The American Journal of Medicine

Diagnostic Imaging: Powerful, Indispensable, and Out of Control

Robert G. Stern — 2012-02-01

SEE RELATED COMMENTARY AND ARTICLE pp. 115 & 155

Patient-centered Imaging

Stephen J. Swensen — 2012-02-01

SEE RELATED EDITORIAL p. 113

Sarcoidosis: Challenging Diagnostic Aspects of an Old Disease

2012-02-01

Abstract: Over the past few years, there have been substantial advances in our understanding of sarcoidosis immunopathogenesis. Conversely, the etiology of the disease remains obscure for a number of reasons, including heterogeneity of clinical manifestations, often overlapping with other disorders, and insensitive and nonspecific diagnostic tests. While no cause has been definitely confirmed, there is increasing evidence that one or more infectious agents may cause the disease, although the organism may no longer be viable. Here we present 2 cases, in which sarcoidosis preceded tuberculosis and non-Hodgkin lymphoma. Development of new lesions in a patient with chronic/remitting sarcoidosis should be looked at with suspicion and promptly investigated in order to rule out an alternative/concomitant diagnosis. In such cases, tissue confirmation from the most accessible site, and bone marrow biopsy—if lymphoma is in the differential diagnosis—should be performed. In conclusion, we strongly advise that physicians be ready to reconsider the diagnosis of sarcoidosis in the presence of atypical manifestations or persistent/progressive disease despite conventional therapy.

The Cardiovascular Effects of Peroxisome Proliferator-activated Receptor Agonists

2012-02-01

Abstract: Although peroxisome proliferator-activated receptor agonists are prescribed to improve cardiovascular risk factors, their cardiovascular safety is controversial. We therefore reviewed the literature to identify landmark randomized controlled trials evaluating the effect of peroxisome proliferator-activated receptor gamma agonists (pioglitazone and rosiglitazone), alpha agonists (fenofibrate and gemfibrozil), and pan agonists (bezafibrate, muraglitazar, ragaglitazar, tesaglitazar, and aleglitazar) on cardiovascular outcomes. Pioglitazone may modestly reduce cardiovascular events but also may increase the risk of bladder cancer. Rosiglitazone increases the risk of myocardial infarction and has been withdrawn in European and restricted in the United States. Fibrates improve cardiovascular outcomes only in select subgroups: fenofibrate in diabetic patients with metabolic syndrome, gemfibrozil in patients with dyslipidemia, and bezafibrate in patients with diabetes or metabolic syndrome. The cardiovascular safety of the new pan agonist aleglitazar, currently in phase II trials, remains to be determined. The heterogenous effects of peroxisome proliferator-activated receptor agonists to date highlight the importance of postmarketing surveillance. The critical question of why peroxisome proliferator-activated receptor agonists seem to improve cardiovascular risk factors without significantly improving cardiovascular outcomes requires further investigation.

Current Views on Diagnostic Approach and Treatment of Lymphedema

2012-02-01

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

Whooping Cough in Adults: An Update on a Reemerging Infection

Robert D. Paisley, Jason Blaylock, Joshua D. Hartzell — 2012-02-01

Abstract: Pertussis, or whooping cough, which is commonly thought of as a pediatric illness, is an underappreciated adult pathogen. Recent outbreaks highlight the significance of pertussis in adults and the risk of transmission to at-risk infants who are most susceptible to complications, including death. This article describes the recent epidemiologic shifts and reviews the clinical presentation, diagnosis, and treatment of pertussis. New vaccination recommendations by the Advisory Committee on Immunization Practices in response to recent outbreaks and infant deaths are highlighted.

Using the GRACE Risk Scores in Everyday Practice

Palaniappan Muthappan, Adam Rogers, Kim Eagle — 2012-02-01

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

Transient Ischemic Attacks in a 22-Year-Old

2012-02-01

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

Repeat Abdominal Imaging Examinations in a Tertiary Care Hospital

Ivan K. Ip, Koenraad J. Mortele, Luciano M. Prevedello, Ramin Khorasani — 2012-02-01

Abstract: Background: Reducing unnecessary repeat imaging may reduce waste and costs, and improve health care quality. We aimed to quantify repeat imaging rates in patients with abdominal imaging examinations, and identify factors associated with repeat imaging. Methods: We retrospectively analyzed all diagnostic abdominal computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), fluoroscopy, and radiograph reports performed at our institution between January 1, 2000 and December 31, 2009. Primary outcome measure was the rate of repeat abdominal imaging (RAI) examinations, defined as any imaging examination of the abdomen on the same patient within 0-90 days of the first (enrollment) examination. We used natural language processing tools to extract recommendations for follow-up imaging from radiology reports. Univariate and multivariate logistic regressions were fitted to determine the effect of patient age, sex, study modality, care setting, follow-up recommendations, and history of neoplasm on the primary outcome over time. Results: Over 10 years, 245,184 abdominal imaging examinations were performed (43.2% CT, 20.6% US, 16.6% radiograph, 13.9% fluoroscopy, 5.7% MRI). The RAI rate remained unchanged (41.2% to 41.7%); unadjusted RAI volume increased from 6596 to 12,218 (P <.01). Most repeat studies (88.2%) were not preceded by a radiologist's recommendation. Practice setting, study modality, patient age, sex, underlying health condition, and radiologist's recommendations were associated with higher rate of repeat abdominal imaging examinations. Conclusions: A large proportion of abdominal imaging examinations result in a repeat study. Many factors contribute to repeat imaging, including patient age, sex, underlying disease, initial study modality, practice setting, and radiologist's recommendation.

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

2012-02-01

Abstract: Background: The effect of race/ethnicity on the risk of diabetes associated with sleep duration has not been systematically investigated. This study assessed whether blacks reporting short (<6 hours) or long (>8 hours) sleep durations were at greater risk for diabetes than their white counterparts. In addition, this study also examined whether the influence of race/ethnicity on associations between abnormal sleep durations and the presence of diabetes were independent of individuals' sociodemographic and medical characteristics. Methods: A total of 29,818 Americans (age range: 18-85 years) enrolled in the 2005 National Health Interview Survey, a cross-sectional household interview survey, provided complete data for this analysis. Results: Of the sample, 85% self-ascribed their ethnicity as white and 15% as black. The average age was 47.4 years, and 56% were female. Results of univariate regression analysis adjusting for medical comorbidities showed that black and white participants who reported short sleep duration (<6 hours) were more likely to have diabetes than individuals who reported sleeping 6 to 8 hours (odds ratios 1.66 and 1.87, respectively). Likewise, black and white participants reporting long sleep duration (>8 hours) had a greater likelihood of reporting diabetes compared with those sleeping 6 to 8 hours (odds ratios 1.68 and 2.33, respectively). Significant interactions of short and long sleep with black and white race were observed. Compared with white participants, greater diabetes risk was associated with being short or long sleepers of black race. Conclusion: The present findings suggest that American short and long sleepers of black race may be at greater risk for diabetes independently of their sociodemographic profile or the presence of comorbid medical conditions, which have been shown to influence habitual sleep durations. Among black individuals at risk for diabetes, healthcare providers should stress the need for adequate sleep.

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

2012-02-01

Abstract: Background: The accurate prediction of acute kidney injury (AKI) is an unmet clinical need. A combined assessment of cardiac stress and renal tubular damage might improve early AKI detection. Methods: A total of 372 consecutive patients presenting to the Emergency Department with lower respiratory tract infections were enrolled. Plasma B-type natriuretic peptide (BNP) and neutrophil gelatinase-associated lipocalin (NGAL) levels were measured in a blinded fashion at presentation. The potential of these biomarkers to predict AKI was assessed as the primary endpoint. AKI was defined according to the AKI Network classification. Results: Overall, 16 patients (4%) experienced early AKI. These patients were more likely to suffer from preexisting chronic cardiac disease or diabetes mellitus. At presentation, BNP (334 pg/mL [130-1119] vs 113 pg/mL [52-328], P 267 pg/mL or NGAL >231 ng/mL correctly identified 15 of 16 early AKI patients (sensitivity 94%, specificity 61%). During multivariable regression analysis, the combined BNP/NGAL cutoff remained the independent predictor of early AKI (hazard ratio 10.82; 95% CI, 1.22-96.23; P = .03). Conclusion: A model combining the markers BNP and NGAL is a powerful predictor of early AKI in patients with lower respiratory tract infection.

Statin Use and Musculoskeletal Pain Among Adults With and Without Arthritis

2012-02-01

Abstract: Background: Musculoskeletal symptoms are common adverse effects of statins, yet little is known about the prevalence of musculoskeletal pain and statin use in the general population. Methods: We conducted a cross-sectional study of the National Health and Nutrition Examination Survey 1999-2004. We estimated the prevalence of self-reported musculoskeletal pain according to statin use and calculated prevalence ratio estimates of musculoskeletal pain obtained from adjusted multiple logistic regression modeling. Results: Among 5170 participants without arthritis, the unadjusted prevalence of musculoskeletal pain was significantly higher for statin users reporting pain in any region (23% among statin users, 95% confidence interval [CI], 19-27, compared with 18% among those not using statins, 95% CI, 17-20; P=.02) and in the lower extremities (12% among statin users, 95% CI, 8-16, compared with 8% among those not using statins, 95% CI, 7-9; P=.02). Conversely, among 3058 participants with arthritis, statin use was not associated with higher musculoskeletal pain in any region. After controlling for confounders, among those without arthritis, statin use was associated with a significantly higher prevalence of musculoskeletal pain in any region, the lower back, and the lower extremities (adjusted prevalence ratios: 1.33 [CI, 1.06-1.67]; 1.47 [CI, 1.02-2.13]; 1.59 [CI, 1.12-2.22], respectively). Among participants with arthritis, no association was observed between musculoskeletal pain and statin use on adjusted analyses. Conclusion: In this population-based study, statin use was associated with a higher prevalence of musculoskeletal pain, particularly in the lower extremities, among individuals without arthritis. Evidence that statin use was associated with musculoskeletal pain among those with arthritis was lacking.

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

2012-02-01

Abstract: Background: Antibiotic medications are associated with an increased risk of bleeding among patients receiving warfarin. The recent availability of data from the Medicare Part D prescription drug program provides an opportunity to assess the association of antibiotic medications and the risk of bleeding in a national population of older adults receiving warfarin. Methods: We conducted a case-control study nested within a cohort of 38,762 patients aged 65 years and older who were continuous warfarin users, using enrollment and claims data for a 5% national sample of Medicare beneficiaries with Part D benefits. Cases were defined as patients hospitalized for a primary diagnosis of bleeding and were matched with 3 control subjects on age, race, sex, and indication for warfarin. Logistic regression analysis was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the risk of bleeding associated with prior exposure to antibiotic medications. Results: Exposure to any antibiotic agent within the 15 days of the event/index date was associated with an increased risk of bleeding (aOR 2.01; 95% CI, 1.62-2.50). All 6 specific antibiotic drug classes examined (azole antifungals [aOR, 4.57; 95% CI, 1.90-11.03], macrolides [aOR, 1.86; 95% CI, 1.08-3.21], quinolones [aOR, 1.69; 95% CI, 1.09-2.62], cotrimoxazole [aOR, 2.70; 95% CI, 1.46-5.05], penicillins [aOR, 1.92; 95% CI, 1.21-2.07], and cephalosporins [aOR, 2.45; 95% CI, 1.52-3.95]) were associated with an increased risk of bleeding. Conclusion: Among older continuous warfarin users, exposure to antibiotic agents—particularly azole antifungals—was associated with an increased risk of bleeding.

Lifestyle Risk Factors Predict Disability and Death in Healthy Aging Adults

2012-02-01

Abstract: Background: Associations between modifiable health risk factors during middle age with disability and mortality in later life are critical to maximizing longevity while preserving function. Positive health effects of maintenance of normal weight, routine exercise, and nonsmoking are known for the short and intermediate term. We studied the effects of these risk factors into advanced age. Methods: A cohort of 2327 college alumnae aged 60 years or more was followed annually (1986-2005) by questionnaires addressing health risk factors, history, and Health Assessment Questionnaire disability. Mortality data were ascertained from the National Death Index. Low-, medium-, and high-risk groups were created on the basis of the number (0, 1, ≥2) of health risk factors (overweight, smoking, inactivity) at baseline. Disability and mortality for each group were estimated from unadjusted data and regression analyses. Multivariable survival analyses estimated time to disability or death. Results: The medium- and high-risk groups had higher disability than the low-risk group throughout the study (P<.001). Low-risk subjects had onset of moderate disability delayed 8.3 years compared with high-risk subjects. Mortality rates were higher in the high-risk group (384 vs 247 per 10,000 person-years). Multivariable survival analyses showed the number of risk factors to be associated with cumulative disability and increased mortality. Conclusion: Seniors with fewer behavioral risk factors during middle age have lower disability and improved survival. These data document that the associations of lifestyle risk factors on health continue into the ninth decade.

Systematic Review of Guidelines on Peripheral Artery Disease Screening

Bart S. Ferket, Sandra Spronk, Ersen B. Colkesen, M.G. Myriam Hunink — 2011-11-14

Abstract: Background: Peripheral artery disease (PAD) screening may be performed to prevent progression of PAD or future cardiovascular disease in general. Recommendations for PAD screening have to be derived indirectly because no randomized trials comparing screening versus no screening have been performed. We performed a systematic review of guidelines to evaluate the value of PAD screening in asymptomatic adults. Methods: Guidelines in English published between January 1, 2003 and January 20, 2011 were retrieved using MEDLINE, CINAHL, the National Guideline Clearinghouse, the National Library for Health, the Canadian Medication Association Infobase, and the G-I-N International Guideline Library. Guidelines developed by national and international medical societies from Western countries, containing recommendations on PAD screening, were included. Two reviewers independently assessed rigor of guideline development using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. One reviewer performed full extraction of recommendations, which was validated by a second reviewer. Results: Of 2779 titles identified, 8 guidelines were included. AGREE scores varied from 33% to 81%. Five guidelines advocated PAD screening, others found insufficient evidence for PAD screening or were against it. Measurement of the ankle-brachial index (ABI) was generally recommended for middle-aged populations with elevated cardiovascular risk levels. Those identified as having PAD are reclassified as high risk, warranting intensive preventive interventions to reduce their risk of a cardiovascular event. The underlying evidence mainly consisted of studies performed in patients with established PAD. A meta-analysis that evaluated ABI testing in the context of traditional cardiovascular risk assessment was interpreted differently. Conclusions: Recommendations on PAD screening vary across current guidelines, making the value of PAD screening uncertain. The variation seems to reflect lack of studies that show added value of detection of early PAD beyond expectant management and traditional risk assessment.

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

Daniel R. Murphy, Brian Reis, Dean F. Sittig, Hardeep Singh — 2012-02-01

Abstract: Background: Asynchronous electronic health record (EHR)-based alerts used to notify practitioners via an inbox-like format rather than through synchronous computer “pop-up” messages are understudied. Our objective was to create an asynchronous alert taxonomy and measure the impact of different alert types on practitioner workload. Methods: We quantified and categorized asynchronous alerts according to the information they conveyed and conducted a time-motion analysis to assess practitioner workload. We reviewed alert information transmitted to all 47 primary care practitioners (PCPs) at a large, tertiary care Veterans Affairs facility over 4 evenly spaced 28-day periods. An interdisciplinary team used content analysis to categorize alerts according to their conveyed information. We then created an alert taxonomy and used it to calculate the mean number of alerts of each type PCPs received each day. We conducted a time-motion study of 26 PCPs while they processed their alerts. We used these data to estimate the uninterrupted time practitioners spend processing alerts each day. Results: We extracted 295,792 asynchronously generated alerts and created a taxonomy of 33 alert types categorized under 6 major categories: Test Results, Referrals, Note-Based Communication, Order Status, Patient Status Changes, and Incomplete Task Reminders. PCPs received a mean of 56.4 alerts/day containing new information. Based on 749 observed alert processing episodes, practitioners spent an estimated average of 49 minutes/day processing their alerts. Conclusions: PCPs receive a large number of EHR-based asynchronous alerts daily and spend significant time processing them. The utility of transmitting large quantities and varieties of alerts to PCPs warrants further investigation.

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

Naga V.A. Kommuri, Todd M. Koelling, Scott L. Hummel — 2012-02-01

Abstract: Background: Hospitalizations for decompensated heart failure (HF) are thought to increase long-term mortality. However, previous reports focus on newly hospitalized HF patients or clinical trial populations and do not always adjust for baseline mortality risk. We hypothesized that the number of HF hospitalizations within the prior 12 months would improve overall mortality risk stratification, particularly in otherwise “low-risk” HF inpatients. Methods: We studied 2221 HF patients admitted to 14 Michigan community hospitals during 2002-2004. We estimated 1-year mortality using the multivariable (Enhanced Feedback For Effective Cardiac Treatment [EFFECT]) model and classified patients as low (EFFECT <90), moderate (90-120), and high risk (>120). We used logistic regression and stratified Cox proportional hazard modeling to explore the overall EFFECT model performance and the influence of HF hospitalizations within the prior 12 months on mortality risk. Results: The EFFECT model adequately predicted and stratified for 1-year mortality (odds ratio 1.35 [95% confidence interval (CI), 1.30-1.40] per 10 points, P <.001, C-statistic 0.698), with low-, moderate-, and high-risk group mortality 18%, 35%, and 58%, respectively. The number of prior HF hospitalizations only modestly improved overall discrimination (C-statistic 0.704, P=.04). However, in low-risk patients the number of prior HF hospitalizations progressively increased the hazard for 1-year mortality (none: mortality 13%; 1: mortality 20%, hazard ratio [HR] 1.50 (95% CI, 0.86-2.60), P=.15; 2 or 3: mortality 27%, HR 2.24 (95% CI, 1.39-3.60); P=.001; 4 or more: mortality 31%, HR 2.80 (95% CI, 1.70-4.63); P <.001; P <.001 for trend). There was no consistent relationship between prior HF hospitalizations and 1-year mortality in moderate- or high-risk HF patients. Conclusion: In otherwise “low-risk” HF inpatients, a history of 2 or more HF hospitalizations within the prior 12 months markedly increases 1-year mortality risk. This easily obtained information could help allocate specialized HF resources to the subset of “low-risk” patients most likely to benefit.

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

Esmat Mustafa, Liwen Lai, Yeong-Hau H. Lien — 2012-02-01

Hypothermia is renoprotective against ischemia/reperfusion injury in experimental animals, but its renoprotection is rarely reported in patients with acute kidney injury. We describe here a hypothermic patient who recovered rapidly from acute kidney injury despite hemodynamic instability and respiratory failure.

Rhabdomyolysis: Not a Textbook Case

Sunit-Preet Chaudhry, Kavita Krishnasamy, Ashish A. Bhimani, Austin Arthur Halle — 2012-02-01

A 21-year-old gravida 2, para 1, woman at 34 weeks' gestation with a history of iron deficiency anemia presented to the hospital with lower-extremity numbness, tingling, and weakness, resulting in falls. Vital signs were unremarkable, with the physical examination significant for diminished lower-extremity strength and intact sensation. Laboratory assessment was notable for hemoglobin of 9.5 g/dL, potassium of 2.2 mmol/L, magnesium of 1.81 mg/dL, phosphorus of 3.0 mg/dL, calcium of 8.2 mg/dL, glucose of 91 mg/dL, creatine kinase of 11,089 U/L, albumin of 1.1 g/dL, and thyroid-stimulating hormone of 2.5 mIU/L. Further laboratory evaluation revealed a mild respiratory alkalosis (pH 7.43, PaCO2 34 mm Hg, and bicarbonate 23 mmol/L), serum osmolality of 279 mOsm/kg, urine pH of 7.0, urine osmolality of 257 mOsm/kg, urine sodium of 104 mmol/L, urine potassium of 11 mmol/L, urine chloride 114 mmol/L, and a urine creatinine of 20 mmol/L (urine tests were obtained after intravenous bolus of 750 cc of normal saline). An electrocardiogram (ECG) showed diffuse ST-segment depressions and T-wave inversions across the precordium in addition to QT-interval prolongation and U waves (A). Subsequent cardiac biomarkers and an echocardiogram were normal.

Postmenopausal Women with Constipation and Cardiovascular Disease

Jason N. Salamon, Jeremy Mazurek, Ronald Zolty — 2012-02-01

The secondary analysis of the Women's Health Initiative's observational arm by Salmoirago-Blotcher et al offers a novel approach to the risk factors associated with this disease. This study clearly documents the distribution of the many cardiovascular risk factors, such as smoking and diabetes. Although the study does document the use of symptomatic medications such as diuretics and calcium channel blockers, it would be helpful to know the distribution of mortality-reducing medications in post-cardiovascular injury, such as angiotensin-converting enzyme inhibitors, beta-blockers, and aspirin.

The Reply

Elena Salmoirago-Blotcher, Sybil Crawford, Ira Ockene — 2012-02-01

We would like to thank Salamon et al for their interest in our article. They raise 2 very interesting points. The first is the distribution of medications known to affect cardiovascular mortality, such as statins, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and aspirin in our study population, and the possible impact that these variables might have on our results when included in the multivariate analysis. The distributions of baseline use of ACE inhibitors, beta-blockers, aspirin, and statins by constipation category are shown in the . The prevalence of use of these medications was slightly higher with more severe constipation, although this may be due to age—because both constipation severity and medication use increase with age. Overall, the prevalence of statin use was low. When the Women's Health Initiative (WHI) enrollment started in 1993, the evidence about the effect of statins in the prevention of cardiovascular disease was just appearing, particularly in primary prevention. In multivariate models, we adjusted for baseline use of all cholesterol-lowering agents because other lipid-lowering agents, such as fibrates, also have been associated with a reduction in the risk of cardiovascular mortality and major cardiovascular events.

Aspirin and the Harmful Effect of NSAIDs

Raul Altman, Claudio D. Gonzalez — 2012-02-01

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

The Reply

Anthony A. Bavry — 2012-02-01

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

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

John G.F. Cleland — 2012-02-01

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

A Different Perspective on Income Inequality in America

Andrew Foy, Joseph F. Majdan — 2011-09-08

We read with interest Ritterman's editorial, “A Call to Lead,” and wish to present a different perspective on income inequality in America. First, while true that substantial income inequality exists in the US, this is not necessarily bad. Despite its ominous implications, the level of income inequality within a country depends on the mechanism that produced it and may or may not be a byproduct of wrongdoing or injustice. In a free society, inequality of earning will always exist because such patterns of income emerge from billions upon billions of individual choices and transactions. For this reason, income inequality as an isolated metric is less important compared with overall measures of well-being such as health and education.

The Reply

Jeff Ritterman — 2012-02-01

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

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

Scott M. Wright, Aysegul Gozu, Kathleen Burkhart, Harjit Bhogal, Glenn A. Hirsch — 2012-02-01

Academic health centers have multiple distinct yet interrelated missions related to advancing research and discovery, educating the next generation of physicians, and caring for patients with expertise and humanism. The reverence directed toward accomplishment in research at our academic health center exceeds the value directed toward clinical and educational successes, as reflected in both the culture and the promotion processes. Because promotion decisions and academic rank are heavily influenced by research success and not clinical accomplishments, distinction in the clinical care of patients is thought to be “under-rewarded and taken for granted.” Some academic health centers have established multiple tracks for promotion in an effort to balance the appreciation for all 3 parts of the tripartite mission, but even at those academic health centers, clinicians or clinician-educators who are part of these alternate tracks may feel as though they are members of a “second class.”

Masthead

2012-02-01

The American Journal of Medicine

Diagnostic Imaging: Powerful, Indispensable, and Out of Control

Patient-centered Imaging

Sarcoidosis: Challenging Diagnostic Aspects of an Old Disease

The Cardiovascular Effects of Peroxisome Proliferator-activated Receptor Agonists

Current Views on Diagnostic Approach and Treatment of Lymphedema

Whooping Cough in Adults: An Update on a Reemerging Infection

Using the GRACE Risk Scores in Everyday Practice

Transient Ischemic Attacks in a 22-Year-Old

Repeat Abdominal Imaging Examinations in a Tertiary Care Hospital

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

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

Statin Use and Musculoskeletal Pain Among Adults With and Without Arthritis

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

Lifestyle Risk Factors Predict Disability and Death in Healthy Aging Adults

Systematic Review of Guidelines on Peripheral Artery Disease Screening

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

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

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

Rhabdomyolysis: Not a Textbook Case

Postmenopausal Women with Constipation and Cardiovascular Disease

The Reply

Aspirin and the Harmful Effect of NSAIDs

The Reply

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

A Different Perspective on Income Inequality in America

The Reply

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

Masthead

Contents