The American Journal of Medicine

Learning to Write: A Personal Reflection

Joseph S. Alpert — 2010-08-01

Many of you have asked me how someone's career can evolve to marry medicine and editing and writing. The story actually begins with learning to read. My father's sister, a frequent visitor in our home, was a first grade teacher who began teaching me to read when I was 3 years old. As a journalism major and later as a career journalist, my mother was chief proofreader and critic of any school writing project. But all that changed when I was 14 years old, and my mother, tiring of typing our school essays, enrolled my brother and me in a summer secretarial school typing class where I learned to touch type without looking at my fingers on the keyboard. At the time I had no idea how important this skill would become. In later years, I often jokingly told my mother that the “best thing she ever did for me was to enroll me in the secretarial typing class.” Although typing is not writing, this skill started to pay off in high school when I wrote for the school newspaper and literary magazine, and found that typing efficiency could lead to better writing and more effective self-editing. My mother continued to encourage me to write both literary and academic essays, and I found great satisfaction in doing so.

The Future of Malpractice Reform

Tara F. Bishop, Paul E. Klotman, Bruce C. Vladeck, Mark A. Callahan — 2010-08-01

There are few topics in health care that incite as much fervor as the American malpractice system. Almost every interested party—patients, physicians, and policymakers—has expressed an opinion on malpractice reform. Physicians, particularly through professional organizations, have long argued that the American malpractice system leads to a multitude of problems, such as an aversion to disclose medical errors, defensive medicine (the overuse of clinical services because of malpractice fears), and limitations on access to care, particularly care that is perceived as high risk.

Pain/Depression Dyad: A Key to a Better Understanding and Treatment of Functional Somatic Syndromes

Don L. Goldenberg — 2010-06-11

Abstract: Functional somatic syndromes include some of the most common and frustrating illnesses seen by primary care physicians and medical specialists. An extensive literature search of the 2 best characterized functional somatic syndromes, fibromyalgia and irritable bowel syndrome, reveals the overlap of these 2 disorders and their close relationship to depression. New pathophysiologic studies have shown that there are similar central nervous system changes in fibromyalgia, irritable bowel syndrome, and depression. These clinical and biologic similarities are consistent with the observations that the effective management of fibromyalgia and irritable bowel syndrome is comparable to that of depression.

Assessing the Presence and Severity of Depression in Subjects with Comorbid Coronary Heart Disease

2010-08-01

Abstract: Our understanding of how depression alters the origin and course of coronary heart disease is derived from subjective methodologies. Many psychiatric instruments were not tested for reliability and validity in subjects with comorbid medical illness, particularly coronary heart disease. They largely use scales of categoric or ordinal variables. Instruments used to assess coronary heart disease are considerably more objective and often use interval variables. By searching the websites of Circulation and the Journal of the American College of Cardiology, we entered the word “depression” on August 28, 2009. We ignored articles using “depression” in the context of cardiovascular concepts such as “ST-segment depression.” By searching articles dating back to 1995, we selected publications that studied the prognostic association of depression and coronary heart disease. There were 5 relevant publications: 3 from Circulation and 2 from the Journal of the American College of Cardiology. The methods used to assess coronary heart disease (specifically, myocardial infarction) are largely homogenous across the studies, but the methods used to assess depression are heterogeneous. Parameters used to diagnose myocardial infarction and determine its severity are precise, objective, and reliable, whereas those used to assess depression and its severity exhibit less precision and lack comparable objectivity and reliability. This mismatch may compromise our understanding of the link between coronary heart disease and depression in depressed patients with comorbid coronary heart disease. We propose using precise instruments to identify and quantitate coronary heart disease as outcome variables to assess psychiatric interventions and to better define depression in depressed patients with comorbid coronary heart disease. This should lead to a better understanding of the link between depression and comorbid coronary heart disease.

Celiac Disease Diagnosis: Simple Rules Are Better Than Complicated Algorithms

Carlo Catassi, Alessio Fasano — 2010-08-01

Abstract: Celiac disease is the only treatable autoimmune disease, provided that a correct diagnosis is achieved and a strict, lifelong gluten-free diet is implemented. The current diagnostic algorithm for celiac disease includes initial screening serological tests, followed by a confirmatory small intestinal biopsy showing the autoimmune insult typical of celiac disease. The biopsy, considered the diagnostic gold standard, has been recently questioned as a reliable and conclusive test for every case. Indeed, the wide variability of celiac disease-related findings suggests that it is difficult to conceptualize the diagnostic process into rigid algorithms that do not always cover the clinical complexity of this disease. Instead we find clinically useful the shifting to a quantitative approach that can be defined as the “4 out of 5” rule: the diagnosis of celiac disease is confirmed if at least 4 of the following 5 criteria are satisfied: typical symptoms of celiac disease; positivity of serum celiac disease immunoglobulin, A class autoantibodies at high titer; human leukocyte antigen (HLA)-DQ2 or DQ8 genotypes; celiac enteropathy at the small bowel biopsy; and response to the gluten-free diet.

Sweet's Syndrome

Tasaduq Fazili, David Duncan, Lubna Wani — 2010-08-01

A 31-year-old woman with no significant medical history was admitted to the hospital with a 5-day history of development of slightly painful, pustular lesions on her face and neck, chest, upper back, axillae, and suprapubic area. The patient had been seen in an urgent care center and diagnosed with “strep throat” approximately 2 weeks before admission and had received a course of oral amoxicillin. Five days before admission, she was reevaluated at the urgent care center because of low-grade fever and pustular lesions on the right side of her face and neck. Oral trimethoprim/sulfamethoxazole was administered, but her skin lesions continued to progress as described, and she presented for admission.

Malignant Mimicry

2010-08-01

Although syphilis has been known historically as “the Great Mimicker,” some other diseases also merit this appellation, presenting with a plethora of symptoms and signs commonly ascribed to other ailments. We recently had the opportunity to care for a patient whose pathologic condition masqueraded as an alternative condition.

A Diagnosis in Vein

Gregory Piazza, Marshall A. Wolf, Marie Gerhard-Herman — 2010-08-01

Frequently, patients describe symptoms that seem to have limited relevance to their presentation but ultimately prove to be the critical clue to the diagnosis. This case illustrates the importance of listening carefully to our patients. Dismissal of seemingly insignificant symptoms can lead to vain diagnostic efforts.

Captain Ignose to the Rescue

Robert M. Reed — 2010-08-01

Some patients require powerful incentive before they seek a physician's help. After years of avoiding medical attention, a 68-year-old man presented from home with shortness of breath that was so severe, he was unable to leave the house to purchase cigarettes. He had become progressively more homebound during the previous year due to gradually deteriorating respiratory status. In the weeks before presentation, his chronic dyspnea had become far worse, preventing him from performing routine activities. During the same period, he also had developed a severe physical and emotional malaise. He took no medications, lived alone, and had smoked 2 packs of cigarettes a day for more than 40 years.

A Toxic Combination

Nabil S. Zeineh — 2010-08-01

This case reminds the physician to be cautious when administering QT-prolonging medications to patients with underlying heart disease. A 73-year-old man with a known history of chronic obstructive pulmonary disease presented to the emergency department with severe dyspnea and altered mental status. He was promptly intubated by the emergency department physicians, placed on mechanical ventilation, and given intravenous levofloxacin and corticosteroids. He was transferred to the medical intensive care unit for management. An electrocardiogram (ECG) taken at admission showed signs of left ventricular hypertrophy and a QTc interval (QT interval corrected for heart rate) of 450 msec.

Trouble in Transit

Narendrakumar Alappan, James M. Tauras, Cynthia C. Taub — 2010-08-01

This report describes the case of a 50-year-old woman who presented with a rarely seen but extremely dangerous condition that was diagnosed via transesophageal echocardiography.

Prevalence and Characteristics of Tinnitus among US Adults

Josef Shargorodsky, Gary C. Curhan, Wildon R. Farwell — 2010-08-01

Abstract: Background: Tinnitus is common; however, few risk factors for tinnitus are known.Methods: We examined cross-sectional relations between several potential risk factors and self-reported tinnitus in 14,178 participants in the 1999-2004 National Health and Nutrition Examination Surveys, a nationally representative database. We calculated the prevalence of any and frequent (at least daily) tinnitus in the overall US population and among subgroups. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) after adjusting for multiple potential confounders.Results: Approximately 50 million US adults reported having any tinnitus, and 16 million US adults reported having frequent tinnitus in the past year. The prevalence of frequent tinnitus increased with increasing age, peaking at 14.3% between 60 and 69 years of age. Non-Hispanic whites had higher odds of frequent tinnitus compared with other racial/ethnic groups. Hypertension and former smoking were associated with an increase in odds of frequent tinnitus. Loud leisure-time, firearm, and occupational noise exposure also were associated with increased odds of frequent tinnitus. Among participants who had an audiogram, frequent tinnitus was associated with low-mid frequency (OR 2.37; 95% CI, 1.76-3.21) and high frequency (OR 3.00; 95% CI, 1.78-5.04) hearing impairment. Among participants who were tested for mental health conditions, frequent tinnitus was associated with generalized anxiety disorder (OR 6.07; 95% CI, 2.33-15.78) but not major depressive disorder (OR 1.58; 95% CI, 0.54-4.62).Conclusions: The prevalence of frequent tinnitus is highest among older adults, non-Hispanic whites, former smokers, and adults with hypertension, hearing impairment, loud noise exposure, or generalized anxiety disorder. Prospective studies of risk factors for tinnitus are needed.

Blood Pressure and Outcomes in Very Old Hypertensive Coronary Artery Disease Patients: An INVEST Substudy

2010-08-01

Abstract: Background: Our understanding of the growing population of very old patients (aged ≥80 years) with coronary artery disease and hypertension is limited, particularly the relationship between blood pressure and adverse outcomes.Methods: This was a secondary analysis of the INternational VErapamil SR-Trandolapril STudy (INVEST), which involved 22,576 clinically stable hypertensive coronary artery disease patients aged ≥50 years. The patients were grouped by age in 10-year increments (aged ≥80, n=2180; 70–<80, n=6126; 60–<70, n=7602; <60, n=6668). Patients were randomized to either verapamil SR- or atenolol-based treatment strategies, and primary outcome was first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke.Results: At baseline, increasing age was associated with higher systolic blood pressure, lower diastolic blood pressure, and wider pulse pressure (P <.001). Treatment decreased systolic, diastolic, and pulse pressure for each age group. However, the very old retained the widest pulse pressure and the highest proportion (23.6%) with primary outcome. The adjusted hazard ratio for primary outcomes showed a J-shaped relationship among each age group with on-treatment systolic and diastolic pressures. The systolic pressure at the hazard ratio nadir increased with increasing age, highest for the very old (140 mm Hg). However, diastolic pressure at the hazard ratio nadir was only somewhat lower for the very old (70 mm Hg). Results were independent of treatment strategy.Conclusion: Optimal management of hypertension in very old coronary artery disease patients may involve targeting specific systolic and diastolic blood pressures that are higher and somewhat lower, respectively, compared with other age groups.

Paradoxical Preservation of Vascular Function in Severe Obesity

2010-08-01

Abstract: Background: Obesity is associated with a high risk of coronary artery disease morbidity and mortality. Yet, postmortem studies have shown that severely obese subjects exhibit smooth coronary arteries, thus suggesting that they may be protected from atherosclerosis. We assessed vascular function and its possible determinants in a cohort of normal-weight to severely obese insulin-sensitive subjects (body mass index [BMI] 23.2-49 kg/m2).Methods: Seventy-one healthy, insulin-sensitive subjects (Homeostasis Model Assessment of Insulin Resistance index <2.5), divided into normal-weight (n = 13; BMI = 23.2 ± 1.6), obese (n = 35; BMI=32.6±2.5), and severely obese (n=23; BMI=49.0±7.9) groups, were enrolled. Vascular function was evaluated by flow-mediated dilation and carotid intima–media thickness. High-sensitivity C-reactive protein, leptin, adiponectin, vascular growth factors, and CD34+KDR+/CD133+ endothelial progenitor cells, known markers of vascular health/protection, also were measured.Results: Flow-mediated dilation was higher in severely obese than in obese and normal-weight individuals (P=.019 and P=.011 respectively). Intima–media thickness was consistently lower in severely obese than in obese individuals (P=.040) and similar in severely obese and normal-weight individuals (P >.99). Levels of high-sensitivity C-reactive protein and leptin were higher in severely obese than in obese and normal-weight individuals (high-sensitivity C-reactive protein: P=.018 and P=.05, respectively; leptin: P <.001 for both comparisons). CD34+KDR+ endothelial progenitor cells were significantly higher in severely obese versus obese individuals (P=.039).Conclusion: Our study demonstrates that vascular function is paradoxically better in severely obese than in obese subjects and similar to that found in normal-weight subjects. Despite higher levels of high-sensitivity C-reactive protein and leptin, severely obese individuals may be partially protected from atherosclerosis, possibly by a greater mobilization of endothelial progenitor cells.

Venous Compression for Prevention of Postthrombotic Syndrome: A Meta-analysis

2010-08-01

Abstract: Purpose: To determine the effectiveness of venous compression stockings or compression bandages on the reduction of postthrombotic syndrome in patients with deep venous thrombosis.Methods: We attempted to identify all published trials in all languages identified by PubMed through June 2009. Meta-analysis was performed.Results: Based on 5 randomized trials of patients with deep venous thrombosis comparing treatment with venous compression to controls, mild-to-moderate postthrombotic syndrome occurred in 64 of 296 (22%) treated with venous compression, compared with 106 of 284 (37%) in controls (relative risk=0.52). Severe postthrombotic syndrome occurred in 14 of 296 (5%) treated, compared with 33 of 284 (12%) controls (relative risk=0.38). Any postthrombotic syndrome occurred in 89 of 338 (26%) treated, compared with 150 of 324 (46%) controls (relative risk=0.54).Conclusion: Venous compression reduced the incidence of postthrombotic syndrome, particularly severe postthrombotic syndrome. Venous compression in patients with deep venous thrombosis would seem to be indicated for this purpose. There was, however, wide variation in the type of stockings used, time interval from diagnosis to application of stockings, and duration of treatment. Further investigation, therefore, is needed.

Health Insurance and Cardiovascular Disease Risk Factors

2010-08-01

Abstract: Background: Compared with those with health insurance, the uninsured receive less care for chronic conditions, such as hypertension and diabetes, and experience higher mortality.Methods: We investigated the relations of health insurance status to the prevalence, treatment, and control of major cardiovascular disease risk factors—hypertension and elevated low-density lipoprotein (LDL) cholesterol—among Framingham Heart Study (FHS) participants in gender-specific, age-adjusted analyses. Participants who attended the seventh Offspring cohort examination cycle (1998-2001) or the first Third Generation cohort examination cycle (2002-2005) were studied.Results: Among 6098 participants, 3.8% were uninsured at the time of the FHS clinic examination and ages ranged from 19 to 64 years. The prevalence of hypertension and elevated LDL cholesterol was similar for the insured and uninsured; however, the proportion of those who obtained treatment and achieved control of these risk factors was lower among the uninsured. Uninsured men and women were less likely to be treated for hypertension with odds ratios for treatment of 0.19 (95% confidence interval [CI], 0.07-0.56) for men and 0.31 (95% CI, 0.12-0.79) for women. Among men, the uninsured were less likely to receive treatment or achieve control of elevated LDL cholesterol than the insured, with odds ratios of 0.12 (95% CI, 0.04-0.38) for treatment and 0.17 (95% CI, 0.05-0.56) for control.Conclusion: The treatment and control of hypertension and hypercholesterolemia are lower among uninsured adults. Increasing the proportion of insured individuals may be a means to improve the treatment and control of cardiovascular disease risk factors and to reduce health disparities.

Depression and Incident Diabetic Foot Ulcers: A Prospective Cohort Study

2010-08-01

Abstract: Objective: To test whether depression is associated with an increased risk of incident diabetic foot ulcers.Methods: The Pathways Epidemiologic Study is a population-based prospective cohort study of 4839 patients with diabetes in 2000-2007. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio and 95% confidence interval (CI) for incident diabetic foot ulcers, comparing patients with major and minor depression with those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin, diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses also adjusted for peripheral neuropathy and peripheral arterial disease as defined by diagnosis codes.Results: Compared with patients without depression, patients with major depression by Patient Health Questionnaire-9 had a 2-fold increase in the risk of incident diabetic foot ulcers (adjusted hazard ratio 2.00; 95% CI, 1.24-3.25). There was no statistically significant association between minor depression by Patient Health Questionnaire-9 and incident diabetic foot ulcers (adjusted hazard ratio 1.37; 95% CI, 0.77-2.44).Conclusion: Major depression by Patient Health Questionnaire-9 is associated with a 2-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders or mediators.

Early Creatinine Shifts Predict Contrast-induced Nephropathy and Persistent Renal Damage after Angiography

2010-08-01

Abstract: Purpose: The purpose of this study was to evaluate incidence and predictors of contrast-induced nephropathy after coronary angiography and interventions, and to assess renal function at 30 days. The prognostic value of any early shift of serum creatinine compared with baseline was investigated; such measurement, being a delta, is largely independent of creatinine variations.Methods: There were 216 patients at risk for contrast-induced nephropathy prospectively evaluated at baseline and at 12, 24, and 48 hours after exposure to contrast media, and 190 (88%) evaluated 1 month after discharge.Results: Contrast-induced nephropathy occurred in 39 patients (18%), and 30-day renal damage was detected in 15 (7%). Contrast media/kg volume predicted contrast-induced nephropathy (P=.002), and percentage change of creatinine 12 hours from baseline was significantly higher in patients with nephropathy (P <.001). At multivariate analysis, percentage change of creatinine 12 hour-basal was the best predictor of nephropathy (P <.001). A 5% increase of its value yielded 75% sensitivity and 72% specificity (area under the curve 0.80; odds ratio 7.37; 95% confidence interval, 3.34-16.23) for early contrast-induced nephropathy detection. Furthermore, it strongly correlated with the development of renal impairment at 30 days (P=.002; sensitivity 87%, specificity 70%; area under the curve 0.85; odds ratio 13.29; 95% confidence interval, 2.91-60.64).Conclusion: Minimal elevations of serum creatinine at 12 hours are highly predictive of contrast-induced nephropathy and 30-day renal damage after exposure to contrast media.

Age Disparity in the Dissemination of Imatinib for Treating Chronic Myeloid Leukemia

2010-08-01

Abstract: Background: Imatinib is a highly effective treatment for chronic myeloid leukemia. It was approved by the Food and Drug Administration in 2001 and thereafter rapidly became front-line therapy. This study characterized the prevailing chronic myeloid leukemia therapies in the United States and assessed the impact of imatinib on chronic myeloid leukemia survival and mortality rates in the general population.Methods: Investigators with the National Cancer Institute's Patterns of Care study reviewed medical records and queried physicians regarding therapy for 423 patients with chronic myeloid leukemia diagnosed in 2003 who were randomly selected from cancer registries in the Surveillance, Epidemiology, and End Results Program. Characteristics associated with the receipt of imatinib were documented, as were survival differences between those who received imatinib and those who did not. Population-based data were used to assess chronic myeloid leukemia survival and mortality rates in time periods before and after the introduction of imatinib.Results: Imatinib was administered to 76% of patients in the Patterns of Care study. Imatinib use was inversely associated with age: 90%, 75%, and 46% for patients ages 20 to 59 years, 60 to 79 years, and 80 or more years, respectively. Elderly patients who received imatinib survived significantly longer than those who did not. After adjusting for age, imatinib use did not vary significantly by race/ethnicity, socioeconomic status, urban/rural residence, presence of comorbid conditions, or insurance status. Overall, chronic myeloid leukemia survival in the Surveillance, Epidemiology, and End Results population improved, and mortality in the United States declined dramatically during the period when imatinib became widely available; these improvements diminished with increasing age.Conclusion: Age disparities in treatment with imatinib likely contributed to worse survival for many elderly patients with chronic myeloid leukemia.

Diagnosis: The Eyes Have It

Beth R. Kutzbach, Deanne T. Kashiwagi, Steven M. Couch, M. Caroline Burton — 2010-08-01

A 43-year-old white woman was transferred to the Mayo Clinic for evaluation of bilateral proptosis and decreased vision in the left eye. Eight months before admission, the patient had a sinus infection and was treated with levofloxacin. She developed a marked lower-extremity rash and respiratory failure requiring mechanical ventilation. This was believed to be Stevens-Johnson syndrome, although no biopsy was performed.

Cytomegalovirus Infection: A Potential Threat to Atrioventricular Conduction?

2010-08-01

In January 2009, a 34-year-old woman with transient high-degree atrioventricular block was referred to the Hippokration Hospital (A). The patient reported effort dyspnea accompanied by asthenia, headaches, myalgias, and diffuse arthralgias, but not syncope. Her medical history was unremarkable, and she did not report smoking, alcohol, or illicit drug abuse and never received blood products. There was no family history of rhythm and conduction disorders.

Loop Diuretics for Heart Failure-associated Hyponatremia

Vijay Lapsia, Amir Kazory — 2010-08-01

Hyponatremia is a common finding in patients with severe heart failure and is associated with adverse outcomes. There are no universally accepted consensus guidelines on management of heart failure-associated hyponatremia, and current therapeutic options remain very limited.

A New “Hump”

Tahmeed Contractor, Abhimanyu Beri — 2010-08-01

Mediastinal masses can result from a broad spectrum of pathologies, including tumors, cysts, lymphadenopathy, and vascular enlargements. Although a significant proportion of these are found incidentally, symptoms can occur due to compression or invasion of surrounding structures, including the tracheobronchial tree, great vessels, and nerves.

Not Your Otitis Media 101

Matthew Gingo, Michael G. Risbano, Paul D. Russ, Edward D. Chan — 2010-08-01

A 58-year-old man with diabetes mellitus presented with a left earache and decreased hearing. Despite antibiotic treatment for otitis media, followed by treatment with another antibiotic and wick placement for refractory otitis media and newly diagnosed otitis externa, dizziness and headache developed.

Diagnostic Value of Chest Radiographs in Bedridden Patients with Suspected Pneumonia

2010-08-01

We read with great interest the article by Esayag et al regarding the diagnostic value of chest radiography for the diagnosis of pneumonia in bedridden patients. Few studies have provided an accurate estimation of chest radiography for the diagnosis of pneumonia, which is a particularly important issue in hospitalized patients. However, some key points are to be discussed.

The Reply

2010-08-01

We appreciate the comments of Solbiati et al about our article and this opportunity to elaborate on key points excluded from the final manuscript due to editorial restrictions on the length of the article.

Optimization of Tissue Oxygenation in Critically Ill Jehovah's Witness Patients

Peter V. Dicpinigaitis — 2010-08-01

As an intensivist who occasionally manages critically ill Jehovah's Witness patients, I read the review by Berend and Levi with interest. I would like to contribute to the discussion of the management of critically ill, severely anemic patients who decline blood transfusion by highlighting the importance of dissolved, non–hemoglobin-bound oxygen in this clinical setting. The oxygen content of arterial blood (Cao2) is determined by oxygen (O2) bound to hemoglobin (Hb) and the concentration of dissolved oxygen in plasma, as shown in the following equationwhere Sao2 represents the oxygen saturation of hemoglobin in arterial blood and Pao2 represents the partial pressure of oxygen in arterial blood. Under normal circumstances, dissolved oxygen in plasma is of little clinical importance, comprising only approximately 1.5% of the total arterial blood oxygen content. However, in the setting of severe anemia, the dissolved component of oxygen can assume a significant role in tissue oxygenation, thus offering physicians an important therapeutic intervention.

The Reply

Kenrick Berend, Marcel Levi — 2010-08-01

The case discussed by Dicpinigaitis shows that even patients with hemoglobin levels as low as 1.8 g/dL can survive without blood transfusion. Rapidly increasing a patient's oxygen-carrying capacity by either increasing the amount of dissolved oxygen in plasma by breathing up to 100 percent oxygen, hyperbaric oxygen therapy, or using alternative oxygen carriers seems obligatory. In addition, metabolic demand might be reduced by mechanical ventilation with pharmacologic paralysis and careful control of body temperature. The suggestion by Dicpinigaitis to increase the level of dissolved oxygen content to very high levels seems attractive. However, although supplemental oxygen may be lifesaving in these cases, excessive supplemental oxygen can be deleterious, especially in case of prolonged duration of oxygen therapy. According to human and animal studies, high concentrations of inspired oxygen can cause compromising hemodynamic effects and a spectrum of pulmonary problems, ranging from mild tracheobronchitis and absorptive atelectasis to an extensive inflammatory response with destruction of the alveolar–capillary barrier. In this respect, it might be extremely difficult, if not impossible, to assess the optimal oxygen treatment strategy for induced hyperoxia in these cases.

Post-Lyme Disease Symptoms

Victoria Cairns — 2010-08-01

It is encouraging to see the results of the study by Cerar et al showing that 6 and 12 months after enrollment the frequency of symptoms in a group of patients treated for early Lyme disease in Slovenia did not exceed that of a control group without Lyme disease. This is in contrast to the results of our meta-analysis of 5 studies in which significantly more Lyme disease patients than controls had fatigue, musculoskeletal pain, and neurocognitive difficulties years after diagnosis and treatment. The patients in this new study all had a solitary erythema migrans at study entry, with a median of 6-7 days since the erythema migrans was first observed. Patients with multiple erythema migrans lesions or an extracutaneous manifestation of Lyme disease were excluded. In the 5 studies in the meta-analysis, many of the patients were infected in the 1980s and early 1990s when diagnosis and treatment were more likely to be delayed, many had neurological symptoms in the acute phase, and some had multiple erythema migrans lesions.

The Reply

Daša Cerar, Franc Strle, Tjaša Cerar, Eva Ružić-Sabljić, Gary P. Wormser — 2010-08-01

We appreciate the comments made by Cairns. Cairns asserts that post-Lyme syndrome is associated with a delay in antibiotic treatment, with neurologic symptoms in the acute phase, and with multiple erythema migrans skin lesions, but this conclusion is not evidence-based. The retrospectively controlled studies that she relied on in her meta-analysis certainly included such groups, but also were likely to have included patients with single erythema migrans skin lesions, and misdiagnosed patients. Our prospectively controlled study of patients with a single erythema migrans skin lesion may be considered as a starting point to address the question of whether post-Lyme disease syndrome exists in adults. The findings of our study do not support its existence, because we found that the frequency of nonspecific symptoms in controls equaled or exceeded that of patients at both 6 and 12 months after the patients were treated. At the 12-month time-point, the 95% confidence interval surrounding the difference in frequency of such symptoms indicates that an insufficient sample size was not the explanation for the results. The fact that patients themselves selected controls might have biased our results; however, when comparing basic demographics (sex, age, and the frequency of underlying chronic illnesses) between patients and controls we did not find significant differences. Furthermore, another prospectively controlled study of children with neurologic Lyme disease, in which the frequencies of nonspecific symptoms such as headache and fatigue were actually higher among sex- and age-matched controls at 6 months into follow-up, corroborates our results.

Persistent Symptoms Following Treatment of Early Lyme Disease: False Hope?

Raphael B. Stricker, Lorraine Johnson — 2010-08-01

Cerar et al conclude that almost all Lyme disease patients treated for an erythema migrans rash with short-course antibiotic therapy have complete resolution of symptoms at 1 year following treatment. Unfortunately, the design of this Slovenian study promotes a false expectation of therapeutic success that cannot be generalized to all patients afflicted with Borrelia burgdorferi, the spirochetal agent of Lyme disease.

The Reply

Daša Cerar, Tjaša Cerar, Eva Ružić-Sabljić, Gary P. Wormser, Franc Strle — 2010-08-01

Stricker and Johnson have incorrectly summarized our study protocol. Approximately 50% of our patients began antibiotic treatment after 1 week of illness, with 23.5% having symptoms in excess of 3 weeks before enrollment. Although we limited our study to patients with a single erythema migrans skin lesion, such patients are by far the most prevalent group of patients with Lyme disease in Slovenia. Of the 34,166 cases of Lyme disease reported in Slovenia from 2000 to 2008, more than 90% had erythema migrans. Furthermore, among adult patients with erythema migrans evaluated by the Department of Infectious Diseases at the University Medical Center in Ljubljana, more than 90% had only a single erythema migrans skin lesion (unpublished data). In other recent clinical experience in Europe and the United States, approximately 90% or more of symptomatic patients with definite Lyme disease had erythema migrans.

Subjective Symptoms after Treatment of Lyme Disease

Sam T. Donta — 2010-08-01

The study by Cerar et al documents that prompt treatment of patients with early Lyme disease seems to result in generally good outcomes. But some of the inference, perhaps the impetus for the study, is that patients with Lyme disease do not develop any relapsing, persistent, chronic symptoms that can be considered to be due to persistent infection. The fact that the authors acknowledge the controversy, there are patients who have persisting symptoms, and the abundant evidence that both untreated and treated patients with Lyme disease can develop a chronic illness needs to be further acknowledged and addressed. Their study did not deal with patients who had delayed treatment or no treatment and whether a short course of doxycycline or other antibiotic would be effective in those patients. Our and others' observations have shown that there are numerous such patients, and certain antibiotic regimens seem to be effective if given for a sufficient period of time. What is needed is not further denial of the existence of patients with Lyme disease who have chronic symptoms, but study of the basis for such symptoms, be it persisting infection or other mechanisms to explain the chronic illness. The tools currently exist to be able to delineate the underlying process, and we all need to come together to initiate and support research to answer these questions.

The Reply

Daša Cerar, Franc Strle, Tjaša Cerar, Eva Ružić-Sabljić, Gary P. Wormser — 2010-08-01

In response to Donta's letter to the editor, the question of whether the frequency of nonspecific symptoms after treated Lyme disease exceeds the background frequency of such complaints in the general population remains unanswered and was the impetus for our study. Our results indicate there is no increase in the frequency of nonspecific symptoms in the particular subgroup of patients with Lyme disease in our study. Further assessment of the outcome in other groups of patients with Lyme disease is warranted, but these studies must incorporate appropriate control groups to provide meaningful data.

No Effect of Selenium Supplementation on Serum Glucose Levels in Men with Prostate Cancer

2010-08-01

Abstract: Background: Literature indicates a relationship between selenium supplementation and risk of diabetes. However, because these data are inconclusive, we investigated the effect of selenium supplementation on serum glucose levels in men with prostate cancer enrolled in a clinical trial testing of the effect of selenium on prostate cancer progression.Methods: Subjects were randomized to receive placebo (n=46), selenium 200 μg/day (n=47), and selenium 800 μg/day (n=47). Serum glucose levels were obtained every 6 months for up to 5 years. Longitudinal analysis was carried out to assess whether rate of change of serum glucose levels was significantly different in the selenium-supplemented groups as compared with placebo. Sensitivity analyses were performed to assess the robustness of findings.Results: Changes in serum glucose levels during the course of the trial were not statistically significantly different as compared with placebo for the selenium 200 μg/day (P=.56) or selenium 800 μg/day (P=.91) treatment groups.Conclusion: These results do not support a relationship between selenium supplementation and changes in serum glucose levels. Recommendations about selenium supplementation and risk of diabetes will require more definitive studies.

AAIM Report on Master Teachers and Clinician Educators Part 1: Needs and Skills

2010-08-01

The Alliance for Academic Internal Medicine (AAIM) is composed of key internal medicine professional bodies committed to the preservation, growth, and refinement of the specialty. Member organizations include the Association of Professors of Medicine, Association of Specialty Professors, Association of Program Directors in Internal Medicine, Clerkship Directors in Internal Medicine, and Administrators of Internal Medicine. A primary mission of AAIM is to foster change in medical education. To this end, in 2006 AAIM chartered the Education Redesign Task Force, composed of representatives of the member organizations and the American College of Physicians and American Board of Internal Medicine, to address several topics critical to the mission of internal medicine education. A second task force was similarly chartered in 2008 and charged to examine 3 additional issues: defining the essence of internal medicine, formulating a pathway toward competency-based medical education, and describing and examining issues related to clinical medical educators, specifically the master teacher.

William Carlos Williams and Mikhail Bulgakov on Feeling versus Reason

Helle Mathiasen — 2010-08-01

William Carlos Williams, MD, and Mikhail Bulgakov, MD, published disturbing fiction about doctors practicing crisis medicine. Such stories demonstrate that doctors are fallible humans who struggle to moderate their negative emotions and act according to reason. Gripping and realistic, “The Use of Force” and “The Steel Windpipe” offer extraordinary insights into medical practice.

Supplement to The American Journal of Medicine®

2010-08-01

The American Journal of Medicine now provides its readers with access to peer-reviewed Official Journal CME (and non-CME) Multimedia Activities. These activities are designed to deliver quality education through an interactive experience that takes full advantage of online capabilities. All Multimedia Activities are peer reviewed and approved by the editorial leadership, which has identified the content as educational and of interest to our readership.

Managing Gout in the Primary Care Setting: What You and Your Patients Need to Know

Paul P. Doghramji, N. Lawrence Edwards, Joan McTigue — 2010-08-01

Abstract: The US prevalence of gout, a rapidly progressive inflammatory arthritic condition linked to serum uric acid levels, has grown in recent years, in part due to the increasing prevalence and incidence of predisposing factors in the population, such as metabolic syndrome, obesity, and the use of diuretics. Left untreated, gout can be debilitating and cause deformity. Although a definitive diagnosis requires joint aspiration, only ∼11% of patients with suspected gout undergo this procedure, and a presumptive diagnosis based on patient medical history and presentation with characteristic symptoms and comorbidities is a reasonable guidelines-based approach that has utility in the primary care setting, where approximately 70% of all cases and nearly 3,000,000 visits occur. The therapeutic standard for patients with recurrent gout flares is urate-lowering therapy (ULT), including allopurinol and the recently introduced febuxostat, the first new treatment for gout in 40 years. Although ULT must be taken consistently to sustain benefits, inadequate dosing and patient nonadherence or intolerance to therapy often lead to treatment failure. It is important that primary care clinicians understand gout diagnosis and therapeutic approaches and can communicate effectively with patients to improve treatment adherence.Online Access: http://cmeaccess.com/cme/ajm_gout_program/This CME Multimedia Activity is also available through the Website of The American Journal of Medicine (www.amjmed.com). Click on the CME Multimedia Activity button in the navigation bar for full access.

2010-08-01

The American Journal of Medicine

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AAIM Report on Master Teachers and Clinician Educators Part 1: Needs and Skills

William Carlos Williams and Mikhail Bulgakov on Feeling versus Reason

Supplement to The American Journal of Medicine®

Managing Gout in the Primary Care Setting: What You and Your Patients Need to Know

Contents