A rare but fatal waterborne infection
A 58-year-old African American male with a history of hepatitis C and polysubstance abuse presented to the ER following a one-day history of catfish sting to his left hand. Physical examination was notable for erythema and swelling over his left hand. Labs were significant for WBC of 1700/mcL, lactic acidosis (serum lactate 16.3 mmol/L), creatinine kinase (CK) of 2458 Unit/L, creatinine of 1.27 mg/dL, and an INR of 2.4. CT of the left extremity showed superficial soft tissue edema. He was started on broad-spectrum antibiotics for his severe wound infection. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 15, 2021 Category: General Medicine Authors: Rahul Peravali, Khawaja Muddassir Tags: Clinical Communication to the Editor Source Type: research

Effect of Vitamin D and/or Marine n-3 Fatty Acid Supplementation on Changes in Migraine Frequency and Severity: A randomized placebo-controlled trial
There is interest in whether supplements, including vitamin D and marine omega-3 (n-3) fatty acids, may be effective migraine prophylaxis. However, few studies have evaluated whether vitamin D or n-3 fatty acid supplementation may reduce migraine frequency or severity. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Pamela M. Rist, Julie E. Buring, Nancy R. Cook, JoAnn E. Manson, Tobias Kurth Tags: Clinical Research Study Source Type: research

The Johns Hopkins Post-Acute COVID-19 Team (PACT): A Multidisciplinary, Collaborative, Ambulatory Framework Supporting COVID-19 Survivors
The COVID-19 pandemic has rapidly shifted healthcare needs and delivery internationally with about one in five people with COVID-19 requiring hospitalization, including in the intensive care unit (ICU), at pandemic onset.1 ICU survivors in general are at risk for impairments in mental, cognitive and physical health, collectively known as post-intensive care syndrome (PICS);2,3 similar challenges have been described post acute hospitalization (Post-Hospital Syndrome (PHS).4 Risks may be higher among COVID-19 survivors. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Emily Brigham, Jacqueline O'Toole, Soo Yeon Kim, Michael Friedman, Laura Daly, Adam Kaplin, Meghan Swarthout, Brian Hasselfeld, Melissa Lantz-Garnish, Tracy Vannorsdall, Anna Agranovich, Sarath Raju, Ann Parker Tags: Advancing High Value Health Care Source Type: research

A mass in the stomach
A 42-year-old woman presented to the emergency department with complaints of fatigue, abdominal pain, shortness of breath, and palpitations. She felt well until one week prior to presentation when she started to have shortness of breath and fatigue with activities of daily living. Over the next few days, her symptoms progressed and she was unable to walk minimal distances around her house. On the day of admission, she had an episode of severe epigastric pain that lasted approximately thirty minutes and resolved spontaneously. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Siddharth Agarwal, Amrit K. Kamboj, Stephanie L. Hansel Tags: Clinical Communication to the Editor Source Type: research

Graves ’ disease with motion sickness: A case report
We report the case of a 24-year-old woman with no known underlying disease who consulted our clinic for repeated motion sickness for the past month. The first symptom of motion sickness was nausea during her daily bus ride. She started taking the train, but the motion sickness persisted. Soon after entering the train, she experienced a floating sensation and nausea before vomiting. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Morika Suzuki, Takashi Watari Tags: Clinical Communication to the Editor Source Type: research

Sometimes it is not as Simple as Sepsis: An Unusual Cause of Coagulopathy
A 54-year-old man with a history of depression and anxiety developed the sudden onset of shortness of breath, chest numbness, palpitations, and flushing. The patient felt his symptoms were similar to prior anxiety attacks and he took his home dose of alprazolam. When his symptoms did not improve, his spouse activated emergency medical services and he was transported by ambulance to the emergency department. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Kunal Shah, Ashley Hanlon, Oluwatoyosi A. Onwuemene Tags: Diagnostic Dilemma Source Type: research

Cardiac Amyloidosis for the Primary Care Provider: A Practical Review to Promote Earlier Recognition of Disease
Cardiac amyloidosis is increasingly recognized as an underdiagnosed cause of heart failure. Diagnostic delays of up to three years from symptom onset may occur, and patients may be evaluated by more than five specialists prior to receiving the correct diagnosis. Newly available therapies improve clinical outcomes by preventing amyloid fibril deposition and are usually more effective in early stages of disease, making early diagnosis essential. Better awareness among primary care providers of the clinical presentation and modern treatment landscape is essential to improve timely diagnosis and early treatment of this disease...
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Kathleen W Zhang, Srilakshmi Vallabhaneni, Jose A Alvarez-Cardona, Ronald J Krone, Joshua D Mitchell, Daniel J Lenihan Tags: Review Source Type: research

Palpable Pulsus Paradoxus in Primary Care Clinic
A 52-year-old man with recently diagnosed metastatic carcinoma of unknown primary site presented to primary care clinic for evaluation of lightheadedness. Two days prior, the patient presented to the emergency department (ED) after an episode of near syncope while standing. Initially hypotensive, he received a one-liter bolus of normal saline, his blood pressure improved, and he no longer felt lightheaded. His symptoms were presumed to be secondary to poor oral intake, and he was discharged home. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Scott L Hagan, Stephen D Farris Tags: Clinical communication to the editor Source Type: research

Long-term Clinical Outcomes of Underdosed Direct Oral Anticoagulants in patients with Atrial Fibrillation and Atrial Flutter
Although direct oral anticoagulants (DOACs) have been shown to be effective at reducing the risk of stroke in patients with atrial fibrillation/flutter (AF), they are sometimes underdosed off-label to mitigate their associated higher bleeding risk. We sought to evaluate frequency and clinical outcomes of inappropriate underdosing of DOACS in patients with AF. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Hasan Ashraf, Pradyumna Agasthi, Anusha Shanbhag, Ramila A. Mehta, Pattara Rattanawong, Mohamed Allam, Sai Harika Pujari, Farouk Mookadam, William K. Freeman, Komandoor Srivathsan, Dan Sorajja, Win-Kuang Shen, Peter A. Noseworthy, Eric H. Yang, Hicham Z. Tags: Clinical Research Study Source Type: research

Icosapent Ethyl for Primary Versus Secondary Prevention of Major Adverse Cardiovascular Events in Hypertriglyceridemia-Value for Money Analysis
Icosapent ethyl (IPE) is approved for the prevention of major adverse cardiovascular events (MACE) in patients with hypertriglyceridemia. However, due to budget constraints, access to IPE will inevitably be limited to a fraction of eligible patients. To help maximize value for money spent, we estimated the number of preventable MACE when providing IPE for primary vs. secondary prevention. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Ronen Arbel, Enis Aboalhasan, Ariel Hammerman, Joseph Azuri Tags: Clinical Research Study Source Type: research

An intelligent diagnosis: smart syndrome
A 92-year-old woman presented to the Emergency Department with a 10-day history of right-sided headache, confusion, and episodic head turning to the left side that was associated with spontaneous laughter and apparent visual hallucinations. Her family also noted her to be inattentive to her left side. She had been seen in the Emergency Department three days prior for the same symptoms, but discharged home after a computed tomography (CT) of the head without contrast did not demonstrate any acute abnormalities. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Leora Branfield Day, Phavalan Rajendram, Lorraine V. Kalia, Wayne L. Gold Tags: Diagnostic Dilemma Source Type: research

Fish Consumption and Cardiovascular Health: A Systematic Review
Fish contains multiple nutrients such as omega-3 long-chain polyunsaturated fatty acids, protein, vitamin D, vitamin B, calcium, selenium, and other nutrients [1,2]. Omega-3 long-chain polyunsaturated fatty acids are known to have anti-inflammatory and lipid lowering effects, as well as anti-hypertensive effects [3]. Previous studies evaluating the impact of fish consumption on cardiovascular disease events have shown inconsistent results [1,4,5]. Therefore, our aim in this investigation was to systematically review the existing literature regarding the relationship between fish consumption and cardiovascular disease event...
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Chayakrit Krittanawong, Ameesh Isath, Joshua Hahn, Zhen Wang, Bharat Narasimhan, Scott L. Kaplin, Hani Jneid, Salim S. Virani, W.H. Wilson Tang Source Type: research

Testosterone Replacement Therapy Causing Extensive Portal and Mesenteric Vein Thrombosis
A 62-year-old man presented to our emergency department reporting a 1 week history of diffuse abdominal pain. His initial vital signs were unremarkable. His past medical history was significant for panhypopituitarism secondary to a remote head trauma. His home medications included intramuscular testosterone cypionate 120 mg weekly. His initial laboratory values were only remarkable for polycythemia (hemoglobin of 177 g/L) (Table 1). A contrast-enhanced abdominal computerized tomography showed extensive venous thrombosis of the portal vein, the superior mesenteric vein and most of the splenic vein, causing mesenteric ischem...
Source: The American Journal of Medicine - January 11, 2021 Category: General Medicine Authors: Laurence Poirier-Blanchette, Maral Koolian, Blair Carl Schwartz Tags: Clinical Communication to the Editor Source Type: research

Erratum to “Cardiovascular Considerations for the Internist and Hospitalist in the COVID-19 Era” American Journal of Medicine, 133(11); 1254–1261
The publisher regrets that the author affiliations as presented in the published article were incorrect. The correct list of authors and their proper affiliations appears above. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 9, 2021 Category: General Medicine Authors: Michael R. Massoomi, R. David Anderson, Mustafa M. Ahmed, Osama Dasa, Philip George, William M. Miles, Juan M. Aranda, Carl J. Pepine Tags: Erratum Source Type: research

“Bowel prep hyponatremia“ unmasking underlying adrenal insufficiency
A 55-year old man was admitted because of nausea and vomiting of sudden onset. One day earlier, he had undergone magnetic resonance colonography for chronic abdominal discomfort and weight loss, reportedly with normal results. In preparation for the procedure, he had consumed a diet literally devoid of protein and salt and ingested copious amounts of fluids over two days. On examination, he was afebrile, euvolemic and appeared tanned; blood pressure was 122/70 mmHg, heart rate 70/min. He had a remote history of sarcoidosis. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 9, 2021 Category: General Medicine Authors: Martin Windpessl, Manfred Wallner, Christoph Schwarz Tags: Clinical Communication to the Editor Source Type: research

Time to Follow the Evidence: Glycemic control and cardiovascular benefits of new diabetes medications.
Both authors had full access to the entire manuscript and both participated in writing and editing the text. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 9, 2021 Category: General Medicine Authors: Boris Draznin, Irl B. Hirsch Source Type: research

“Negative Secular Trends in Medicine: Training Needs More Emphasis on Maturity, Independence and Self-Reliance”
In 2016, I had a series of 6 Commentaries in this Journal on “Negative Secular Trends in Medicine”, things I thought made it less likely that the smartest kids in the class, the people we want to be our physicians, would choose a career in Medicine1-6. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 9, 2021 Category: General Medicine Authors: Robert M. Doroghazi Tags: Commentary Source Type: research

“When Less is More, a Caring Physician's Dilemma”
Recently, an instructive commentary in the American Journal of Medicine discussed what qualities are needed to be a “good” physician. Empathy, kindness, and a good knowledge base were emphasized.1 About the same time, another commentary discussed the appropriateness of treating some patients with stable coronary artery disease with intense medical therapy and avoiding referral for coronary stenting. It discus sed the findings of many trials demonstrating the effectiveness medical intervention alone, summarizing data from the COURAGE, ORBITA, and ISCHEMIA clinical trials. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 9, 2021 Category: General Medicine Authors: Daniel M. Gelfman Tags: Commentary Source Type: research

Race specific comparisons of antihypertensive and metabolic effects of hydrochlorothiazide and chlorthalidone
For decades, thiazide diuretics (TZDs) have been the preferred initial therapy for uncomplicated hypertension1 –4. Though hydrochlorothiazide (HCTZ) is the most commonly prescribed TZD5,6, recent guidelines favor the long acting “thiazide-like” diuretics such as chlorthalidone (CTD) over “thiazide-type” diuretics (HCTZ) for better cardiovascular risk reduction4,7. There are no head to head outcomes trials of these agents, and data comparing blood pressure lowering and adverse events are inconsistent 8–11, with comparisons across non-equipotent or pooled doses8, and limited data at the cl...
Source: The American Journal of Medicine - January 9, 2021 Category: General Medicine Authors: Lakshmi Manasa S. Chekka, Arlene B. Chapman, John G. Gums, Rhonda M. Cooper-DeHoff, Dean and Distinguished professor, Dr. Julie A. Johnson Tags: Clinical Research Study Source Type: research

Terry's nail due to uncontrolled diabetes mellitus
A 35-year-old Japanese woman presented with nausea and frequent vomiting that had begun the previous day. She was slightly confused. Laboratory blood testing revealed a plasma glucose level of 319 mg/dl and serum hemoglobin A1c level of 11.4%. Venous blood gas analysis revealed a pH of 7.33, bicarbonate level of 19.6 mmol/L, sodium level of 144 mEq/L, chloride level of 103 mEq/L, and anion gap of 21.4. The patient was thus diagnosed with diabetic ketoacidosis, admitted to the hospital, and treated with insulin and intravenous fluids. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 8, 2021 Category: General Medicine Authors: Mizuka Masunaga, Junki Mizumoto Tags: Clinical Communications to the Editor Source Type: research

Erratum to “Hypertrophic Cardiomyopathy: Is a ‘Cure’ Coming … Or Is It Already Here?”
The publisher regrets that the figure in the published version of this paper contained incorrect information. The two green boxes in the second row contained incorrect labels: in the darker green box above the words “Surgical Myectomy”, the wording should have read “Symptomatic Heart Failure: Obstructive”.. The pale green box with arrow leading to “Drugs” should have read “Symptomatic Heart Failure: Nonobstructive”. This is a very important clinical designation. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - January 5, 2021 Category: General Medicine Authors: Barry J. Maron, Ethan J. Rowin, Martin S. Maron Source Type: research

Integrative Medicine and the Long Hauler Syndrome —We Meet Again
“What remains in diseases after the crisis is apt to produce relapses.”― Hippocrates, Aphorisms (400 BCE) (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 30, 2020 Category: General Medicine Authors: Randy Horwitz, Victoria Maizes Tags: Commentary Source Type: research

Kamala
My mother used to eat Welch's Grape Jelly by the spoonful straight out of the jar while she studied for the licensing exam for Foreign Medical Graduates (FMGs). She couldn't believe the abundance in this country – the food, the cars, the cosmetics, the frilly dresses for her children. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 30, 2020 Category: General Medicine Authors: Parwathi Paniker Tags: Commentary Source Type: research

The Philosopher-Priest-Scientist and the new age of medicine
Who is the physician of the future? Our present model of the physician-scientist, developed in 19th century Germany, no longer fits the needs of our patients. The physician did not always look this way, with our white lab coats and stethoscope draped over our shoulders. Consider the lessons of history. In 2nd century Alexandria, Galen codified the cause of disease as an imbalance of four humors – black bile, yellow bile, phlegm, and blood – and set the standard for medical diagnosis for the next 1,300 years (Figure 1). (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 30, 2020 Category: General Medicine Authors: Benjamin R. Doolittle Tags: Commentary Source Type: research

Mindfulness and cognitive training interventions in mild cognitive impairment: impact on cognition and mood
With the lack of disease-modifying pharmacologic treatments for mild cognitive impairment and dementia, there has been an increasing clinical and research focus on non-pharmacological interventions for these disorders. Many treatment approaches, such as mindfulness and cognitive training, aim to mitigate or delay cognitive decline, particularly in early disease stages, while also offering potential benefits for mood and quality of life. In this review, we highlight the potential of mindfulness and cognitive training to improve cognition and mood in mild cognitive impairment. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 29, 2020 Category: General Medicine Authors: Gretchen O. Reynolds, Kim Willment, Seth Gale Tags: Review Source Type: research

A Call to Arms: The War of the COVID
“Why did people give themselves smallpox? The practice was then called inoculation; it is now called variolation…An individual could defy providence and choose a safe way to prevent fatal smallpox.”1 (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 29, 2020 Category: General Medicine Authors: Joseph S. Alpert, Arthur William Boylston Tags: Commentary Source Type: research

Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees
The considerable gap in the primary care workforce of the United States is anticipated to widen over the next 10 to 15 years.1 Numerous physician groups have called for increased focus on primary care training in medical education.2-4 In 2009, the Accreditation Council on Graduate Medical Education (ACGME) mandated an increase for ambulatory training during internal medicine residency, requiring a minimum of 130 half-day clinics over three years. This increased requirement presupposes greater exposure will inevitably lead to more primary care physicians, but some have argued it is increased exposure to high-quality, high-f...
Source: The American Journal of Medicine - December 29, 2020 Category: General Medicine Authors: Associate Professor of Medicine Stephen R. Holt, Associate Professor of Medicine Daniel G. Tobin, Assistant Professor of Medicine Laura Whitman, Professor of Medicine Matthew Ellman, Associate Professor of Medicine John P. Moriarty, Associate Professor of Tags: AAIM Perspectives Source Type: research

Standardization in Performing and Interpreting Electrocardiograms
The 12 lead ECG is one of the most performed study to diagnose various cardiovascular conditions. It is estimated that more than 52 million ECGs were analyzed by computer in the United States in 1987. (1) A conservative estimate of the increase of computerized ECGs in the United States from 1987 until 2013 would indicate that 60 million computerized ECGs are taken presently in the United States. The cost of an ECG is $16.46 based on Medicare reimbursement of which $8.30 is for the facility fee and $8.16 for the professional fee for interpretation. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 24, 2020 Category: General Medicine Authors: Muhammad Ajmal, Frank Marcus Tags: Review Source Type: research

Oral Anticoagulation Use in High-Risk Patients Is Improved by Elimination of False-Positive and Inactive Atrial Fibrillation Cases
Multiple registries have reported that>40% of high-risk atrial fibrillation patients are not taking oral anticoagulants. The purpose of our study was to determine the presence or absence of active atrial fibrillation and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 y, Diabetes mellitus, prior Stroke [or transient ischemic attack or thromboembolism], Vascular disease, Age 65-74 y, Sex category) risk factors to accurately identify high-risk atrial fibrillation (CHA2DS2-VASc ≥2) patients requiring oral anticoagulants and the magnitude of the anticoagulant treatment gap. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 23, 2020 Category: General Medicine Authors: Gerald V. Naccarelli, Mohammed Ruzieh, Deborah L. Wolbrette, Mauricio Sendra-Ferrer, John van Harskamp, Barbara Bentz, Gregory Caputo, Nathan McConkey, Kevin Mills, Stephen Wasemiller, Jovan Plamenac, Douglas Leslie, Frendy D. Glasser, Thomas W. Abendroth Tags: Clinical Research Study Source Type: research

Loop Diuretic Prescription and Long-Term Outcomes in Heart Failure: Association Modification by Congestion
The effect of loop diuretics on clinical outcomes in heart failure has not been evaluated in randomized controlled trials. In hospitalized patients with heart failure, a discharge loop diuretic prescription has been shown to be associated with improved 30-day outcomes, which appears to be more pronounced in subgroups with congestion. In the current study, we examined these associations and association modifications during longer follow-up. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 23, 2020 Category: General Medicine Authors: Charles Faselis, Phillip H. Lam, Samir Patel, Cherinne Arundel, Gerasimos Filippatos, Prakash Deedwania, Michael R. Zile, Samuel Wopperer, Tran Nguyen, Richard M. Allman, Gregg C. Fonarow, Ali Ahmed Tags: Clinical Research Study Source Type: research

Oral Anticoagulation Use in High Risk Patients Is Improved by Elimination of False Positive and Inactive Atrial Fibrillation Cases
Multiple registries have reported that greater than 40% of high-risk atrial fibrillation patients are not taking oral anticoagulants. The purpose of our study was to determine the presence or absence of active atrial fibrillation and CHA2DS2VASc risk factors to accurately identify high-risk atrial fibrillation (CHA2DS2VASc ≥ 2) patients requiring oral anticoagulants and the magnitude of the anticoagulant treatment gap. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 23, 2020 Category: General Medicine Authors: Gerald V. Naccarelli, Mohammed Ruzieh, Deborah L. Wolbrette, Mauricio Sendra-Ferrer, John van Harskamp, Barbara Bentz, Gregory Caputo, Nathan McConkey, Kevin Mills, Stephen Wasemiller, Jovan Plamenac, Douglas Leslie, Frendy D. Glasser, Thomas W. Abendroth Tags: Clinical Research Study Source Type: research

Cumulative Marijuana Use and Carotid Intima-Media Thickness at Middle Age: The Coronary Artery Risk Development in Young Adults (CARDIA) Study
Long-term cardiovascular health effects of marijuana are understudied.  Future cardiovascular disease is often indicated by subclinical atherosclerosis, for which carotid intima-media thickness is an established parameter. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 23, 2020 Category: General Medicine Authors: Julian Jakob, Roman von Wyl, Odile Stalder, Mark J. Pletcher, Eric Vittinghoff, Kali Tal, Jamal S. Rana, Stephen Sidney, Jared P. Reis, Reto Auer Tags: Clinical research study, cohort study Source Type: research

Effect of different endurance training protocols during cardiac rehabilitation on quality of life
It was the aim of the study to assess the effect of different types of endurance training during outpatient cardiac rehabilitation on patients ’ health related quality of life (HRQL). (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 23, 2020 Category: General Medicine Authors: Martin Sch önfelder, Hubert Oberreiter, Andreas Egger, Marcus Tschentscher, Silke Droese, Josef Niebauer Tags: Research article Source Type: research

Gaucher Disease and Heart Failure of Unknown Origin
A 46-year-old white woman, diagnosed with Gaucher disease type 1 at age 4, presented with a 6-year history of progressive shortness of breath, exercise intolerance, dizziness, and palpitations. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Emory Ryan, My-Le Nguyen, Grisel Lopez, Kathleen Mitchell, Margaret Lowery, Suma Singh, Anna Cholewa, W. Patricia Bandettini, Charles Moore, Ellen Sidransky Tags: Diagnostic Dilemma Source Type: research

Rather unusual cause of seizures
A 73-year-old man with a history of hypertension, Type 2 diabetes, atrial fibrillation and gastroesophageal reflux disease (GERD) was evaluated for recent episodes of “spells” of aphasia. He was taking metoprolol succinate, diltiazem, apixaban, atorvastatin and omeprazole. Physical examination and a detailed neurological examination were normal. He underwent MR brain and neck angiogram which was unremarkable. Awake and sleep EEG was also normal. Echocardiogra m revealed a normal ejection fraction (63%) without atrial mass or clot. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Prince Singh, Jing Miao, Gary L Swartz Tags: Clinical Communication to the Editor Source Type: research

Tattoo in the oral cavity
A 60-year-old female patient with an unremarkable medical history presented with a greyish patch on her upper right gums. She also wanted to get her broken tooth fixed. The patient noticed this patch one year ago and its size has not increased since then. On intraoral examination, a flat greyish diffuse pigmentation was present on the right upper buccal alveolar mucosa adjacent to the broken second premolar, measuring about 1 cm x 2 cm (Figure A, black arrow). The pigmentation was nontender with an intact overlying mucosal surface and no ulceration. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Dr Shekhar Bhatia, Dr Shivani Kohli, Dr. Selvaruby S. Selvadurai Tags: Clinical Communication to the Editor Source Type: research

Coffee bean sign detected by visual inspection
An 87-year-old Japanese male patient presented with abdominal distension and pain lasting for half a day. On physical examination, two distended ridges running parallel from upper right to lower left were seen in the abdomen (Figure 1A). This pattern of distension looked like radiological “coffee bean sign.” The diagnosis of sigmoid volvulus was soon suspected, which was confirmed by abdominal computed tomography scan (Figure 1B). Endoscopic reduction was performed, and the symptoms diminished. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Junki Mizumoto Tags: Clinical Communications to the Editor Source Type: research

Bilateral pulmonary cavitation as predominant phenotype in ANCA-associated disease
A 48-year-old, female ex-smoker (30 pack years) with a history of lymphocytic colitis presented to a rheumatologist due to bilateral ankle pain and finger stiffness. Based on clinical and laboratory findings, rheumatoid arthritis was diagnosed. The patient reported no respiratory symptoms and no weight loss, night sweats or febrile episodes. However, prior to intended immunosuppressive pharmacotherapy, thoracic imaging was performed. This surprisingly revealed large cavities in both lungs (Fig. 1). (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Fabian Leo, Aaron Juche, Andreas Krause, Hannes Semper, Christian Groh é Tags: Images in Radiology Source Type: research

Diagnostic Dilemma: Gaucher Disease and Heart Failure of Unknown Origin
A 46-year-old Caucasian female, diagnosed with Gaucher disease type 1 at age 4, presented with a six year history of progressive shortness of breath, exercise intolerance, dizziness, and palpitations. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Emory Ryan, My-Le Nguyen, Grisel Lopez, Kathleen Mitchell, Margaret Lowery, Suma Singh, Anna Cholewa, W. Patricia Bandettini, Charles Moore, Ellen Sidransky Tags: American Journal of Medicine: Diagnostic Dilemma Source Type: research

Morphea-like carcinoma en cuirasse revealing a bilateral breast cancer
Breast cancer is the most commonly diagnosed female malignancy worldwide and the first cancer associated with cutaneous metastasis.1 The clinical presentation of these metastasis is very rich. The sclerodermiform aspect known as "carcinoma en cuirasse" is a very rare type with an incidence of approximately 6%.2 (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Mouna Ben Hamouda, Amina Aounallah, Taghrid Tlili, Zied Kenani, Rima Gammoudi, Najet Ghariani, Colandane Belajouza, Badreddine Sriha, Mohamed Denguezli Tags: Clinical Communication to the Editor Source Type: research

A Retrospective Review of 193 Cases of Severe Eosinophilia in the Northeast United States
Eosinophils are innate immune cells that proliferate in reaction to a cytokine stimulus or as part of a clonal proliferation. Eosinophilia, defined as an absolute eosinophil count (AEC) of 500 eosinophils/uL or greater, occurs in a wide variety of conditions including allergic disease, infections, inflammatory conditions, and neoplasms.1 While helminthic infections are thought to be the most common cause of eosinophilia worldwide, prior data suggests that atopic disease may be more common in industrialized nations and further data in specific geographic locations is needed. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 22, 2020 Category: General Medicine Authors: Barbara D. Lam, Andrew J. Hale, Sean M. Bullis, YuTing He, Sundas Khan, Jason A. Freed Tags: Brief observation Source Type: research

Triangular ECG Pattern in a Young Female with COVID-19
A 32-year-old female intravenous drug abuser with hepatitis C infection presented to our institution complaining of 1 day of worsening shortness of breath. Coagulation panel was within normal limits and troponin-I (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 21, 2020 Category: General Medicine Authors: Diego Celli, Marina Byer, Rhea Sancassani, Rosario Colombo Tags: ECG Image of the Month Source Type: research

Triangular EKG Pattern in a Young Female with COVID-19
A 32-year-old female intravenous drug abuser with hepatitis C infection presented to our institution complaining of 1 day of worsening shortness of breath. Coagulation panel was within normal limits and troponin-I (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 21, 2020 Category: General Medicine Authors: Diego Celli, Marina Byer, Rhea Sancassani, Rosario Colombo Tags: ECG image of the month Source Type: research

Swelling of a finger in a renal transplant recipient
A 52-year-old woman presented with a five-month history of painless swelling of a non-dominant hand finger, without contributing factors such as trauma. Past medical history was notable for diabetes mellitus with glycated hemoglobin level of 7.9%, and autosomal dominant polycystic kidney disease responsible for kidney transplant one year earlier. She was receiving immunosuppressive maintenance therapy with prednisone (10 mg daily), tacrolimus (with targeted trough level between 5-7 ng/mL) and mycophenolate mofetil (1,000 mg daily). (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 21, 2020 Category: General Medicine Authors: Weniko Car é, Benoît Heid Picard, Fanny Alby-Laurent, Hélène Lazareth Tags: Clinical Communication to the Editor Source Type: research

Christina's World and the Universe of Lyme Disease
Radonjic's article about Andrew Wyeth's masterpiece, Christina's World,1 is thought-provoking even though it simply covers old ground about the possible diagnosis of Charcot-Marie-Tooth (CMT) polyneuropathy in the woman who is the subject of the painting.2 As is often the case in art and medicine, however, viewing a picture with fresh eyes may reveal new possibilities. Therefore, it is worthwhile to consider a different diagnosis in this young woman of Scandinavian descent lying in a lush New England field of grass. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 18, 2020 Category: General Medicine Authors: Raphael B. Stricker Tags: Letter Source Type: research

Shall We Stop Focusing on QTc Interval in Eating Disorders?
We read the article by Krantz et al1 “Is QTc-Interval Prolongation an Inherent Feature Of Eating Disorders? A cohort study” with great interest. The study concluded that in patients with eating disorders, population-mean QTc was normal and marked QTc prolongation occurred solely in the presence of extrinsic factors, suggesting that QTc prolongation is not intrinsic to eating disorders. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 18, 2020 Category: General Medicine Authors: Seema Rani, Sourabh Agstam Tags: Letter Source Type: research

A Rebuttal to a Physician's Response to Gun Violence
I would like to opine on the commentary,  “Gun Violence: The Physician's Response,” written by my colleague, Dr. Hoffer.1 I appreciate that this is an editorial, but it is published in a respected peer-reviewed journal, and I would expect evidence and argument to achieve a higher standard of excellence than from the editorial column of a local newspaper. I have no complaint that addressing mortality from any cause is in the arena of public health and medical investigation. However, I do expect that we as physicians do not abandon the objective investigative approach that we would apply to a disea...
Source: The American Journal of Medicine - December 18, 2020 Category: General Medicine Authors: Mitchell Dean Maulfair Tags: Letter Source Type: research

The Reply
We thank Drs. Rani and Agstam for their comments about our study evaluating QTc intervals among eating disorder patients.1 They cite a study by Padfield et al2 demonstrating greater exercise-associated QTc prolongation in patients with anorexia. That finding does not at all alter our conclusion that QTc prolongation is not intrinsic to anorexia nervosa,1 because the resting population mean QTc interval was similar to that of healthy cohorts and is the measure used for actually monitoring patients. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 18, 2020 Category: General Medicine Authors: Mori J. Krantz, Morteza Farasat, Philip S. Mehler Tags: Letter Source Type: research

Is an Increase in Heart Rate the Result or Cause of Cardiac Dysfunction?
Nwabuo and colleagues demonstrated the association between temporal changes in resting heart rate in young adults and the risk of heart failure and cardiovascular diseases in middle age.1 For young adults, who have not developed dyslipidemia or diabetes mellitus, the changes in resting heart rate are relatively easy to track and can be useful to predict the future risk of cardiovascular diseases. Moreover, this study also suggested the correlation of the changes in resting heart rate and the suboptimal early life risk factors and lifestyle habits (ie, smoking, alcohol use, and low physical activity). (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 18, 2020 Category: General Medicine Authors: Atsuyuki Watanabe, Hiroshi Ito Tags: Letter Source Type: research

The Reply
The sad facts are indisputable. The United States experiences vastly more deaths from firearms than any other comparable western democracy; the majority are suicides, followed by homicides.2,3 Our firearm deaths per capita are exceeded only by Brazil and Columbia. Recent figures show that US firearm deaths per 100,000 population are 12.2; the figures for Canada are 2.0, for Germany 1.04, for France 1.85, and for Britain 0.23. (Source: The American Journal of Medicine)
Source: The American Journal of Medicine - December 18, 2020 Category: General Medicine Authors: Edward P. Hoffer Tags: Letter Source Type: research