The American Journal of Medicine Blog http://amjmed.org 'The Green Journal' Thu, 12 Apr 2018 20:47:25 +0000 en-US hourly 1 https://wordpress.org/?v=3.9.24 ‘Landolfi’s Sign’—Eyes Don’t See What the Mind Does Not Know! http://amjmed.org/landolfis-sign-eyes-dont-see-what-the-mind-does-not-know/ http://amjmed.org/landolfis-sign-eyes-dont-see-what-the-mind-does-not-know/#comments Fri, 02 Mar 2018 13:15:33 +0000 http://amjmed.org/?p=4701 Still frame of long-axis parasternal view on 2-dimensional color flow transthoracic echocardiogram showing severe aortic regurgitation. as depicted by arrow. The thick arrow at the bottom depicts the point of recording of the diastolic frame. AO = ascending aorta; LA = left atrium; LV = left ventricle.

Still frame of long-axis parasternal view on 2-dimensional color flow transthoracic echocardiogram showing severe aortic regurgitation. as depicted by arrow. The thick arrow at the bottom depicts the point of recording of the diastolic frame. AO = ascending aorta; LA = left atrium; LV = left ventricle.

To the Editor:

A 60-year-old woman was admitted with progressively worsening dyspnea on exertion associated with intermittent lightheadedness and palpitations. On physical examination, a 3/6 diastolic decrescendo murmur was audible along the left sternal border. The murmur was most prominently heard in the left third intercostal space at end expiration with the patient in the sitting position. In addition, bounding carotid and femoral pulses were present, and the pulse pressure was wide. Careful examination of her eyes revealed alternating constriction and dilation of the pupils occuring in synchrony with the patient’s heartbeat, a rarely reported finding known as “Landolfi’s sign” (Figure 1Video S1 available online). Figure 2 is a still frame of the long-axis parasternal view on 2-dimensional color flow transthoracic echocardiography showing significant aortic regurgitation as depicted by the arrow. Figure 3 is a still frame of 2-dimensional–guided pulsed-wave Doppler from the suprasternal view demonstrating diastolic flow reversal at the level of the aortic arch–descending aorta junction (arrow), thus confirming severe aortic regurgitation. “Landolfi’s sign,” described by Michel Landolfi (La Semaine Medicale, July 28, 1909), is believed to be a result of an exaggeration of the physiologic circulatory hippus in the iridial vessels due to high pulse pressure and large stroke volume, thereby resulting in systolic constriction and diastolic dilation of the pupil. “Landolfi’s sign,” “Corrigan’s pulse” (bounding carotid pulsation), “Watson’s waterhammer pulse” (forceful extremity pulsation), “Quincke’s sign” (alternating flushing and blanching of fingernail beds), “de Musset’s sign” (rhythmic head bobbing), “Becker’s sign” (prominent retinal artery pulsations), “Müller’s sign” (systolic bobbing of the uvula), and “Duroziez’s sign” (audible diastolic murmur over femoral artery) are important manifestations of the hyperdynamic circulatory state seen in clinically significant aortic regurgitation.

To read this article in its entirety please visit our website.

-Aditya Saini, MD, Kanupriya Mathur, MD, Gautham Kalahasty, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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Difficulties in Teaching Diagnostic Reasoning in the Digital Age: The Critical Role of the Teacher-Clinician Mentor http://amjmed.org/difficulties-in-teaching-diagnostic-reasoning-in-the-digital-age-the-critical-role-of-the-teacher-clinician-mentor/ http://amjmed.org/difficulties-in-teaching-diagnostic-reasoning-in-the-digital-age-the-critical-role-of-the-teacher-clinician-mentor/#comments Thu, 01 Mar 2018 13:15:32 +0000 http://amjmed.org/?p=4700

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Each case has its lesson—a lesson that may be, but is not always, learnt, for clinical wisdom is not the equivalent of experience. A man who has seen 500 cases of pneumonia may not have the understanding of the disease which comes with an intelligent study of a score of cases, so different are knowledge and wisdom.

William Osler, MD

The greatest difficulty in life and medicine is to convert knowledge into practical wisdom.

William Osler, MD

Mentoring is medicine’s greatest achievement.

Michael A. LaCombe, MD

 

The best mentors are seasoned clinicians who, over decades of insightful practice, have acquired exceptional diagnostic skills. On the basis of decades of insightful clinical experience, mentors also impart wisdom to their mentees. Osler, the role model for master teacher-clinician mentors, are the best teachers of the art of medicine and clinical diagnostic reasoning.

In the digital age, society has become enamored with speed. Information can be accessed in seconds. Instant information is substituted for thoughtful study and reflection.

In teaching clinical reasoning, instant information has important educational implications. Some learners believe information can replace real teacher teaching. However, the critical element in teaching is not simply information; meaningful learning occurs only via student–teacher interactions. Teaching clinical medicine requires more than instant information access.

Medical learners have become addicted to instant information and have become dependent on instant information to solve clinical problems. Today’s learners of medicine have overlooked an essential tenet of clinical problem solving, namely that information is not knowledge and knowledge is not clinical wisdom. Clinical wisdom comes only from thoughtful reflection derived from years of insightful experience.

Without accurate diagnosis, optimal therapy is a matter of chance. The value of the clinical syndromic approach is that it narrows diagnostic possibilities according to the relative diagnostic importance of characteristic findings in the differential diagnosis. Narrowed diagnostic possibilities permit selective diagnostic testing. Not only is the “order everything” approach excessive and needlessly expensive, but unexpected test results are often misleading, leading the unwary to order even more tests. Clinicians should always consider the clinical relevance of test results before embarking on non–clue-directed testing. Clinical judgment often takes a back seat to “shotgun testing.” To be clinically relevant, test results must be interpreted in clinical context. Unless interpreted in the clinical context, test results may be clinically misleading or irrelevant.

Today, in clinical medicine, most do not study. Because information is instant there is no need to remember, study, or correlate clinical findings. If information is instantly available, why acquire diagnostic reasoning skills? Thoughtful study is now often regarded as nonessential or quaint.

In life and medicine, speed comes at a cost. Today’s distracted physicians are hurried and harried, in large part owing to electronic medical record time-imposed limitations. The teacher-clinician mentor saves the mentee the time by imparting the lessons garnered from years of insightful clinical experience. The mentor saves the mentee learning time, but more importantly, imparts wisdom in the process.

Medicine has always been an art, and acquiring clinical excellence has always been difficult and time-consuming. Clinical diagnostic reasoning is best learned from an inspired teacher-clinician. A fortunate few will seek out teacher-clinician mentors to guide them. Instant information is a threat to teaching clinical diagnostic reasoning. I know of no more eloquent a mentoring story than this by Dr. LaCombe; the following text has been excerpted from his book, Bedside: The Art of Medicine.1

To read this article in its entirety please visit our website.

-Burke A. Cunha, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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Geographic Tongue http://amjmed.org/geographic-tongue/ http://amjmed.org/geographic-tongue/#comments Wed, 28 Feb 2018 13:15:31 +0000 http://amjmed.org/?p=4699 Dorsum of tongue showing erythematous patches with white borders (black arrows).

Dorsum of tongue showing erythematous patches with white borders (black arrows).

A 45-year-old female patient presented to our clinic with a painless, erythematous lesion on her tongue. Medical history was negative, with absence of any allergies or habits. The patient recalled that she had a similar lesion on her tongue 6 months earlier, which resolved spontaneously. Clinical examination of the dorsal surface of the tongue revealed multiple erythematous patches with annular, well-demarcated white borders (Figure, black arrows). A hemoglobin level of 13 g/dL (normal range, 12-15 g/dL) and total red blood cell count of 4.8 × 106 cells/µL eliminated anemia. Negative periodic acid Schiff stain performed by taking a smear sample from the tongue eliminated candidial fungal infection. Taking into consideration the history, laboratory findings, and the typical waxing and waning pattern of the lesion, the diagnosis arrived at was geographic tongue. The lesion regressed spontaneously after 1 month. We advised the patient to maintain oral hygiene with regular follow-up visits. Evaluation after 6 months revealed no recurrence of the lesion.

Geographic tongue is also known as benign migratory glossitis owing to the ability of the lesion to migrate over time from one location to another. It is a benign condition commonly seen on the tip, lateral borders, and dorsum of the tongue.1 Geographic tongue has a prevalence rate of 3% in the United States.2 The etiology of geographic tongue is not well understood. Clinically it is characterized by a central erythematous zone consisting of atrophy of the filiform papillae, whereas the white zone shows regenerating filiform papillae along with keratin. Histologically there is epithelial degeneration in the erythematous zone and elongated rete pegs with hyperkeratosis in the white zone. The connective tissue shows infiltration of polymorphonuclear leukocytes and lymphocytes.3 Most cases of geographic tongue are self-healing. The differential diagnosis of geographic tongue includes leukoplakia, lichen planus, and candidiasis. Leukoplakia is caused by chronic irritation from rough teeth, improper fillings, tobacco use, smoking, or human immunodeficiency virus–associated oral hairy leukoplakia. A biopsy is taken of the lesion and the uninvolved mucosa to rule out cancer. Removal of the etiologic factor results in regression of the leukoplakia in a few weeks to a month. Geographic tongue may have variable appearances and symptoms that need to be differentiated from other lesions of the tongue.

To read this article in its entirety please visit our website.

- Tanay Chaubal, MDS (Periodontology and Oral Implantology), Ranjeet Bapat, MDS (Periodontology and Oral Implantology)

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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Dizziness Symptom Type Prevalence and Overlap: A US Nationally Representative Survey http://amjmed.org/dizziness-symptom-type-prevalence-and-overlap-a-us-nationally-representative-survey/ http://amjmed.org/dizziness-symptom-type-prevalence-and-overlap-a-us-nationally-representative-survey/#comments Tue, 27 Feb 2018 13:15:30 +0000 http://amjmed.org/?p=4698

elder-woman-with-walker-stock

 

The traditional approach to dizziness encourages providers to emphasize the type of dizziness. However, symptom types might substantially overlap in individual patients, thus limiting the clinical value of this approach. We aimed to describe the overlap of types of dizziness using a US nationally representative sample.

Methods

The 2008 US National Health Interview Survey was examined for prevalence and overlap of types of dizziness. The data were also separately examined among people who otherwise had typical features of traditionally vertigo-based disorders (ie, benign paroxysmal positional vertigo and Meniere’s disease). Data analysis also included exploratory factor analysis.

Results

Twelve-month prevalence of problems with dizziness or balance was 14.8%, representing 33.4 million individuals. The mean number of dizziness symptoms was 2.4 (95% confidence interval [CI], 2.3-2.4), with 61.1% reporting more than one type. Of subjects who otherwise had typical features of traditionally vertigo-based disorders, the mean number of dizziness types was 3.1 (95% CI, 3.0-3.3), and only 24.6% (95% CI, 21.0%-28.7%) reported vertigo as the primary type. Exploratory factor analysis found that symptom types loaded onto a single factor without other clinical or demographic variables.

Conclusions

Substantial overlap of dizziness types exists among US adults with dizziness. People otherwise having features of traditionally vertigo-based disorders also typically report multiple dizziness types and do not typically report vertigo as the primary type. Symptom types correlate more strongly with each other than with other clinical or demographic variables. These findings suggest that the traditional emphasis on dizziness types is likely of limited clinical utility.

To read this article in its entirety please visit our website.

-Kevin A. Kerber, MD, MS, Brian C. Callaghan, MD, MS, Steven A. Telian, MD, William J. Meurer, MD, MS, Lesli E. Skolarus, MD, MS, Wendy Carender, MPT, James F. Burke, MD, MS

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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An Uncommon Cause of Low Back Pain http://amjmed.org/4686/ http://amjmed.org/4686/#comments Mon, 26 Feb 2018 13:28:22 +0000 http://amjmed.org/?p=4686 Axial computed tomography of the abdomen/pelvis following intravenous contrast showing no evidence of paraspinal muscle pathology but an incidental finding of left greater than right quadratus lumborum muscle asymmetry.

Axial computed tomography of the abdomen/pelvis following intravenous contrast showing no evidence of paraspinal muscle pathology but an incidental finding of left greater than right quadratus lumborum muscle asymmetry.

A 21-year-old active duty Air Force male without past medical history presented to our Emergency Department with low back pain. The patient had been performing general resistance strength training, including specific exercises focusing on the low back region, for about 2 months. A few hours after a workout session, he developed acute pain to the left lumbar paraspinal region, which was associated with muscle tightness in that area, as well as left leg pain. The patient confirmed usage of whey protein supplements and creatine, but no others. In the Emergency Department, he was found to be in severe pain and was treated with a trigger point injection in the paraspinal area and increasing doses of narcotic pain medications. Physical examination showed marked tenderness to palpation over the left lumbar paraspinal region with tightness of the muscles, but no asymmetry, swelling, or bruising. There was no evidence of radiculopathy. Creatinine kinase (CK) was noted to be elevated at 17,480 U/L. Given this combination of rhabdomyloysis and poor pain control despite high doses of pain medications, the patient was admitted to the Internal Medicine service for further management.

In his early hospital course, he received intravenous fluids for his rhabdomyolysis and a combination of muscle relaxants, intravenous nonsteroidal anti-inflammatory drugs, and intravenous narcotics for his pain. The pain medications had only a small effect in decreasing his pain, but initially, his CK trended down and thus, the course of management was held. Upon re-check, however, his CK started to trend back up and continued to do so despite increasing rates of intravenous fluids. CT scan of the abdomen and pelvis was performed (Figure 1), which did not show tear, hematoma, or other concerning pathology in the paraspinal area, although it did show left greater than right quadratus lumborum asymmetry, felt to be a normal variant. We attempted to perform magnetic resonance imaging of the lumbar spine; however, the patient did not tolerate the test even after high doses of narcotic pain medications. Despite continued medical management, the patient’s CK continued to climb and he developed paresthesia over the left paraspinal area. Orthopedic consultation was obtained and direct measurement of paraspinal compartment pressures showed a markedly increased pressure of 198 mm Hg on the left and 48 mm Hg on the right. Given this, the patient was taken to the operating room for left-sided paraspinal fasciotomy, which confirmed lumbar paraspinal compartment syndrome, with findings as in Figure 2.

To read this article in its entirety please visit our website.

-Daniel M. Golovko, MD, Jeffrey B. Knox, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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Urschel’s Sign in Paget Schroetter Syndrome http://amjmed.org/urschels-sign-in-paget-schroetter-syndrome/ http://amjmed.org/urschels-sign-in-paget-schroetter-syndrome/#comments Mon, 26 Feb 2018 13:15:29 +0000 http://amjmed.org/?p=4697 Prominent superficial veins over the right upper arm and shoulder, reflective of Urschel's sign.

Prominent superficial veins over the right upper arm and shoulder, reflective of Urschel’s sign.

A 32-year-old man, employed as a deckhand, was referred for right upper extremity swelling and pain of 3 months’ duration. Physical examination revealed swelling of the right upper extremity and prominent superficial veins over the right upper arm and shoulder (Urschel’s sign; Figure). Blood work including thrombophilia screen was unremarkable. Right upper extremity venous duplex ultrasonography and computed tomography venogram showed occlusion of the proximal right subclavian vein. Dynamic computed tomography with right arm abduction confirmed venous thoracic outlet syndrome. He underwent first rib resection. Peripheral venoplasty was attempted but failed owing to chronic thrombosis and fibrotic changes in the vessel. He was started on anticoagulation and was subsequently referred to vascular surgery for venous bypass evaluation. His long-term therapy included continued anticoagulation and compression sleeve therapy, as well as less physically demanding duties at work.

Axillary–subclavian vein thrombosis resulting from repetitive, strenuous upper extremity activity is known as effort thrombosis or Paget Schroetter syndrome. Physical examination finding of associated dilated superficial venous collaterals over the shoulder and upper arm is known as Urschel’s sign.

A relatively uncommon disorder, it is of interest to the general physician because it still represents the most common vascular disorder of the professional, collegiate, or high school athlete. It most typically occurs in young and otherwise healthy males. In our patient this condition was most likely the result of the repetitive overhead movements required by his occupation. Early thoracic outlet decompression and catheter-directed thrombolysis are key to improving outcomes in Paget Schroetter syndrome.

To read this article in its entirety please visit our website.

-Sean M. Lawless, MD, Rohan Samson, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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Sometimes the Eyes Say More Than the Mouth http://amjmed.org/sometimes-the-eyes-say-more-than-the-mouth/ http://amjmed.org/sometimes-the-eyes-say-more-than-the-mouth/#comments Sun, 25 Feb 2018 13:28:21 +0000 http://amjmed.org/?p=4685 Ocular fundus image of the left eye shows mild optic disc swelling, multifocal retinochoroidal exudates, retinal phlebitis, and mild vitreous opacity.

Ocular fundus image of the left eye shows mild optic disc swelling, multifocal retinochoroidal exudates, retinal phlebitis, and mild vitreous opacity.

A 48-year-old man with a history of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS)-associated cryptococcal meningitis was referred to our hospital with blurred vision in his left eye for several months. He was diagnosed with bilateral chronic posterior uveitis (Figure). After ruling out secondary uveitis, such as sarcoidosis, Behçet disease, Vogt-Koyanagi-Harada disease, herpesvirus infection, and tuberculosis, uveitis was highly suspected to be attributable to syphilis, namely ocular syphilis, considering AIDS as his underlying disease and previous unprotected sexual contact with males and females. Positive results from a rapid plasma reagin test (RPR) (1:32) and Treponema pallidum agglutination assay were confirmed. The patient was treated with intravenous penicillin G for 14 days and ophthalmic symptoms improved; complete resolution of ocular inflammation was observed at 7 months post treatment. At 9 months post treatment, decreased reactivity on RPR was confirmed on an outpatient basis.

Ocular syphilis, such as uveitis, retinitis, and optic neuritis, is caused by T. pallidum infection and can result in a variety of ocular signs and symptoms, including redness, blurry vision, and vision loss.1

Although ocular syphilis is usually an infrequent manifestation of syphilis infection, clusters of ocular syphilis were recently reported in the US.1 Most suspected cases of ocular syphilis were in males and 50% were in HIV-infected persons, which is consistent with the epidemiology of syphilis in the US.1

A cerebrospinal fluid examination is recommended for patients with ocular syphilis to rule out neurosyphilis, because the concurrent infection rate is high; neurosyphilis was ruled out in our case.2

A detailed medical interview about sexual contact and serological testing for syphilis infection should be performed in patients with uveitis of unknown etiology, because ocular symptoms can be the initial manifestation of syphilitic disease; visual prognosis is usually excellent with treatment.23

To read this article in its entirety please visit our website.

- Tatsuya Fujikawa, MD, PhD, Yuka Sogabe, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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Nutritional Nightmare: Hypoparathyroidism Secondary to Celiac Disease http://amjmed.org/nutritional-nightmare-hypoparathyroidism-secondary-to-celiac-disease/ http://amjmed.org/nutritional-nightmare-hypoparathyroidism-secondary-to-celiac-disease/#comments Sat, 24 Feb 2018 13:28:20 +0000 http://amjmed.org/?p=4684 Feet fully extended and adducted.

Feet fully extended and adducted.

A 33-year-old woman with history of diverticulitis status post hemicolectomy and idiopathic hypoparathyroidism presented with tetany and facial twitching for 3 months. She was transferred to a tertiary medical center for refractory tetany. She presented to her physician earlier in the week for diffuse muscle cramps and facial twitching. On review of her medical record, she had been admitted 3 times in the previous 2 months for similar complaints and was subsequently diagnosed with idiopathic hypoparathyroidism with critically low parathyroid hormone (<4.0 pg/mL) and corrected calcium levels (6.86 mg/dL) but with a normal 25-hydroxyvitamin D level (38.5 ng/mL). Family history was negative for autoimmune illness. Physical examination was significant for positive Chvostek’s sign and Trousseau’s sign, and her feet were fully extended and adducted (Figure). On each prior admission the patient was administered intravenous calcium gluconate, magnesium sulfate, and daily oral calcium carbonate solution, with improvement in both ionized calcium levels and symptoms until discharge. As an outpatient, however, she required increasing doses and frequencies of oral calcitriol and calcium carbonate. On maximum doses she continued to suffer from intractable symptoms, with critically low calcium levels despite reporting excellent compliance with her medications. She also developed anxiety from recurrence of her symptoms. Each time she was discharged home with home care and nursing requirements, on coordinated follow-up she continued to present with recurrent tetany with hypocalcemia. Despite multiple efforts, the patient could not be sustained on an oral regimen.

Assessment

We reanalyzed her history, completed a focused physical examination, and performed a detailed review of her laboratory and imaging findings. A nutritionist was consulted to identify dietary requirements and to increase total body stores of calcium while identifying losses because the patient’s diet consisted mainly of poultry, rice, pasta, and vegetables. Eventually it was discovered that the patient suffered from chronic loose stools, with roughly 2-5 bowel movements daily, which were progressively increasing in frequency and quantity throughout the day. Furthermore, she reported a significant weight loss of 6 pounds in a period of less than 2 weeks. Her husband noted the patient would take a separate pair of clothing to work daily: she would soil her clothes so often that it became a regular component of her lifestyle, and she did not think much of this as a symptom. Retrospective review of calcium levels showed an estimated daily loss of 0.27 mg/dL over a 10-day period, with a daily 24-hour urinary calcium excretion ratio of 0.001. This shows the importance of going through a meticulous review of daily activities, exposures, and eating habits. In this case a review of the patient’s bowel movements, although not felt to be of concern for the patient, was central to her underlying mechanism of disease and subsequent hospitalizations.

Serologic workup revealed an elevated level of tissue transglutaminase antibody and presence of immunoglobulin A endomysial antibody, suggestive of gluten-sensitive enteropathy. A computed tomography scan of the abdomen and pelvis was normal. Celiac disease was diagnosed on the basis of the results of these tests, and hence a gluten-free diet was used.

To read this article in its entirety please visit our website.

-Sachin R. Patel, MD, Raymond J. Shashaty, MD, Philip Denoux, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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The Hyperlipidemia Effect: Pseudohyponatremia in Pancreatic Cancer http://amjmed.org/the-hyperlipidemia-effect-pseudohyponatremia-in-pancreatic-cancer/ http://amjmed.org/the-hyperlipidemia-effect-pseudohyponatremia-in-pancreatic-cancer/#comments Fri, 23 Feb 2018 13:28:20 +0000 http://amjmed.org/?p=4683
Computed tomography confirmed ultrasound findings, including the presence of a mass at the head of the pancreas and pancreatic ductal dilation.

Computed tomography confirmed ultrasound findings, including the presence of a mass at the head of the pancreas and pancreatic ductal dilation.

A patient’s newly discovered malignancy was evidently accompanied by a sodium deficit. The 48-year-old man presented to the Emergency Department for evaluation of abdominal pain and weight loss. He described gradual onset of severe, burning, epigastric pain with radiation to the back. In addition, he reported a 70-lb weight loss over 2 months, yellowing of the eyes and skin, darkening of the urine, and occasional clay-colored stools. He had not experienced fevers, nausea, vomiting, or diarrhea. His abdominal discomfort had caused him to eat less in recent days than he would have previously.

The patient admitted that over the previous 2 months, he had been using heroin, which partially relieved the pain. His medical history included chronic low back pain and hypertension, for which he took lisinopril, 10 mg daily, and hydrochlorothiazide, 25 mg daily. His serum sodium was low at 121 mmol/L. He was admitted to the General Medicine department for further evaluation and management of his hyponatremia and abdominal pain.

Assessment

On examination, the patient’s vital signs were within normal limits. He was cachectic with jaundice of the sclerae and skin. His jugular venous pressure waveform was not elevated, and the rest of his cardiopulmonary examination was normal as well. A palpable mass was identified in his right upper quadrant, and severe tenderness was elicited by both light and deep palpation. No peritoneal signs were present. He had no lower-extremity edema and no stigmata suggestive of chronic liver disease or endocarditis. The neurological examination was normal.

In addition to hyponatremia, the patient had the following laboratory results: potassium level 3.2 mg/dL; blood glucose level 106 mg/dL; blood urea nitrogen level 21 mg/dL; serum osmolality 272 mOsm/kg; total bilirubin level 32.9 mg/dL; alkaline phosphatase level 2134 U/L; aspartate aminotransferase level 276 U/L; and alanine aminotransferase level 197 U/L. Urine osmolality was 537 mOsm/kg, and a random urine sodium was 71 mEq/L.

Abdominal ultrasound revealed a hypoechoic, heterogeneous mass, measuring 4.8 cm × 3.3 cm × 2 cm, at the head of the pancreas, as well as pancreatic ductal dilation, narrowing of the splenic vein confluence, diffuse biliary intrahepatic dilation, and mild pancreatic duct dilation. The findings were confirmed on abdominal computed tomography, which also demonstrated a tumor surrounding the superior mesenteric artery (Figure). The findings, combined with the patient’s symptoms, pointed toward malignancy. No evidence of distant metastasis was seen.

To read this article in its entirety please visit our website.

-Michael L. Adashek, DO, Bennett W. Clark, MD, C. John Sperati, MD, MHS, Colin J. Massey, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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High Prevalence and Clinical/Sociodemographic Correlates of Miscarriages Among Flight Attendants http://amjmed.org/high-prevalence-and-clinicalsociodemographic-correlates-of-miscarriages-among-flight-attendants/ http://amjmed.org/high-prevalence-and-clinicalsociodemographic-correlates-of-miscarriages-among-flight-attendants/#comments Thu, 22 Feb 2018 13:28:19 +0000 http://amjmed.org/?p=4682

pregnant woman getting check up

There are many occupational health hazards associated with long hours of air travel, including cosmic radiation exposure, circadian rhythm disruptions, prior and secondhand smoke exposure, for flight attendants who flew before smoking bans were initiated in the 1990s. Previous studies in flight attendants have found increased incidence of breast cancer and melanoma. However, there is little information on the relationship of airline travel and reproductive health in flight attendants. Secondhand smoke exposure has numerous negative health effects, such as increased cardiac events and respiratory infections, but its effect on reproductive health is not known. This study seeks to examine the role of secondhand smoke exposure on the miscarriage rate in flight attendants who flew before the smoking ban.

Methods

Flight attendants who flew before the smoking ban and participating in a study of health effects of secondhand smoke were asked to complete a reproductive health survey. We compared miscarriage rates of flight attendants to the general population using 2010 data from the Centers for Disease Control and Prevention.

Results

In our cohort of 145 female flight attendants exposed to secondhand smoke, there were 45 miscarriages (26%), compared with a 17.1% rate in the Centers for Disease Control and Prevention report (P = .002). There was no difference in secondhand smoke exposure between the flight attendants with miscarriage and the group without miscarriage (P = .93).

Conclusions

This study found an increased incidence of miscarriage in flight attendants, which was unrelated to secondhand smoke exposure. Other factors, such as circadian rhythm disruption and radiation, may be related to these reproductive health findings and require further investigation.

There is increasing recognition of the occupational hazards associated with long hours of air travel. The recognition of the association of secondhand smoke exposure and health problems led to successful efforts by flight attendants to have smoking banned on airplanes in the 1990s.12 Secondhand smoke exposure is associated with an increased risk of lung cancer, coronary heart disease, and stroke.34 We have previously shown that flight attendants exposed to secondhand smoke have an association between secondhand smoke exposure and increased rates of hypertension,5 as well as increased rates of respiratory illnesses compared with the general population.6 Before airline smoking bans it is estimated that secondhand smoke exposure of flight attendants in aircraft cabins was 6 times that of the average worker and 14 times that of the average person.7 In addition to secondhand smoke exposure, other health-related factors, such as circadian rhythm disruption, are associated with flying.8 Serum melatonin levels are a marker for disruption of circadian hormone production. In a prior study of flight attendants and teachers, flight attendants were found to have higher adjusted melatonin levels.8 Therefore traveling through many time zones is an adverse health exposure for flight attendants. The time changes can have 3 major effects on circadian rhythms: desynchronization between external time cues and internal physiologic rhythms, disruption of internal physiologic rhythms relative to each other, and resultant sleep loss.9 Pilots and flight attendants are also exposed to ionizing radiation while logging many flight hours. As a profession they have one of the highest occupational radiation exposures.9 At aircraft altitudes of 25,000 or more feet, primary cosmic radiation interacts with molecules of the atmosphere and generates secondary and tertiary radiation. These types of radiation include neutrons—known human carcinogens1011—as well as charged particles with high relative biological effectiveness. Large-scale analyses have examined the incidence of breast cancer and melanoma among flight crewmembers.1213 These studies found a significantly increased risk for melanoma, breast, and bone cancer among female flight attendants. However, there are currently no official radiation dose limits for flight crew members in the United States.

During our previous work with flight attendants and secondhand smoke exposure, we observed that airline crew members seemed to have more miscarriages than the general population. To measure any effects on reproductive health in flight attendants who flew before the smoking ban, we surveyed our cohort of flight attendants to determine whether their miscarriage risk is increased compared with the general population.

To read this article in its entirety please visit our website.

-Bettina Heidecker, MD, Rachel Maureen Spencer, BA, Victoria Hayes, BA, Sarah Hall, BA, MA, Nisha Parikh, MD, Eveline Oestreicher Stock, MD, Rita Redberg, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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