Smoking and Solid Organ Transplantation
Smoking is the leading preventable cause of death worldwide. On average a smoker can expect a decrease of 10 years in life expectancy. 1 It is estimated that during the 20th century 100 million deaths were attributable to smoking, a figure that is expected to rise to 150 million deaths between 2000 and 2025 and further increase throughout the 21st century. There are an estimated 1 billion smokers worldwide, which is expected to increase by 30 million new smokers each year. While consumption per adult per day has decreased in high income countries, there is still an upward trend in low and middle income countries. (Source: ...
Source: The American Journal of Medicine - November 16, 2018 Category: General Medicine Authors: Karim H. Anis, Larry A. Weinrauch, John A. D'Elia Tags: Review Source Type: research

The Rise of Documentation and the Destruction of Modern Medicine
The doctor-patient relationship has remained a central theme in the art of medicine since Hippocrates. Investing time into this relationship ensures trust and communication between both parties during patient's most vulnerable moments. Unfortunately though, it seems as if the doctor-patient interaction has been gradually declining over time. The widespread implementation and dissemination of the electronic health record (EHR) has helped streamline the documentation process, is used as a means of communication between the primary and consulting physicians and is supposed to systematize healthcare. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 16, 2018 Category: General Medicine Authors: Muhammad Shahzeb Khan, Haris Riaz Tags: Editorial Source Type: research

Typically Atypical: Merkel Cell Carcinoma
Unlike melanoma, Merkel cell carcinoma, another potentially deadly skin cancer, has no definitive physical characteristics. A man in his 60s presented to our clinic with a 4-month history of a rapidly enlarging, raised nodule on his head. It was associated with intermittent tenderness due to its size and location but did not cause significant pain. At his initial presentation, the patient denied having fever, chills, unintentional weight loss, and other systemic symptoms. His past medical history was noteworthy for actinic keratoses and multiple basal cell carcinomas. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 14, 2018 Category: General Medicine Authors: Andrew J. Krispinsky, Susan Massick Tags: Images in Dermatology Source Type: research

Clinical characteristics and one-year outcomes of elderly patients with st-elevation or non-st-elevation acute coronary syndrome undergoing percutaneous coronary intervention
Acute coronary syndromes have been classified according to the finding of ST-segment elevation on the presenting ECG, with different treatment strategies and practice guidelines. However, a comparative description of the clinical characteristics and outcomes of acute coronary syndrome elderly patients undergoing percutaneous coronary intervention during index admission has not been published so far. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 14, 2018 Category: General Medicine Authors: Nuccia Morici, Stefano Savonitto, Luca A Ferri, Daniele Grosseto, Irene Bossi, Paolo Sganzerla, Giovanni Tortorella, Michele Cacucci, Maurizio Ferrario, Gabriele Crimi, Ernesto Murena, Stefano Tondi, Anna Toso, Nicola Gandolfo, Amelia Ravera, Elena Corrad Tags: Clinical Research Study Source Type: research

Days spent at home in the last six months of life among community-living older persons
Days spent at home has recently been identified as an important patient-centered outcome; yet, relatively little is known about time spent at home at the end of life among community-living older persons. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 14, 2018 Category: General Medicine Authors: Thomas M. Gill, Evelyne A. Gahbauer, Linda Leo-Summers, Terrence E. Murphy, Ling Han Tags: Clinical Research Study Source Type: research

Nodular thyroid dermopathy: Not a hallmark of Graves ’ disease
A 40-year-old male presented to the outpatient department with complaints of multiple, nontender, raised nodular lesions on his shins bilaterally for the past one year (Figure A). The lesions had an insidious onset and were progressively increasing in size. He was evaluated at an outside clinic. Biopsy was performed multiple times, and possibility of spindle cell lipoma and myxoid liposarcoma was kept. Patient was referred to our institute for further management. However, on eliciting a detailed history, he had easy fatigability, and cold intolerance. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 14, 2018 Category: General Medicine Authors: Mandeep Singla, Abhinav Gupta Tags: Clinical Communication to the Editor Source Type: research

Cannabis legalization does not influence patient compliance with opioid therapy
Prescription opioid use and opioid related deaths continue to increase nationwide. Several states have adopted legislation allowing for recreational use of cannabis. Little is known about how recreational cannabis law impacts compliance in chronic pain patients prescribed opioid therapy. The goals of this study were to: 1) Retrospectively assess the effect of cannabis use on compliance with opioid therapy in a high-risk patient population and 2) Determine the impact that legalization of recreational cannabis had on patients prescribed therapeutic opioids. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 10, 2018 Category: General Medicine Authors: Sheng-Ying Lo, Gabrielle N. Winston-McPherson, Amy J. Starosta, Mark D. Sullivan, Geoffrey S. Baird, Andrew N. Hoofnagle, Dina N. Greene Tags: Clinical Research Study Source Type: research

Altitude Sickness Prevention with Ibuprofen Relative to Acetazolamide
Acetazolamide is the drug of choice for prevention of acute mountain sickness, established in over 200 studies in the past 40 years.1 The primary mechanism of acetazolamide in combatting the hypobaric hypoxia of high altitude is through a bicarbonate diuresis that induces a compensatory respiratory alkalosis.2 Ibuprofen has been found effective for chemoprophylaxis of acute mountain sickness3,4 while secondary findings in unpowered studies have shown mixed results.4,5 This raises the possibility that ibuprofen's inhibition of the cyclo-oxygenase inflammatory cascade and ensuing cerebral processes, similar to glucocorticoid...
Source: The American Journal of Medicine - November 9, 2018 Category: General Medicine Authors: Patrick Burns, Grant S. Lipman, Keiran Warner, Carrie Jurkiewicz, Caleb Phillips, Linda Sanders, Mario Soto, Peter Hackett Tags: Brief Observation Source Type: research

Risk Estimation in Type 2 Myocardial Infarction and Myocardial Injury: The TARRACO Risk Score
Cardiac troponin (cTn) is the recommended and preferred biomarker for diagnosing acute myocardial infarction.1,2 The use of high-sensitivity (hs) cTn assays and broad testing across various clinical scenarios has led to a progressive increase in the number of patients displaying increased cTn concentrations>99th percentile in the settings of acute and chronic pathologies other than type 1 myocardial infarction. Several studies suggest that most increased levels of cTn in contemporary practice are due to either type 2 myocardial infarction or myocardial injury. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 9, 2018 Category: General Medicine Authors: German Cediel, Yader Sandoval, Anne Sexter, Anna Carrasquer, Maribel Gonz ález-del-Hoyo, Gil Bonet, Carme Boqué, Karen Schulz, Stephen W. Smith, Antoni Bayes-Genis, Fred S. Apple, Alfredo Bardaji Tags: Clinical Research Study Source Type: research

Divisions, Departments, and the 2018 Red Sox Baseball Team: Qualities of Leadership that Lead to Success
I am a converted Red Sox baseball fan. I grew up in New Haven, Connecticut and was an ardent New York Yankees fan growing up. However, during my many years living in Massachusetts, as well as having numerous contacts with players for the Red Sox at the University of Massachusetts Medical Center, I became a convert to the local religion, The Boston Red Sox, as well as a frequent visitor to their cathedral, Fenway Park. The 2018 Red Sox team had a spectacular season ending with crushing victories on their way to the World Series Championship. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - November 9, 2018 Category: General Medicine Authors: Joseph S. Alpert Tags: Commentary Source Type: research

Internal Medicine Residency Program Director Burnout and Program Director Turnover: Results of a National Survey
Burnout, a work-related syndrome involving high levels of emotional exhaustion, depersonalization, and sense of reduced personal accomplishment,1 is common among physicians and learners; across a range of different studies, roughly one-half of all physicians meet criteria for burnout.2,3 Burnout has been associated with a number of different negative outcomes, including physician turnover and diminished patient care quality, professionalism, physician health, work effort, and health care system measures. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 29, 2018 Category: General Medicine Authors: Alec B. O'Connor, Andrew J. Halvorsen, John M. Cmar, Kathleen M. Finn, Kathlyn E. Fletcher, Lisa Kearns, Furman S. McDonald, Sara L. Swenson, Sandhya Wahi-Gururaj, Colin P. West, Lisa L. Willett Tags: AAIM Perspectives Source Type: research

Importance of Aminotransferase Elevation in Detecting Myopathy
I read with interest the expert review of myopathies by Drs. Domingo-Horne and Salajegheh published in a recent issue of the Journal.1 Indeed, when myopathy is specifically suspected, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are less useful markers than serum creatine kinase. However, it is worth mentioning that aminotransferases are frequently noted to be elevated incidentally and may be the first clue to yet-unsuspected myopathy. A failure to consider skeletal muscle as a source of their elevation can lead to unnecessary evaluation for hepatic pathology and a missed opportunity for timel...
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Zaven Sargsyan Tags: Letter Source Type: research

The Sunshine Act Has Been for a World that Doesn't Exist Anymore!
McCarthy et al rightly raised concerns about the lack of disclosure of conflicts of interest by physicians using social media.1 This state of affairs is most depressing.1 (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Alain Braillon Tags: Letter Source Type: research

RoPES, Strokes and Closures
We read with great interest the review article by Dalen and Alpert regarding “Which Patent Foramen Ovales Need Closure to Prevent Cryptogenic Strokes?”1 The authors have provided a succinct contemporary review and have also distinctively tabulated the results of the path-defining trials in this somewhat contentious field. The main message provided by the authors is that in patients with cryptogenic stroke, a patent foramen ovale associated with an atrial septal aneurysm should be closed and that closure is not indicated when an atrial septal aneurysm is absent. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Adil S. Wani, Suhail Q. Allaqaband, M. Fuad Jan Tags: Letter Source Type: research

The Reply
We appreciate the excellent comments by Dr. Sargsyan. It is correct that when considering the etiologies underlying elevated serum alanine (ALT) and aspartate (AST) transaminases, one should also consider muscle as a potential source, particularly in the presence of elevated serum creatine kinase,1 before attributing them to liver pathology and moving on to invasive procedures, such as liver biopsy. In these circumstances, and as noted in our review,2 we check for elevation in serum gamma glutamic transferase (GGT) levels, that would suggest liver, rather than muscle pathology. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Mohammad Kian Salajegheh, Rose M Domingo-Horne Tags: Letter Source Type: research

About Autoresuscitation in Accidental Hypothermia
The unusual and interesting report by Pasquier and colleagues1 describes an almost fully-conscious man who walked, underwent a cardiac arrest with subsequent autoresuscitation, apparently whilst severely hypothermic. A full discussion is impossible here but some comments are appropriate. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Les Gordon, Hermann Brugger Tags: Letter Source Type: research

The Reply
We recently highlighted concerns that many physicians who use social media for professional purposes are not appropriately disclosing relationships with industry, and we outlined potential reasons and solutions for this lack of disclosure.1 In his letter to the editor, Dr. Braillon shares many of our sentiments; however, he believes that the lack of disclosure may be due to the ‘toothless’ nature of the guideline recommendations (which lack punitive capacity), or reflect a lack of concern with ‘integrity’ and ‘professionalism’ among many physicians. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Cian P. McCarthy, Matthew DeCamp, John W. McEvoy Tags: Letter Source Type: research

The Reply
We want to thank Dr Gordon and Dr Brugger for their comments on our article “Autoresuscitation in accidental hypothermia”, recently published in The American Journal of Medicine.1 We appreciate their insight on the putative mechanisms leading to auto-resuscitation. As we have nothing to add regarding the latter point, some additional comments may be helpful to explain s ome issues regarding the temperature measurement they pointed out in their letter. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Mathieu Pasquier, Matthieu de Riedmatten, Peter Paal Tags: Letter Source Type: research

The Reply
When preparing our review of patent foramen ovale closures,1 we were not aware of the 2013 report by Kent et al.,2 cited by Wani and colleagues in their comments. We would certainly agree that a cryptogenic stroke in a young patient without risk factors for cerebrovascular disease is more likely to be due to paradoxical embolism than a cryptogenic stroke in an elderly patient with risk factors for cerebrovascular disease. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: James E Dalen Tags: Letter Source Type: research

Tramadol: Distinguishing the Pathophysiology of Serotonin Syndrome and Seizures
We read with interest the narrative review on tramadol-induced risks of serotonin syndrome and seizures by Hassamal et al.1 We would like to comment on the statement that these two complications result from excessive serotonergic activity. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Authors: Bruno M égarbane, Camille Lagard, Lucie Chevillard Tags: Letter Source Type: research

Table of Contents
(Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 27, 2018 Category: General Medicine Source Type: research

Drugs, the thyroid and the heart: a lethal cocktail
A 53 year old man was referred for evaluation of a raised International Normalised Ratio (INR) blood result. He had been taking warfarin and amiodarone for two years following a transient episode of atrial fibrillation following a percutaneous coronary interventional procedure. He was receiving treatment for severe left ventricular systolic dysfunction and Type 2 diabetes mellitus (Table 1). Initial evaluation revealed breathlessness at rest with evidence of decompensated cardiac failure (Figure 1, resting tremor, no thyromegaly, and he was unable to stand unaided. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 26, 2018 Category: General Medicine Authors: Andrew Jamieson Tags: Clinical Communication to the Editor Source Type: research

Prevalence, Determinants, and Clinical Associations of High-Sensitivity Cardiac Troponin in Patients Attending Emergency Departments
High-sensitivity cardiac troponin assays may improve the diagnosis of myocardial infarction but increase the detection of elevated cardiac troponin in patients without acute coronary syndrome. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Kuan Ken Lee, Ala Noaman, Amar Vaswani, Matthew Gibbins, Megan Griffiths, Andrew R. Chapman, Fiona Strachan, Atul Anand, David A. McAllister, David E. Newby, Alasdair J. Gray, Nicholas L. Mills, Anoop S.V. Shah Tags: Clinical Research Study Source Type: research

Prevalence, determinants and clinical associations of high-sensitivity cardiac troponin in patients attending the Emergency Department
High-sensitivity cardiac troponin assays may improve the diagnosis of myocardial infarction but increase the detection of elevated cardiac troponin in patients without acute coronary syndrome. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Kuan Ken Lee, Ala Noaman, Amar Vaswani, Matthew Gibbins, Megan Griffiths, Andrew R. Chapman, Fiona Strachan, Atul Anand, David A. McAllister, David E. Newby, Alasdair J. Gray, Nicholas L. Mills, Anoop S.V. Shah Tags: Clinical Research Study Source Type: research

The association between serum calcium levels and short-term mortality in chronic heart failure patients
Patients with chronic heart failure have a vulnerable myocardial function and are susceptible to electrolyte disturbances. In these patients, diuretic treatment is frequently prescribed, though it is known to cause electrolyte disturbances. Therefore, we investigated the association between altered calcium homeostasis and the risk of all-cause mortality in chronic heart failure patients. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Anne-Sofie Caroline Jensen, Christoffer Polcwiartek, Peter S øgaard, Rikke Nørmark Mortensen, Line Davidsen, Mette Aldahl, Matilde Alida Eriksen, Kristian Kragholm, Christian Torp-Pedersen, Steen Møller Hansen Tags: Clinical Research Study Source Type: research

Concomitant use of direct oral anticoagulants with antiplatelet agents and the risk of major bleeding in patients with non-valvular atrial fibrillation
Direct oral anticoagulants (DOACs) are increasingly being used for ischemic stroke prevention among patients with non-valvular atrial fibrillation,1,2 partly because of their favorable efficacy and safety compared with vitamin K antagonists (VKAs).3 However, the safety of DOACs in patients with non-valvular atrial fibrillation requiring additional use of antiplatelet agents remains uncertain. This is important, as up to 30% of patients with non-valvular atrial fibrillation may receive concomitant treatments of oral anticoagulants with antiplatelets due to comorbid cardiovascular conditions. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Antonios Douros, Christel Renoux, Hui Yin, Kristian B. Filion, Samy Suissa, Laurent Azoulay Tags: Clinical Research Study Source Type: research

Wanted: Local Medical Experts /Champions to Prevent Gun Violence
In response to the current, horrific, US public health crisis, an epidemic of gun violence, due primarily to handguns, physician leaders are calling upon health care professionals to become involved in solutions, both in their medical and community lives.1,2,3 A lack of knowledge about guns and gun violence is cited by some4 as an impediment, preventing many of these potential partners from joining into the project. My recent experiences working on gun violence does indeed support this concern about an information deficit among many medical colleagues (Physicians, Nurses, Medical Social Workers and Hospital Administrators)...
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: James Webster Source Type: research

CLIPPERS: An Increasingly Recognized Chronic Inflammatory Central Nervous System Disorder
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare chronic inflammatory neurological syndrome affecting multiple regions of the brain, including brainstem, cerebellum, and spinal cord, that has become increasingly recognized since its introduction in 2010 by Pittock et al.1 The hallmark neuroimaging finding for CLIPPERS consists of multiple punctate, curvilinear lesions, notably “peppering” of the pons with spread to other parts of the cerebellum on gadolinium enhanced MRI. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Kshipra Joshi, Todd Golden, Sehem Ghazala Tags: Clinical Communication to the Editor Source Type: research

A Point-of-care Ultrasound Exam to Refine Referral for Outpatient Echocardiography
Background: Few data exist on the potential utility of a cardiac point-of-care ultrasound (POCUS) exam in the outpatient setting to assist diagnosis of significant cardiac disease.Objective: Using a retrospective sequential cohort design, we sought to derive and then validate a POCUS exam for cardiac application and model its potential use for prognostication and cost-effective echo referral.Methods: For POCUS exam derivation, we reviewed 233 consecutive outpatient echo studies for 4 specific POCUS “signs” contained therein representing left ventricular systolic dysfunction, left atrial enlargement, inferior ve...
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Paul J. Han, Ben T. Tsai, Martin, William D. Keen, Jill Waalen, Bruce J. Kimura Source Type: research

An overlooked cause of polyuria
A 40-year-old female presented to the outpatient department with complaints of frequent urination and excessive thirst for three months. She was passing large volumes of urine throughout the day and night, but she denied dysuria, urgency, or hesitancy. She used to consume two cups of tea in a day. Twenty-four hour urine output was six litres with corresponding increase in fluid intake. There was no relevant medical history, except for the frequent use of proton pump inhibitors and laxatives for pain epigastrium and constipation respectively. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Mandeep Singla, Abhinav Gupta Source Type: research

Canakinumab: Promises and Future in Cardiometabolic Diseases and Malignancy
Inflammation has proven in multiple studies to be responsible for the progression of cardiometabolic diseases and malignancies. The interleukin family has been critically associated with progression of atherosclerosis, insulin resistance, and various malignancies. Given the advent of pharmacologic interleukin-1 (IL1) inhibition, this pathway can potentially be targeted to improve outcomes. In the recently concluded Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS) trial, investigators looked at the potential role of IL 1 (especially IL-1 β) inhibition in halting the progression of atherosclerosis. (Sour...
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Aneesh Dhorepatil, Somedeb Ball, Raktim K Ghosh, Meera Kondapaneni, Carl J Lavie Tags: Review Source Type: research

Genomics and Precision Medicine to Combat Opioid Use Disorder
Chronic pain is a debilitating disorder affecting approximately 100 million, or almost 30% of the adult population of the United States (US).1 Among patients with chronic pain about half report its occurrence to be daily and severe.. Chronic pain costs about $630 billion annually and is the leading primary complaint by patients to healthcare providers as well as the chief reason for lost productivity. The annual cost of pain is greater than for coronary heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion). (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Janet Robishaw, Jennifer Caceres, Charles H. Hennekens Tags: Commentary Source Type: research

Classic Lesion, Not So Classic Cause
Calciphylaxis, also known as calcific uremic arteriolopathy is a serious disorder characterized by skin necrosis secondary to reduction in the blood flow caused by calcification, fibrosis, and thrombus formation in the dermo-hypodermic arterioles. While calcific uremic arteriolopathy has been reported in non-uremic patients, it is primarily observed in patients with end-stage renal disease, especially those with longstanding and often poorly controlled hyperphosphatemia, secondary hyperparathyroidism, and longer dialysis vintage. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Abhilash Koratala, Amir Kazory Tags: Clinical Communication to the Editor Source Type: research

Annals of Communication: Giving a Patient a Diagnosis and Other Idioms in Development
Communication is at the heart of the medical enterprise. We doctors share our research and our interpretations of that research in words. We use words to learn about the concerns of our patients and record our impressions, our findings, and our plans; words to share with patients and families what we have discovered, how we interpret those discoveries, what we believe to be the best approaches to optimize outcomes based on the best medical information currently available; and we use words as therapy. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Alan Jay Cohen Tags: Commentary Source Type: research

Management of Acute Ischemic Stroke
The treatment of acute ischemic stroke has undergone a revolution recently with the publication of five positive thrombectomy trials in the early time window, 0-6 hours from stroke onset in 2015 and the more recent publication of two positive late window trials that included carefully selected patients up to 24 hours from stroke onset.1-3 The treatment efficacy of thrombectomy was highly robust in both time windows and the benefits can likely be expanded to less strictly selected patients. The treatment of acute ischemic stroke with thrombectomy built upon the more modest benefits observed previously with i.v. (Source: The...
Source: The American Journal of Medicine - October 25, 2018 Category: General Medicine Authors: Yunyun Xiong, Bharti Manwani, Marc Fisher Tags: Review Source Type: research

Fulminant Emphysematous Pancreatic Pseudocyst: Infected with Normal Skin Flora
A 49-year-old man was alcoholic and had major depressive disorder. He experienced epigastric pain, poor appetite, and weight loss for 1 month. Ultrasonography of the abdomen revealed a pancreatic cyst (7  × 8 cm) with echogenic debris (Figure 1A). Contrast-enhanced computed tomography (CT) of the abdomen showed a complicated pancreatic pseudocyst (Figure 1B), compressed common bile duct, and dilated biliary tracts (Figure 1C). Laboratory data revealed an amylase level of 59 U/L (normal range: 2 8–100 U/L), a lipase level of 175 U/L (normal range: 22–51 U/L), a white blood cell count of 10700/µL ...
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Chih-Wen Wang, ChiaYen Dai, Tzer-Ming Chuang, Chung-Feng Huang, Ming-Lun Yeh, Ching-I Huang, Zu-Yau Lin, Shinn-Cherng Chen, Jee-Fu Huang, Ming-Lung Yu, Wan-Long Chuang Tags: Clinical Communication to the Editor Source Type: research

A Genetic Origin? Purpura Fulminans
Over days, a patient's relatively small lesion evolved into widespread tissue damage. A previously healthy 49-year-old Arab woman was admitted for a 2-cm painful red lesion on her left breast. She had been well until a few days earlier when she developed left flank pain and was treated with ofloxacin for a presumed urinary tract infection. During the first 48 hours of her admission, the erythematous lesion over the left breast progressed, developing the appearance of a hematoma. Ultimately, it involved the entire breast (Figure 1). (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Orly Avnery, Gili Kenet, Martin H. Ellis Tags: Diagnostic Dilemma Source Type: research

Impact of Geriatrician-performed Comprehensive Geriatric Care on Medication Use and Cognitive Function in Older Adults Referred to a Non-hospital Based Rehabilitation Unit
People aged ≥65 years occupy approximately two thirds of medical beds in hospitals1. The worldwide reduction in length of in-hospital stay means that in the future, most rehabilitation of frail older adults after acute hospital care will occur in outpatient community settings. Non-hospital based community reh abilitation units in Denmark offer older adults an opportunity to improve function in order to reduce re-hospitalization and institutionalization. Within this context, these frail older adults may be candidates for an outpatient comprehensive geriatric assessment2. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Dmitri Zintchouk, Merete Gregersen, Torsten Lauritzen, Else Marie Damsgaard Tags: Clinical Research Study Source Type: research

ECG of the Month: Telltale T Waves
Although the patient's electrocardiogram (ECG) contained a well-known marker for severe stenosis of the left anterior descending artery, it was essential that the workup address diagnostic possibilities beyond the most conspicuous. A 43-year-old African American man presented with a 1-month history of progressive dyspnea on exertion. He had an unremarkable medical history and an excellent baseline exercise capacity. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Nitin Kondamudi, Shah R. Ali, Amit Khera Source Type: research

Prevalence, Echocardiographic Correlations and clinical outcome of Tricuspid Regurgitation in patients with significant Left Ventricular Dysfunction
to evaluate the prevalence and clinical significance of tricuspid regurgitation in patients with left ventricular dysfunction (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Shirit Sara Kazum, Alexander Sagie, Tzippy Shochat, Tuvia Ben-Gal, Tamir Bental, Ran Kornowski, Yaron Shapira, Mordehay Vaturi, Tal Hasin Tags: Clinical Research Study Source Type: research

Complicated Necrotizing Otitis Externa Progressing to Coalescent Mastoiditis and Temporal Lobe Abscess
A 77-year-old male with a history of hypertension, chronic kidney disease, and poorly-controlled type 2 diabetes mellitus presented to our intensive care unit from an outside hospital with complicated necrotizing otitis externa. One month prior, the patient developed purulent drainage from the right external auditory canal with associated hearing loss. One week prior, he was prescribed ciprofloxacin/dexamethasone otic suspension and oral ciprofloxacin tablets for his symptoms. Despite this regimen, he experienced progressive purulent otorrhea, along with subjective fevers, chills, headaches, and altered mental status. (Sou...
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Talha Demirci, Sharon O'Brien Source Type: research

Reinfarction in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) – coronary findings and prognosis
Background: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is common. There are limited data on the mechanisms and prognosis for reinfarction in MINOCA patients.Methods: In this observational study of MINOCA patients hospitalized in Sweden and registered in the SWEDEHEART registry between July 2003 and June 2013 and followed until December 2013 we identified 9,092 unique patients with MINOCA out of 199,163 MI admissions in total. The 570 (6.3%) MINOCA patients who were hospitalized due to a recurrent MI constituted the study group. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Anna M Nordenskj öld, Bo Lagerqvist, Tomasz Baron, Tomas Jernberg, Nermin Hadziosmanovic, Harmony R Reynolds, Per Tornvall, Bertil Lindahl Tags: Clinical Research Study Source Type: research

A Simpler Answer – After All This Time
We present a case in which a patient with long-term misdiagnosis of a rare problem was found to have a common condition that explained her symptoms. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Donna J. Coetzee, Gregory Vercellotti, Andrew P.J. Olson Tags: Clinical Communication to the Editor Source Type: research

No more thrombotic thrombocytopenic purpura/hemolytic uremic syndrome please
Old habits die hard. It is so in the medical field too. For decades, we have used the term thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS) for patients presented with acute renal failure, microangiopathic hemolysis and thrombocytopenia, without diarrhea prodrome. Although, thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome are now known as two distinct diseases,1 TTP/HUS still can be seen in medical records and even in medical journals today. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Yeong-Hau H. Lien Source Type: research

The New Privacy Crisis: What's Health Got to Do with It?
When The New York Times and The Observer broke the news in March that a little-known consulting firm named Cambridge Analytica had used private data from millions of Facebook users, allegedly without their consent, few readers could have foreseen the major implications for their health care. They certainly could not have known that Cambridge Analytica's client list extended far beyond the victorious political campaigns of Ted Cruz and Donald Trump, to a major healthcare provider, New York University's Langone hospital, and a major insurance provider, the London-traded Hiscox Ltd. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Anthony W. Orlando, Arnold J. Rosoff Source Type: research

Outcomes of Catheter Directed Therapy Plus Anticoagulation Versus Anticoagulation Alone for Submassive and Massive Pulmonary Embolism with Subgroup Analysis
Acute pulmonary embolism is a leading cause of cardiovascular morbidity and death. PE has been described by the Surgeon General as the most common preventable cause of death among hospitalized patients. Massive and submassive pulmonary embolism, accounting for 5-10% and 20-25% of cases respectively, and are associated with increased mortality [1, 2, 3]. The International Cooperative Pulmonary Embolism Registry (ICOPER) reported 90 day mortalities of up to 52.4% for massive pulmonary embolism and up to 19% for submassive pulmonary embolism [4]. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 24, 2018 Category: General Medicine Authors: Charles Hennemeyer, Abdul Khan, Hugh McGregor, Cheyenne Moffett, Gregory Woodhead Tags: Retrospective Clinical Research Study Source Type: research

Autonomic Disorders
Autonomic complaints are frequently encountered in clinical practice. They can be due to primary autonomic disorders or secondary to other medical conditions. Primary autonomic disorders can be categorized as orthostatic intolerance syndromes and small fiber neuropathies, the latter are associated with autonomic failure, pain, or their combinations. The review outlines orthostatic intolerance syndromes (neurally mediated syncope, orthostatic hypotension, postural tachycardia syndrome, inappropriate sinus tachycardia, orthostatic cerebral hypoperfusion syndrome and hypocapnic cerebral hypoperfusion) and small fiber neuropat...
Source: The American Journal of Medicine - October 8, 2018 Category: General Medicine Authors: Peter Novak Source Type: research

Transitional care interventions for heart failure: what are the mechanisms?
Two decades ago heart failure clinics were proposed widely as an effective means of improving care.1 Despite dozens of trials over subsequent years, it has often been difficult to ascertain the true effectiveness of such programmes due to poor descriptions of study populations, interventions, comparators and outcomes. This is compounded by the use of terms such as ‘transitional care’, ‘integrated care’, ‘coordinated care’, ‘community care’, ‘person-centred care’. These differences in terminology continue to make drawing conclusions of the effectiveness of interven...
Source: The American Journal of Medicine - October 6, 2018 Category: General Medicine Authors: David R. Thompson, Chantal F. Ski, Alexander M. Clark Tags: Commentary Source Type: research

Team-based primary care for the multimorbid patient: Matching complexity with complexity
Complex, multimorbid patients are individuals within whom multiple chronic diagnoses (usually, more than two)1 intersect additional complications – diminished function, cognitive impairment, homelessness, or substance abuse, for example. As many as one third of patients are multimorbid, with correlates of socioeconomic deprivation, increasing health services utilization, and mental health comorbidity.2 The growing scope and scale of care fo r complex, multimorbid patients has led to corresponding changes in the comprehensiveness required of health systems. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - October 6, 2018 Category: General Medicine Authors: Linnaea Schuttner, Michael Parchman Tags: Commentary/Editorial Source Type: research

Aspirin to Prevent Sudden Cardiac Death in Athletes with High Coronary Artery Calcium Scores
While proficient cardiac resuscitation has improved survival following cardiac arrest during road races in Japan, this accomplishment does not address coronary artery disease as the underlying cause of an increasing frequency of cardiac arrest in middle-aged men during marathons and ironman triathlons in the United States since the year 2000. Based on the high prevalence of subclinical coronary artery disease by cardiac computed tomography in endurance athletes with low conventional cardiac risk-factor profiles, we recommend coronary artery calcium scores as a more reliable and independent predictor of incident cardiac eve...
Source: The American Journal of Medicine - October 5, 2018 Category: General Medicine Authors: Arthur J. Siegel, Timothy D. Noakes Tags: Review Source Type: research