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On Hoofs and Zebras – Struma Ovarii
A 75-year-old mother of ten suffering from a urinary tract infection developed macrohematuria and therefore an abdominal ultrasound was performed, followed by a CT scan when an unexpected large pelvic mass was discovered. Past history included hypertension, paroxysmal atrial fibrillation, and remote history of minor stroke (on candesartan, dabigatran, bisoprolol); bilateral chronic lymphedema; and hysterectomy due to prolapse at the age of 40. Imaging revealed nephrolithiasis and a prominent left adnexal mass suspected as ovarian cancer.
Source: The American Journal of Medicine - July 20, 2023 Category: General Medicine Authors: Ami Schattner, Ina Dubin, Livnat Uliel, Daniela Dick-Necula Tags: Clinical Communication to the Editor Source Type: research

Above the threshold time of coagulation: delayed diagnosis of acquired hemophilia A
A man in his 80 ’s presented to our hospital's emergency department with left hip pain after falling while transferring from a wheelchair on a visit day. He had been taking clopidogrel for> 10 years after atherothrombotic stroke and apixaban 2.5 mg b.i.d. for 2 years since he was diagnosed with deep vein thrombosis. The patient had no coagulation abnormalities when he started apixaban therapy and had never experienced bleeding events. His medical history included cervical spondylosis surgery, right femoral neck fracture, hypertension, and benign prostatic hypertrophy.
Source: The American Journal of Medicine - February 23, 2023 Category: General Medicine Authors: Mayu Kikuchi, Yukinori Harada, Ayano Hamai, Sachi Takaoka Tags: Diagnostic dilemma Source Type: research

Starry Eye
A 73-year-old female with a past medical history of stroke, hypertension, end stage renal disease on hemodialysis presents to the emergency department for altered mental status and slurred speech. On physical examination, she had a right pupillary defect in a star-like pattern with initial concern for a blown pupil (see image) raising suspicion for acute stroke. Her initial blood pressure was 230/110 mmHg and neuroimaging were unremarkable for stroke. She was admitted for hypertensive emergency.
Source: The American Journal of Medicine - November 6, 2022 Category: General Medicine Authors: Cameron Kahn, Azeem Rathore, Jeffrey House Tags: Clinical Communication to the Editor Source Type: research

Catch Me If You Can: ECG Artifacts
An 83-year-old female with prior stroke and hypertension presented to the emergency department with right arm pain following a mechanical fall. She denies any associated prodromal symptoms, presyncope, or syncope. On admission, she was afebrile with a regular heart rate of 86 beats per minute, elevated blood pressure (190/87 mm Hg), and 96% oxygen saturation on room air. A physical examination was notable for a right humerus fracture, confirmed on the right arm X-ray.
Source: The American Journal of Medicine - September 20, 2022 Category: General Medicine Authors: Golda Harvatin, Jalaj Garg, Dmitry Abramov, Diane Tran, Purvi Parwani Tags: ECG Image of the Month Source Type: research

Safety and Efficacy of Thiazide Diuretics in Hypertension
More than 30 years ago the prospective, randomized Systolic Hypertension in the Elderly Program (SHEP) study documented that treatment with a thiazide, specifically chlorthalidone, substantially reduced outcome in elderly patients with isolated systolic hypertension.1 Treatment was associated with a 36% reduction in stroke in 4736 patients, and a reduction in major cardiovascular events, by 55 events per 1000 patients over 5 years. In view of the above and other prospective studies in aggregate, we are puzzled by the conclusions of Ravioli et al,2 that taking of a thiazide was the strongest independent predictor of falls a...
Source: The American Journal of Medicine - May 1, 2022 Category: General Medicine Authors: Franz H. Messerli, Stefano F. Rimoldi, Samuel J Mann Tags: Letter Source Type: research

Frank's sign in a double stroke patient
A 72-year-old male, non-smoker, with a medical history of hypertension, hypercholesterolemia, atrial fibrillation and a past myocardial infarction 15 years ago, presented to the emergency department complaining about difficulty of speaking and left-hand weakness of 6-hour duration. Apart from an elevated blood pressure, at 170/100 mmHg, physical examination revealed dysarthria, accompanied by left brachial monoplegia and hypoesthesia. A bilateral earlobe wrinkle extending obliquely and backward, at a 45o angle, from the tragus to the edge of the auricle (Frank's sign) was observed (Figure 1A).
Source: The American Journal of Medicine - April 23, 2022 Category: General Medicine Authors: Konstantinos C. Christodoulou, Ioannis Stouras, Xafnoula Zlatidou, Despoina Kakagia Tags: Clinical Communication to the Editor Source Type: research

Microvascular dysfunction as a systemic disease: A review of the evidence
Microvascular dysfunction describes a varied set of conditions which includes vessel destruction, abnormal vasoreactivity, in situ thrombosis, and fibrosis which ultimately results in tissue damage and progressive organ failure. Microvascular dysfunction has a wide array of clinical presentations, ranging from ischemic heart disease to renal failure, stroke, blindness, pulmonary arterial hypertension, and dementia. An intriguing unifying hypothesis suggests that microvascular dysfunction of specific organs is an expression of a systemic illness that worsens with age and is accelerated by vascular risk factors.
Source: The American Journal of Medicine - April 22, 2022 Category: General Medicine Authors: Daniel S. Feuer, Eileen M. Handberg, Borna Mehrad, Janet Wei, C. Noel Bairey Merz, Carl J. Pepine, Ellen C. Keeley Tags: Review article Source Type: research

Sickle Cell Trait and Risks for Common Diseases: Evidence from the UK Biobank
Sickle cell disease is an autosomal recessive disease caused by the inheritance of two pathogenic mutations of the hemoglobin subunit beta gene (HBB) (usually Glu6Val, though other pathogenic mutations exist).1 The altered hemoglobin makes red blood cells prone to being crescent-shaped, which can cause vaso-occlusion and result in numerous serious complications and comorbidities including: vaso-occlusive crisis, acute chest syndrome, infections, pulmonary hypertension, stroke, pulmonary embolism, renal failure, retinopathy, splenic sequestration, priapism, cholelithiasis, and osteonecrosis.
Source: The American Journal of Medicine - April 21, 2022 Category: General Medicine Authors: Joseph Hulsizer, W. Kyle Resurreccion, Zhuqing Shi, Jun Wei, Skylar Ladson-Gary, S. Lilly Zheng, Brian T. Helfand, Liana Billings, Michael S. Caplan, Jianfeng Xu Source Type: research

Polycythemia Vera Presenting as ST-Segment Elevation Myocardial Infarction
An 80-year-old woman with a history of hypertension, pre-diabetes, chronic kidney disease (stage 3b), and a remote ischemic stroke without residual deficits presented to the emergency department complaining of several hours of epigastric discomfort and malaise. An electrocardiogram (EKG) performed at triage revealed normal sinus rhythm with>1 mm ST segment elevation in leads V4-6 and lead 1, reciprocal ST depression in aVR, and Q waves in V1 and V2 (Figure 1). The troponin I was elevated to 1.66 ng/mL (reference range
Source: The American Journal of Medicine - March 31, 2022 Category: General Medicine Authors: Eric Hirsch, Lindor Qunaj, Azeem Latib, Benjamin Galen Tags: Diagnostic Dilemma Source Type: research

Effects of Anticoagulation on Low-Density Lipoprotein-Cholesterol and Ischemic Stroke in Patients with Nonvalvular Atrial Fibrillation
The study by Omelchenko et al1 concluded that, unlike the general population, low-density lipoprotein-cholesterol (LDL-C) levels were not associated with ischemic stroke risk among patients with atrial fibrillation treated with direct oral anticoagulants (DOACs). To arrive at this conclusion, they retrospectively analyzed data of 21,229 patients with a first-time diagnosis of nonvalvular atrial fibrillation treated with DOACs categorized according to the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category, ...
Source: The American Journal of Medicine - September 28, 2021 Category: General Medicine Authors: Zeeshan H. Ismail, Zekarias T. Asnake, Joshua K. Salabei Tags: Letter Source Type: research

Optimizing Blood Pressure Control without adding Anti-hypertensive Medications
Hypertension is a major risk factor for cardiovascular diseases and chronic kidney disease, the leading causes of death globally.1 The recent decrease in blood pressure to 130/80 mmHg substantially increases hypertension prevalence.2 A positive outcome of this change is early hypertension diagnosis that allows proactive use of lifestyle interventions. Lowering blood pressure by any anti-hypertensive drug class results in a significant reduction in major cardiovascular events, stroke, and chronic kidney disease progression.
Source: The American Journal of Medicine - June 28, 2021 Category: General Medicine Authors: Vishnu Priya Pulipati, Jon W. Mares, George L. Bakris Tags: Commentary 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 - 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

Peripheral arterial disease in patients with atrial fibrillation: The Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study.
Atrial fibrillation and peripheral arterial disease are two conditions associated with high risk of cardiovascular and cerebrovascular complications and mortality.1 –5 There is evidence that coexistence of both these clinical conditions can result to an additive risk of adverse events.6 Indeed, atherosclerotic vascular disease has been linked with stroke, thromboembolism and death in subjects with atrial fibrillation and has been therefore included as one of the components of risk scores, such as the CHA2DS2-VASc score (Congestive Heart failure, Hypertension Age> 75 years, DM, Stroke, Vascular disease) in order to strati...
Source: The American Journal of Medicine - September 17, 2020 Category: General Medicine Authors: Antonios Vitalis, Alena Shantsila, Marco Proietti, Rajiv K. Vohra, Mark Kay, Brian Olshansky, Gregory Y.H. Lip Source Type: research

Regular Bleeding Risk Assessment Associated with Reduction in Bleeding Outcomes: The mAFA-II Randomized Trial
The mobile atrial fibrillation application (mAFA-II) randomized trial reported that a holistic management strategy supported by mobile health reduced atrial fibrillation-related adverse outcomes. The present study aimed to assess whether regular reassessment of bleeding risk using the Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol (HAS-BLED) score would improve bleeding outcomes and oral anticoagulant (OAC) uptake.
Source: The American Journal of Medicine - April 11, 2020 Category: General Medicine Authors: Yutao Guo, Deirdre A. Lane, Yundai Chen, Gregory Y.H. Lip, mAF-App II Trial investigators Tags: Clinical Research Study Source Type: research

Digital Management of Hypertension Improves Systolic Blood Pressure Variability
Higher systolic blood pressure variability has been shown to be a better predictor of all-cause and cardiovascular disease mortality, stroke, and cardiac disease compared with average systolic blood pressure.
Source: The American Journal of Medicine - December 19, 2019 Category: General Medicine Authors: Richard V. Milani, Jonathan K. Wilt, Alexander R. Milani, Robert M. Bober, Eric Malamud, Jonathan Entwisle, Carl J. Lavie Tags: Clinical Research Study Source Type: research

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