Fainting with HIV

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

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

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

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

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

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

Stimulating the interest for conflicting scientific debates

Blog Commentary

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

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

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

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

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

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

-- Alain Braillon MD, PhD

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

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

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

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

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

Ludwig's Angina

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

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

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

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

It Is Only the Ignorant Who Despise Education

“It is only the ignorant who despise education.”

Publius Cyrus, Latin Poet, 43-85 AD

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

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

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

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

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

Do you need one more reason to quit smoking?

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

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

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

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

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

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

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

Medical Education Today: Is Science Enough?

Blog Commentary

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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