Showing papers by "Lincoln Hospital published in 2009"

Pathogenesis of neuropsychiatric systemic lupus erythematosus and potential biomarkers

Abstract: Systemic lupus erythematosus is a chronic, multisystemic, autoimmune disease that may involve the central, peripheral, and autonomic nervous systems and can present with a wide variety of neurological and psychiatric manifestations. In this article, we review the recent literature pertaining to the pathogenesis of neuropsychiatric systemic lupus erythematosus (NPSLE). We searched the PUBMED database with no chronological constraints using the following terms: “neuropsychiatric systemic lupus erythematosus” cross-referenced with the terms “pathogenesis” and “biomarkers” for full-text articles in English. The etiology of NPSLE is as yet unknown, though numerous autoantibodies and cytokines have been suggested as possible mediators. Of the numerous autoantibodies and biomarkers examined, anti-phospholipid, anti-ribosomal P, anti-neuronal, anti-glial fibrillary acidic protein (GFAP), anti-endothelial cell, anti-N-methyl-d-aspartate (NMDA), microtubule-associated protein 2 (MAP-2), and matrix metalloproteinase-9 (MMP-9) appear to be elevated in patients with NPSLE. Cytokines that may be involved in the pathology of NPSLE include interleukin (IL)-2, IL-6, IL-8, IL-10, tumor necrosis factor (TNF)-α, and interferons (IFN)-α and -γ. With continued advances in immunological research, new insights into the pathophysiologic mechanisms of NPSLE may lead to the development of biomarkers and new treatment strategies.

Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department.

Abstract: Acute pharyngitis is commonly seen in children. Group A β-hemolytic Streptococcus is the most common bacterial cause of acute pharyngitis and accounts for approximately 15% to 30% of cases in children, but this condition is generally overdiagnosed and overtreated. The availability of rapid s

CYP1A1 genotype modifies the impact of smoking on effectiveness of HAART among women.

Abstract: We have recently shown that cigarette smoking is associated with lesser responses to potent antiretroviral therapies. Certain Cytochrome P-450 enzymes activate compounds derived from tobacco smoke into toxic forms that may promote HIV-1 gene expression through promotion of DNA-adduct formation by the oxidation of chemical constituents of cigarette smoke, such as polyaromatic hydrocarbons and dioxins. To explore the association between environmental and genetic factors to viral replication in women who smoke and receive highly active anti-retroviral therapy (HAART), we assessed the impact of polymorphisms in a panel of four Cytochrome P-450 genes (CYP1A1, CYP2A6, CYP2D6, and CYP2E1) and two Glutathione S-transferase genes (GSTM1 and GSST1) in 924 participants of the Women's Interagency HIV Study (WIHS). Our findings showed that GSTM1 and GSST1 deletions were not associated with HAART effectiveness. By contrast, homozygosity for the CYP1A1-m1 polymorphism, was associated with impaired viral response to treatment among smokers (relative hazard (RH) = 0.54; 95% confidence interval = 0.31-0.94) after adjustment for pretreament viral load, CD4 count, age, hepatitis C infection, prior HAART therapy and race, although it had no effect among nonsmokers. We conclude that the association of the CPY1A1-m1 variant with a reduced response to HAART therapy in HIV infected smokers is consistent with this enzyme's role in the metabolic conversion of environmental toxins to DNA adducts, which may directly promote HIV-1 gene expression.

Predicting performance using background characteristics of international medical graduates in an inner-city university-affiliated Internal Medicine residency training program

Abstract: IMGs constitute about a third of the United States (US) internal medicine graduates. US residency training programs face challenges in selection of IMGs with varied background features. However data on this topic is limited. We analyzed whether any pre-selection characteristics of IMG residents in our internal medicine program are associated with selected outcomes, namely competency based evaluation, examination performance and success in acquiring fellowship positions after graduation. We conducted a retrospective study of 51 IMGs at our ACGME accredited teaching institution between 2004 and 2007. Background resident features namely age, gender, self-reported ethnicity, time between medical school graduation to residency (pre-hire time), USMLE step I & II clinical skills scores, pre-GME clinical experience, US externship and interest in pursuing fellowship after graduation expressed in their personal statements were noted. Data on competency-based evaluations, in-service exam scores, research presentation and publications, fellowship pursuance were collected. There were no fellowships offered in our hospital in this study period. Background features were compared between resident groups according to following outcomes: (a) annual aggregate graduate PGY-level specific competency-based evaluation (CBE) score above versus below the median score within our program (scoring scale of 1 – 10), (b) US graduate PGY-level specific resident in-training exam (ITE) score higher versus lower than the median score, and (c) those who succeeded to secure a fellowship within the study period. Using appropriate statistical tests & adjusted regression analysis, odds ratio with 95% confidence intervals were calculated. 94% of the study sample were IMGs; median age was 35 years (Inter-Quartile range 25th – 75th percentile (IQR): 33–37 years); 43% women and 59% were Asian physicians. The median pre-hire time was 5 years (IQR: 4–7 years) and USMLE step I & step II clinical skills scores were 85 (IQR: 80–88) & 82 (IQR: 79–87) respectively. The median aggregate CBE scores during training were: PG1 5.8 (IQR: 5.6–6.3); PG2 6.3 (IQR 6–6.8) & PG3 6.7 (IQR: 6.7 – 7.1). 25% of our residents scored consistently above US national median ITE scores in all 3 years of training and 16% pursued a fellowship. Younger residents had higher aggregate annual CBE score than the program median (p < 0.05). Higher USMLE scores were associated with higher than US median ITE scores, reflecting exam-taking skills. Success in acquiring a fellowship was associated with consistent fellowship interest (p < 0.05) and research publications or presentations (p <0.05). None of the other characteristics including visa status were associated with the outcomes. Background IMG features namely, age and USMLE scores predict performance evaluation and in-training examination scores during residency training. In addition enhanced research activities during residency training could facilitate fellowship goals among interested IMGs.

Biological targets in the treatment of rheumatoid arthritis: a comprehensive review of current and in-development biological disease modifying anti-rheumatic drugs

Abstract: Enhanced understanding of the rheumatoid arthritis (RA) pathophysiology and the role of cytokines has enabled the development of innovative biological agents in the last 10 years that target specific parts of the immune response. Failure to achieve adequate response with traditional disease modifying anti-rheumatic drugs (DMARDs) and increasing evidence of ongoing radiographic deterioration of the affected joints despite seemingly clinical response were essential stimuli for the development of biologics. The current and upcoming biological agents are primarily aimed at neutralizing circulating and cell-bound pro-inflammatory cytokines, interfering in the interaction of antigen-presenting and T-lymphocytes, eliminating circulating B-lymphocytes or by interfering with the intracellular signaling mechanisms of immuno-competent cells that lead to inflammation. These agents have improved the currently available treatments due to greater efficacy, fast action and greater tolerability. However, use of these agents has also been associated with significant, although rare, adverse events and considerable cost. Therefore, these agents should be used with caution by experienced clinicians. The present work aims to provide a global and updated review of the current and in-development biological DMARDs for the treatment of RA.

Do workshops in evidence-based practice equip participants to identify and answer questions requiring consideration of clinical research? A diagnostic skill assessment.

Abstract: Evidence-based practice (EBP) requires practitioners to identify and formulate questions in response to patient encounters, and to seek, select, and appraise applicable clinical research A standardized workshop format serves as the model for training of medical educators in these skills We developed an evaluation exercise to assess the ability to identify and solve a problem requiring the use of targeted skills and administered it to 47 North American junior faculty and residents in various specialties at the close of two short workshops in EBP Prior to the workshop, subjects reported prior training in EBP and completed a previously validated knowledge test Our post-workshop exercise differed from the baseline measures and required participants to spontaneously identify a suitable question in response to a simulated clinical encounter, followed by a description of a stepwise approach to answering it They then responded to successively more explicitly prompted queries relevant to their question We analyzed responses to identify areas of skill deficiency and potential reasons for these deficiencies Twelve respondents (26%) initially failed to identify a suitable question in response to the clinical scenario Ability to choose a suitable question correlated with the ability to connect an original question to an appropriate study design Prior EBP training correlated with the pretest score but not with performance on our exercise Overall performance correlated with ability to correctly classify their questions as pertaining to therapy, diagnosis, prognosis, or harm We conclude that faculty and residents completing standard workshops in EBP may still lack the ability to initiate and investigate original clinical inquiries using EBP skills

Ethnic disparity in mortality after diagnosis of colorectal cancer among inner city minority New Yorkers.

Abstract: BACKGROUND: Ethnic disparities in colorectal cancer (CRC) mortality are observed in the United States. The authors studied this among minority New Yorkers with CRC. METHODS: In a study of CRC patients in a New York City teaching hospital, 5-year data on demographics and clinical features were reviewed. Adjusted cancer-related deaths and early deaths (within 6 months of diagnosis) were compared among African Americans (AAs) and Hispanics. Descriptive analyses, odds ratios (ORs), and 95% confidence intervals (CIs) are reported. A P value of <.05 was considered significant. RESULTS: Among 202 CRC subjects, we noted the following: Hispanics, 148 (73%); AAs, 54 (27%); women, 107 (53%); mean age, 64.5 years; and screening colonoscopy, 44 (22%). CRC was diagnosed by colonoscopy in 157 (78%) and by surgery in 45 (22%) cases. One hundred twenty-two (60%) had stage 0-II CRC, and 69 (34%) had proximal colonic lesions. Fifty-four of 202 patients died during the study period (median, 27 months), of whom 24 (11.9%) were early deaths. Significantly higher odds of death (OR, 3.98; 95% CI, 2.03-7.81), especially early death (OR, 5.94; 95% CI, 2.42-14.6) was observed among AAs. There was no difference in demographic and other clinical features, or treatment between Hispanics and AAs (P = nonsignificant). CONCLUSIONS: The first to compare inner city minority subjects with CRC, the authors observed increased odds of death in AAs, despite similar clinical features and living environment. Tumor behavior or host response among AAs could explain this difference. Aggressive therapeutic and early detection strategies need to be tested in a large randomized study setting to substantiate our study findings. Cancer 2009. © 2009 American Cancer Society.

Stenotrophomonas maltophilia bacteremia in end-stage renal disease patients receiving maintenance hemodialysis

Abstract: Stenotrophomonas maltophilia is typically a low-virulence gram-negative bacterium but can become pathogenic in patients in immunocompromised states and can cause nosocomial infections in the presence of invasive medical devices such as central venous catheters, peritoneal catheters, endotracheal/tracheostomy tubes, and urinary catheters, resulting in a variety of infections. End-stage renal disease patients are immunocompromised, and S. maltophilia bacteremia has been reported in patients receiving peritoneal dialysis via peritoneal catheters. A significant number of patients receive hemodialysis via central venous catheters, which present a high risk for S. maltophilia infection, but to our knowledge, no case has been reported.

Confirming the Diagnosis of Cannabinoid Hyperemesis

Abstract: To the Editor: I was delighted to read the interesting case report by Chang and Windish1 of 2 patients with cannabinoid hyperemesis and compulsive bathing. However, I was surprised by the authors' claim that these cases were the first reported in the United States. I found 3 other case reports that had already been published in the United States by simply searching PubMed and Google.2-4 Although still rarely reported, cannabinoid hyperemesis may be much more common than currently recognized. Because this syndrome has been recognized only recently and its validity has been questioned,5 it is of paramount importance to clearly define and fully report all new cases. The diagnosis is suggested by the characteristic triad of habitual cannabis use, cyclic vomiting, and compulsive bathing, but confirmation relies heavily on patient follow-up. Previous case reports and case series have shown that, almost universally, patients improve in the months after marijuana cessation, thus confirming the diagnosis. Unfortunately, adequate patient follow-up was lacking for the 2 cases by Chang and Windish, and the diagnosis remains uncertain. I hope that the authors can convey their patients' outcome and that a future issue of Mayo Clinic Proceedings might provide the necessary follow-up to confirm the suspected diagnosis.

Fungal endocarditis in a premature infant complicated by a right atrial mycetoma and inferior vena cava thrombosis.

Abstract: The incidence of fungal endocarditis in premature infants is on the rise, reported in the last decade secondary to use of central venous lines, the frequent use of broad spectrum antibiotics and neonatal surgical interventions. Central line related thrombosis is a significant risk factor for persistent fungemia and end organ complications including endocarditis. We present a fatal case of progressive thrombosis of the inferior vena cava and right atrial mycetoma in a premature infant with candidemia who underwent ileostomy for bowel perforation. Renal failure occurred secondary to inferior vena cava thrombosis and right atrial mycetoma, both of which had a potential for hemodynamic compromise and embolism.

An uncommon cause of throat pain.

Abstract: Throat pain is a common presenting complaint in the pediatric emergency department and often occurs secondary to non-life-threatening conditions. Certain etiologies may initially appear benign, but if not recognized and treated, may result in airway compromise. Patients with blunt trauma to the neck may present with throat pain. This is an uncommon pediatric injury usually due to a sharp blow to the anterior neck. This injury is rarely seen in isolation. We present a case of laryngeal injury due to blunt trauma to the neck. This case illustrates the potentially serious consequence after an apparently minor traumatic injury.

A neonate with asymmetric arm movements.

Abstract: Abnormal arm posture or movements in a neonate may cause significant concern in a pediatric emergency department. This can be secondary to osteomyelitis, which may rarely present with asymmetric arm movements in the neonatal period. The diagnosis of osteomyelitis is difficult to establish in a neonate because systemic signs may not be present at this age. We report an infant with upper limb weakness and asymmetric movements 3 weeks after delivery.

Imported leishmaniasis in Australia.

Abstract: To the Editor in Chief: Stark and colleagues 1 reported a series of imported leishmaniasis cases diagnosed in Sydney, Australia Although we agree with its importance, given the context of travel and migration increases between endemic and nonendemic areas, we would like to discuss some misleading messages in their article and its relevance for travel medicine They stated that humans and vertebrates are reservoirs with more than 25 species capable of producing human disease, but in fact, 17 species have been confirmed: 11 in the New World ( Viannia and Leishmania subgenuses), 5 in the Old World ( Leishmania subgenus), and 1 in both Old and New World, Leishmania (Leishmania) infantum / chagasi 2Leishmaniases are zoonoses with important reservoirs, but humans should not be pragmatically included there The species reported in human infections are …

Community-associated methicillin-resistant staphylococcal infection in an inner city hospital pediatric inpatient population.

Abstract: Background: Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a serious problem in the community setting, primarily as a cause of skin and soft tissue infections. Methods: A retrospective study based on the review of pediatric inpatients admitted to Lincoln Medical and Mental Health Center from March 2006 to February 2007 was performed. Results: Eighteen (55%) of the thirty-three patients identified were infected with community associated (CA) MRSA. All patients had skin and soft tissue infections. Seventeen (94%) of eighteen CA-MRSA isolates were susceptible to trimethoprim-sulfamethoxazole and tetracycline, respectively, and eleven (61%) were susceptible to levofloxacin. Conclusions: Skin and soft tissue infections are the most common clinical manifestation of CA-MRSA in our population. The 55% prevalence of MRSA in our patients suggests reconsidering empirical antimicrobial choices. Surgical intervention is important in the management of these infections, and clindamycin resistance among CA-MRSA isolates should be monitored locally to determine if empiric therapy is appropriate.

An unusual cause of lower back pain

Abstract: Silicone products, in their solid form, have long been used for cosmetic applications within the body and are thought to be well tolerated, the most frequent complications being occasional sensitivity and encapsulation. In contrast, silicone oil injections may cause granulomas, stimulating the formation of an inflammatory nidus and promoting macrophage activation and migration. In the case of injection of so-called industrial silicone not approved for medical uses, complications may …

Antibiotic associated hemorrhagic colitis: The need to distinguish from Clostridium difficile colitis

Abstract: 47 INTRODUCTION Antibiotic-associated diarrhea is common, but bloody diarrhea following antibiotic use is rare. The development of hemorrhagic colitis in any individual is frightening and demands urgent consideration of several causes in the etiology with the need to make a rapid diagnosis, as treatment differs with the etiology. The following is a description of amoxcillinclavulanate associated bloody diarrhea, with dramatic recovery on discontinuing the antibiotic. THE CASE A 55-year-old female was hospitalized with abdominal discomfort, cramps and bloody diarrhea; she used amoxicillin-clavulanate (Augmentin XR), 500 mg twice daily for five days for sinusitis. She noted diarrhea with bright blood the night before admission to the hospital. There was no fever or chills. Prior use of the standard form of amoxicillin was not associated with any side effects. Other medications included levothyroxin and atorvastatin. No other additional recent antibiotic use was evident from her history. At admission, the patient was afebrile, blood pressure was 98/60 mmHg, pulse 74 per minute and regular. The abdomen was distended, diffusely tender, with no rebound or guarding; bowel sounds were present. Rectal examination confirmed bright red blood with stool. Remaining examination was non-contributory. Soon after admission, the hematocrit dropped to 35.7% from a baseline value of 41; the white cell count was WBC 4.3 K/UL, Platelets 206 K/UL; electrolytes, renal and liver function tests were normal (serum creatinine 1.0). The sedimentation rate was 17 mm/hour. Stool examination was negative for ova and parasites; three C. difficile assay for toxins A and B were Antibiotic Associated Hemorrhagic Colitis: The Need to Distinguish from Clostridium difficile Colitis! A CASE TO REMEMBER