The American Journal of Medicine

We Can Reduce US Health Care Costs

James E. Dalen — 2010-03-01

The primary reason that the US needs health care reform is that we pay more for health care than any other country in the world; yet our health outcomes are below that of other western nations. Our health outcomes are suboptimal because millions of Americans have limited access to ongoing primary and preventive care because they can't afford our health insurance.

Reexamining the Physician Scholar–Professional Organization Relationship

Stephen A. Geraci — 2010-03-01

Physician faculty at most medical schools are expected to establish a “national reputation,” often in part through scholarly contributions to national nonprofit professional organizations. Yet, those who generate most of their income through clinical work and teaching (ie, clinician scholars, clinician educators) find it increasingly difficult to volunteer their time and effort to these organizations compared with their historical colleagues. Those receiving salaries, fixed or based on billings/collections or work relative value units, have increasingly limited discretionary time off-site, and protected time on-site, for such endeavors. Travel issues (connecting, delayed and canceled flights, fewer travel options) add further to the cost of committee and meeting work. Employer-provided travel funding is a fraction of its former level, having totally disappeared at many institutions, whereas support from healthcare-associated industry has been banned or severely limited by some employers as an apparent conflict of interest, leaving the physician scholars to provide their own out-of-pocket travel support for many such activities. Colleagues have less uncommitted time to provide coverage of clinical duties during off-site meetings. Simultaneously, the physician contributor's responsibilities per activity have mushroomed by the need to address a host of regulatory and quality requirements (securing copyright releases, adhering to standardized formatting, preparing educational goals and hand-outs, composing assessment questions, validating statistics, and reviewing and rewriting test questions).

Thank You, Thank You, Thank You

Joseph S. Alpert — 2010-03-01

The machinery that makes The American Journal of Medicine (AJM) function is powered by many different individuals performing a variety of tasks. Without its long list of employees and volunteers, the Journal could not function. I am writing this editorial to thank the individuals who have made AJM what it is today, and what it will become in the future. The order in which these expressions of appreciation appear in this essay should not be construed as any indication of the importance of the individual or the group named. They are all equally important in the success of the Journal. To use a sports analogy, a baseball team needs a second baseman just as much as it needs a center fielder.

Atrial Fibrillation in Heart Failure: A Comprehensive Review

Prakash C. Deedwania, Joel A. Lardizabal — 2010-03-01

Abstract: Chronic heart failure and atrial fibrillation are 2 major disorders that are closely linked. Their coexistence is associated with adverse prognosis. Both share several common predisposing conditions, but their interaction involves complex ultrastructural, electrophysiologic, and neurohormonal processes that go beyond mere sharing of mutual risk factors. Rate control approach remains the standard therapy for atrial fibrillation in heart failure because current strategies at rhythm control have so far failed to positively impact mortality and morbidity. This is largely because of the shortcomings of current pharmacologic anti-arrhythmic agents. Surgical and catheter-based therapies are promising, but long-term data are lacking. The role of non-anti-arrhythmic therapeutic agents also is being explored. Further progress toward improved understanding the complex relationship between atrial fibrillation and heart failure should improve management strategies.

Primary Care of the Transplant Patient

Peggy B. Hasley, Robert M. Arnold — 2010-03-01

Abstract: A total of 153,245 patients are living with a solid organ transplant in the US. In addition, patients are experiencing high 5-year survival rates after transplantation. Thus, primary care physicians will be caring for transplanted patients. The aim of this review is to update primary care physicians on chronic diseases, screening for malignancy, immunizations, and contraception in the transplant patient. Several studies on the treatment of hypertension and hyperlipidemia demonstrate that most agents used to treat the general population also can be used to treat transplant recipients. Little information exists on the medical management of diabetes in the transplant population, but experts in the area believe that the treatment of diabetes should be similar. Transplant recipients are at increased risk for all malignancies. Aggressive screening should be employed for all cancers with a proven screening benefit. Killed immunizations are safe for the transplant population, but live virus vaccines should be avoided. Women of childbearing age should be counseled about the impact of immunosuppressants on the efficacy and side effects of contraception.

Diabetic Retinopathy: An Update on Treatment

Ryan J. Fante, Vikram D. Durairaj, Scott C.N. Oliver — 2010-03-01

Abstract: Diabetic retinopathy is a progressive disease that results from vascular injury due to chronic hyperglycemia. It is the leading cause of blindness in working-age adults in the US and is usually asymptomatic until late stages. Treatment with laser photocoagulation is effective at preventing severe vision loss; thus, diabetic patients should be referred for regular screening by an ophthalmologist. New inhibitors of vascular endothelial growth factor may provide targeted nonsurgical treatment to improve vision in diabetic retinopathy.

The Improving Continuous Cardiac Care (IC3) Program and Outpatient Quality Improvement

Paul S. Chan, William J. Oetgen, John A. Spertus — 2010-03-01

For decades, the American College of Cardiology (ACC) and the American Heart Association (AHA) have distilled clinical evidence into guidelines and, recently, guidelines into performance measures. Yet, there remains a significant gap between the potential for high quality health care and the quality of health care that is actually delivered to patients. Although some programs, such as the ACC's National Cardiovascular Data Registries and the AHA's Get with the Guidelines, have demonstrated improvements in the quality of inpatient care, the quality and opportunity for improvement in the outpatient setting are largely unknown. The importance of quantifying and improving care in the outpatient setting is becoming increasingly important, with the recent emphasis on reporting of postdischarge mortality and readmission rates as a reflection of inpatient hospital care. Thus, there is a compelling need to systematically measure the quality of care, as quantified by established performance measures, in the outpatient setting.

Exotic Origin, Familiar Culprit

Tinsay A. Woreta, Leonard S. Feldman, Rosalyn W. Stewart — 2010-03-01

Certain diseases are great mimickers in medicine, presenting with diverse clinical manifestations that masquerade as other entities. We present a case, which illustrates the importance of considering these diseases in the differential diagnosis of patients who present with non-specific signs and symptoms.

A Post-cure Complication

Joana Nunes, Rui Tato Marinho, José Velosa — 2010-03-01

Long-term drug therapy for hepatitis C virus (HCV) infection would prove to have persistent effects—both desirable and undesirable. A 29-year-old woman with chronic hepatitis C, genotype 4, was to embark on a treatment regimen of oral ribavirin, 1000 mg, once daily and subcutaneous injections of pegylated interferon alfa-2b, 80 μg, once a week. At her initial physical examination, she had a body mass index of 26 (25-29 indicates overweight). Laboratory results showed that her alanine transaminase level, at 88 IU/mL, was well above the normal reference value (<31 IU/mL). Her albumin level and prothrombin time were within the normal range. She had no other relevant medical or family history.

Computer Calls for Cardiology Consult STAT!

Charles Broy — 2010-03-01

Although the electronic readouts provided by electrocardiographic systems often include an interpretation of the electrocardiogram (ECG), the clinician must not rely on this interpretation alone. In the following case, the “assistance” provided by the computer's interpretation of a routine ECG proved quite misleading.

Diabetes Mellitus and Confusion

Leonard Chow, Gulshan Sharma — 2010-03-01

Diabetes mellitus can predispose patients to many additional health calamities. A 54-year-old Hispanic woman with a known history of diabetes presented to the emergency department with a 1-day history of confusion, fever, nausea, and vomiting. On arrival, she had a temperature of 101.1° F (38.4° C), blood pressure of 115/73 mm Hg, heart rate of 125 beats/minute, respiratory rate of 20 breaths/minute, and an oxygen saturation of 99% on room air. Her physical examination disclosed dry mucous membranes, tachycardia with regular rhythm, clear lungs, mild tenderness to palpation on the suprapubic area, and dry skin with decreased turgor. She was disoriented and unable to respond appropriately to questions.

Analgesic Use and the Risk of Hearing Loss in Men

Sharon G. Curhan, Roland Eavey, Josef Shargorodsky, Gary C. Curhan — 2010-03-01

Abstract: Background: Hearing loss is a common sensory disorder, yet prospective data on potentially modifiable risk factors are limited. Regularly used analgesics, the most commonly used drugs in the US, may be ototoxic and contribute to hearing loss.Methods: We examined the independent association between self-reported professionally diagnosed hearing loss and regular use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen in 26,917 men aged 40-74 years at baseline in 1986. Study participants completed detailed questionnaires at baseline and every 2 years thereafter. Incident cases of new-onset hearing loss were defined as those diagnosed after 1986. Cox proportional hazards multivariate regression was used to adjust for potential confounding factors.Results: During 369,079 person-years of follow-up, 3488 incident cases of hearing loss were reported. Regular use of each analgesic was independently associated with an increased risk of hearing loss. Multivariate-adjusted hazard ratios of hearing loss in regular users (2+ times/week) compared with men who used the specified analgesic <2 times/week were 1.12 (95% confidence interval [CI], 1.04-1.20) for aspirin, 1.21 (95% CI, 1.11-1.33) for NSAIDs, and 1.22 (95% CI, 1.07-1.39) for acetaminophen. For NSAIDs and acetaminophen, the risk increased with longer duration of regular use. The magnitude of the association was substantially higher in younger men. For men younger than age 50 years, the hazard ratio for hearing loss was 1.33 for regular aspirin use, 1.61 for NSAIDs, and 1.99 for acetaminophen.Conclusions: Regular use of aspirin, NSAIDs, or acetaminophen increases the risk of hearing loss in men, and the impact is larger on younger individuals.

Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?

2010-03-01

Abstract: Background: Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions.Methods: We studied 4 alerts: hemoglobin A1c ≥15%, positive hepatitis C antibody, prostate-specific antigen ≥15 ng/mL, and thyroid-stimulating hormone ≥15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up.Results: Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84).Conclusions: Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

Orthostatic Syndromes Differ in Syncope Frequency

2010-03-01

Abstract: Background: There are conflicting opinions on whether postural tachycardia syndrome predisposes to syncope. We investigated this relationship by comparing the frequency of syncope in postural tachycardia syndrome and orthostatic hypotension.Methods: We queried our autonomic laboratory database of 3700 patients. Orthostatic hypotension and postural tachycardia syndrome were defined in standard fashion, except that postural tachycardia syndrome required the presence of orthostatic symptoms and a further increase in heart rate beyond 10 minutes. Syncope was defined as an abrupt decrease in blood pressure and often, heart rate, requiring termination of the tilt study. Statistical analysis utilized Fisher's exact test and Student's t test, as appropriate.Results: Of 810 patients referred for postural tachycardia syndrome, 185 met criteria while another 328 patients had orthostatic hypotension. Of the postural tachycardia syndrome patients, 38% had syncope on head-up tilt, compared with only 22% of those with orthostatic hypotension (P<.0001). In the postural tachycardia group, syncope on head-up tilt was associated with a clinical history of syncope in 90%, whereas absence of syncope on head-up tilt was associated with a clinical history of syncope in 30% (P<.0001). In contrast, syncope on head-up tilt did not bear any relationship to clinical history of syncope in the orthostatic hypotension group (41% vs 36%; P=.49).Conclusion: Our results demonstrate that syncope (both tilt table and clinical) occurs far more commonly in patients who have postural tachycardia syndrome than in patients with orthostatic hypotension. These findings suggest that one should be clinically aware of the high risk of syncope in patients with postural tachycardia syndrome, and the low-pressure baroreceptor system that is implicated in postural tachycardia syndrome might confer more sensitivity to syncope than the high pressure system implicated in orthostatic hypotension.

Long-term Effect of Chronic Oral Anticoagulation with Warfarin after Acute Myocardial Infarction

Salman A. Haq, John F. Heitner, Terrence J. Sacchi, Sorin J. Brener — 2010-03-01

Abstract: Background: Antiplatelet therapy is the principal component of the antithrombotic regimen after acute myocardial infarction. It remains unclear whether additional chronic oral anticoagulation (OAC) improves outcomes. We set out to evaluate the risk and benefit of long-term OAC after myocardial infarction.Methods: We pooled 10 randomized clinical trials comparing warfarin-containing regimens (OAC) with or without aspirin with non-OAC regimens with or without aspirin (No OAC) for patients with recent infarction. The primary endpoint was all-cause mortality. Other endpoints included recurrent infarction, stroke, and major bleeding. We calculated the odds ratio (OR) (fixed effect, OR <1 indicates benefit for OAC) for death and other ischemic and hemorrhagic complications at the longest interval of follow-up available.Results: Among 24,542 patients, 14,062 were assigned to OAC and 10,480 to no OAC. The patients were followed for 3-63 months, for 89,562 patient-years. Death occurred in 2424 patients (9.9%), 1279 OAC patients, and 1145 in the no OAC group, OR 0.97 (95% confidence interval [CI], 0.88-1.05), P=.43. Similarly, there was no effect on recurrent infarction. Stroke occurred in 578 patients (2.4%), 271 in the OAC group and 307 in the no OAC group, OR 0.75 (95% CI, 0.63-0.89), P=.001. There was substantially more major bleeding (OR 1.83 [95% CI, 1.50-2.23], P <.001) in the OAC group. Separate analyses, performed for patients (n=11,920) randomized to aspirin versus aspirin and OAC yielded very similar results.Conclusion: As compared with placebo or aspirin, OAC with or without aspirin does not reduce mortality or reinfarction, reduces stroke, but is associated with significantly more major bleeding.

Acute Myocardial Infarction Hospitalization in the United States, 1979 to 2005

Jing Fang, Michael H. Alderman, Nora L. Keenan, Carma Ayala — 2010-03-01

Abstract: Background: We reported earlier that there was no decline of acute myocardial infarction hospitalization from 1988 to 1997. We now extend these observations to document trends in acute myocardial infarction hospitalization rates and in-hospital case-fatality rates for 27 years from 1979 to 2005.Methods: We determined hospitalization rates for acute myocardial infarction by age and gender using data from the National Hospital Discharge Survey and US civilian population from 1979 to 2005, aggregated by 3-year groupings. We also assessed comorbid, complications, cardiac procedure use, and in-hospital case-fatality rates.Results: Age-adjusted hospitalization rate for acute myocardial infarction identified by primary International Classification of Diseases code was 215 per 100,000 people in 1979-1981 and increased to 342 in 1985-1987. Thereafter, the rate stabilized for the next decade and then declined slowly after 1996 to 242 in 2003-2005. Trends were similar for men and women, although rates for men were almost twice that of women. Hospitalization rates increased substantially with age and were the highest among those aged 85 years or more. Although median hospital stay decreased from 12 to 4 days, intensity of hospital care increased, including use of coronary angioplasty, coronary bypass, and thrombolytics therapy. During the period, reported comorbidity from diabetes and hypertension increased. Acute myocardial infarction complicated by heart failure increased, and cardiogenic shock decreased. Altogether, the in-hospital case-fatality rate declined.Conclusion: During the past quarter century, hospitalization for acute myocardial infarction increased until the mid-1990s, but has declined since then. At the same time, in-hospital case-fatality rates declined steadily. This decline has been associated with more aggressive therapeutic intervention.

Higher Incidence of Mild Cognitive Impairment in Familial Hypercholesterolemia

2010-03-01

Abstract: Objective: Hypercholesterolemia is an early risk factor for Alzheimer's disease. Low-density lipoprotein (LDL) receptors might be involved in this disorder. Our objective was to determine the risk of mild cognitive impairment in a population of patients with heterozygous familial hypercholesterolemia, a condition involving LDL receptor dysfunction and lifelong hypercholesterolemia.Methods: By using a cohort study design, patients with familial hypercholesterolemia (N=47) meeting inclusion criteria and comparison patients without familial hypercholesterolemia (N=70) were consecutively selected from academic specialty and primary care clinics, respectively. All patients were older than 50 years. Those with disorders that could affect cognition, including history of stroke or transient ischemic attacks, were excluded from both groups. Thirteen standardized neuropsychologic tests were performed in all subjects. Mutational analysis was performed in patients with familial hypercholesterolemia, and brain imaging was obtained in those with familial hypercholesterolemia and mild cognitive impairment.Results: Patients with familial hypercholesterolemia showed a high incidence of mild cognitive impairment compared with those without familial hypercholesterolemia (21.3% vs 2.9%; P=.00). This diagnosis was unrelated to structural pathology or white matter disease. There were significant differences, independent of apolipoprotein E4 or E2 status, between those with familial hypercholesterolemia and those with no familial hypercholesterolemia in several cognitive measures, all in the direction of worse performance for those with familial hypercholesterolemia.Conclusion: Because prior studies have shown that older patients with sporadic hypercholesterolemia do not show a higher incidence of mild cognitive impairment, the findings presented suggest that early exposure to elevated cholesterol or LDL receptor dysfunction may be risk factors for mild cognitive impairment.

Adoption of Once-monthly Oral Bisphosphonates and the Impact on Adherence

2010-03-01

Abstract: Background: The extent of the adoption of once-monthly bisphosphonates into general clinical practice is not known, nor is it known if the novel formulation improves adherence.Methods: We analyzed administrative claims 2003-2006 from a large employer-based health insurance database for incident use of oral bisphosphonates and stratified users by daily, weekly, and monthly dosing regimen. We measured adherence as the medication possession ratio (MPR) during the first year of therapy. We compared patient characteristics by dosing regimen and evaluated how the dosing regimen influenced the MPR.Results: We identified 61,125 incident users of bisphosphonates (n=1034 daily, n=56,925 weekly, n=3166 monthly). Monthly bisphosphonate users were, on average, slightly older than the other groups (mean age 66 years for monthly users vs 65 years for weekly users or 66 years for daily users, P<.05) and more often lived in the North Central or South United States (76% vs 72% weekly users or 69% daily users, P<.05). There were no detectable differences among the dosing groups in the history of serious gastrointestinal risk, comorbidity burden, or prior osteoporotic fractures. During the first year of bisphosphonate therapy, 49% of monthly users had MPR≥80% compared with 49% of weekly users (not significant) or 23% of daily users (P<.0001).Conclusion: We found little evidence of preferential prescribing of monthly bisphosphonates to certain types of patients. Furthermore, we found no evidence of improved bisphosphonate adherence with monthly dosing relative to weekly dosing, although adherence with either weekly or monthly dosing was significantly better than with daily dosing.

Postprandial Hypotension

Gina L. Luciano, Maura J. Brennan, Michael B. Rothberg — 2010-03-01

Abstract: Postprandial hypotension is both common in geriatric patients and an important but under-recognized cause of syncope. Other populations at risk include those with Parkinson disease and autonomic failure. The mechanism is not clearly understood, but appears to be secondary to a blunted sympathetic response to a meal. This review discusses the epidemiology, risk factors, and pathophysiology of postprandial hypotension in the elderly, as well as diagnosis and treatment strategies. Diagnosis can be made based on ambulatory blood pressure monitoring and patient symptoms. Lifestyle modifications such as increased water intake before eating or substituting 6 smaller meals daily for 3 larger meals may be effective treatment options. However, data from randomized, controlled trials are limited. Increased awareness of this disease may lead to improved quality of life, decreased falls and injuries, and the avoidance of unnecessary testing.

Physical Activity and the Risk of Community-acquired Pneumonia in US Women

Mark I. Neuman, Walter C. Willett, Gary C. Curhan — 2010-03-01

Abstract: Background: Exercise bolsters the immune system and can prevent various infections in certain populations. However, limited data exist regarding the role of physical activity and the risk of community-acquired pneumonia.Methods: During a 12-year period, we prospectively examined the association between physical activity and the risk of community-acquired pneumonia among 83,165 women in the Nurses' Health Study II who were between the ages of 27 and 44 years in 1991. We excluded women who had pneumonia before 1991 and those with a history of cancer, cardiovascular disease, or asthma. Biennial self-administered mailed questionnaires were used to determine activity level. Cases of pneumonia required a diagnosis by a physician and confirmation with a chest radiograph.Results: We identified 1265 new cases of community-acquired pneumonia during 965,168 person-years of follow up. After adjusting for age, women in the highest quintile of physical activity were less likely to develop pneumonia than women in the lowest quintile (relative risk [RR] = 0.72; 95% confidence interval [CI], 0.60-0.86; P for trend<.001). However, the association was attenuated and only marginally significant after further adjusting for body mass index, smoking, and alcohol use (RR=0.84; 95% CI, 0.70-1.01; P for trend=.06). Women in the highest quintile of walking were less likely to develop pneumonia compared with women who walked the least (multivariate adjusted RR=0.82; 95% CI, 0.69-0.98); however, the trend across quintiles was not significant (P for trend=.25).Conclusion: Higher physical activity does not substantially reduce pneumonia risk in well-nourished women.

Polymyalgia Rheumatica with Bilateral Subclavian Artery Stenosis

Daniela Ghetie, Alla Rudinskaya, Alan Dietzek — 2010-03-01

The overlap between polymyalgia rheumatica and giant cell arteritis has prompted physicians' attention since the early 1970s. Polymyalgia rheumatica occurs in approximately 50% of patients with giant cell arteritis, and approximately 15% of patients with polymyalgia rheumatica develop giant cell arteritis. Some experts consider polymyalgia rheumatica and giant cell arteritis to be different manifestations of the same pathologic process. Although the association of occlusive vascular disease is well known in giant cell arteritis, it is not considered to be a typical manifestation of polymyalgia rheumatica.

Nocturia: An Uncommon Presentation of Lower-Limb Lymphedema

2010-03-01

We report a case of nocturia as an uncommon presentation of lower-limb lymphedema in a 56-year-old man. To our knowledge, this is the first case reported in the literature. A 56-year-old man was admitted to the Department of Internal Medicine, University of Genova, on May 2008 for progressively worsening edema of the lower limbs. He had a history of nocturia (6-7 voids per night) since February 2007. Laboratory examination showed normal serum creatinine (0.7 mg/dL), urea nitrogen (13 mg/dL), and glucose (68 mg/dL). Urinalysis revealed normal urine pH (5.5), specific gravity (1.020), and osmolarity (750 mOsm/kg), and absence of proteinuria. Microalbuminuria, serum total protein, and albumin levels were in the normal range (20 mg/24 h, 7.2 g/dL, and 4.2 g/dL, respectively). Serum levels of protein C, protein S, and antithrombin III were in the normal range. Methylenetetrahydrofolate reductase C677T gene mutation, factor V Leiden, and prothrombin G20210A gene mutations were absent. Thoracic and abdominal computed tomography scans excluded thoracic duct obstruction and thrombosis of the superior and inferior venae cavae and the renal and iliac veins, and showed normal kidneys without perfusion defects. Lower-limb venous Doppler ultrasonography excluded venous insufficiency and thrombosis. Echocardiography showed only septal myocardial hypertrophy. Lower-limb 99mTc lymphoscintigraphy suggested dilated superficial lymphatic collectors and deep lymphatic trunks, delayed and asymmetric visualization of regional lymph nodes, and the presence of “dermal back-flow.” Clinical and imaging data were suggestive for the diagnosis of lower-limb lymphedema. Treatment with low-dose aspirin (100 mg/d), low-molecular-weight heparin (4.000 IU/d), and chlortalidone (25 mg/d) was started. Edematous enlargement was treated with massage and a compression stocking. This approach was helpful and allowed the complete remission of nocturia and lymphedema within 10 days. The use of an elastic stocking transmitted high-grade compression (60 mm Hg) and prevented fluid accumulation. At present, the patient feels good, always uses an elastic stocking, and is receiving treatment with low-dose aspirin (100 mg/d).

Eroded Pacemaker in an Elderly Patient

Eliza Heather McCaw, Bryan Ristow, Richard Hongo — 2010-03-01

An 84-year-old man with severe ischemic cardiomyopathy and history of congestive heart failure was transferred to our hospital for biventricular implantable cardioverter defibrillator pocket erosion. He had originally undergone dual-chamber pacemaker implantation for intermittent complete atrioventricular block in 2000. He then developed worsening heart failure symptoms in the setting of declining left ventricular (LV) systolic function, and the device was upgraded to a biventricular system in 2006. There was initial improvement that disappeared due to LV lead dislodgement. Attempted LV lead revision in July 2007 was not successful. Two weeks later he underwent epicardial LV lead placement via mini-thoracotomy. Postoperatively he had ongoing discomfort at the wound, and in December 2007 he developed worsening redness and discomfort over the device.

Relief of Chronic Neuropathic Pain through Endothelin Antagonism

Desmond M. Murphy, Dermot S. O'Callaghan, Sean P. Gaine — 2010-03-01

The endothelin system and the potent vasoconstrictor endothelin-1 are fundamentally involved in the development and progression of pulmonary arterial hypertension. The effects of endothelin-1 are predominantly mediated through actions at 2 receptors, endothelin-A and endothelin-B. Nonselective endothelin receptor antagonism and selective endothelin-A antagonism have both proved to be successful treatment strategies for pulmonary arterial hypertension.

Transient Collateral Circulation during Coronary Vasospasm

Shigemasa Tani, Shingo Furuya, Ken Nagao, Atsushi Hirayama — 2010-03-01

A 62-year-old man who was a heavy smoker presented to the hospital with chest pain that occurred while he was sleeping. Coronary angiography was performed, which showed collateral vessels from the left anterior descending artery to the right coronary artery but no significant organic stenosis in the left coronary artery. Right coronary angiography was immediately performed, showing severe stenosis of the proximal right coronary artery (), although no electrocardiographic changes were observed. Vasospasm of the right coronary artery was treated immediately by intracoronary administration of isosorbide dinitrate. A left coronary angiography performed immediately after the isosorbide dinitrate administration showed disappearance of the collateral vessels from the left anterior descending artery to the right coronary artery seen in the earlier test ().

Bromide Toxicity from Consumption of Dead Sea Salt

Brent R. Taylor, Romina Sosa, William J. Stone — 2010-03-01

Bromide salt is an effective antiepileptic and sedative in small doses and was once a common ingredient of many medicines and patent tonics such as Dr. Miles' Nervine and Bromo-Seltzer. Unfortunately, the long 10-12 day half-life of bromide results in an intolerably narrow therapeutic window. Bromide toxicity or “bromism” accounted for over 2% of admissions to psychiatric hospitals before the removal of bromide salts from most US medications in 1975. With the advent of Internet commerce, patients now have greater access to relatively unregulated medications and products. We report a case of bromide toxicity after the consumption of Dead Sea salt obtained over the Internet.

Emergence of Fluoroquinolone Resistance in Outpatient Urinary Escherichia Coli Isolates

François Caron, Manuel Etienne — 2010-03-01

Johnson et al recently reported in a large area a rapid and impressive increase in fluoroquinolone resistance in Escherichia coli urine isolates after switching from trimethoprim-sulfamethoxazole to levofloxacin for the initial therapy of urinary tract infection (UTI).

Program Director Satisfaction Revisited: An Alternate View

Gregory C. Kane — 2010-03-01

Your February 2009 issue included a landmark contribution from Hinchey and colleagues regarding the second administration of the internal medicine program director satisfaction survey. It is important to recognize that among the variables measured, the program director salary, balance of time on service, and number of support staff were important factors in the satisfaction of the cohort. I must confess that I too scanned Table 3 to view the spectrum of salary responses—that is only human nature. But I realized that maybe we missed the point here and that an alternate perspective needed to be shared.

The Reply

Kevin T. Hinchey, Furman S. McDonald, Brent W. Beasley — 2010-03-01

Kane thoughtfully and correctly recognizes factors that contribute to program director satisfaction. The important landmark events in the lives and training of the young physicians in our programs triggered happy memories and general assent from all of us. In fact, the data we presented are concordant with Kane's statements. To understand the components of the Program Director Satisfaction Survey (PD-Sat) instrument, the reader is referred to Table 2 of our article, where it is clear that the facets of “work with residents” and “work with colleagues” make up the near majority of total satisfaction compared with the other 5 facets combined. Furthermore, the essence of what Kane has identified, “work with residents,” was the only facet to demonstrate statistical stability in both the 1996 and 2005 administrations of the instrument, indicating that this is a particularly enduring component of program director satisfaction. Kane focused on the associations in Tables 3 and 4 of our article, which were found by assessing the link between scores on the PD-Sat instrument and the variables that were otherwise measured in the 2005 Association of Program Directors in Internal Medicine Program Director's Survey. We note in the results that the regression model identifying the 4 potentially modifiable, statistically independent, and significant factors associated with program director satisfaction accounted for only 14% of the total variance in PD-Sat scores. Clearly, there are other variables that account for program director satisfaction, and it is likely that many of them relate to the primary facet of “work with residents,” as Kane has suggested. We look forward to further studies of program director satisfaction that may test this and other hypotheses to further delineate the components of program director satisfaction so that we may all better mentor the next generation of program directors to provide the stability in leadership our residents deserve for the growth of their careers.

Influence of Hispanic Ethnicity and Diabetic End-stage Renal Disease

Patricio A. Pazmiño — 2010-03-01

I read with interest the large national Veterans Administration cohort study by Choi et al on the white/black racial differences in risk of end-stage renal disease and death. In the results section, it is noted that 325,568 or 13.9% of patients with nonwhite/black or unknown race were excluded. This study of patients receiving care in the Veterans Health Administration is then based on analysis of 2,015,891 (84.5%) patients (1,704,101 white and 311,790 black patients), and it would be important to find out if they have data analysis of the Veterans Administration groups studied according to ethnicity (Hispanic, non-Hispanic, or unknown).

The Reply

Andy I. Choi, German T. Hernandez, Rudolph A. Rodriguez, Ann M. O'Hare — 2010-03-01

We thank Pazmiño for his interest in our article and for his important comments on the burden of kidney disease among Hispanics in this country. In our study, we focused on the disparities in risk of mortality and end-stage renal disease between white and black patients. Non-black race/ethnic minorities represent approximately 6% of the patients receiving care in the Veterans Health Administration, therefore, we were underpowered to examine end-stage renal disease and mortality in these groups. However, we are in complete agreement with Pazmiño that disparities in kidney disease are not limited to blacks and that public health efforts to reduce the burden of kidney disease will need to account for Hispanics—who are a rapidly increasing segment of the population—along with other underrepresented groups. We plan further study of kidney disease in these race/ethnic minority groups in the future.

Severe H1N1-Associated Acute Respiratory Distress Syndrome: A Case Series

Andrew R. Lai, Kevin Keet, Celina M. Yong, Janet V. Diaz — 2010-03-01

Abstract: Background: Acute respiratory distress syndrome resulting from novel influenza A virus (H1N1) infection remains uncommon.Methods: We describe the clinical profiles of adult patients with acute respiratory distress syndrome due to microbiologically confirmed H1N1 admitted to a medical intensive care unit in San Francisco, California over a 2-month period.Results: Between June 1 and July 31, 2009, 7 patients (age range: 25-66 years; 4 patients under the age of 40 years; 6 male; 1 pregnant) were diagnosed with H1N1, with 5 of 6 (83%) having initial false-negative rapid testing. All developed respiratory failure complicated by acute respiratory distress syndrome, with 4 additionally developing multiorgan dysfunction. All were managed with a lung protective ventilator strategy (average number of days on the ventilator: 16), and 4 patients also required additional rescue therapies for refractory hypoxemia, including very high positive end-expiratory pressure, inhaled epoprostenol, recruitment maneuvers, and prone positioning. Despite these measures, 3 patients (43%) ultimately died.Conclusions: Clinicians should be vigilant for the potential of H1N1 infection to progress to severe acute respiratory distress syndrome in a variety of patient demographics, including younger patients without baseline cardiopulmonary disease. A high degree of suspicion is critical, especially with the relative insensitivity of rapid testing, and should prompt empiric antiviral therapy.

Measuring Resident Hours by Tracking Interactions with the Computerized Record

Daniel Shine, Ellen Pearlman, Brendan Watkins — 2010-03-01

The impact of resident duty hours on clinical and educational outcomes continues to concern professional and government oversight groups. Duty hours regulations have both stimulated and responded to a growing literature; but even after considerable study, the relationships remain uncertain among sleep, fatigue, effective education, hospital working conditions, hand-offs, patient safety, and resident burn-out. To be persuasive, reports investigating these relationships must accurately and completely measure the independent variable: resident duty hours. The almost universal practice of deriving duty hours from retrospectively completed time-cards, whether actual or computerized, has been criticized as potentially biased and poorly reproducible.

2010-03-01

The American Journal of Medicine

We Can Reduce US Health Care Costs

Reexamining the Physician Scholar–Professional Organization Relationship

Thank You, Thank You, Thank You

Atrial Fibrillation in Heart Failure: A Comprehensive Review

Primary Care of the Transplant Patient

Diabetic Retinopathy: An Update on Treatment

The Improving Continuous Cardiac Care (IC3) Program and Outpatient Quality Improvement

Exotic Origin, Familiar Culprit

A Post-cure Complication

Computer Calls for Cardiology Consult STAT!

Diabetes Mellitus and Confusion

Analgesic Use and the Risk of Hearing Loss in Men

Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?

Orthostatic Syndromes Differ in Syncope Frequency

Long-term Effect of Chronic Oral Anticoagulation with Warfarin after Acute Myocardial Infarction

Acute Myocardial Infarction Hospitalization in the United States, 1979 to 2005

Higher Incidence of Mild Cognitive Impairment in Familial Hypercholesterolemia

Adoption of Once-monthly Oral Bisphosphonates and the Impact on Adherence

Postprandial Hypotension

Physical Activity and the Risk of Community-acquired Pneumonia in US Women

Polymyalgia Rheumatica with Bilateral Subclavian Artery Stenosis

Nocturia: An Uncommon Presentation of Lower-Limb Lymphedema

Eroded Pacemaker in an Elderly Patient

Relief of Chronic Neuropathic Pain through Endothelin Antagonism

Transient Collateral Circulation during Coronary Vasospasm

Bromide Toxicity from Consumption of Dead Sea Salt

Emergence of Fluoroquinolone Resistance in Outpatient Urinary Escherichia Coli Isolates

Program Director Satisfaction Revisited: An Alternate View

The Reply

Influence of Hispanic Ethnicity and Diabetic End-stage Renal Disease

The Reply

Severe H1N1-Associated Acute Respiratory Distress Syndrome: A Case Series

Measuring Resident Hours by Tracking Interactions with the Computerized Record

Contents