging may decrease the use of CT scans in situations of little benefit.

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-- John J. You, MD, MS, Jonathan Gladstone, MD, Sean Symons, MD, MPH, Dalia Rotstein, MD, Andreas Laupacis, MD, MS, Chaim M. Bell, MD, PhD

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

AJM editor publishes book on academic medicine (video)

2011-01-18T08:00:00.010-07:00

Dr. James E. Dalen, associate editor for The American Journal of Medicine, has published a new book on academic medicine-- University Hospitals, Doctors and Patients.

Research conducted at university hospitals has contributed to medical advances in recent decades, but it has also contributed to the dramatic increase in healthcare cost and the increase in the use of medical technology. Hear about the book in Dalen's own words by clicking on the video, above.

As an editor, Dalen reviews many of the cardiology and healthcare policy manuscripts submitted to AJM and often contributes original articles to the Journal. He has written extensively on healthcare reform:

We Can Reduce US Health Care Costs

Only in America: Bankruptcy Due to Health Care Costs

It's Time to Bail Out Seniors Trapped in the Medicare Donut Hole!

Dalen, a noted cardiologist and medical educator, has spent his entire career in university hospitals in Massachusetts and Arizona. The former Dean of Medicine and Vice President for Health Sciences at The University of Arizona, he is now Professor Emeritus and teaches medicine and public health.

Recent Trends in the Incidence, Treatment, and Outcomes of Patients with STEMI and NSTEMI

2011-01-14T08:00:00.000-07:00

This population-based study revealed decreases in the magnitude of ST-segment elevation myocardial infarction, as well as increased longevity among ST- and non-ST-segment elevation myocardial infarction patients. The authors suggest that prevention programs and improved treatment efforts may have contributed to these positive changes.

Abstract
Background
Despite the widespread use of electrocardiographic changes to characterize patients presenting with acute myocardial infarction, little is known about recent trends in the incidence rates, treatment, and outcomes of patients admitted for acute myocardial infarction further classified according to the presence of ST-segment elevation. The objectives of this population-based study were to examine recent trends in the incidence and death rates associated with the 2 major types of acute myocardial infarction in residents of a large central Massachusetts metropolitan area.

Methods
We reviewed the medical records of 5383 residents of the Worcester (MA) metropolitan area hospitalized for either ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment acute myocardial infarction (NSTEMI) between 1997 and 2005 at 11 greater Worcester medical centers.

Results
The incidence rates (per 100,000) of STEMI decreased appreciably (121 to 77), whereas the incidence rates of NSTEMI increased slightly (126 to 132) between 1997 and 2005. Although in-hospital and 30-day case-fatality rates remained stable in both groups, 1-year postdischarge death rates decreased between 1997 and 2005 for patients with STEMI and NSTEMI.

Conclusions
The results of this study demonstrate recent decreases in the magnitude of STEMI, slight increases in the incidence rates of NSTEMI, and decreases in long-term mortality in patients with STEMI and NSTEMI. Our findings suggest that acute myocardial infarction prevention and treatment efforts have resulted in favorable decreases in the frequency of STEMI and death rates from the major types of acute myocardial infarction.

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-- David D. McManus, MD, FACC, Joel Gore, MD, FACC, Jorge Yarzebski, MD, MPH, Frederick Spencer, MD, Darleen Lessard, MS, Robert J. Goldberg, PhD

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

You Only Have to Exercise on the Days that You Eat

2011-01-12T08:00:00.001-07:00

Evidence continues to increase supporting the idea that the inclusion of frequent exercise in our modern, 21st century lives is very important for health maintenance and improvement. One recent review study found a decrease in the development of coronary heart disease ranging from 10% to more than 60% when patients exercised regularly. Higher levels of exercise each week were associated with increased benefit. Decreased all-cause mortality also was reported from the Copenhagen City Heart Study with increasing leisure time exercise. A series of experiments in mice revealed that regular exercise prevented cellular senescence in circulating leukocytes as well as in the vascular tree. King et al demonstrated prompt benefit when middle-aged adults adopted healthier lifestyles including regular exercise. Reduced colds were reported in postmenopausal obese women who exercised 45 minutes per day, 5 days per week for 1 year. Moreover, patients with peripheral vascular disease, hypertension, and heart failure all benefited from regular exercise. Numerous other studies have supported the concept that frequent exercise can improve quality and quantity of life.

I have often wondered how and why regular exercise became so important for human beings.

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 the January 2011 issue of The American Journal of Medicine.