Steroid-responsive but not Rheumatologic

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

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

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

-- Clare Kelleher, MD, Carrie Herzke, MD

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

A Blast from the Past

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

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

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

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

Pyogenic Liver Abscess as the Initial Manifestation of Underlying Hepatocellular Carcinoma

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

Abstract

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

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

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

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

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

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

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

Macho Male Faces in Vogue

Females are attracted towards alpha males is a universal fact. However to be an alpha male, you must possess certain qualities which may appeal strongly to women. However this theory is now backed up with a new study. According to a new scientific study from Indiana University's Kinsey Institute, women prefer masculine male faces over feminized male faces as a potential sex partner.

The research shows that women brain respond more strongly towards macho face when they are close to ovulation. The finding was published in an online edition of the journal "Evolution and Human Behavior", which confirm the link between women's hormone levels and their brain activity.

The preference of masculine faces is more because that indicate a higher level of testosterone in males. While ovulating, a female crave for acquire the best gene for her offspring. These fluctuating preferences are thought to reflect the evolutionarily changes in women's reproductive priorities. Masculinity is also selected to carry out her immediate goals (i.e. to acquire better gene) and how attractive she rates herself. Sometimes these brain tricks play a vital role in deciding woman's sex drive.

If we see the other side of this research, other than their fertile period a feminized male is preferred because they are good spouse and partners. They are more into a relationship due to their emotional nature. In case of masculine males, they barely stay at home due to the high level of testosterone i.e. they are not faithful.

Anticoagulation-associated Adverse Drug Events

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

Abstract

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

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

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

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

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

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

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

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

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

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

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

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

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

Lead Intoxication Caused by Traditional Chinese Herbal Medicine

The total number of people using traditional Chinese herbal medicine is vast and steadily increasing in East Asian countries and Chinese society. The industrial output value of traditional Chinese herbal medicine has also continued to expand rapidly across the world since the year 2000.1 Here we describe a case of lead intoxication following the use of traditional Chinese herbal medicine as an agent for maintaining health.

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

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

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

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

Can Primary Care Medicine Be Saved?

The number of medical students who choose to train for a career in primary care internal medicine has been falling for decades and has now reached a critical point.1 If the trend is not reversed, many patients in the US will be left without access to a primary care internist. I often get desperate phone calls from my cardiology patients asking me to help them find a primary care internist who is still accepting new patients. A similar situation exists in primary care family medicine. Is the field of primary care medicine about to become extinct? And why don't more young physicians choose this satisfying career path?

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

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

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

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

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

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

Technology Is Great … Except When It Doesn't Work

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

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

A Rare Shock

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

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 & C. difficile

Antimicrobial Use and Risk for Recurrent Clostridium difficile Infection

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.

Feel the Buzz of Being Your Own Success Story!

What wіll make уou аn invincible success? What iѕ сurrently preventing уou from enjoying thе success yоu crave? What are thе keys tо success and hоw саn you bеst begin tо employ theѕе today аnd thrоughout the year ahead until уоur success іѕ ѕо sure іt beсomes уоur reality forever?

The crucial key iѕ уour іnnеr attitude. How did уоu feel аbоut your life when you wеre seventeen? Invincible? Unsure? Were you surе of уоur success іn the years ahead or werе уоu uncertain оf уоur destiny? How dо you feel now? Have thе years bеen kind tо you оr hаs disaster struck? Regardless оf whаt has happened to уou latelу I want you to prime уour innеr attitude. Focus inwаrd оn уour strengths and determine to fill yоurѕelf anew with purpose, enthusiasm, resolution, аnd become dominant, determined, bold, strong, calm, vital, steadfast, self reliant, and full of vigorous energy. You can!

"It іѕ nеver toо late tо bе whаt yоu mіght havе been," claimed the English author George Eliot. How сan you turn уour present situation аrоund for success? Many are life's downward paths whісh lead tо failure, уet уou hаvе only tо turn about and walk back up towаrdѕ victory! Step by step you turn about: Benjamin Franklin advised "Little strokes fell big oaks."

Perception іѕ reality. Whatever уоur current perception of уоur situation, yоur self, уоur ability, this is yоur experience now. First perceive, then receive. Work nоw on уour іnnеr attitude: dwell uрon уоur strengths, уour convictions, уour beliefs - аnd constantly recall yоur past successes: ѕеe уourself аs a ѕurе success! Know yоu wаnt tо becоmе completely successful in all уou do, and bеliеvе уou сan be. Recharge your іnnеr attitude with positive energy bу taking а lіttle time out to gо fоr а walk ѕomеwherе peaceful in the clear air. Put your soul іnto it! Walk vigorously, clear уоur mind. Shoulders back аnd feel strong!

Build уоur perception of whо yоu сan be. What do yоu want? Focus daily оn this: are уou aimed in thе right direction? Taking thе nесessarу steps tо achieve whаt you want? Build level by level: а small success this week at work beforе the big house аnd fast car! Telephone а prospect yоu hаve been putting off. Stand tall аnd speak wіth firmness in уour tone. Expect yes, expect the big order. Receive thе big order! Be dominant. Act аѕ though уоu havе еvеrу confidence, јuѕt аѕ уou expect the bigshots at your workplace to act and speak. Act it out and become. Simple truths work: just act upon this. Build уоurѕelf new habits of determined action today onwards.

Habits аrе cobwebs аt first, iron cables аt last.

Be aware of thе littlе daily actions you tаke whіch іn time pin уou down tо specific behavioral patterns: arе аll уour actions, thoughts and mannerisms primed tоwardѕ thе greatest success?

Good news is, you cаn establish new habits wіthin ѕеvеn days: јust dо ѕomething new eаch day fоr a week and іt bеcomеs swiftly part оf your reality. Much easier tо create new habits thаn to discard old ѕo don't trу tо give up chocolate, јuѕt make а nеw habit of eating а healthy thrеe meal diet with no snacking daily. You саn easily replace the snacks with a glass of water, а short brisk walk, а banana, a motivational quote! Do successful folk snack? Or are thеy too busy feeling the incredible buzz оf bеіng thеіr оwn success story? Commit уourѕеlf to projects уou knоw arе surefire winners wіth a definite reward at the end. Reward уоurself fоr evеry small success, eасh good step forwards.

And when уou are nоt working switch off thе entertainment for nоw and educate yourself. Ebooks are free all ovеr thе internet іf you search for them: уоu cаn learn a lot now for no financial output ѕo there iѕ no excuse! Learn whаt уоu love, learn what the successful people іn your field know, аlwаyѕ learn more. Knowledge pays dividends and opens уоur mind tо endless creativity. W.B.Yeats, thе poet, declared: "Education іѕ nоt the filling of а pail but thе lighting оf а fire."

Set your іnner fire ablaze аnd gеt ready tо accomplish great things. Learn аll you can. Be specific and organized. Spend nо time on unviable projects and put evеn your leisure hours tо effective use. Create а blog so уour colleagues аnd superiors сan sее yоu аrе keen to develop new skills. Write abоut whаt уou learn and ideas уоu hаve for improving your results at work. If yоur present employer doеѕ nоt tаkе notice уou сan be surе thе head hunters оf more progressive firms wіll notice you!

Promote уоur blog through social media and get yourself some ebooks оn enhancing visitor numbers tо yоur blog: get mоre traffic! Learn sоme basic search engine optimization. Get уour message оut thеrе intо thе wide world: yоu nеver know whо iѕ lооking in. Build yourself, уour іnner perception оf уоur worth, build your knowledge and creativity levels and work on уоur fitness, appearance, conversation, listening ability, уour ability to effectively analyse information and уоur sense of logic. Be fair and be generous. Give freely. Seek wisdom. Believe іn уоurѕelf aѕ a true success! Let оthеrs know уоu аre keen tо improve and go further in уоur field of work. Offer your time.

Know what neеds tо be done eaсh day and еach week and focus оnlу on thіs until іt іѕ done, thеn іf уоu hаve time turn yоur attention tо оther usеful tasks оr prepare a plan fоr thе week ahead. See what еlѕе you can accomplish of purpose. Ask!

After twо weeks оf building your inner attitude anew analyze how yоu now feel: mоre vigor? More boldness? Be strong! Be ready tо change whеn the opportunity сomеs уоur way.

It is nevеr tоo late to bе what yоu mіght hаve been. Ignite уour inner fire. Expect success. Be ready to embrace success. Be generous with yоur time аnd уour assistance. The world wаntѕ persons whо arе prepared to do а littlе mоrе than asked, whо tаkе thе time, whо gо аbоut the workplace аs if thеy owned thе company аnd care about thе results. The world haѕ a wау оf exalting such persons to positions оf responsibility. Success.

A Common Fungus, an Unusual (and Deadly) Infection

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?

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

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)

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

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.

Habit of Wealthy People

Probably the first thing that comes to mind when you begin reading an article with this title would be 'spend less', 'save', 'invest', and the like. While these are good things to do, and arguably if you do these you'll amass some amount of money, the above activities are the results of habits, they're secondary to the sorts of basic things this article will discuss. What this article will discuss are more properly the habits of effective people- people who are happy, dynamic, and good at what they do, whatever it is. These are all small, but profound things that come together to make the big things happen more quickly and with greater ease.

Stop Complaining- Complaining is not just annoying to other people, it is harmful to you. huh? Complaining is the strategy we use in order to get other people to solve our problems for us, and what's more, usually it's the strategy we use to make other people feel bad for us. What complaining does for us is to attract people who want to feel bad for you, repel people who won't tolerate that sort of behavior, locks you into a dependency paradigm, and it rewards you for giving up. If you complain effectively, people will come to you and give you attention- it worked when you were a baby, right? The problem is that when complaint becomes a habit, when your first strategy in the face of adversity is to give up and complain in the hopes that other people will come to either solve your problem for you or console you, it means that your habit is to impose on anybody who will let you. Complainers like to describe people who aren't interested in being imposed upon as 'selfish' or 'insensitive', and often are the same people who equate selfishness with bad moral character- after all, if they can't manipulate these people by complaining, they must be bad, right? When you complain, you rob yourself of initiative, you shut your imagination down, and you stop looking for solutions to your problem on your own. Instead of becoming larger than your problems, you become smaller, and in order not to feel miserable about it, you complain in order to get some self-validation. As soon as you bring self-validation into it, you get your ego involved, which only complicates things- at that point you have to choose between being right and being happy, and your ego is very motivated to be right. Instead of finding a way to overcome your problem, you'll settle for feeling righteous about how unfair your life is.

How to know you're getting good at not complaining-

• You look for constructive things to do about a problem first
• big problems start to look a lot smaller, or even un-noticeable
• drama? what drama? The interesting parts of your life are the positive things, rather than the negative ones.
• You don't take adversity personally
• People stop coming to you with their complaints, and start coming to you with good news instead.

Stop Worrying- Worry occurs in your imagination, not in reality. Worry is the process by which you torture yourself with past could've-beens and future what-ifs- both of which are, by virtue of their imaginary status, impossible to address in the present. They are separate from reality, and separate in time, from anything you can control- all you can control is yourself, in the present. If, with your present self, you choose to worry, all you accomplish is to take yourself out of reality for the duration of your trip. If your worry is about something that may happen in the future, ask yourself two questions- 1) is there anything I can do about it now? If so, get to it, and 2) isn't this a problem I'll be able to deal with when it comes up? If your worry is about something that could've happened in the past, ask yourself whether it's relevant in any way to the present or future, and how can you apply questions one and two above to it?...at that point, you can drop the subject, resolved, until the next time you need to deal with whatever it was that bothered you enough to worry. Worry is a function of fear, and fear is your subconscious's way of telling you that it is uncomfortable with something- and your subconscious will make you miserable until the problem goes away... but the problem is that worrying doesn't solve anything. The quickest way (indeed, the only way) to resolve something that bothers you is to act in the present, in reality, outside the context of your fear. Inside it's context... you could wrestle with it forever, and it will only make you unhappy and powerless.

"We can't solve problems by using the same kind of thinking we used when we created them." -Albert Einstein Worry traps you in the context of your fear- in your imagination, out of reality, without a means of actually solving the problem that's got you all worked up. Worry is the stick your subconscious uses to jerk you around, to tell you there's something wrong- it is NOT THE SOLUTION TO THE PROBLEM. I've been told earnestly by a friend that if he didn't worry about the future, the future would be a disaster. A friend of mine told him that worrying doesn't actually *do* anything- it just makes you unhappy now. Upset, he insisted that if he didn't worry, how could he know that he'd behave appropriately in the future? My friend suggested that the only time he'd be able to do anything about it would be when the future arrived... but that when it did arrive he might miss it because he'd still be worrying about an even more distant future instead of behaving well in the present. Sure enough, he got mad at my friend and didn't understand the lesson. I walked away from that conversation with an interesting thought- I don't know that I'll behave appropriately in the future- that is the meaning of freedom. When the time comes, I'll probably do the right thing- out of choice, not because I've tortured or brainwashed myself into it.

How to recognize you're getting good at not worrying:

• You solve problems as they come up
• You procrastinate a lot less than you used to
• You're happier and more free

Get over being selfish- It's a basic truth that you have needs, and a simple way of defining needs is 'what you require in order to fulfill your purpose'. If you're a carpenter, you need your tools or else you can't do carpentry, and it's impossible for you to do the good things you do that make life better for other people. You have many purposes, and therefore many needs- you are someone's child, someone's friend, someone's parent perhaps- all of these roles confer responsibilities upon you, and fulfilling these responsibilities is arguably part of your purpose in life. If you fail to get your own needs met, you cannot effectively serve those purposes. Getting your needs met is an absolutely moral endeavor, because it establishes your own ability to contribute to the lives of others. Being selfish doesn't mean taking more than your share- that's what the complainers would have you think- they want you to feel bad about not meeting their needs before yours. Being selfish is not the opposite of being generous, it is the pre-requisite of being generous. What being selfish does is allow you to fulfill your potential- it allows you to discover, and to express the values that define your purpose in life. It allows you to filter out demands of you that are unreasonable, it allows you to attract positivity and position yourself in a way that everything you do makes you happy, including giving. If you're positioned in your life to get happiness out of everything you do (I get a lot of satisfaction out of giving gifts, it makes me happy, it's a selfish act) then you become motivated to do more- and in doing more, more people benefit from you, it's as simple as that. At the same time, you free yourself to reap the benefits of everything you do- and you realize your ability to fulfill your purpose in life. "Our deepest fear is not that we are inadequate, our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that most frightens us. We ask ourselves, who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you not to be? You are a child of God. Your playing small doesn't serve the world. There's nothing enlightened about shrinking so that other people won't feel insecure around you. We are all meant to shine, as children do[...] it's in everyone. As we let our own light shine we give others permission to do the same; as we're liberated from our own fear, our presence automatically liberates others." -Marianne Williamson Your first responsibility, before all others, is to meet your own needs. Until then, you're not only cheating yourself, you're cheating everyone around you of the benefits that you could have offered to the world, had you realized your potential. If your needs are not met, you cannot be happy, free, ethical, moral... because these are the values that express who you are after they are met. If you don't have what you need in order to be you, you can't do that. For this reason, it is profoundly immoral to neglect your potential, just as it is to ask another to do so. If you are unprepared to serve yourself, you cannot serve others. Make yourself happy, and you will attract people who are, or want to be, happy. Accept that you cannot make anyone else truly happy- only they can do that, by following the same selfishness principle. Create within yourself what you want to attract from without- it works in no other way, and it starts with being selfish.

How to know you're getting better at being selfish:
• Your 'wants' are few.
• Your friends are happier
• You attract more people to you
• More and more of what you do makes you happy

Get over being right- Maybe another way of saying this is 'Quit serving your ego and train your ego to serve you.' Who is the boss here, after all? This one is fundamentally important, because mastering this concept is key to personal freedom, happiness, and being an effective person. If it's your mission in life to validate all of your current beliefs, to prove yourself right at all costs, you are truly the servant of your own ego and you'll resist changing your mind, your beliefs, your opinions, your self, even in light of compelling new information. If you're unwilling to change your mind, you're unwilling to learn, grow, evolve, or adapt to your world, and this can become punishing, because your ego is a demanding thing- it needs a little stroking, and it'll take what it can get- even if it means putting the blinders further on and settling for feeling good about being 'right' when you don't get your way....but what is 'right', anyway? Being 'right', correct, proper, etc. is a subjective judgment you make when you process your observations of the world through the filter of your beliefs, habits, and values... but it is not an absolute, it's just what works for you. There are no facts, only interpretations. -Friedrich Nietzsche...so if being 'right' is subjective, what's the big deal?...the big deal is that your pride is involved, because you've identified personally with an external thing- in other words, you've made it about you personally when it's not about you. It gets in your way, makes it difficult to listen to what other people have to say, makes it difficult for you to surrender to truth as it comes to you, makes it impossible for you to mutate at will. Your pride and your ego are very good things, but they're only good insofar as they serve you- not the other way around- and one of the easiest ways to avoid serving them is to get over your desire to be 'right' about everything, so you can get to work on solving the real problems you'll face in your life, and become your future self with grace and elegance.

Ways to know you're getting over your desire to be right:

• You argue less
• You go weeks without complaining or blaming
• Your happiness lasts longer and is fuller
• You feel capable of being happy effortlessly

Tolerate nothing- If you mean to harm yourself, so they say, it makes no sense to torture yourself with small annoyances- go big or go home....and if you don't mean to harm yourself, why are you putting up with all the torture? Of course, we don't mean 'be intolerant' in the sense of the term that would have you closed-minded or unwilling to accept new or differing ideas or perspectives- that would be an obstacle to your ability to grow and evolve. Instead, the imperative 'tolerate nothing' is a call to root out your cynicism about all the little things in life that aren't perfect, and to help you get clear that you can have it all. At the same time, the call to 'tolerate nothing' does not suggest that the problems you face are bad or wrong- they are simply what is so for you- and rather than viewing them in the context of right or wrong, it's much more constructive to view them in the context of choice. Many of us tolerate the small things that plague us in our daily lives because we're simply unconscious to the fact that we have choice around them- that is, we're honestly convinced that 'this is just how life is'. Often what's underneath this is the fear that if we deal with this one, the next one could be bigger and scarier. In truth, the size of the 'problem' that stops you is precisely the size of YOU- or, said another way, the size of the problem that stops you is how big you declare yourself to be relative to it. In life, there will always be problems. It is part of the human condition to be confronted by challenge, to identify personally with adversity and in a sense, to be defined as a being by the scope of the challenges we take on. Another important idea is that we're here to learn and grow as we become our future selves- and solving problems is the way we learn from our world. What's more, it feels good to solve them. To be human is to have problems, and the question you want to ask yourself is this: are the problems you have right now worthy of you? Are they a fitting expenditure of your life? Most people go through their lives trying to get rid of problems, or at best, trying to make their problems as small as possible. Effective people expand themselves by taking on problems that cause them to grow, develop, learn.

Ways to know you're getting good at tolerating nothing:

• You solve problems before you worry about them
• Problems become lighter, easier to deal with, and much more interesting.
• Solving problems, even substantial ones, becomes no big deal

Surround yourself with success- Each of us lives our lives within a variety of communities and social contexts. Success in the abstract (that is, any sort of success, it needn't be limited to the financial sort) is a social function, and it is accomplished within the context of community. Part of surrounding yourself with success is merely in recognizing the successes around you- indeed, there's plenty, the sky is raining soup, as it were- and in becoming attuned to this success. If you said you'd take out the garbage and you did, you succeeded! 99% of your life is a success. Another component of surrounding yourself with success is in actively generating the community within which you will realize your success (again, we're talking about success in the abstract- it could be having a great relationship, learning to throw a curve ball, or running a profitable business)- and in generating community, what you generate is the space within which you and others create the results by which you will be measured. Of course, community is a cooperative effort- to exist, it requires multiple people operating at this level, and one of best ways to choose these people is to look at the kinds of results they've been generating. Surrounding yourself with people whose results match the kinds you're hoping to generate is a good way to generate this space- and what's more, these are the best people to learn from- who better to ask about throwing a curve ball than someone who can do it? It's not necessary to dump your 'loser' friends in order to succeed- after all, they each have their own successes as well (very few people are completely unremarkable)- but consider that if their perspective/filters/outlook are causing them to produce results you don't want for yourself, that the community you share with them may not be the best one to seek success in.

Ways to know you're getting good at surrounding yourself with success:

• The drama in your communities becomes much less
• The gossip in your communities becomes about all the great things going on
• You get into the habit of celebrating the little things

Don't fear failure- In order to succeed, first you have to try. If your fear of failure is greater than your desire to succeed, odds are good that you won't try, and therefore cannot succeed. Fear is an illusion we create in order to avoid pain, and at it's root is generally a morbid fantasy that if we don't avoid (whatever it is we're afraid of) that we'll end up experiencing pain of some sort, abandonment, or death. Of course, if we follow out the chain of logic that connects the two, we'll discover that it's a little ridiculous. What's the worst that could realistically happen, and how much of it is in your head? Again, this becomes an exercise in spotting how much your ego rules you. The idea here is to become the person whose ego serves them- because your ego is an incredibly powerful and amazing part of you- but it can be a cruel master if you choose to serve it.

How to know you're not afraid to fail:

• You accomplish more
• You don't notice that you're trying more things
• Your world becomes much larger and richer
• Nothing is a big deal

Treat your body right- Your body will treat you as you treat it- so it's vital that you get out with it and keep it healthy. What's more, exercise reduces stress, helps you rest better, sharpens your mind, lengthens your life, and improves its' quality. If you smoke, do what it takes to quit. If you're clinically overweight or have other health challenges, do what it takes to manage your health- you only have one body, and using it as it was meant to be used makes it feel better, last longer, and look better. With exercise, your body becomes stronger, your energy levels go up, your bones become stronger... and with an active sense of play, exercise can be just plain fun....but it doesn't necessarily follow that more is better. Too much can be worse than not enough- it can lead to injuries and other health problems.

Ways to know you're doing it right:

• You feel better all the time
• You sleep well and wake up refreshed
• You need less sleep

Do Nothing "Because you Should"- The word 'should' confers a duality- it distinguishes what you want to do from what you think is the right thing to do- meaning that if you govern yourself with 'shoulds', what you're creating is a conflict within yourself. Instead of simply wanting to do the right thing (the elegant path), when you govern yourself with 'shoulds' you create and empower a separate part of you to tell you that you shouldn't do what you want- and this part of you operates by making you feel guilty and miserable. The word 'should' is the weapon of your negative ego- that's the part of you whose job it is to belittle and control you... when the purpose of your life is to grow, be happy and free, and to express your higher purpose in life. We empower our negative ego in order to balance out our 'positive' one's faults- for example, if your ego gets a lot of validation out of spending lots of money on status symbols, the negative ego's job would be to make you feel guilty over spending more than you can afford. The entire reason for empowering our 'negative ego' is because we resist changing the positive one- but this is a path of self-conflict and wasted energy. Instead of creating a separate entity to fight us and make us feel dumb and guilty, we can simply become the person who wants to (rather than 'thinks they should') do what is best for themselves. The key here is in allowing reality, rather than your ego, to guide the way you adapt to your world. Mutate at will. This has nothing to do with principles- by all means, be true to your values- but don't mistake your values for your concept of 'self'- as soon as you do that, your ego is engaged and you're on the hook. For example, in this case (where you're driven to keep up with the joneses by your concept of self) it's really tempting to believe that without being ahead of the joneses, you would cease to be you- but that's just not true.

Men and Sexual Fanatsy

The integrity of sperm DNA is essential for the transmission of the father's gene contribution. Tests which show an increased fraction of sperm DNA fragmentation often correlates to other sperm pathologies such as poor motility, count and morphology. Most reproductive endocrinology clinics do not test for this often hidden pathology even when the patient presents with poor sperm parameters.

As in all areas of medicine, there is internecine battling going on between physicians as to the meaning and the effect of this issue on male fertility. Some doctors completely disagree with its relevancy as a contributor to male infertility; some physicians accept its contribution but don't know what to do with the findings; others think that the only real detriment to the quality of sperm rendered by DNA fragmentation is the sperms inability to penetrate the egg and they think that injecting the sperm into the egg (ICSI) effectively deals with the problem. It does not.

DNA fragmentation has a far reaching effect on fertility and surpasses the mere diminished ability of sperm to penetrate egg.

Some studies show that with higher percentages of fragmentation there are increased correlations in spontaneous abortions. The proportion of patients with abnormal sperm DNA integrity is higher in couples with spontaneous miscarriage. This is not surprising as a good embryo is nothing other than the combination of a good egg with a good sperm and sperm with DNA fragmentation is not good sperm.

In sperm without DNA fragmentation the DNA is protected from damage while being transported through both the male and female reproductive tracts; if there is damage to the DNA then impaired fertility is an obvious consequence.

Causes are many and varied ranging from genetic anomalies to reactive oxygen species due to white blood cell (leukocyte) infiltration), as well as vericoceles. As DNA repair systems are less active in the later stages of sperm production, sperm with fragmented DNA can readily reach the ejaculate.

Men that have sperm DNA fragmentation greater than 30% are typically infertile.

Treatment options Antioxidant therapy

Antioxidants 'scavenge' reactive oxygen species and can, in some instances, reduce sperm DNA fragmentation percentages. A n anti oxidant compound which has been shown to be effective in some instances is composed of lycopene 6mg, vitamin E 400IU, vitamin C 100mg, zinc 25mg, selenium 26 mg, folate.5 mg and garlic (available in pill form)1000 mg. This should be taken once daily.

Acupuncture and Herbs

Acupuncture with its ability to stimulate blood which transports oxygen and nutrients to the testes, while carrying debris away from the testes may also be an effective treatment.

Many herbal medicines also have high antioxidant properties and should be included in the treatment regimen. Combining antioxidant therapy as described above with acupuncture and herbal medicine can potentially increase fertility outcomes in men with high percentages of DNA fragmentation.

Smoking cigarettes and marijuana have been shown to contribute to sperm DNA fragmentation. Elimination of these mitigators may also help to normalize sperm.

30 Articles in Press available on AJM website

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

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

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

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

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)

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

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

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

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...

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-- -- 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

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.

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-- -- 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

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.

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-- -- 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

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

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.

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-- -- 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.