New CME Feature... CaseBook Consults: Improving Outcomes in Gout

A new continuing medical education module has been added to The American Journal of Medicine website. Check it out.

CaseBook Consults: Improving Outcomes in Gout
(iPad compatible)
Presenters: Paul P. Doghramji, MD, FAAFP, Brian F. Mandell, MD, PhD, FACR, MACP, and Rick S. Pope, MPAS, PA-C, DFAAPA

Despite the fact that gout can be diagnosed with relative certainty and that effective therapies have been available for a long time, gout is underdiagnosed and undertreated, management is less than optimal, and poor clinical outcomes are not uncommon. It is the aim of this CE activity to provide information that will assist primary care providers to improve management and clinical outcomes for their patients with gout. Specifically, the program will convey the key factors needed to confidently make a presumptive diagnosis of gout, explore the rationale, timing and duration of pharmacologic treatment of gout and hyperuricemia, discuss the importance of achieving a target SUA level of ≤6.0 mg/dL with urate lowering therapy (ULT), and provide examples of how to educate and communicate with patients to improve adherence to urate-lowering therapy and overall outcomes.

Commercial Support: This activity is supported by an educational grant from Takeda Pharmaceuticals North America, Inc.

Review and Sponsorship: This multimedia activity was peer reviewed by The American Journal of Medicine and The Journal for Nurse Practitioners and is jointly sponsored by Beth Israel Medical Center; St. Luke's and Roosevelt Hospitals and Health Education Alliance, Inc.

To log into this activity or view other CME modules, click here.

Leading Causes of Infertility in Men

There are many reasons why it is difficult for couples to conceive. Some women have problems with their reproductive organs while some men have infertility issues. About 30% of the infertility cases in the country are due to problems with men. if you and your partner have been trying for a baby for a year and have had no success, it is time to consult your doctor. The good news is that more than 90% of infertility problems can be treated successfully. There is no need to worry yourselves too much. With the right doctor and the right treatment, you will soon become the parents of a healthy baby.

There are many things which can cause infertility in men. There are various treatment for each problem. The sooner they are addressed, the greater chances of conceiving a baby. With sperm analysis, these problems can be determined.
Irregular sperm. If a man has little to no sperm; poor sperm movement; and abnormally shaped sperm, there is lesser chances for the sperm to fertilize the eggs. The possible solutions for this problem are fertility drugs, artificial insemination and intracytoplasmic sperm injection.

Blockages. Some men have blockages on their ejaculatory ducts which prevent the sperm from going into the ejaculate fluid. This can also prevent the sperm from getting to the egg. The common causes of blockages are congenital defects, infection, injury and a vasectomy. One of the possible solutions for this is to perform surgery to repair the obstruction or reverse the vasectomy. More than 50% of men have had more sperm after the surgery is performed.

Varicocele. Varicocele is enlarged veins in the scrotum, very similar to varicose veins. This raises the testes' temperature which negatively affects the production of sperm. A physical exam can help detect this problem and surgery is often recommended to repair the varicocele. More than 40% of men go on to impregnate their partner within two years after surgery is performed.

Sperm allergy. Although this is a bit unusual, there are men who have this problem. The body can produce antibodies which can kill the sperm and this commonly happens after a vasectomy is done. Other instances when this happens are during testicular torsion, trauma and infection. For men who have this problem, the possible solutions are artificial insemination and ART or assisted reproductive technologies.

Unexplained fertility problems. Aside from fertility issues which have been identified, there are also fertility problems which cannot be explained. This happens when doctors cannot pinpoint the cause of the problem. According to some experts, it could be the toxins in the environment; however, there are still no direct links between fertility problems and environmental toxins. Often, the best solution for this is a variety of fertility drugs. Fertility drugs can increase sperm production and when combined with artificial insemination, it can produce a success rate of up to 40%.

Schizophrenia for Primary Care Providers: How to Contribute to the Care of a Vulnerable Patient Population

Patients with schizophrenia represent a vulnerable population with high medical needs that are often missed or undertreated. Primary care providers have the potential to reduce health disparities experienced by this population and make a substantial difference in the overall health of these patients. This review provides primary care providers with a general understanding of the psychiatric and medical issues specific to patients with schizophrenia and a clinically practical framework for engaging and assessing this vulnerable patient population and assisting them in achieving optimal health. Initial steps in this framework include conducting a focused medical evaluation of psychosis and connecting patients with untreated psychosis to psychiatric care as promptly as possible. Given the significant contribution of cardiovascular disease to morbidity and mortality in schizophrenia, a top priority of primary care for patients with schizophrenia should be cardiovascular disease prevention and treatment through regular risk factor screening, appropriate lifestyle interventions, and other indicated therapies.

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

-- Mark Viron, MD, Travis Baggett, MD, MPH, Michele Hill, MB, MRCPsych, Oliver Freudenreich, MD

This article originally appeared in March 2012 issue of The American Journal of Medicine.

The Art Of Weight Loss and The Help It Brings

When you are out hunting for a weight loss, there are always those few extra pounds that you never seem quite able to get completely rid off no matter how hard you try. You have tried countless of diets, numerous training routines, and let us be honest- you have tried your way through more than a couple of short cuts that you instinctively knew sounded to good to be true, but still you could not resist the temptation of losing weight while eating a bucket of chicken wings from the closest fast-food restaurant.

Getting Started Again

You may ask yourself why you should bother getting up in the saddle, as so many diets has proved over and over that they do not keep what they promise. It is a tiresome routine to constantly be put through, as each disappointment you encounter makes it harder and harder for you to keep your faith and your strength up.

But the good news is, that there is actually diets that still work, that still keep what they promise and if you commit to holding your end of the bargain- which is to exercise- the diet will combine with your efforts and you can be on your way to achieving that slender beach-body that you have so sorely missed since High School.

No Pain, No Gain

What you should be on the look-out for when it comes to diets, it is to take to heart the old advice that if something sounds to good to be true, it probably is too good to be true. A good, balanced diet, containing the right ingredients and nutrition, is not a quick fix or a short-cut to the body you always wanted, it is a foundation. So the diet that puts some of the responsibility back on you, is probably a safer bet to try than any other.

The magical pill of reducing fat just is not available. There is no laboratory that has solved this problem, at least not in a way that is going to leave you in a healthy state of mind after taking it, so you just have to mentally prepare yourself for the effort the diet to be successful, is going to require from your side.

Of course, you can lose a lot of pounds by not eating anything at all, as well as you can by just drinking a protein shake a day, but this definitely is not the way to a sustainable future for your body, or for your mind, and these shock-therapies when it comes to diets will for sure be made up for by your body once you quit them. Gaining weight after going through such an ordeal is almost always the case, and if you want to make your weight loss permanent, know that it will require some effort from your side as well.

What's new in AJM's March issue?

AJM Editor-in-Chief Joseph S. Alpert, MD reviews new research in the March 2012 issue of The American Journal of Medicine.

Tips in Removing Cellulite

Many women face the problem of having cellulite, the fatty deposits or substance found under the connective tissues which is beneath the surface of the skin. This substance presses on these tissues thus making the skin ripple and wrinkled thus giving it a "cottage cheese" or "orange peel" look. The good news is there are products, treatments and even procedures in order to remove or reduce the appearance of these fatty deposits found on the tummy area, thighs, hips and buttocks. In this article are the tips in removing the cottage cheese appearance of the skin.

Because this fatty substance is actually fat, it is important to eliminate it through regular exercise before they push the tissues to the skin. These exercises include flexibility training, strength training and cardiovascular workout. Such workouts should be done at least thrice a week to be effective.

Another way to help eliminate the orange peel appearance of the skin is to lather it with a moisturizer containing a sunless tanner. The latter will make your skin a little darker thus diminishing the cellulite. Your skin will be hydrated by the moisturizer thus eliminating the rippling of your skin. You can use this technique as you exercise your fats away.

There are many creams out in the market that remove these fatty substances but make sure you buy a high-quality one. This can be quite expensive but it is more effective than the ones which are inexpensive. The cream should have anti-inflammatory properties and antioxidants.

Skin brushing is a technique many women try because of its affordability and simplicity. Get a gentle body brush or a loofah sponge and mildly massage this on your whole body, especially the areas with the fatty deposits. Aside from exfoliation, this shall encourage blood flow which would help flush out fat deposits from the body thus minimizing the orange peel of the affected areas.

There are also invasive procedures that immediately eliminate the dimpling of the skin. These are mesotherapy and liposuction. This should be performed by a licensed plastic or cosmetic surgeon. It is important to speak to the doctor first prior to undergoing such surgeries. They may not be ideal for your health and your body.

When exercising, this should be followed by a healthy diet filled with fruits and vegetables. These have antioxidants and fiber that help remove fatty deposits and toxins from the body. These toxins also help in the storage of fats in the body thus it is imperative to remove them.

The Health Benefits From Dark Chocolate

Chocolate has the reputation of being a sweet and sinful treat that is full of calories and sugar. Well, take heart chocolate lovers along comes the dark variety and science is telling us now that it is a super healthy food.

Dark chocolate that is 70 percent cocoa, at a minimum, contains a high amount of antioxidants. Antioxidants neutralize the free radicals in our bodies. Why is this good? Free radicals are a by-product of the natural process of oxidation that occurs within our bodies. Our bodies are like machines they generate fuel from our food intake so that we can live and be active. At the same time free radicals are created; like a waste product. Free radicals cause disease, illness and the aging process!

Dark chocolate is also a low glycemic food and that is good news for those who are diabetic or trying to lose weight. Be careful here though, it still has its share of calories so overindulging is not recommended. The fact that it is low on the glycemic index means it doesn't create an insulin response which triggers reactions in the body that contribute to weight gain especially around your waistline.

We are now hearing about chronic inflammation and the ill effects it has on the body, particularly the heart. Well, dark chocolate decreases the inflammation in your body and protects the heart thus reducing the incidence of heart disease. Studies are now showing that it also increases blood flow to the brain and this in turn boosts memory and alertness. Sounds like a good snack choice for those studying for an exam!

The health benefits of dark chocolate are numerous and discoveries are still being made. Just remember a bar must contain at least 70 percent cocoa and if it does not say this percentage on the label then it doesn't contain enough cocoa to provide you with these health benefits. I have seen many chocolate bars on the market that are only labeled as "dark" so be sure to read the label carefully. As with all foods moderation is key; dark chocolate is not low in calories so limit yourself to a small bar each day at a maximum.

Repeat Abdominal Imaging Examinations in a Tertiary Care Hospital

The volume of repeat abdominal imaging examinations has grown by 85% over the past decade. Many factors contribute to repeat imaging, including patient age, sex, underlying disease, initial study modality, practice setting, and radiologist’s recommendation.

Abstract

Background
Reducing unnecessary repeat imaging may reduce waste and costs, and improve health care quality. We aimed to quantify repeat imaging rates in patients with abdominal imaging examinations, and identify factors associated with repeat imaging.

Methods
We retrospectively analyzed all diagnostic abdominal computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), fluoroscopy, and radiograph reports performed at our institution between January 1, 2000 and December 31, 2009. Primary outcome measure was the rate of repeat abdominal imaging (RAI) examinations, defined as any imaging examination of the abdomen on the same patient within 0-90 days of the first (enrollment) examination. We used natural language processing tools to extract recommendations for follow-up imaging from radiology reports. Univariate and multivariate logistic regressions were fitted to determine the effect of patient age, sex, study modality, care setting, follow-up recommendations, and history of neoplasm on the primary outcome over time.

Results
Over 10 years, 245,184 abdominal imaging examinations were performed (43.2% CT, 20.6% US, 16.6% radiograph, 13.9% fluoroscopy, 5.7% MRI). The RAI rate remained unchanged (41.2% to 41.7%); unadjusted RAI volume increased from 6596 to 12,218 (P <.01). Most repeat studies (88.2%) were not preceded by a radiologist's recommendation. Practice setting, study modality, patient age, sex, underlying health condition, and radiologist's recommendations were associated with higher rate of repeat abdominal imaging examinations. Conclusions
A large proportion of abdominal imaging examinations result in a repeat study. Many factors contribute to repeat imaging, including patient age, sex, underlying disease, initial study modality, practice setting, and radiologist's recommendation.

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

-- Ivan K. Ip, MD, MPH, Koenraad J. Mortele, MD, Luciano M. Prevedello, MD, Ramin Khorasani, MD, MPH

This article originally appeared in February 2012 issue of The American Journal of Medicine.

When will malpractice lawsuits be filed against armchair doctors?

Blog Commentary

Ferket and colleagues could have added to their long list a guideline from the Haute Autorité de Santé (High Authority for Health, the French agency for quality of care) which recommended in 2006 for the screening peripheral artery disease and its treatment with aspirin, despite evidence was lacking.(1,2)

This French recommendation is surprising because: a) aspirin does not have a marketing authorization for such a use; b) it was even published in the official bulletin of the French republic to enforce good clinical practices.(3)

Guidelines are generally characterized by poor methodology but the main concern is the neurotic quest of many bodies to issue recommendations for acting despite poor evidence. Only the US Preventive Services Task Force (USPSTF) dare to recommend against routine screening for peripheral arterial disease (Grade: D) as evidence was lacking.(4)

From April 1998 to October 2008, the Aspirin for Asymptomatic Atherosclerosis trial screened 28,980 men and women aged 50 to 75 years, free of clinical cardiovascular disease.(5) Of those, 3,350 with a low ankle brachial index (< or = 0.95) were entered in an intention-to-treat double-blind randomized controlled trial comparing aspirin vs placebo. Aspirin resulted in neither reduction in mortality nor reduction in cardio-vascular events but caused major hemorrhage (HR, 1.71; 95% CI, 0.99-2.97).

Five of the guidelines scrutinized by Ferket and colleagues advocated for screening.(1) This was waste of money as systematic reviews for a complex clinical topic may cost in the range of $300,000 to $350,000 or more (communication from Beth A. Collins Sharp, director, Evidence-Based Practice Centers Program, Agency for Healthcare Research and Quality, November 14, 2008). Failure to withdraw or to update these five guidelines enduringly results in inappropriate care to healthy people.

-- Alain Braillon MD, PhD, France

1 Ferket BS, Spronk S, Colkesen EB, Hunink MG. Systematic Review of Guidelines on Peripheral Artery Disease Screening. Am J Med. 2011 Nov 11 doi:10.1016/j.amjmed.2011.06.027

2 Haute Autorité de Santé. Prise en charge de l’artériopathie chronique oblitérante athéroscléreuse des membres inférieurs - Indications médicamenteuses, de revascularisation et de rééducation. April 2006 Available at http://www.has-sante.fr/portail/upload/docs/application/pdf/AOMI_fiche.pdf Accessed 20 Dec 2011.

3 Avenant à l’accord de bon usage des soins relatif à l’utilisation des antiagrégants plaquettaires NOR : SJSU0722012X Journal Officiel de la République Française. 19 December 2007 Texte 33 sur 143.

4 U.S. Preventive Services Task Force. Screening for Peripheral Arterial Disease. August 2005 current as of December 2011. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspspard.htm Accessed 20 Dec 2011.

5 Fowkes FG, Price JF, Stewart MC et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA. 2010 ;303:841-8

NOTE: Conflict of interests-- Dr Braillon, a senior tenured consultant in Public Health was sacked in Sept 2010 by the National Management Centre (French Department of Health) against the advice of the National Statutory Committee. He won a lawsuit in Sept 2011 against the Haute Autorité de Santé for breach of the Freedom of Information Act but the Haute Autorité de Santé failed to apply the judgment.(Lee SS. The power of one and saving private Braillon. Liver Int 2012;32:1)

Spontaneous Blue Finger Syndrome: A Benign Process

While isolated acute blue discoloration of a finger may be secondary to acute ischemia or vasospasm and underlying systemic illness, some cases are neither dangerous nor signify a systemic condition.

A 46-year-old woman experienced 3 episodes of acute finger discoloration over 2 years. The first episode involved a spontaneous, nontraumatic, nonpainful purple “lump” at the base of the 4th finger. As an embolic phenomenon was suspected, transthoracic echocardiography was performed and was normal. She was discharged on aspirin 81 mg daily. The lesion resolved within several days. A second episode, 22 months later, involved the palmar aspect of the distal phalanx of her right thumb becoming spontaneously red and tender.

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

-- Ido Weinberg, MD, MSc, MHA, Michael R. Jaff, DO

This article originally appeared in January 2012 issue of The American Journal of Medicine.