Kenneth Nugent

Do comorbid psychiatric disorders contribute to the pathogenesis of tako-tsubo syndrome? A review of pathogenesis.

Patients with tako-tsubo cardiomyopathy have unusual characteristics, including a disproportionate occurrence in postmenopausal women and a strong association with mental and physical stress. These patients present with chest pain, abnormal electrocardiographic findings, and myocardial enzyme leaks. They appear to have acute coronary syndrome but have normal epicardial coronary vessels and reversible left ventricular dysfunction. High circulating levels of catecholamines likely cause this syndrome through direct injury of myocardial cells. The frequent occurrence in postmenopausal women has not been explained. This association might reflect changes in autonomic control of the cardiovascular system and in baroreceptor sensitivity in postmenopausal women. Women in this age group also have a high frequency of both depression and anxiety. These 2 psychiatric diagnoses are associated with episodic symptoms, including acute panic attacks, which can be associated with catecholamine release in the heart. Therefore, tako-tsubo cardiomyopathy may occur in postmenopausal women as a consequence of comorbid psychiatric diagnoses and normal age-related changes in autonomic control of the cardiovascular system. This hypothesis warrants prospective case-control studies.

Low-dose oral interferon α possibly retards the progression of idiopathic pulmonary fibrosis and alleviates associated cough in some patients

Idiopathic pulmonary fibrosis (IPF) has no effective treatment and a relatively short life expectancy after diagnosis. Interferon α (IFNα) inhibits the growth of proliferating fibroblasts.1 IFNα also inhibits the production of collagen by fibroblasts independently of its effect on fibroblast replication.2 Biological activity of low-dose IFNα by oromucosal administration has been reported in several species including man,3 despite the expected rapid inactivation by digestive enzymes.4 We therefore tested the effect of oral administration of very low doses of IFNα on the progression of IPF. Twelve of 20 patients with IPF aged 50–82 years (mean 67) completed treatment for at least 12 months with IFNα administered by lozenge (150 IU) taken three times each day. IPF was diagnosed according to the diagnostic criteria set forth by the American Thoracic Society. Three subjects had …

Abdominal wall hematomas associated with low-molecular-weight heparins: an important complication in older adults.

compatible with acute pancreatitis. In the present case, diagnosis of acute pancreatitis was based on radiological findings. The decisive finding is the persistent normal lipase (and amylase) level throughout the course of a case of acute pancreatitis. Typically, during acute pancreatitis, the lipase level increases within the first 4 to 8 hours, reaches a peak at 24 hours and remains high for 1 to 2 weeks. Lipase is a highly sensitive and specific marker of pancreatic pathology, giving it a prominent place in the diagnosis of acute pancreatitis. According to a recent systematic review, the negative predictive value of lipase varies between 94% and 100%, but a normal lipase level cannot exclude the diagnosis of acute pancreatitis. Moreover, lipase level does not correlate with disease severity according to guidelines and studies. This is the sixth case described in the literature. Of the previous case descriptions, two died, two were aged 80 and older, and four had diabetes mellitus. False negatives for amylase were associated with a context of underlying chronic pancreatitis, an alcoholic home, and hypertriglyceridemia. None of these situations played a role in the reported case; the possibility of a genetic polymorphism in these two enzymes could be discussed. Morphological examination of reference is the CT scan, which is recommended as part of the initial examination only in cases of diagnostic uncertainty but is used systematically after 48 hours to assess disease severity according to Balthazar score. In summary, the diagnosis of acute pancreatitis cannot be excluded according to normal enzyme laboratory tests. Although exceptional, this needs to be taken into account in older adults, in whom atypical clinical presentation occurs frequently.

Electronic cigarettes in the media

Electronic cigarettes (e-cigarettes) are an increasingly popular source of nicotine and an increasingly popular topic in the media. Concerns about potential hazards associated with e-cigarette use and advertising, especially to adolescents, have led to studies on e-cigarettes in both traditional media (TV, mail, print, and outdoor advertising) and social media (websites, social networking sites, blogs, and e-mails). This review presents a narrative description of available studies related to e-cigarettes in the media. These articles have focused on promotion in both traditional and social media across a broad range of topics and have concentrated on target audiences, smoking cessation, harm reduction, and advertising. E-cigarette advertising is the most frequent topic in the published articles. Identifying the target audience also is a common objective in articles. The representation of e-cigarettes as a “healthier alternative” to traditional cigarettes and their use as a “smoking cessation aid” are main themes presented through all types of media.

Amiodarone-Induced Loculated Pleural Effusion: Case Report and Review of the Literature

Pleural effusion is an uncommon manifestation of amiodarone toxicity and is usually associated with amiodarone‐induced interstitial pneumonitis. We describe a 70‐year‐old woman who came to the emergency department with bilateral pleuritic chest pain and malaise 4 weeks after her amiodarone dose was increased from 200 mg/day to 600 mg/day. She had bilateral exudative pleural effusions without associated pneumonitis. She was diagnosed with amiodarone‐induced pleural effusions after a thorough workup during her hospitalization excluded other causes for the effusions. Due to intractable arrhythmias, the patients amiodarone was not discontinued, and she was discharged home. Four days later at a follow‐up visit at the pulmonary clinic, the patient complained of worsening chest pain as well as dyspnea and cough. A computed tomography scan showed left‐sided pleural effusion with multiple loculations. She underwent a pulmonary vein isolation procedure, and amiodarone was discontinued. She was treated with prednisone 40 mg/day, tapered over the next 2 weeks. Three weeks after the amiodarone was stopped, the patient was asymptomatic, and a chest radiograph showed complete resolution of the effusions. Review of the patients medical records revealed that she had experienced similar symptoms and exudative pleural effusions 2 years earlier after a similar dose escalation of amiodarone; the symptoms and pleural effusions resolved after the amiodarone dosage was reduced. Use of the Naranjo adverse drug reaction probability scale indicated that the association between the pleural effusions and amiodarone was highly probable (score of 9). This case report emphasizes that amiodarone should be considered in the differential diagnosis of patients with exudative effusions after a thorough workup has excluded other causes. Amiodarone should be replaced with alternative antiarrhythmic therapy if clinically feasible, and corticosteroids may be beneficial.

One Hundred–Foot Walk Test for Functional Assessment of Clinic Patients

Background:Gait velocity measurements provide functional assessment of patients with diverse diseases and allow predictions about future adverse events. The optimal distance for patient classification is uncertain. Methods:Participants were identified in internal medicine clinics and had to be independently ambulatory. Study investigators collected medical information, used a qualitative test to assess gait and balance (G and B score), and measured gait velocity with a timed 100-foot walk. Results:One hundred eighty-four patients participated in this study. The mean age was 57.8 ± 12.7 years; 50% of the participants were men. The mean gait speed was 3.33 ± 0.71 ft/sec. Gait speed decreased with age and with body mass index (BMI) and increased with height and male sex. Patients with more comorbidities had decreased speed (P < 0.01). There were significant correlations between gait speed and grip strength (P < 0.01) and between lower G and B scores and slower gait speeds (P < 0.01). G and B scores were negatively correlated with age, BMI, and certain diagnoses. They also predicted risk for past falls. The mean heart rate change during the test was 8 beats per minute. Patients in the highest quartile for heart rate change had lower gait speeds than patients in the other 3 quartiles, suggesting physiologic impairment. Conclusions:A 100-foot walk test in clinic patients provides a practical functional assessment. Gait speed was slower in patients with multiple comorbidities and poor balance. Patients with increased heart rate responses during this test seem to have physiologic impairment. This test has the potential to predict adverse events and to quantitatively determine responses to therapeutic interventions but needs prospective evaluation in clinical studies.

Coccidioidomycosis with diffuse miliary pneumonia.

Coccidioidomycosis is a well-known infection in the southwestern United States, and its occurrence is becoming more frequent in endemic areas. This disease can have a significant economic and medical impact; therefore, accurate diagnosis is crucial. In conjunction with patient symptoms, residence in or travel to an endemic area is essential for diagnosis. Diagnosis is usually made with serology, culture, or biopsy and confirmed with DNA probe technology. Pulmonary disease is the most common presentation and is seen in almost 95% of all cases. One-half to two-thirds of all Coccidioides infections are asymptomatic or subclinical. Most pulmonary infections are self-limited and do not require treatment except in special populations. When treatment is warranted, itraconazole and fluconazole are frequently used. Diffuse miliary pneumonia is uncommon and is especially rare in immunocompetent patients. Herein we describe a rare presentation of miliary coccidioidomycosis in a nonimmunocompromised patient.

The utilization of standardized order sets using AASLD guidelines for patients with suspected cirrhosis and acute gastrointestinal bleeding.

To improve the adherence to AASLD (American Association for the Study of Liver Diseases) guidelines for variceal bleeding, we developed and implemented standardized order sets for gastrointestinal bleeding in our hospital on October 1, 2009. We performed medical record reviews of hospitalized patients with gastrointestinal bleeding with suspected cirrhosis from October 2009 to October 2010 to determine the use of octreotide, prophylactic antibiotics, and endoscopy. We reviewed 300 Medical records and identified 26 patients with suspected cirrhosis and gastrointestinal bleeding who had adequate information to determine whether or not the order set was used. Antibiotic was used in 76% of patients, octreotide was used in 76% of patients, and upper endoscopy was completed in 94% of patients within 24 hours. The use of antibiotics was higher than that used in historical controls in our hospital. Implementation of standardized order sets appears to have improved adherence to standard recommendations. However, larger studies with longer follow-ups are needed to evaluate this effect on clinical outcomes and cost of care.

Posterior Reversible Leukoencephalopathy Syndrome After Kratom Ingestion

Posterior reversible encephalopathy syndrome has been associated with hypertension, preeclampsia, cancer chemotherapy, and drugs of abuse, such as amphetamine and methamphetamine. We report a young man who suddenly developed severe headache, disorientation, and aphasia following ingestion of kratom and Adderall. Computed tomography and magnetic resonance imaging of his head revealed foci of vasogenic edema in the posterior occipital lobes, frontal lobes, and brainstem. In addition, he had a small area of hemorrhage in the left posterior occipital lobe. Lumbar puncture revealed an increased number of red blood cells but no other abnormalities. His initial blood pressure was elevated but returned to normal during hospitalization. This case suggests that kratom can cause posterior reversible encephalopathy syndrome and needs to be considered when patients present to emergency centers with headaches, confusion, and visual disturbances.