Dec 2012: Gait Speed & Functionality

Gait speed and functional ability give physicians longevity clues regarding their geriatric patients. Editor-in-chief Dr. Joseph S. Alpert reviews new geriatric research in the December 2012 issue of The American Journal of Medicine.

Lead Poisoning & Ayurvedics

Ayurvedic Remedy for Diabetes as a Cause of Lead Poisoning: A Case Report

The popularity of alternative or complementary medicine has dramatically increased over the years. These types of medicine are assumed by patients to be safe and free of side effects.

A 56-year-old man presented to the emergency department with diffuse abdominal pain of 3 months' duration, decreased oral intake, and constipation. Laboratory values showed that hemoglobin had decreased to 9.7 g/dL (from a baseline of 14 g/dL 1 year previously). Levels of serum iron, transferrin, haptoglobin, vitamin B12, and folic acid were within normal limits. The anemia was normocytic, and liver enzymes were mildly elevated. Abdominal computed tomography, upper gastrointestinal endoscopy, and colonoscopy results were unremarkable. Peripheral blood smear demonstrated prominent basophilic stippling within the erythrocytes, which prompted measurement of a blood lead level that was markedly elevated (101 μg/dL). Urine porphyrins also were elevated.

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--Amishi Desai, MBBS, Harry Staszewski, MD

--This article originally appeared in the October 2012 issue of The American Journal of Medicine.

Nov 2012: Bandemia Research

Editor-in-chief Dr. Joseph S. Alpert discusses new research in the November 2012 issue of The American Journal of Medicine.

In Praise of Paper(s)

It was Sunday, and I had a bit more energy than was good for me. Our house was swimming in post-holiday clutter, and we desperately needed additional storage space. I spied my rusty 5-drawer filing cabinet tucked into the corner of the garage. It was crammed with 2 decades' worth of papers, covering everything from “Death and Dying” to “A Hemodynamic Approach to the Treatment of Heart Failure” (I'm a general internist). But it's 2012, and we're fully wired, so, really, what's the point of all those papers? They seemed to be just taking up space that was needed for other important items, such as Legos and sports paraphernalia.

 I wheeled over the big blue bin, fully intending to dump all of the files and get rid of the cabinet. But then I started thumbing through the articles: “The Thrombolysis in Myocardial Infarction (TIMI) Trial,” “A Comparison of Enalapril with Hydralazine-Isosorbide Dinitrate in the Treatment of Chronic Congestive Heart Failure,” and “A Practical Approach to Acid-base Disorders,” to name a few. Then there were the compilation handouts, put together by bright and enthusiastic colleagues and faculty: Dr SK on beta-blockers and congestive heart failure (1997), Dr CG on infections of the central nervous system (1990), Dr MS with a summary of the key articles on vasodilator therapy in congestive heart failure (1997), and my own handouts—erudite, user-friendly, and completely illegible (pre-word processing)!

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--Charlie Goldberg, MD

--This article originally appeared in the November 2012 issue of The American Journal of Medicine.

Telephone Follow-up

Telephone Follow-up as a Primary Care Intervention for Postdischarge Outcomes Improvement: A Systematic Review

Recent economic and political pressures, including passage of the Affordable Health Care for America Act, have thrust the concerns about identifying opportunities for affordable and high-quality health care to the forefront of public debate, and have accelerated the exploration of methods to improve the quality and cost-effectiveness of healthcare. Approximately 1 in 5 Medicare patients are readmitted within 30 days of their primary hospitalization, at a cost of $17.4 billion annually. The potential opportunities for significant cost-savings and quality improvement have intensified research in the field of transitional care, defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different levels or locations of care."

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--J. Benjamin Crocker, MD, Jonathan T. Crocker, MD, Jeffrey L. Greenwald, MD

--This article originally appeared in the September 2012 issue of The American Journal of Medicine.

All Wrapped Up

All Wrapped Up and Nowhere to Flow

When imaging revealed a mass, the differential diagnosis encompassed several possibilities. A 55-year-old white man was admitted for evaluation of acute kidney injury. Right-sided flank discomfort had worsened over the previous year, culminating in significant pain that now warranted evaluation. He denied fever, weight loss, night sweats, hematuria, dysuria, and oliguria. His past medical history was significant for a 3.8-cm infrarenal abdominal aortic aneurysm that had last been imaged 2 years earlier. In addition, he had hyperlipidemia, a multinodular goiter, and back spasms. He quit smoking cigarettes 10 years earlier with a 30 pack-year history. Family history was notable for an abdominal aortic aneurysm in his father.

The patient's only medication was nortriptyline for back pain. An HMG-CoA-reductase inhibitor had not been prescribed due to myalgias. Two years before admission, his creatinine was 1.2 mg/dL; 2 months prior to admission, it was 1.7 mg/dL. At the time of evaluation, laboratory studies demonstrated a blood urea nitrogen level of 71 mg/dL and a creatinine level of 6.7 mg/dL. His estimated glomerular filtration rate was 9 mL/min/1.73 m2 per the Modification of Diet in Renal Disease equation.

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--Amir A. Naderi, MD, Brian A. Houston, MD, C. John Sperati, MD, MHS

--This article originally appeared in the September 2012 issue of The American Journal of Medicine.