A bone to pick about chest pain.

Chest pain is an extremely common presenting symptom that is usually related to a cardiac cause. This case illustrates an unusual presentation of multiple myeloma as a cause of atypical chest pain. This case presentation shows the importance of having a broad differential diagnosis while evaluating patients with atypical chest pain. It also illustrates the potential role of Tc-99m sestamibi imaging as a diagnostic modality in patients with multiple myeloma.

A Rare Case of Diffuse Large B Cell Lymphoma Presenting as a Cardiac Mass.

BACKGROUND Primary mediastinal diffuse large B cell lymphoma (DLBCL) presenting as a large intracardiac tumor is extremely rare and has not been significantly reported in the literature. Cardiac lymphoma consists of 2 subtypes: mediastinal DLBCL invading the heart and primary cardiac lymphoma. Both subtypes have a poor prognosis and are treated similarly. Mediastinal DLBCL is a life-threatening condition that, if diagnosed early, has a better survival rate. This is a rare case of a mediastinal DLBCL invading the right atrium as a large intracardiac mass, causing partial obstruction of the tricuspid valve without hemodynamic compromise. CASE REPORT A 57-year-old female presented with unintentional weight loss, fatigue, exertional dyspnea, and cough for 8 weeks. Transesophageal echocardiogram showed a mass (3.5×3.5 cm) in the posterior wall of the right atrium partially obstructing the tricuspid valve. Biopsy revealed DLBCL. Given new-onset lymphoma, a human immunodeficiency virus (HIV) test was done and came back positive. CD4 count was 100 cells/mm³. Chemotherapy was initiated with rituximab, cyclophosphamide, epirubicin, vincristine, and prednisone (R-CHOP). Highly active anti-retroviral (HAART) therapy was started for HIV. After treatment with R-CHOP and HAART, the patient had complete resolution of the mass and symptoms on follow-up imaging and evaluation at 6 months. CONCLUSIONS Mediastinal DLBCL invading the heart is a life-threatening form of non-Hodgkin's lymphoma (NHL) and early diagnosis and treatment is critical as prognosis is poor especially if diagnosed in later stages of the disease. Testing for HIV is important as 5% of HIV patients are susceptible to developing NHL.

Patient experiences with MedlinePlus.gov: a survey of internal medicine patients.

BACKGROUND: In 2004, the American College of Physicians joined with the National Library of Medicine in an effort to help patients find reliable health information free of commercial bias as the Web site MedlinePlus.gov. The aim of this study was to evaluate the usefulness of the MedlinePlus.gov site as perceived by patients who were referred to the site by their internist. MATERIALS AND METHODS: A 27-item questionnaire developed by the American College of Physicians Foundation was distributed between january and May 2005 to a convenience sample of 893 adult patient volunteers attending 34 internal medicine practices across the United States. RESULTS: The questionnaire revealed that although most patients (55%) routinely look up medical information, only 43% had used MedlinePlus.gov. Of those who had used the site, 95% were satisfied with the information they found there, and 94% said the information they found at MedlinePlus.gov would help them make better health decisions. DISCUSSION: Patients who used the MedlinePlus.gov site at the recommendation of their physician found it to use, informative, and felt it would help them make better health decisions. Directing patients to this high quality, noncommercial, educational resource online may be an important adjunct to patient education efforts by physicians.

Reversible pulmonary hypertension and isolated right-sided heart failure associated with hyperthyroidism.

Hyperthyroidism may present with signs and symptoms related to dysfunction of a variety of organs. Cardiovascular pathology in hyperthyroidism is common. A few case reports describe isolated right heart failure, tricuspid regurgitation, and pulmonary hypertension as the prominent cardiovascular manifestations of hyperthyroidism. Although most textbooks do not mention hyperthyroidism as a cause of pulmonary hypertension and isolated right heart failure, the literature suggests that some hyperthyroid patients may develop reversible pulmonary hypertension and isolated right heart failure. We report a case of hyperthyroidism presenting with signs and symptoms of isolated right heart failure, tricuspid regurgitation, and pulmonary hypertension, which resolved with treatment of hyperthyroidism.

Diagnosis and treatment of peripheral arterial disease compared with other atherosclerotic vascular diseases in a university primary care clinic.

BACKGROUND: Despite the fact that peripheral arterial disease (PAD) significantly increases the risk of cardiovascular mortality, it is significantly underdiagnosed and undertreated. The purpose of this study was to evaluate the practice at a northeast Tennessee university primary care clinic regarding the diagnosis and treatment of PAD. METHODS: A retrospective medical record survey was conducted to evaluate practice patterns in diagnosing and treating PAD in a university primary care clinic. A clinic population of 711 patients was selected using International Classification of Diseases-9 codes for coronary artery disease (CAD), cerebovascular disease (CVD), and/or PAD. A sample of 180 patients (25.3%) was randomly selected using a systematic statistical method. Of these, 125 patients met the diagnostic criteria for CAD, CVD, and/or PAD. The study covered a 3-year period, from July 2001 until June 2004. Demographic and other data, including the use of antiplatelet therapy, were collected. RESULTS: One hundred ten patients met all of the inclusion and exclusion criteria. Thirty-nine percent were males, and 61% were females. Overall, 79% had CAD, 53% had CVD, and 25% had PAD. Almost half of the patients had some combination of these. Only about 2% had PAD only compared with 36% with CAD only and 17% with CVD only. Although the prevalence of CAD and CVD (among other atherosclerotic vascular diseases) in our clinic was comparable to national figures, the prevalence of PAD was significantly lower (p = .004). The overall use of any antiplatelet agent was 84.2% for patients with only CAD and 80% for only CVD. There was not an adequate number of patients with only PAD to evaluate the use of antiplatelet therapy in this group. CONCLUSION: The low prevalence of PAD only (most PAD patients had coexisting CAD and CVD) indicates that PAD is underdiagnosed at our clinic. There was suboptimal use of aspirin and other antiplatelet drugs among patients with atherosclerotic vascular disease.

The role of omega-3 fatty acids in cardiac protection: an overview.

There have been increasing research efforts in recent years to evaluate the role of various dietary supplements, such as antioxidant vitamins, L-arginine, glucan, isoflavones, soy estrogens, omega-3 fatty acids, etc., in cardiovascular health. Although there is not adequate evidence of the beneficial effects of many nutriceuticals on cardiac function, in the case of omega-3 fatty acids, the evidence has been more convincing. Fish oil has historically been thought to be good for cardiovascular health; however, data have revealed a stronger cardioprotective role of fish oil in recent years. Fish oil and specifically omega-3 fatty acids exhibit cardioprotective effects by mainly improving mortality in coronary artery disease patients. This is achieved through multiple mechanisms with the antiarrhythmic mechanism being the most prominent one. Effects on sodium and calcium channels and heart rate variability are well-accepted mechanisms of how omega-3 fatty acids exercise antiarrhythmic effects. In this review we will address some of the basic science and clinical data regarding omega-3 fatty acids and their direct cardiovascular protective role with details on the proposed mechanisms of this role. We will also address fish pollutants and their significance and finally, the current recommendations about using these fatty acids for cardiovascular protection.

Practice patterns in treating high-risk patients with hyperlipidemia at a northeast Tennessee university clinic.

BACKGROUND: This study was conducted to test the hypothesis that internal medicine residents at a northeast Tennessee university clinic were not compliant with the latest National Cholesterol Educational Program Adult Treatment Panel (NCEP-ATP) guidelines in treating hyperlipidemia in patients with diabetes and coronary artery disease. METHODS: A retrospective medical record survey was conducted to evaluate residents' pattern in lowering low-density lipoprotein (LDL) cholesterol to below 100 mg/dL in patients with diabetes and coronary artery disease. The survey covered a 5-year period, from July 1998 to June 2003, and included 15 randomly chosen residents who were in training for 3 consecutive years. Charts were randomly selected from residents' clinics using International Classification of Diseases-9 codes for coronary artery disease or diabetes mellitus with hyperlipidemia. Five hundred fifty charts were reviewed. Only 41 (7.45%) met the inclusion criteria. RESULTS: Analysis of data using Epi-Info 2002 (Centers for Disease Control and Prevention, Atlanta, GA) revealed that only 68.3% of patients with diabetes and coronary artery disease reached target LDL cholesterol levels. Of the patients who reached target levels, only 42.9% maintained them. Analysis of variance and chi-square tests revealed that the frequency of cholesterol measurement, but not the frequency of physicians' visits, was associated with a higher likelihood of reaching the target LDL level. CONCLUSION: There was a suboptimal compliance among internal medicine residents in the frequency of screening for, reaching, and maintaining the target LDL cholesterol level, according to the latest NCEP-ATP guidelines, among high-risk patients with hyperlipidemias.

Attitudes toward hormone replacement therapy in the new millennium: university physicians' and patients' perspectives.

BACKGROUND: Recent studies are changing the way physicians and patients view hormone replacement therapy (HRT). This study was performed at the East Tennessee State University (ETSU) internal medicine clinic to evaluate the current behaviors of university physicians and patients with respect to HRT. METHODS: A retrospective chart review was conducted at the main internal medicine outpatient clinic at ETSU. Two hundred seventy-four postmenopausal female patients were randomly selected using a computerized systematic sampling technique of International Classification of Diseases, Ninth Revision (ICD-9) codes for menopause or postmenopause. The study period was from July 2002 until June 2004. Patients were postmenopausal women age 35 years or over who had been seen by their physicians at least twice a year during the study period. Patients who were noncompliant with HRT or physician's visits or had contraindications or side effects to HRT mandating discontinuation of the treatment were excluded. Data regarding physicians' patterns in discussion and discontinuation of the therapy and patients' responses were collected. Epi Info 2002 was used for statistical analysis. RESULTS: One hundred seventy-seven patients met all of the criteria, of whom 140 were 35 to 75 years of age. Of this age group, 49 patients (35%) had coronary artery disease (CAD), 101 (72.1%) were on HRT prior to July 2002, and 30 (21.4%) had osteoporosis. Seventy-five patients (53.6%) had documented discussions with their physicians about HRT after July 2002. Most patients who were on HRT had no CAD (p = .0008). Of the patients who were on HRT, only 36 (35.6%) continued treatments (23 continued the same dose, and 13 had the dose modified), whereas 65 (64.3%) had treatments discontinued. HRT discussions were carried on mostly when patients had treatments stopped or modified (p = .0032). Of these patients who had discussions, 60 (80%) were advised to stop or modify the dose and agreed, and only 15 (20%) disagreed or received unbiased discussions from their physicians about HRT. Thiry-seven patients were over 75 years of age. This older group had a higher rate of HRT discontinuation (82%) but a lower rate of documented discussion (22%) than the younger group. CONCLUSION: Physicians should pay more attention to the importance of providing high-quality and well-balanced patient counseling when addressing uncertain treatments and adequately document discussions with patients in medical records.

Vertigo. A neurobiological review.

Dizziness is one of the most common presenting symptoms in clinical practice. Yet, the meaning of this symptom is patient-dependent and can span from true vertigo due to vestibular dysfunction to syncope or vertebro-basilar stroke. This review addresses the neurobiological background of vertigo and the most common syndrome of benign paroxysmal positional vertigo, with an outline of the approach towards localization and management of the acute vertiginous patient.

The use of M-latency in the diagnosis of carpal tunnel syndrome.

OBJECTIVE: To study the use of M-latency (ML) as an electrodiagnostic parameter for diagnosis of carpal tunnel syndrome (CTS). METHODS: One hundred and one consecutive patients (77 females, mean age 42 years and 24 males, mean age 46 years) referred with a clinical diagnosis of CTS to the Neurodiagnostic laboratories at the King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia were evaluated between November 1999 and October 2000. Standardized nerve conduction studies on 191 hands, including 191 median and 108 normal ulnar nerves were performed. RESULTS: The results were categorized into 3 groups based on using (A) distal sensory peak latencies (DSL) >=3.5 ms, (B) DSL <3.5 ms and (C) DSL <3.5 ms and ML <4.0 ms. The ML was significantly longer than the distal motor latency (DML) for the median nerves in groups (A) and (B) but not in group (C). There was no significant difference between ML and DML for the normal ulnar nerves in all 3 groups. By using the combined DSL <3.5 ms and ML >=4.0 ms parameters, the diagnostic yield of 147 (77%) from group (A) increased by an additional 10 patients (5%) to reach 157 (82%). CONCLUSION: The M-latency may be utilized as a more sensitive parameter than DML, in combination with DSL, for confirmation of CTS in symptomatic patients with borderline distal sensory latencies.

Newly diagnosed seizures in adults.

OBJECTIVE: To study the clinical, electroencephalographic (EEG) and computed tomography (CT) profile in a hospital population of over 18-years adult patients with newly diagnosed recurrent seizures. METHODS: The clinical profiles obtained from history including detailed description of the seizures, examination, EEG and CT findings were recorded prospectively for all over-18 patients who were referred to the electrodiagnostic service at King Fahd Hospital of the University, Al-Khobar, Eastern Province, Kingdom of Saudi Arabia from January 1, 1996 to December 31, 1997. The data was entered into a standard database file and analyzed using a personal computer. RESULTS: Seventy-three patients (43 males, 30 females, mean age 32.3 years) with newly diagnosed recurrent seizures were studied. A positive family history of seizures was found in 12.3%. The main seizure types were partial in 27 (37%), partial with secondary generalization in 22 (30.1%) and generalized in 24 (32.9%). The types of epileptic syndromes included localization-related 34 (46.6%), generalized 24 (32.9%) and undetermined 15 (20.5%). The EEG was abnormal in 45 (61.6%) with epileptiform activity, focal in 22 (48.9%), generalized in 11 (24.4%) and non-epileptiform activity in 12 (26.7%). The cranial CT findings were normal in 44 patients (60.3%) and abnormal in 29 (39.7%) patients, with focal lesions in 19 (65.5%) and generalized cerebral atrophy in 10 (34.5%). CONCLUSION: Our results showed that partial and partial with secondary generalization seizures are the most frequent seizure type and the most common epileptic syndrome was the localization-related type in this age group. These results are comparable to previous population- and hospital-based western reports.

Cerebral palsy in Saudi children.

OBJECTIVE: To describe the clinical profile, and identify its risk factors, of cerebral palsy (CP) as seen in a cohort of consecutive Saudi children aged between one and 3 years of age prospectively over a one-year period. METHODS: Saudi children aged 1-3 years with CP (diagnosis based on specified criteria) were selected from children presenting to the Neurology service at the King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia with delayed milestones, seizures, mental retardation and difficulty with walking and evaluated at 3-monthly intervals for one year from January to December 2000. Information on gestation duration, labor and delivery, birth weight and the medical history of the mothers was obtained. Cranial computerized tomography and electroencephalography were carried out in addition to baseline investigations (toxoplasmosis, other, rubella, cytomegalovirus, and herpes simplex virus serology, serum lactate, pyruvate, amino acid screen, thyroid function tests, and chromosome analysis). Somatosensory, molecular genetics and muscle biopsy for histopathologic and histochemical studies were not performed in any of the patients. RESULTS: One hundred and eighty-seven children with CP were seen during the study period: 109 males (mean age 20.3 +/- 8.69 months); 78 females (mean age 20.6 +/- 8.55 months). Seventy-three had microcephaly (<5th percentile) with a mean head circumference of 44.5 +/- 3.69 cms for males and 43.0 +/- 4.16 for females. The main symptoms were inability to walk independently (54%), delayed speech (52%) and seizures (45%). The main neurologic features were motor weakness (85%), spasticity (60%), language dysfunction (42%), mental retardation (31%) and head lag (30%). A history of previous CP in the family was obtained in 8 patients (4%) but none of them had other features of hereditary spastic paraplegia. Electroencephalography abnormalities, present in 113 (73%) were more frequent in those without seizures than with seizures. Cranial computerized tomography abnormalities were mainly cerebral atrophy (60%) and hydrocephalus (53.7%). Twenty-five percent were from twin pregnancies; 56 (34%) were of low birth weight, 20% were pre-term deliveries, birth asphyxia was present in 165 and breech presentation was encountered in 8%. CONCLUSION: The main risk factors identified were twin pregnancy, pre-term delivery, prolonged labor, low birth weight and a history of previous CP in the family. Our findings suggest that improved maternal and childcare particularly in the ante and perinatal periods may reduce the incidence of CP in this environment.

A Randomized, Placebo-Controlled Trial of Omega-3 Fatty Acids for Inhibition of Supraventricular Arrhythmias After Cardiac Surgery: The FISH Trial.

BACKGROUND: Omega-3 polyunsaturated fatty acids (n3-PUFAs) might have antiarrhythmic properties, but data conflict on whether n3-PUFAs reduce rates of atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG). We hypothesized that n3-PUFAs would reduce post-CABG AF, and we tested this hypothesis in a well-powered, randomized, double-blind, placebo-controlled, multicenter clinical trial. METHODS AND RESULTS: Patients undergoing CABG were randomized to pharmaceutical-grade n3-PUFAs 2 g orally twice daily (minimum of 6 g) or a matched placebo ≥24 hours before surgery. Gas chromatography was used to assess plasma fatty acid composition of samples collected on the day of screening, day of surgery, and postoperative day 4. Treatment continued either until the primary end point, clinically significant AF requiring treatment, occurred or for a maximum of 2 weeks after surgery. Two hundred sixty patients were enrolled and randomized. Before surgery, n3-PUFA dosing increased plasma n3-PUFA levels from 2.9% to 4% and reduced the n6:n3-PUFA ratio from 9.1 to 6.4 (both P<0.001). Similar changes were noted on postoperative day 4. There were no lipid changes in the placebo group. The rate of post-CABG AF was similar in both groups (30% n3-PUFAs versus 33% placebo, P=0.67). The post-CABG AF odds ratio for n3-PUFAs relative to placebo was 0.89 (95% confidence interval 0.52-1.53). There were no differences in any secondary end points. CONCLUSIONS: Oral n3-PUFA supplementation begun 2 days before CABG did not reduce AF or other complications after surgery. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov Unique identifier: NCT00446966. (J Am Heart Assoc. 2012;1:e000547 doi: 10.1161/JAHA.111.000547.).

Buerger disease in an elderly man.

Buerger disease is characterized by progressive distal extremity ischemia in persons with recent tobacco consumption. Typically, affected persons are young men. There have been case reports of Buerger disease in older men. Almost all of the reported cases were characterized with progressive, severe disease requiring amputation. We report a case of an older man with features of Buerger disease without significant proximal progression despite active smoking. Arteriographic and pathologic studies confirmed the diagnosis.

Interaction between warfarin and levofloxacin: case series.

Warfarin is the most widely used oral anticoagulant and is indicated for many clinical conditions. Levofloxacin, a fluoroquinolone, is one of the most commonly prescribed antibiotics in clinical practice and is effective against Gram-positive, Gram-negative, and atypical bacteria. While small prospective studies have not revealed any significant drug-drug interaction between warfarin and levofloxacin, several case reports have indicated that levofloxacin may significantly potentiate the anticoagulation effect of warfarin. We report 3 cases of serious bleeding complications that appear to be the result of the interaction between warfarin and levofloxacin. Physicians should be aware of this potential interaction and use caution when prescribing levofloxacin to patients taking warfarin.

Are we ready for arabization in medical education?

OBJECTIVE: To obtain the views of faculty members of the College of Medicine, King Faisal University on Arabization of medical education. METHODS: A cross-sectional study was conducted in the College of Medicine, King Faisal University, Dammam, between January and June 2001 using a standardized 41-item questionnaire to obtain the views of faculty members in both basic science and clinical departments on issues relating mainly to scientific research. The responses were recorded on a 5-point scale: strongly agree, agree, undecided, disagree and strongly disagree. A couple of questions were used to probe the issue of publications in Arabic and translations into Arabic. RESULTS: The response rate of faculty was 67% (74 of a total of 110 faculty members). The participating faculty members included 22 professors, 27 associate professors, 23 assistant professors and 2 lecturers belonging to 24 departments (6 basic sciences, 18 clinical). Thirty- four members (45.9%) were in favor of Arabization and 40 (54%) were against. CONCLUSIONS: Faculty members form the backbone for the implementation of Arabization in medical education. The opinions obtained in this preliminary survey of the faculty of the College of Medicine at King Faisal University indicate that we are still far from achieving this goal in our medical education.

Newly diagnosed seizures in adolescents: a comparative study.

OBJECTIVE: To study the clinical, EEG and CT profile in a hospital population of adolescents with newly diagnosed recurrent seizures. METHODS: The clinical profiles obtained from history including detailed descriptions of the seizures, examination, electroencephalographic (EEG) and computed tomography (CT) findings were recorded prospectively for all 14 to18-year-old patients who were referred to the electrodiagnostic service at King Fahd Hospital of the University, Al- Khobar, Eastern Province, Saudi Arabia from 1(st) January 1996 to 31(st) December 1997. The data were entered into a standard dbase file and analyzed using a personal computer. The results were compared with 2 previous concomitant subsets of data obtained from 263 children ≤13 years (72%) and 73 adults > 18 years (20%) over the same study period. RESULTS: Twenty-nine patients (14 males and 15 females, a mean age of 15.7 years) with newly diagnosed recurrent seizures were studied. A positive family history of seizures was found in 10.3%. The main seizure types were partial in 11 (37.9%), partial with secondary generalization in 6 (20.7%) and generalized in 12 (41.4%). The types of epileptic syndromes included localization-related 15 (51.7%), generalized 12 (41.4%) and undetermined 2 (16.9%). The EEG was abnormal in 21 (72.4%) with epileptiform activity, focal in 11 (52.4%), generalized in 9 (42.8%) and none-epileptiform activity in 1 (4.8%). The cranial CT findings were normal in 21 patients (72.4%) and abnormal in 8 (27.6%) patients, with focal lesions in 6 (75%) and generalized cerebral atrophy in 2 (25%). The frequency of adolescents presenting with newly-diagnosed seizures was 8% of the total study population of 365 patients including children and adults. CONCLUSION: The results showed that partial and partial with secondary generalization seizures and the localization-related epileptic syndrome are the most frequent seizure and epileptic syndrome types in adolescents. The least frequent of newly diagnosed seizures in adolescents compared to children and adults confirms the bimodality of peak frequency in the young and old that has been observed in the west.

Acute exacerbations of chronic bronchitis.

Preview Acute bacterial exacerbations of chronic bronchitis cause considerable morbidity and mortality, particularly in the elderly. Effective antimicrobial therapy results in fewer hospitalizations for respiratory failure and better resolution of symptoms. However, there is growing concern regarding treatment failures caused by resistant organisms. The authors therefore describe the activity of pharmacologic agents from different classes and indicate which ones may be considered primary treatment for this serious condition.