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.