Charles Howard M.D.

Velasco, C. E. and C. Howard (2017). “Trouble on both sides: Pulmonary embolism with pneumothorax.” Am J Med 130(5): 530-533.

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Potential causes of syncope range from fairly trifling to life threatening. For a 49-year-old, previously healthy, African American man, the trigger proved dangerous. While unloading cargo from a truck, he fainted and fell approximately 3 feet to the ground. When emergency medical services arrived, his manager reported that the patient lost consciousness but was unable to quantify the period of time. The patient, upon awakening, experienced shortness of breath with severe right-sided chest and back pain. He attributed his accident to fatigue, stating that he had worked as a security guard the previous night, was tired, and simply fell asleep while emptying the vehicle. He denied seizure-like activity, prodrome, drug use, a family history of syncope, and loss of bowel or bladder function.

Howard, C. E. and P. A. McCullough (2017). “Decoding acute myocardial infarction among patients on dialysis.” J Am Soc Nephrol 28(5): 1337-1339.

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In this issue of the Journal of the American Society of Nephrology, Shroff et al. utilized hospital billing records from patients on HD in the United States.3 In brief, professional coding specialists determine the principal diagnosis as that condition, established after study, which resulted in the patient’s admission to the hospital. Secondary diagnoses include comorbidities, complications, and other diagnoses that are documented by the attending physician on the inpatient face sheet, discharge summary, history and physical, consultation reports, operative reports, and other ancillary reports. Age, sex, discharge destination, principal diagnosis, up to 24 secondary diagnoses, and up to 25 procedure codes are entered into a computerized algorithm to generate the Medicare diagnosis-related group that determines payment to the hospital.4 The authors demonstrated that although the overall AMI claims in patients on dialysis have increased, the proportion of those in the principal position decreased, whereas those in the secondary position increased.3 In particular, the overall and proportional increase of NSTEMI claims increased dramatically in both the principal and secondary coding positions. These data are consistent with the general population, where several studies have shown a sharp decline in ST-segment elevation myocardial infarction (STEMI) and a lesser decline or increase in NSTEMI.5,6 Interestingly, other data sources suggest that unstable angina is ever less frequent because more sensitive troponin assays clinch a diagnosis of NSTEMI over unstable angina in about 98% of cases.7

Velasco, C. E. and C. Howard (2017). “Trouble on both sides; pulmonary embolism with pneumothorax.” Am J Med: 2017 Jan [Epub ahead of print].

Full text of this article.

Potential causes of syncope range from fairly trifling to life threatening. For a 49-year-old, previously healthy, African American man, the trigger proved dangerous. While unloading cargo from a truck, he fainted and fell about 3 feet to the ground. When emergency medical services arrived, his manager reported that the patient lost consciousness but was unable to quantify the period of time. The patient, upon awakening, complained of shortness of breath with severe right-sided chest and back pain. He attributed his accident to fatigue, stating that he had worked as a security guard the previous night, was tired, and simply fell asleep while emptying the vehicle. He denied seizure-like activity, prodrome, drug use, a family history of syncope, and loss of bowel or bladder function.