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.

Promoting Health to Preschoolers

Targeting Preschool Children to Promote Cardiovascular Health: Cluster Randomized Trial

School programs can be effective in modifying knowledge, attitudes, and habits relevant to long-term risk of chronic diseases associated with sedentary lifestyles. As part of a long-term research strategy, we conducted an educational intervention in preschool facilities to assess changes in preschoolers' knowledge, attitudes, and habits toward healthy eating and living an active lifestyle.

Using a cluster design, we randomly assigned 14 preschool facilities in Bogotá, Colombia to a 5-month educational and playful intervention (7 preschool facilities ) or to usual curriculum (7 preschool facilities ). A total of 1216 children aged 3-5 years, 928 parents, and 120 teachers participated. A structured survey was used at baseline, at the end of the study, and 12 months later to evaluate changes in knowledge, attitudes, and habits.

Children in the intervention group showed a 10.9% increase in weighted score, compared with 5.3% in controls. The absolute adjusted difference was 3.90 units (95% confidence interval [CI], 1.64-6.16; P <.001). Among parents, the equivalent statistics were 8.9% and 3.1%, respectively (absolute difference 4.08 units; 95% CI, 2.03 to 6.12; P <.001), and among teachers, 9.4% and 2.5%, respectively (absolute difference 5.36 units; 95% CI, −0.29-11.01; P = .06). In the intervened cohort 1 year after the intervention, children still showed a significant increase in weighted score (absolute difference of 6.38 units; P <.001).

A preschool-based intervention aimed at improving knowledge, attitudes, and habits related to healthy diet and active lifestyle is feasible, efficacious, and sustainable in very young children.

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

 -- Jaime Céspedes, MD, German Briceño, MD, MSc, Michael E. Farkouh, MD, MSc, Rajesh Vedanthan, MD, MPH, Jorge Baxter, MA, Martha Leal, MD, MSc, Paolo Boffetta, MD, PhD, Mark Woodward, MSc, Marilyn Hunn, Rodolfo Dennis, MD, MSc, Valentin Fuster, MD, PhD

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

Related article: Moving Countries Toward Healthier Lifestyles

Burton's Line: A Tell Tale Sign

Burton's Line

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

You can read "Burton's Line: A Tell Tale Sign" here: http://amjmed.org/burtons-line-a-tell-tale-sign/

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

Jan 2013: Learning Healthy Behaviors

Can healthy habits learned as very young children translate into long-term healthy lifestyles? Editor-in-chief Dr. Joseph S. Alpert reviews new research in the January 2013 issue of The American Journal of Medicine.

Toward Healthier Lifestyles

Moving Countries Toward Healthier Lifestyles

Unhealthy habits learned during childhood often persist through adulthood; so, why not teach healthy habits during early childhood to see if they persist?

This issue of The American Journal of Medicine contains an article that describes the success of a powerful new tool for changing lifestyle habits related to healthy eating and exercise. In recent decades in developed countries, we have seen a shift in the etiologies that most commonly cause death and disability, from infectious diseases to degenerative illnesses related to a significant degree to unhealthy lifestyles. Attempts to change these lifestyle choices in adults have often met with limited success. Earlier studies have tested the hypothesis that childhood interventions aimed at inculcating healthy lifestyle principles might be a more effective way to influence future generations and might have a beneficial spillover effect on the parents of these children.

In this issue, the article by Céspedes et al(1) describes a study involving more than 1000 lower- and middle-class children enrolled in preschools in Bogotá, Columbia, plus their parents and teachers. Children in the intervention group were exposed to educational and play activities, including “Sesame Street” videos and similar other media, that emphasized healthy eating and an active lifestyle. Meanwhile, parents and teachers participated in workshops and training related to healthy habits. Children in the control group continued with their regular preschool curriculum.

Baseline, 6-month, and 18-month surveys revealed a significant change in these very young children's attitudes toward healthy eating and an active lifestyle, but changes in knowledge, habits, and body mass index were not significant. The intervention group children had a significant increase (10.9%) in their weighted score (knowledge 70, attitudes 20, habits 10).

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

-- Joseph S. Alpert, MD, and Pamela Powers Hannley, MPH

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

Related article: Targeting Preschool Children to Promote Cardiovascular Health: Cluster Randomized Trial