Community Hospital Internal Medicine Perspectives Research Articles

Origins of JCHIMP

With this, the first issue of the Journal of Community Hospital Internal Medicine Perspectives ( www.jchimp.org ), volume 1, the efforts of many individuals are no longer a concept but a reality. The journal’s origins can be traced back to 2007 at the Association of Program Directors in Internal Medicine (APDIM) semi-annual meeting in Minneapolis, Minnesota. Prior to that meeting, the Department of Medicine at Union Memorial Hospital in Baltimore, Maryland had conducted a very successful research survey of internal medicine program directors in Pennsylvania, Maryland, and the District of Columbia. Using this regional success as a model, a national network was organized in Minneapolis. (Published: 9 May 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 6328 - DOI: 10.3402/jchimp.v1i1.6328

Patient safety in community-based teaching hospitals

It has been over 10 years since the Institute of Medicine (IOM) re-ignited the patient safety movement in the United States with their publication ‘To Err is Human’. Five years after that publication there were modest improvements in certain indicators like death in low mortality Diagnosis Related Groups (DRGs), iatrogenic pneumothorax, and certain postoperative complications. At that time there was actually worsening in the rates of hospital acquired decubitus ulcers and postoperative deep vein thromboses and pulmonary emboli (1). Five years after the IOM report, leaders in patient safety such as Lucien Leape, Donald Berwick (2), and Robert Wachter (3) described safety systems that were then in their infancy (or at best early adolescence). These included specific tools like electronic health records and computerized physician order entry systems, as well as safe practices like improved team training, sharing of best practices, and full disclosure to patients following injuries. Strategies to encourage the development of these systems included ‘pay for performance’ schemes, non-payment for ‘never events’, regulation and accreditation, better reporting systems, funding for health information technology, malpractice reform, and workforce and training systems were identified. In January 2010, Robert Wachter added to this list of safety reform systems additional elements (4). Some of which were identified in the IOM report. These were policies to promote safety research, better ways to engage patients and their families in the avoidance of errors, internal leadership, and the creation of business models that encouraged safety and national and organizational support (5). (Published: 18 July 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 6433 - DOI: 10.3402/jchimp.v1i2.6433

THE EVOLUTION of JCHIMP

In the last issue, which was the first issue of JCHIMP, I discussed the origins and background of the journal (1). The journal was conceived in late summer 2010 and emerged with the first issue in May 2011. At the outset we were not certain of our direction beyond the fact that we wanted to be a clinically oriented, general internal medicine journal supporting the interests of community teaching hospitals and the trainees and faculty who work in them. It can be difficult to conduct scholarly work in the community setting in comparison to many universitybased programs because of institutional culture, emphasis on clinical volumes, and lack of resources. Nevertheless, good scholarly work has been evident in venues like the American College of Physicians Associates Meeting each year where residents and students present clinical vignettes and other scholarly work of high quality. Too often, the scholarly effort ends there; JCHIMP provides further options. Contracting with Co-Action Publishing in Stockholm has had a major positive impact. Our 15 member editorial board and over 110 reviewers are a testimony to broad support and interest - even at this early stage. In our first issue, David Solomon, champion of open access medical journals, pointed out the glowing future of electronic open access journals as the numbers are increasing and the quality improving (2). We believe that our journal, JCHIMP, will fill a much needed niche of internal medicine open access journals that focus on community programs and the people who work and study there. (Published: 18 July 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 7292 - DOI: 10.3402/jchimp.v1i2.7292

Is it really sinus tachycardia?

A56-year-old male with a history of hypertension and coronary disease was admitted after complaining of mild shortness of breath and palpitations. He had undergone coronary bypass surgery 4 years prior to admission and had been followed regularly by his physicians. His resting heart rate at his last office visit B6 months before was 58/min and his hypertensive regimen, consisting of lisinopril only, was recently intensified. He had been under severe stress recently and had not been eating well. His caffeine intake was limited to one large coffee daily. (Published: 18 July 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 7241 - DOI: 10.3402/jchimp.v1i2.7241

Acute coronary syndrome in a patient with coexistent conduction abnormality

A46-year-old man had a 1-week history of exertional chest tightness and dyspnea. His symptoms became especially prominent while shoveling snow and he presented to the emergency department. He was free of pain at the time of initial presentation and denied any pain at rest. One hour after reaching the emergency room his pain recurred and he became hypotensive and a second ECG was obtained. Past history was negative for hypertension, diabetes, and dyslipidemia, but he admitted to rare checkups. He had one presumed vasovagal episode years before, having passed out while laughing forcefully. There was a remote history of pyloric stenosis and abdominal hernia repair. (Published: 9 May 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 7016 - DOI: 10.3402/jchimp.v1i1.7016

Hyperkalemia and severe rhabdomyolysis

A47-year-old homeless man with a history of bipolar disorder and polysubstance abuse was found under a bridge with altered mental status and severe left calf pain. Evaluation in the emergency department revealed a cachectic, pale man with a blood pressure of 132/84, pulse 74, and respirations 18. He was afebrile. Oxygen saturation was 98% on room air. Examination revealed marked swelling of the left leg, which was also pulseless. A compartment syndrome was diagnosed. Urgent fasciotomy was performed, and the patient was treated in the critical care unit. After a long hospital course he was discharged after 22 days. (Published: 17 October 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 8707 - DOI: 10.3402/jchimp.v1i3.8707

Current coronary intervention controversy: who's to judge?

Dear Editor, The alleged overutilization of coronary interventional procedures by a cardiologist at St. Joseph Medical Center in Maryland has received significant press coverage. The issues of appropriate use and patient safety have led to multiple lawsuits on behalf of patients and the issue of defamation of character has resulted in countersuits. The possibility of conflict of interest involving the physician and a coronary device manufacturer has been highlighted. The hospital has informed and apologized to patients, has resolved regulatory concerns, and has thoroughly restructured its peer review process in the catheterization laboratory. (Published: 17 October 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 7201 - DOI: 10.3402/jchimp.v1i3.7201

Overlapping Phenotypes

Patient KM is a 26-year-old male in whom a systolic ejection murmur was recently identified on a routine physical examination. As part of his evaluation, he underwent 2-dimensional echocardiography, which revealed asymmetrical left ventricular (LV) hypertrophy with a maximum LV wall thickness of 22 mm in the basal anterior septum and extension of hypertrophy into the posterior septum. His LV ejection fraction was 55%, with a normal cavity size and no evidence of resting LV outflow tract obstruction. In addition, the myocardium was noted to be highly trabeculated from the apex to the midportion of the LV (Figure 1; online-only Data Supplement Movie I). The right ventricle was normal in size and function. He has never developed heart failure …

Apical Ballooning Syndrome

Case presentation: A 60-year-old woman presented to the emergency department 2 hours after the onset of severe retrosternal chest pain that started soon after she was told that her son had died in a car accident. A 12-lead ECG demonstrated ST-elevation in the precordial leads (Figure 1), and the plasma troponin T level was elevated at 0.07 ng/mL. A diagnosis of acute ST-elevation myocardial infarction was made, and the patient was admitted for emergency coronary angiography, which revealed normal coronary arteries. The left ventriculogram showed severe systolic dysfunction involving the mid and apical segments (Data Supplement Movie I). Figure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads. Physicians have long been aware of the possible association between stress and cardiovascular events. Awareness has increased of a distinct cardiac syndrome that was originally described in the Japanese population and was called Takotsubo cardiomyopathy, named after the octopus-trapping pot with a round bottom and narrow neck that resembles the left ventriculogram during systole in these patients.1,2 Other names used to describe the condition include apical ballooning syndrome (ABS), broken heart syndrome, and stress or ampulla cardiomyopathy. The precise incidence of ABS is unknown, but it may account for 1% to 2% of patients who present with an acute myocardial infarction.3 The majority of patients have a clinical presentation that is indistinguishable from an acute coronary syndrome. Most present with chest pain at rest, although some patients have dyspnea alone as their initial presenting symptom. Rarely, patients present with syncope or an out-of-hospital cardiac arrest.4 ABS appears to occur almost exclusively in postmenopausal women; however, a few cases have been reported in younger women and males.4 The patients are usually hemodynamically stable, but clinical findings of mild-to-moderate congestive heart failure …

Subclinical hypothyroidism: a modifiable risk factor for depression?

The authors assessed the lifetime history of major depression in 16 subjects with subclinical hypothyroidism and 15 subjects whose thyroid function was completely normal. The lifetime frequency of depression was significantly higher in the subjects who met the criteria for subclinical hypothyroidism (56%) than in those who did not (20%), suggesting that subclinical hypothyroidism may lower the threshold for the occurrence of depression.