AJM Blog Moves to Word Press

The American Journal of Medicine blog is in the process of moving to Word Press. The new address is http://amjmed.org. This old blog site will eventually be only a redirect. If you're a follower of AJM here on Blogger, we'll hope you begin following our new and improved blog on Word Press.

The new format allows for much richer content, which can be viewed and searched in multiple ways.

• As always, new blog posts will appear on the front page of the blog.
  
• The new site has a slide show of featured stories, which will change weekly.
  
• In addition, there are collections at the top of the page that show all of the blog posts on a given topic. The current collections view shows all posts related to Diabetes/Obesity, Cancer, Cardiology, Drugs, and Prevention-- plus a collection of Commentaries. These collection topics will also change periodically.
  
• The word cloud and search functions allow users to surf the blog for specific topics or articles.
  
• Lastly, there is a handy tab box on the front page that lists the latest posts, the most popular posts, comments, and tags.

Not What It Looks Like

Not What It Looks Like: A Transient Cardiomyopathy

The American Journal of Medicine blog has moved to: http://amjmed.org.

You can read "Not What It Looks Like: A Transient Cardiomyopathy" here: http://amjmed.org/not-what-it-looks-like/

Open Access on AJM

AJM Offers Open Access Option to Authors

The American Journal of Medicine now offers authors a choice in disseminating their research - either by publishing it as a subscription article or as an Open Access article.

All articles published Open Access will be immediately and permanently free for everyone to read and download from ScienceDirect. Permitted reuse is defined by the author's choice of Creative Commons user licenses.

To help authors comply with new Open Access policies and mandates, Elsevier has established agreements with many funding bodies including the Wellcome Trust, RCUK and the Austrian Science Fund.

Some funding bodies will also reimburse you for Open Access publication fees, making it even easier to publish Open Access. For more information on specific funding body agreements see our funding bodies agreements page.

How do I find out more? For full information on publishing your paper Open Access in The American Journal of Medicine, including publication fees, licenses, and more, please visit the journal Open Access page and guide for authors. Find out more here.

Beyond Mammography?

Is it time to end the one-size-fits all approach to breast cancer screening? Yes! say authors of a provocative new review article and related editorial in the June 2013 issue of The American Journal of Medicine, now available on our website.

News: AJM & Marijuana

Marijuana & Diabetic Control:
AJM Makes News Worldwide

The Impact of Marijuana Use on Glucose, Insulin, and Insulin Resistance among US Adults-- recently released by The American Journal of Medicine-- sparked worldwide news recently.

In the meantime, the AJM blog has moved to http://amjmed.org.

This story on marijuana and diabetic control is now here: http://amjmed.org/news-ajm-marijuana/

Marijuana Use & Insulin Control

Novel Study Reports Marijuana Users Have Better Blood Sugar Control

Current Marijuana Users Have 16% Lower Fasting Insulin Levels Compared to Non-Users, According to The American Journal of Medicine

Regular marijuana use is associated with favorable indices related to diabetic control, say investigators. They found that current marijuana users had significantly lower fasting insulin and were less likely to be insulin resistant, even after excluding patients with a diagnosis of diabetes mellitus. Their findings are reported in the July issue of The American Journal of Medicine. (Read the study here.)

Marijuana (Cannabis sativa) has been used for centuries to relieve pain, improve mood, and increase appetite. Outlawed in the United States in 1937, its social use continues to increase and public opinion is swinging in favor of the medicinal use of marijuana. There are an estimated 17.4 million current users of marijuana in the United States. Approximately 4.6 million of these users smoke marijuana daily or almost daily. A synthetic form of its active ingredient, tetrahydrocannabinol, commonly known as THC, has already been approved to treat side-effects of chemotherapy, AIDS-induced anorexia, nausea, and other medical conditions. With the recent legalization of recreational marijuana in two states and the legalization of medical marijuana in 19 states and the District of Columbia, physicians will increasingly encounter marijuana use among their patient populations.

A multicenter research team analyzed data obtained during the National Health and Nutrition Survey (NHANES) between 2005 and 2010. They studied data from 4,657 patients who completed a drug use questionnaire. Of these, 579 were current marijuana users, 1,975 had used marijuana in the past but were not current users, and 2,103 had never inhaled or ingested marijuana. Fasting insulin and glucose were measured via blood samples following a nine hour fast, and homeostasis model assessment of insulin resistance (HOMA-IR) was calculated to evaluate insulin resistance.

Participants who reported using marijuana in the past month had lower levels of fasting insulin and HOMA-IR and higher levels of high-density lipoprotein cholesterol (HDL-C). These associations were weaker among those who reported using marijuana at least once, but not in the past thirty days, suggesting that the impact of marijuana use on insulin and insulin resistance exists during periods of recent use. Current users had 16% lower fasting insulin levels than participants who reported never having used marijuana in their lifetimes.

Large waist circumference is linked to diabetes risk. In the current study there were also significant associations between marijuana use and smaller waist circumferences.

“Previous epidemiologic studies have found lower prevalence rates of obesity and diabetes mellitus in marijuana users compared to people who have never used marijuana, suggesting a relationship between cannabinoids and peripheral metabolic processes, but ours is the first study to investigate the relationship between marijuana use and fasting insulin, glucose, and insulin resistance,” says lead investigator Murray A. Mittleman, MD, DrPH, of the Cardiovascular Epidemiology Research Unit at the Beth Israel Deaconess Medical Center, Boston. 

“It is possible that the inverse association in fasting insulin levels and insulin resistance seen among current marijuana users could be in part due to changes in usage patterns among those with a diagnosis of diabetes (i.e., those with diabetes may have been told to cease smoking). However, after we excluded those subjects with a diagnosis of diabetes mellitus, the associations between marijuana use and insulin levels, HOMA-IR, waist circumference, and HDL-C were similar and remained statistically significant,” states Elizabeth Penner, MD, MPH, an author of the study.

Although people who smoke marijuana have higher average caloric intake levels than non-users, marijuana use has been associated with lower body-mass index (BMI) in two previous surveys. “The mechanisms underlying this paradox have not been determined and the impact of regular marijuana use on insulin resistance and cardiometabolic risk factors remains unknown,” says coauthor Hannah Buettner.

The investigators acknowledge that data on marijuana use were self-reported and may be subject to underestimation or denial of illicit drug use. However, they point out, underestimation of drug use would likely yield results biased toward observing no association.

Editor-in-Chief Joseph S. Alpert, MD, Professor of Medicine at the University of Arizona College of Medicine, Tucson, comments, “These are indeed remarkable observations that are supported, as the authors note, by basic science experiments that came to similar conclusions.

“We desperately need a great deal more basic and clinical research into the short- and long-term effects of marijuana in a variety of clinical settings such as cancer, diabetes, and frailty of the elderly,” continues Alpert.” I would like to call on the NIH and the DEA to collaborate in developing policies to implement solid scientific investigations that would lead to information assisting physicians in the proper use and prescription of THC in its synthetic or herbal form.”

Divulged through Imaging

Imaging Divulged What Signs and Symptoms Didn't: Acute Pericarditis

Shortness of breath in an 85-year-old man posed a diagnostic challenge. He presented with a 2-month history of progressively worsening dyspnea on exertion. Over the previous week, he also experienced orthopnea and bilateral lower-extremity edema. He denied chest pain or recent febrile illness. His medical history included heart failure with preserved systolic function and hypothyroidism. He was a nonsmoker, and his family history was not significant.


On presentation, he had a temperature of 99.3° F (37.4° C), heart rate of 87 beats per minute, blood pressure of 124/62 mm Hg, and respiratory rate of 20 breaths per minute. Physical examination revealed mildly distended jugular veins, bilateral basal lung crackles, normal heart sounds without murmurs, rubs, or gallops, and 2+ symmetric bilateral lower-extremity edema.

The patient's history and physical findings were consistent with decompensated heart failure. Intravenous diuretic therapy was started. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm with right bundle branch block (Figure 1). A chest x-ray demonstrated an enlarged cardiac silhouette with left pleural effusion. This was further investigated with transthoracic echocardiography, which disclosed a moderate-sized pericardial effusion without evidence of tamponade physiology; the left-ventricle ejection fraction was preserved (Figure 2-- shown above).


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

-- Tarun Jain, MD, Mushabbar A. Syed, MD

This article originally appeared in the May 2013 issue of The American Journal of Medicine.

Rare but Revealing

A Rare but Revealing Sign: Necrolytic Migratory Erythema

Rash can signal any number of disorders, from the relatively minor to the life-threatening. For a 62-year-old woman, an unrelenting skin complaint proved to be evidence of an unusual disease. She presented with a 2.5-year history of an intermittent pruritic rash in her underarms and gluteal cleft and on her groin and legs. It had become persistent in the last 3 months and was refractory to treatment with high-potency topical steroids, topical antifungal agents, and topical antibiotics prescribed by her primary care providers. She had been diagnosed with diabetes mellitus 5 months prior to our evaluation. In addition, she described a 20-pound weight loss and associated fatigue. Over the preceding 3 months, the patient had also developed new-onset alopecia.

Physical examination revealed widespread, circumscribed, bilateral and symmetric erythematous eroded plaques with scale, which were located primarily in the axilla and gluteal cleft and on the trunk, groin, and upper legs (Figure, A and B). Erythematous scaly plaques were also noted in continuity with the oral labial commissures, consistent with angular cheilitis (Figure, C). Examination of the mouth demonstrated swelling and redness of the tongue consistent with glossitis.

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

-- Nicholas L. Compton, MD, Andy J. Chien, MD, PhD

This article originally appeared in the May 2013 issue of The American Journal of Medicine.

The Immortality Myth

Dismissing the Immortality Myth: Improving Care and Incidentally Reducing Costs

Is our "death evasion fantasy" driving up health care costs? Check out this provocative commentary from our May 2013 issue. -Ed.

A major driver of health care costs that seems to be off limits for any discussion is the American trait of denying death, with a pervasive refusal to confront personal mortality, and the prevailing death rate of one per person. Consider the absurd protestations of “death panels” and “rationing” in response to the simple proposal that Medicare should pay for discussions about patients' end-of-life preferences. This dark cloud of avoidance impairs the integrity, honesty, and objectivity of the physician-patient relationship(1) and is a major cause of the use of costly,(2) sometimes harmful and futile care in the last year, weeks, and days of patients' lives. Often this care is more aggressive than patients or their families expected or desired.(3) There is abundant evidence that such care leads to the well-documented overuse of diagnostic and treatment options, contributing to unsustainable costs of medical care and associated US fiscal problems.(4) Much worse than the economic issues involved, however, is the fact that this often prevents closure with loved ones and may result in a disastrous quality of life for those with terminal illness.

This death evasion fantasy is facilitated subtly by the medical establishment with the implied promise that if enough is spent on health care and research, wars on cancer and Alzheimer's and heart disease will be won and virtual immortality could become a reality. In truth, immortality is not something to be pursued. Consider Jonathan Swift's description of the Struldbruggs in the land of the Luggnagians when visited by Gulliver.(5) They were born with the chance of becoming immortal, however, they inform him that immortality is a curse, not a blessing. As they age, their young bodies age as well and they become more disabled, chronically ill, and misanthropic, reporting that they will embrace death as an alternative to centuries of such a pathetic, painful existence.

Studies document that many physicians avoid discussions of poor prognosis, and recommend high-tech, heroic interventions rather than hospice and palliative care in obvious terminal situations.1 It is easier to order another diagnostic or therapeutic procedure than to explain that the end is near and that the clinician and system stand ready to do whatever needs to be done to help the family and patient deal with this painful reality and all the associated difficult issues, while reaffirming that the patient will not be allowed to die in pain or be abandoned. The literature on how physicians make their personal end-of-life decisions, whether anecdotal,(6) guideline oriented,(7) or personal,(8) is consistent. As physicians are faced with a terminal illness they generally focus on quality of life, utilizing hospice and palliative care. While physicians use technology regularly in their practices, they recognize its limitations, and for their late-stage care they avoid the technologic imperative of “We can, therefore we must.” They most often die at home with family, eschewing futile interventions with well-documented adverse effects. They know how to access any level of care for themselves, but most often choose to avoid prolonged intensive care unit stays, life support systems, and recurrent episodes of hopeless cardiopulmonary resuscitation.

To provide patients with the same understanding of care options in critical end-of-life situations which physicians choose for themselves requires a major cultural shift. One underlying objective should be to have Americans come to accept life as a journey, understanding that death, not immortality, is the end point. Current societal and medical opinion and medical practice clearly do not support such an approach. Patients and families are generally unprepared to face major decisions which seem to them to arise unexpectedly even while their physicians have been well aware of the grim prognostic realities for some time. In these circumstances, many clinicians may agree to “do everything” as part of a system that encourages excessive treatment as the path of least resistance. While these last-ditch initiatives may occasionally be carried out because of considerations of financial gain or be due to litigation fears, they are overwhelmingly a result of lack of prior planning discussions and poor communication.

As remedies, Callahan and Nuland(9) have proposed thoughtful changes in the priorities and organization of health care. They recommend concentrating funding on public health and social programs while promoting primary care, de-emphasizing sub-specialization and high-tech end-of-life initiatives. They advocate focusing on care rather than cure as the goal for chronic illness and having physicians explain how over-aggressive care enhances the likelihood of a poor death. As important and desirable as these systemic changes could be, involvement by all physicians at the sharp end of care will arguably be even more crucial in achieving realistic agreements dealing with the limits of medicine, life choices, and the inevitability of death. Physicians have the understanding, knowledge, perspective, skill set, experience, and cachet to do this. Currently lacking is a willingness and commitment by the profession to start the difficult negotiations to unify all the diverse attitudes and opinions of practitioners of medicine in all specialties—admittedly a difficult task.

As the concept of life as a journey becomes established as a societal standard and the immortality myth is dismissed, it will hasten early, routine discussions of patients' preferences and values. For each of them, what is most important? Is it maintaining: Cognition? Mobility? Sexual performance? Personal comfort and pain avoidance? Overall functional status? Family? Or is longevity at any cost their most important objective? The “ten year prognosis”(10) is a realistic and optimistic starting point. With an established basis of mutual trust between patient and physician, a series of collaborative, transparent deliberations become easier to initiate and more comfortable to carry out, with evidence-based discussions about options for the possible and even unpredictable eventualities. Such conversations are ideally done before the onset of a life-threatening illness, but also can be carried out in potentially terminal situations.(11)

Specific examples of such shared discussions are easy to cite: What are the expected results from this chemotherapy program; cure, improved survival, or a better quality of life for this patient?(11) In recommending this carotid artery procedure, what is the likelihood of a complete cure, versus an intermediate outcome such as a stroke? Is PSA testing appropriate for this patient? Why is a feeding tube not recommended for patients with advanced dementia? Is palliative or hospice care now the best option in this patient's situation? Such decisions are expedited once the parameters and ground rules for individual care have been established. Best of all, every patient will be made comfortable as they record their clear wishes via open discussions with their physicians, who can advise them not to give up too early when life can be enjoyed, but can help make appropriate, personalized choices when death looms.

As physicians and patients talk realistically about actions regarding prognoses including death, rather than accepting the default unspoken myth of immortality, multiple benefits will accrue. A marked reduction in overall costs of health care will occur,(2) freeing significant amounts of money to be spent on other medical and social priorities. The much more important outcome will be that patients will be better served as they receive exactly the type and level of care that they want. Physicians also will achieve greater professional satisfaction, reminding them of the reasons that they initially entered the profession.

To view the references for this article, please visit our website.

-- James Webster, MD, MS

This article originally appeared in the May 2013 issue of The American Journal of Medicine.

Coughing Up a Diagnosis

Coughing Up a Diagnosis: A Cavitary Lung Lesion with Worsening Eosinophilia

A 37-year-old woman from Botswana appeared to have community-acquired pneumonia, but in fact, she had a more exotic infection. She was hospitalized with a productive cough and dyspnea of 2 days' duration. Right lower lobe consolidation was seen on a chest x-ray. Her past medical history was unremarkable. Laboratory testing revealed a leukocyte count of 9.5 × 103 cells/μL with neutrophil predominance (8.6 × 103 cells/μL; 91%), and an eosinophil count of 0.19 × 103 cells/μL (2%). She did well on levofloxacin therapy and was discharged. Four days later, she was rehospitalized with recurrent symptoms.

On physical examination, the patient had a blood pressure of 124/73 mm Hg, a pulse rate of 110 beats per minute, a respiratory rate of 40 breaths per minute, and a temperature of 102.2° F (39° C). Her oxygen saturation was 100% on room air. Decreased breath sounds and egophony were noted at the right lung base. Laboratory testing demonstrated a leukocyte count of 13 × 103 cells/μL with a neutrophil count of 8.5 × 103 cells/μL (65%) and an eosinophil count of 1.2 × 103 cells/μL (9%).

A chest x-ray disclosed persistent right lower-lobe consolidation with a new air lucency (Figure 1). Chest computed tomography (CT) showed a cavity measuring 6 × 5 × 7 cm within the right lower-lobe consolidation and a floating membrane inside the cavity (Figures 2 and 3). The tracheal and right main-stem bronchial mucosa had an irregular cobblestone appearance on bronchoscopy; purulent secretions were evident in the right lower-lobe bronchus. Mucosal biopsy of the carina revealed eosinophilic infiltrates without additional diagnostic features.

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

-- Hiroshi Sekiguchi, MD, Jun Suzuki, Bobbi S. Pritt, MD, Jay H. Ryu, MD

This article originally appeared in the April 2013 issue of The American Journal of Medicine.

Mortality from Homicide

Mortality from Homicide among Young Black Men: A New American Tragedy

In 1925, in the classic novel An American Tragedy, Theodore Dreiser portrayed a poignant yet powerful picture of youthful loneliness in industrial society and of the American mirage that beckons some of the young to disaster.

In 2012, an American tragedy of far greater urgency and public health importance is the alarming rate of homicide among young black men. Interracial homicide, whether the victim or the perpetrator is black, is abhorrent. Nonetheless, from the perspective of the health of the general public, the circumstances in which a young black man is both the victim and the perpetrator cause far more premature deaths.

Homicide is, far and away, the leading cause of death of young black men. In stark contrast, accidents are, far and away, the leading cause of death among young nonblack men and women of all races and ethnicities. Black men are 6 times more likely to die as the result of and 7 times more likely to commit murder than their white counterparts. One eighth of the population is black, but one half of all homicide victims are black. Their reduced life expectancy of more than 6 years would be improved more from eliminating homicide than abolishing any other causes of death except cardiovascular disease or cancer.(1)

From 1999 to 2009, among those aged 15 to 34 years, there were 106,271 homicides, 85% (89,887) among men and 49% (52,265) among black men. One major and hotly debated issue is firearms. Specifically, 81% (85,643) of all homicides were due to firearms, including 91% (47,513) among black men.2 All attempts to address this complex issue should include, but not be limited to, optimizing the health of the general public, the strength of the existing evidence, and the constitutional right of individuals to bear arms.

In most circumstances, public health practitioners are charged to identify threats to the health of the community and to bring scientific evidence to the attention of policy makers, even if the threats are lawful and whether or not policy makers choose to act on that evidence. For example, cigarettes are both lawful and popular, but public health support of laws controlling their exposure to the general population has contributed to the reduction of the premature mortality they cause.

To date, however, this has not been the case for firearms.

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

 -- Charles H. Hennekens, MD, DrPH, Joanna Drowos, DO, MPH, MBA, Robert S. Levine, MD

This article originally appeared in the April 2013 issue of The American Journal of Medicine

Diet & Healthy Aging

Does Overall Diet in Midlife Predict Future Aging Phenotypes? A Cohort Study 

Does your diet predict your likelihood of healthy aging?

Abstract 

Background
The impact of diet on specific age-related diseases has been studied extensively, but few investigations have adopted a more holistic approach to determine the association of diet with overall health at older ages. We examined whether diet, assessed in midlife, using dietary patterns and adherence to the Alternative Healthy Eating Index (AHEI), is associated with aging phenotypes, identified after a mean 16-year follow-up.

Methods
Data were drawn from the Whitehall II cohort study of 5350 adults (age 51.3±5.3 years, 29.4% women). Diet was assessed at baseline (1991-1993). Mortality, chronic diseases, and functioning were ascertained from hospital data, register linkage, and screenings every 5 years and were used to create 5 outcomes at follow-up: ideal aging (free of chronic conditions and high performance in physical, mental, and cognitive functioning tests; 4%), nonfatal cardiovascular event (7.3%), cardiovascular death (2.8%), noncardiovascular death (12.7%), and normal aging (73.2%).

Results
Low adherence to the AHEI was associated with an increased risk of cardiovascular and noncardiovascular death. In addition, participants with a “Western-type” diet (characterized by high intakes of fried and sweet food, processed food and red meat, refined grains, and high-fat dairy products) had lower odds of ideal aging (odds ratio for top vs bottom tertile: 0.58; 95% confidence interval, 0.36-0.94; P=.02), independently of other health behaviors.

Conclusions
By considering healthy aging as a composite of cardiovascular, metabolic, musculoskeletal, respiratory, mental, and cognitive function, the present study offers a new perspective on the impact of diet on aging phenotypes.


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

 -- Tasnime Akbaraly, PhD, Séverine Sabia, PhD, Gareth Hagger-Johnson, PhD, Adam G. Tabak, MD, Martin J. Shipley, MSc, Markus Jokela, PhD, Eric J. Brunner, PhD, Mark Hamer, PhD, G. David Batty, PhD, Archana Singh-Manoux, PhD, Mika Kivimaki, PhD

This article originally appeared in the May 2013 issue of The American Journal of Medicine.

May 2013: The Unhealthy Western Diet

Does a "Western-style" diet of fried and sweet food, processed and red meat, refined grains, and high-fat dairy products reduce a person's likelihood of achieving older ages in good health? Check out Dr. Joseph S. Alpert's video and the related article by Akbaraly et al in the May 2013 issue of The American Journal of Medicine.

April 2013: Bell's Palsy

Bell's palsy is a common diagnosis. In the April 2013 issue of The American Journal of Medicine, you can read about new treatment options. In this video, Editor-in-chief Dr. Joseph S. Alpert discusses this new research.

Herbalife International has a wide array of organic vitamin supplements, beauty and weight loss products

 Many satisfied consumers vouch for the credibility of the company's wellness product range. The articles must be able to adequately promote the products that you selling. Each article must focus on online spreadsheet one particular product. You can even compare it to other products of the same line, expounding on its supremacy over such product. You can also discuss about the price of the product in question, stating its affordability when compared to products from other companies. You can also include promos and discounts in order to entice potential clients or customers to buy your more of your Herballife Nutrition Network. You first introduce the name of the product that you are marketing. You gain levels by selling products and gaining volume points. Volume points for most products are equal to the manufacturers recommended selling price of the product and are based upon the US dollar value of the products.

Herbalife scores high in this category. More importantly, as a marketing professional, you can rest assured that the company's products have rocketed them to vast success. Companies like Herbalife are able to survive because of their independent contractors. High upfront commissions draw people like you to the company and it is the ever-growing residual income that makes them stay.
How is one to sell a product- even the greatest thing ever made- without proper marketing and advertising in place? Stocks of Herbalife (HLF) currently sell for over forty dollars per share.
With the right marketing plan, you can reach people in any, or all of those locations.

Herbalife's Family Foundation (HEF) was formed by the company's founder, Mark Hughes, in 1994. The children at risk count on the participation of companies like Herbalife for their survival. Training In this category, Herbalife falls middle of the road. It will be up to you to create your marketing system. First pro of the business, Herbalife has an easy start up system. Next, Herbalife has numerous quality product lines for inner and outer nutrition. Herbalife also has compensation with great potential for substantial income. As it is designed from a multi-level marketing structure you grow your business by teaching other business owners within your down line to run a successful business. Cons of the business, Herbalife has high startup costs due to inventory. To begin with Herbalife you must buy into the company by purchasing inventory. The amount of inventory you purchase indicates your level with the company. 

The level in the company governs your commission percentage with each sale and leaves you with the responsibility of selling the corresponding inventory amount. The marketing plan relies heavily on your local market and the problem there is nobody's local market is the same. You may not have the influence required to sell things like a business opportunity or nutrition products to your market. In addition, your warm market may not be a qualified market, which means not interested in or have the money to spend on the product or the opportunity. In the network marketing arena, the type of products run the gamut. Vitamins, nutritional supplements, cosmetics, tonics, cleaning products, and Internet programs just to name a few. You have got to identify with the products in order to represent them well and build a business. It just doesn't make much sense to invest in a company whose products don't excite you. You must value the products before you put a value on the business in your life.

In searching for the right home based business opportunity, assess the core mission and objectives of the companies you put on a short list. What do the companies stand for? As a strong advocate of environmental responsibility and stewardship, Barnett was immediately attracted to the company's safe, clean and environmentally friendly product line. It's about the ability of the company to create new products, bolder business initiatives, and reach beyond the current status quo. Most distributors in Herbalife and other network marketing companies struggle for this very reason. Here's the reason: to make good money in Herbalife or any network marketing company, you have to have a big, growing distribution network. Treat your business like a million dollar business by utilizing the MLM tools that will help you create those kinds of results.

If there is a history of milk allergies in your family, you may need a lactose free baby Formula 1. Most formulas are sold according to stages. Do your best to stick to the correct formula stage. As well as coming in three forms, baby formula comes in different types: the main ones being cow's milk and soybean. In addition to these basic formula types, you can also find lactose free formula, formula supplemented with DHA and ARA, and formula for preemies.
 

All baby milk formulas are fortified with iron and Vitamin D (these can be lacking in breast milk) and contain lactose (milk sugar). Soy based formula is now becoming more popular. Unlike cow's milk it does not contain lactose. If your child has lactose intolerance then soy formula milk may be right for your child.

Don't Forget the Thyroid

Don't Forget the Thyroid: Graves' Disease

An atypical presentation can confound the diagnosis, and that is what happened when a 33-year-old African-American woman presented to another hospital with a 3-month history of worsening abdominal pain. She had been in good health until she started experiencing persistent abdominal pain and distension associated with nausea, vomiting, loose stools, decreased appetite, and weight loss. Her past medical history was significant for an episode of deep venous thrombosis during pregnancy and an unevaluated thyroid nodule. She had no history of heavy alcohol or intravenous drug use, and her family history was unremarkable. Unemployed, she was taking classes at the local community college. Her clinical picture at the outside hospital was consistent with liver disease.

The patient's initial physical examination showed jaundice, abdominal distension and tenderness, and a positive fluid wave. Her work-up at the first hospital revealed a persistently-elevated international normalized ratio (INR) despite several units of fresh frozen plasma and vitamin K. In addition, she had an increased alkaline phosphatase level; other liver enzyme levels were normal. Viral hepatitis and autoimmune antibody panels were negative. Sinusoidal congestion suggestive of Budd Chiari syndrome was evident after a hepatic biopsy, but a hepatic duplex scan revealed normal blood flow and an overall impression of a liver within normal limits. Because her physicians were concerned that she was in acute liver failure, she was transferred to our hospital for further evaluation of hepatic failure and possible liver transplant.

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

-- Aroop Pal, MD, Margaret Le, BS, Leland Graves, MD

This article originally appeared in the March 2013 issue of The American Journal of Medicine.

Digging Deeper

Digging Deeper into Dyspnea 

A 49-year-old homeless woman was admitted for worsening shortness of breath and lower extremity edema. Two weeks prior she was hospitalized for appendicitis and underwent successful laparoscopic appendectomy. Her history was notable for severe obesity, with a body mass index of 59.9 kg/m2, bipolar disorder, hypertension, impaired fasting glucose, asthma, and difficult-to-control chronic lower extremity edema for 2 years, managed with diuretics. For 2 years she complained of progressive weight gain of 40 kg and progressive dyspnea limiting her from performing daily activities. These symptoms had been attributed to her severe obesity. There was no history of tuberculosis or rheumatic disease, although she had a severe pneumonia 2.5 years prior with associated empyema. She denied recent fever, cough, or hemoptysis.

On physical examination her weight was 159 kg, temperature 36.3°C, pulse 94 beats per minute, respirations 16 breaths per minute, blood pressure 116/90 mm Hg, and oxygen saturation 98% on room air. She had a very large body habitus and no scleral icterus. Her jugular venous pressure could not be seen. Auscultation revealed clear lungs, a normal S1 and S2 with no murmurs, gallops, or rubs. The abdomen was obese soft, and nontender with healing laparoscopy incisions. The lower extremities showed 2+ pitting edema and multiple superficial skin ulcerations on the lower legs at various stages of healing.

Due to the recent appendectomy, a computed tomography (CT) scan of the abdomen was obtained, demonstrating normal postsurgical changes with marked hepatic congestion. An included portion of the lower thorax revealed a markedly thickened pericardium measurinf >6 mm in multiple locations (Figure, panel A). A transthoracic echocardiogram, although limited by suboptimal image quality, showed a subtle interventricular septal bounce, mild respiratory changes in the mitral E velocity, increased mitral medial annulus e′ velocity of 0.15 m/s (Figure, panel B), and dilated inferior vena cava with expiratory flow reversals in the hepatic veins. Subsequent tuberculin skin test and QuantiFERON-TB tests were negative, and sputum samples were negative for acid-fast bacilli.

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

-- Mackram F. Eleid, MD, Barry A. Borlaug, MD, Sharon Mulvagh, MD

This article originally appeared in the March 2013 issue of The American Journal of Medicine.

Restless Legs

Is Restless Legs Syndrome Associated with Cardiovascular Disease?

Restless legs syndrome is a common condition characterized by a strong urge to move the limbs that is usually worse during the evening and nighttime hours, that is worsened by rest, and that improves with activity. However, the prevalence has varied in different studies, primarily depending on the criteria chosen to define this disorder. Prior studies using the International Restless Legs Syndrome Study Group criteria (1) have placed the prevalence between 3.9% and 14.3%.(2) Restless legs syndrome is associated with diverse adverse consequences.(3, 4) Health-related quality of life is reduced in those with restless legs syndrome and is lower in those with more severe disease. Restless legs syndrome also can lead to an increased prevalence of insomnia, depression, and anxiety.(3, 4, 5)

Several large epidemiologic studies have suggested a causal association between restless legs syndrome and cardiovascular disorders and hypertension after controlling for confounders such as age, witnessed apneas, and smoking.(6, 7, 8) Furthermore, a recent study using prospectively obtained data from the Nurses' Health Study found an increased risk of incident nonfatal myocardial infarction in those with a history of restless legs syndrome for 3 years or more (hazard ratio, 1.80; 95% confidence interval [CI], 1.07-3.01).(9) The increased risk of coronary heart disease persisted after adjustment for blood pressure, diabetes duration, and use of diabetes medications. However, not all studies have observed an association between restless legs syndrome and cardiovascular disease.(10, 11)

In this issue of the Journal, additional evidence from 2 studies is presented relating to the putative association between restless legs syndrome and hypertension and cardiovascular disease. In the first study by Winter et al,(12) 22,786 male participants of the US Physicians' Health Studies I and II were studied. The mean age of the participants was 67.8 years. Restless legs syndrome was present in 7.5% of the participants, and the prevalence increased significantly with age. Furthermore, the odds of restless legs syndrome were higher in those with a history of diabetes. Conversely, frequent exercise and alcohol consumption of 1 or more drinks per day reduced the odds of restless legs syndrome. Of note, those with prevalent stroke had higher odds of a positive history of restless legs syndrome (odds ratio [OR], 1.41; CI, 1.05-1.86), whereas those with a history of myocardial infarction had lower odds of restless legs syndrome history (OR, 0.73; CI, 0.55-0.97).

The second study by Winter et al(13) analyzed data from 30,262 female health professionals (mean age, 63.6 years) participating in the Women's Health Study. The prevalence of restless legs syndrome was 12.0% and more likely with severe obesity and smoking. Exercise≥4 times/week was associated with lower odds of restless legs syndrome (OR, 0.84; CI, 0.74-0.95). However, there was no association between restless legs syndrome and prevalent major cardiovascular disease defined as nonfatal myocardial infarction or stroke. Women who underwent coronary revascularization had increased odds (OR, 1.39; CI, 1.10-1.77) for restless legs syndrome compared with those with no intervention. However, this relationship also was no longer significant after excluding those with potential causes of restless legs syndrome.

To what extent do these new observations improve our understanding of restless legs syndrome?

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

-- Rohit Budhiraja, MD, Stuart F. Quan, MD

This article originally appeared in the March 2013 issue of The American Journal of Medicine.

Related articles:

Vascular Risk Factors, Cardiovascular Disease, and Restless Legs Syndrome in Women

Vascular Risk Factors, Cardiovascular Disease, and Restless Legs Syndrome in Men

Cyanosis

Descriptions of cyanopathia or Morbus caeruleus (cyanosis) have populated medical literature since the time of Hippocrates, although the actual pathophysiology behind its development eluded physicians until the advent of objective anatomy and physiology. Morgagni, “accurate anatomist,” philosopher, and one of the fathers of contemporary medicine, is often credited with having first described cyanosis (in association with stasis due to pulmonic stenosis [1761]),(1) however, it was actually deSenac, personal physician to King Louis XV (and the first to elucidate the relationship between atrial fibrillation and mitral stenosis), who first described the pathophysiology of cyanosis (albeit not entirely correctly!) in 1749.(2) It was not until over 2 centuries later, however, that Christen Lundsgaard actually quantified the amount of deoxygenated hemoglobin that was required to produce that bluish discoloration that produces the clinical finding of cyanosis.(2)

Features of Cyanosis
Cyanosis is an abnormal bluish discoloration of the skin and mucous membranes; it is caused by high levels of deoxygenated (reduced) hemoglobin (or its derivatives) circulating within the superficial dermal capillaries and subpapillary venous plexus (not, as commonly taught, the deeper arteries and veins).(1) Hypoxemia, not to be confused with hypoxia (which reflects tissue oxygenation), is the deficient oxygenation of blood that leads to cyanosis.(3)

Whether or not cyanosis is apparent to the human eye depends on dermal thickness, cutaneous pigmentation, and state of the cutaneous capillaries.(4) In light of this, cyanosis is best appreciated in areas of the body where the overlying epidermis is thin and the blood vessel supply abundant, such as the lips, malar prominences (nose and cheeks), ears, and oral mucous membranes (buccal, sublingual); it is better appreciated in fluorescent lighting.(1)

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

-- Sarah M. McMullen, MD, Ward Patrick, MD

This article originally appeared in the March 2013 issue of The American Journal of Medicine.

AJM mobile apps

Free American Journal of Medicine apps for mobile devices

American Journal of Medicine subscribers can now access the Journal more easily from their iPads, iPhones, or Androids.

Want to read The American Journal of Medicine on your iPad? Check out the Journal's free iPad app here.

For access to multiple Elsevier journals, including AJM, from your mobile devises, check out the HealthAdvance Journals app here.

March 2013: Lyme Disease

The March 2013 issue of The American Journal of Medicine includes a thorough review of acute and chronic Lyme disease diagnosis and treatment, in addition to explaining some common misconceptions about Lyme disease. In this video, Editor-in-chief Dr. Joseph S. Alpert discusses some of the high points of the article.

The Fallen Soldier

Remembering the Fallen Soldier: John McCrae on Flanders Fields

The name John McCrae is not one instantly recognized in the annals of medical history. Although a friend and colleague of such giants as William Osler and Harvey Cushing, McCrae's contribution to history is the mournful poem In Flanders Field, which he wrote on a World War I battlefield during a brief respite from caring for his wounded and dying comrades.

Born on November 30, 1872, in the town of Guelph, Canada, John Alexander McCrae was destined to serve in the military. Descending from Highland Scots, the McCrae family had a proud tradition of serving in the army. He joined a corps of cadets during high school and by age 15 years served as the bugler for his father's artillery unit in the Canadian militia. After high school, McCrae obtained a scholarship to the University of Toronto and graduated with a biology degree in 1894. Although plagued by severe asthma attacks throughout his life, McCrae served as an officer in the Canadian militia while in college and subsequently received a commission in the field artillery.(1)

Deciding on a career in medicine, McCrae graduated first in his class at the University of Toronto Medical School in 1898. He completed internship at Toronto General Hospital and then left Canada to serve as a Resident House Officer under William Osler at Johns Hopkins. Although awarded a pathology fellowship at McGill University in 1900, he instead left training to serve his native Canada in the intervening Boer War. McCrae finished his military service in 1901 and returned to Canada, where he completed fellowship and was named Pathologist for Montreal General Hospital.

McCrae's driving interests in military service and science were tempered by a fondness for writing poetry.

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

-- Mathew W. Lively, DO, Richard D. Layne, MD

This article originally appeared in the January 2013 issue of The American Journal of Medicine.

Adherence to PIOPED II Investigators' Recommendations for Computed Tomography Pulmonary Angiography

Non-adherence to recommendations for CT pulmonary angiography is common and exposes patients to increased risks, including potential false positive diagnoses of pulmonary embolism.

Abstract 
Background 
Computed tomography (CT) pulmonary angiography use has increased dramatically, raising concerns for patient safety. Adherence to recommendations and guidelines may protect patients. We measured adherence to the recommendations of Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED II) investigators for evaluation of suspected pulmonary embolism and the rate of potential false-positive pulmonary embolism diagnoses when recommendations of PIOPED II investigators were not followed.

Methods
We used a structured record review to identify 3500 consecutive CT pulmonary angiograms performed to investigate suspected pulmonary embolism in 2 urban emergency departments, calculating the revised Geneva score (RGS) to classify patients as “pulmonary embolism unlikely” (RGS≤10) or “pulmonary embolism likely” (RGS>10). CT pulmonary angiograms were concordant with PIOPED II investigator recommendations if pulmonary embolism was likely or pulmonary embolism was unlikely and a highly sensitive D-dimer test result was positive. We independently reviewed 482 CT pulmonary angiograms to measure the rate of potential false-positive pulmonary embolism diagnoses.

Results 
A total of 1592 of 3500 CT pulmonary angiograms (45.5%) followed the recommendations of PIOPED II investigators. The remaining 1908 CT pulmonary angiograms were performed on patients with an RGS≤10 without a D-dimer test (n=1588) or after a negative D-dimer test result (n=320). The overall rate of pulmonary embolism was 9.7%. Potential false-positive diagnoses of pulmonary embolism occurred in 2 of 3 patients with an RGS≤10 and a negative D-dimer test result.

Conclusions 
Nonadherence to recommendations for CT pulmonary angiography is common and exposes patients to increased risks, including potential false-positive diagnoses of pulmonary embolism.

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

-- Daniel M. Adams, MD, Scott M. Stevens, MD, Scott C. Woller, MD, R. Scott Evans, PhD, James F. Lloyd, BS, Gregory L. Snow, PhD, Todd L. Allen, MD, Joseph R. Bledsoe, MD, Lynette M. Brown, MD, PhD, Denitza P. Blagev, MD, Todd D. Lovelace, MD, Talmage L. Shill, MD, Karen E. Conner, MD, MBA, Valerie T. Aston, RRT, C. Gregory Elliott, MD

This article originally appeared in the January 2013 issue of The American Journal of Medicine.

Related Article: Chasing Pulmonary Emboli: Let's Agree on One Big Thing

Skepticism: What Is True?

Skepticism or 'Things I Was Taught that Weren't True

"The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.” 
Sir William Osler

“The altar cloth of one aeon is the doormat of the next.”
 Mark Twain

“The most erroneous stories are those we think we know best—and therefore never scrutinize or question.”
Stephen Jay Gould

“In questions of science, the authority of a thousand is not worth the humble reasoning of a single individual.” 
Galileo Galilei

“So many centuries after the Creation, it is unlikely that anyone could find hitherto unknown lands of any value.” 
Spanish Royal Commission, rejecting Christopher Columbus' proposal to sail west.

“What is allegedly true and useful today may be shown to be worthless tomorrow … remember Socrates and remain skeptical!”(1)
 J.S.A.

What was once true but have been disproven? To find out, read this article in its entirety on our website.

-- Joseph S. Alpert

This article originally appeared in the February 2013 issue of The American Journal of Medicine.

Mortality Rates for Black Males

United States Counties with Low Black Male Mortality Rates

In only 66 out of 1307 US counties, black men have a lower mortality than white men. What makes these counties different?

Abstract
Objective
In the United States, young and middle-aged black men have significantly higher total mortality than any other racial or ethnic group. We describe the characteristics of US counties with low non–Hispanic Black or African American male mortality (ages 25-64 years, 1999-2007).

Methods
Information was accessed through public data, the US Census, the US Compressed Mortality File, and the Native American Graves Repatriation Act military database.

Results
Of 1307 counties with black mortality rates classified as reliable by the National Center for Health Statistics (at least 20 deaths), 66 recorded lower mortality among black men than corresponding US whites. Most notable, 97% of the 66 counties were home to or adjacent a military installation versus 37% of comparable US counties (P<.001). Blacks in these counties had less poverty, higher percentages of elderly civilian veterans, and higher per capita income. Within these counties, national black:white disparities in mortality were eliminated for ischemic heart disease, accidents, diseases of the liver, chronic lower respiratory diseases, and mental disorder from psychoactive substance use. Application of age-, race-, ethnicity-, gender-, and urbanization-specific mortality rates from counties with relatively low mortality would reduce the black:white mortality rate ratio for black men aged 25 to 64 years from 1.67 to 1.20 nationally and to 1.00 in areas outside large central metropolitan areas.

Conclusions
These descriptive data demonstrate a small number of communities with low mortality rates among young and middle-aged black/African American men. Their characteristics may provide clinical and public health insights to reduce these higher mortality rates in the US population. Analytic epidemiologic studies are necessary to test these hypotheses.


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

-- Robert S. Levine, MD, George Rust, MD, Muktar Aliyu, MD, PhD, Maria Pisu, PhD, Roger Zoorob, MD, MPH, Irwin Goldzweig, MS, Paul Juarez, PhD, Baqar Husaini, PhD, Charles H. Hennekens, MD, DrPH

 This article originally appeared in the January 2013 issue of The American Journal of Medicine.

Feb 2013: Statin Dosing

Is alternate day statin dosing a good idea? In this video, Editor-in-chief Dr. Joseph S. Alpert reviews new research into statin dosing in the February 2013 issue of The American Journal of Medicine.

Chasing Pulmonary Emboli

Chasing Pulmonary Emboli: Let's Agree on One Big Thing

Clinical practice guidelines can be great. It's nice to have guidelines for the diagnosis, management, and long-term care objectives for basically every condition known to medicine. Clinical practice guidelines are supposed to be the foundation of 21st century evidence-based medicine. But clinicians frequently do not follow clinical practice guidelines. Just Google “clinical practice guidelines”: after you note 7,100,000 citations on clinical practice guidelines in less than 0.5 seconds, you begin to understand why. First, which clinical practice guideline do you follow? Various professional organizations fight over the same meta-analyses and come to different conclusions—notoriously in regard to mammography recommendations, for example. There are differences in the United States among different organizations regarding when to start mammography, how often to screen, and when to stop. Other advanced medical systems in Europe look at the same data and choose very different intervals and start-up and ending ages. There are distinguished researchers who maintain that screening mammography in low-risk patients is entirely without merit and may do more harm than good.1 Which clinical practice guideline do you follow and how did you choose it? Or choose to ignore it?

Clinicians do not follow clinical practice guidelines for many reasons: lack of knowledge, disagreement (whether due to thoughtful analysis or simple egocentricity), distaste for cookbook approaches, inconvenience, inertia, patient unwillingness, and the like. There is an entire literature not only on clinical practice guidelines but also on why clinical practice guidelines are fabulous or awful, and even on why many clinicians refuse to follow them. But enough about this mess.

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

-- Robert G. Stern

This article originally appeared in the January 2013 issue of The American Journal of Medicine.

Related Article:  Adherence to PIOPED II Investigators' Recommendations for Computed Tomography Pulmonary Angiography

House Afire

Like a House Afire: Cardiac Sarcoidosis 

It seemed like an obvious case of acute coronary syndrome—but was it really? A 36-year-old man of Sri Lankan origin presented to his local rural emergency department with severe central chest pain. He described persistent chest tightness radiating to his left arm. This had developed at rest and was unaffected by inspiration or posture. Over the preceding 24 hours, he had several short-lived episodes of similar but milder pain that resolved spontaneously. Otherwise, the patient had been well with no recent viral illness. His medical history was significant for diet-controlled type 2 diabetes mellitus and hypercholesterolemia. He was a smoker and had a strong family history of premature coronary artery disease.

On examination, the patient was hemodynamically stable. His heart sounds were normal, with no pericardial rub, and his lungs were clear on auscultation. An electrocardiogram (ECG) showed sinus rhythm with 1-mm ST elevation in leads I and aVL. A chest radiograph showed normal cardiac and mediastinal contours with clear lung fields. Serum troponin T at admission was significantly elevated at 4.3 μg/L (normal < 0.02).

A random blood glucose measurement was 14.1 mmol/L, and hemoglobin A1c was raised at 9.2%. The patient's white cell count was mildly elevated at 1.36 x103/mm3, and his C-reactive protein level was 23 mmol/L. A diagnosis of acute coronary syndrome was made. Treatment was initiated with aspirin and clopidogrel after a loading dose of clopidogrel, 300 mg. He also received a therapeutic dose of subcutaneous low-molecular-weight heparin and opiate analgesia. He was not given thrombolysis, and no catheterization laboratory facilities were available at this rural location.

Over the next 24 hours, the patient had ongoing pain requiring opiate analgesia. To read this article in its entirety, please visit our website.

 -- James D. Richardson, MBBS, Michael S. Cunnington, MBBS, Adam J. Nelson, MBBS, Julie A. Bradley, PhD, Karen S.L. Teo, PhD, Stephen G. Worthley, PhD, Matthew I. Worthley, PhD

This article originally appeared in the January 2013 issue of The American Journal of Medicine.