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.