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...

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

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

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

Weight and Mortality Following Heart Failure Hospitalization among Diabetic Patients

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

Abstract 


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

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

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

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

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

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

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