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).

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-- 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.

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-- 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.

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-- 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.

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-- -- 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.

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-- --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.