Showing papers by "Lincoln Hospital published in 2011"

Real-Life Utilization of Real-Time Continuous Glucose Monitoring: The Complete Picture

Abstract: Background: Very few studies to date have analyzed the reasons why some people do not use real-time continuous glucose monitoring (RT-CGM) continuously, especially given its positive glycemic outcomes, or choose not to wear it at all, even after learning about its benefits. Methods: A questionnaire was designed to assess real-life use of and issues surrounding RT-CGM. Hemoglobin A1c (HbA1c) and duration of sensor use were also obtained from the patients’ charts. Results: Fifty-eight subjects with type 1 diabetes (T1DM), average age 15.0 ± 4.8 years, T1DM duration 5.7 ± 3.8 years, HbA1c 8.8 ± 2.1%, 50% with RT-CGM, were included in the analysis. Hemoglobin A1c was lower with increased RT-CGM use. Real-time continuous glucose monitoring was ordered to improve control. Users liked the continuous data. The most disliked part was pain and discomfort. Occasional users described RT-CGM as annoying, a hassle, and interfering with their lives. Reasons for discontinuing RT-CGM included problematic equipment and inaccuracy (64%), intrusion in life (36%), and insurance issues (29%). Twenty-one percent of nonusers reported RT-CGM to be inconvenient or a hassle or just did not want it. Fifty-two percent of subjects continue to use RT-CGM despite reported problems. Conclusion: Real-time continuous glucose monitoring is a beneficial tool for improving glycemic control, and many use it despite reported problems and hassles with current devices. However, this technology has not been wholeheartedly embraced by many individuals with T1DM, especially in youngsters, because of issues mentioned here. Based on the findings of this study, it is hoped that improvements will be made to RT-CGM technology so that more people with diabetes will embrace this beneficial tool.

A retrospective look at length of stay for pediatric psychiatric patients in an urban emergency department.

Abstract: Objective: The objective of the study was to compare the length of stay (LOS) of patients with psychiatric diagnoses in a pediatric emergency department (ED) to that of patients with nonpsychiatric diagnoses. Methods: This is a retrospective review of all patients younger than 19 years with psychiatric conditions, who presented to an urban teaching hospital ED with psychiatric symptoms, from January 2004 to December 2007. A control group of patients with nonpsychiatric diagnoses was selected over a random 4-day period. Emergency department LOS (in minutes) of nonpsychiatric versus psychiatric patients was compared. Length of stay was determined from the time of triage to disposition (discharge or admission). Patients with psychiatric diagnoses were further classified into 1 of 2 categories: major psychiatric diagnoses (bipolar disorder, psychoses, major depression, suicidal attempt or ideation, homicidal ideation, and hallucination) and minor psychiatric diagnoses (attention deficit/hyperactivity disorder, adjustment disorder, anxiety or panic attack, and behavioral issues). Results: A total of 1468 patients with psychiatric diagnoses visited the ED. Three hundred eighty-two patients had major psychiatric diagnoses, and 1086 patients had minor psychiatric diagnoses. The control group (patients with nonpsychiatric diagnosis) consisted of 345 patients. Mean LOS of nonpsychiatric patients was 160 minutes (95% confidence interval [CI], 142-177 minutes); LOS for minor psychiatric patients was 737 minutes (95% CI, 670-803 minutes) and 1127 minutes for major psychiatric patients (95% CI, 972-1283 minutes). On the other hand, median LOS of nonpsychiatric patients was 129 minutes; minor psychiatric patients, 328 minutes; and major psychiatric patients, 437.5 minutes. Kruskal-Wallis test showed a significant difference between each group with P = 0.0001. Conclusions: The LOS was significantly higher in patients with psychiatric diagnoses. The mean and median for LOS both rose steadily from nonpsychiatric to major psychiatric diagnoses.

Improving visit cycle time using patient flow analysis in a high-volume inner-city hospital-based ambulatory clinic serving minority New Yorkers.

Abstract: Patient waiting time and waiting room congestion are quality indicators that are related to efficiency of ambulatory care systems and patient satisfaction. Our main purpose was to test a program to decrease patient visit cycle time, while maintaining high-quality healthcare in a high-volume inner-city hospital-based clinic in New York City. Use of patient flow analysis and the creation of patient care teams proved useful in identifying areas for improvement, target, and measure effectiveness of interventions. The end result is reduced visit cycle time, improved provider team performance, and sustained patient care outcomes.

Abdominal Pain in a Postpartum Patient

Abstract: Background Acute abdominal pain is a very common presenting complaint in the Emergency Department (ED). Making the correct diagnosis may be very complicated and difficult. It is even more difficult and complicated in the postpartum period, because other less common but important diagnoses must be considered. One of these potentially life-threatening diagnoses for which patients should be evaluated is uterine rupture. Objectives To discuss uncommon, but important, causes of abdominal pain that may occur in the postpartum period. To learn the clinical presentation, risk factors, evaluation, and management of uterine rupture in the postpartum patient. Case Report We present the case of a 36-year-old woman who presented to the ED with 2 days of abdominal pain and fever. The patient had had a caesarian section (C-section) 2 weeks before this admission. This was her fourth C-section. On examination, she had right lower quadrant tenderness. A computed tomography scan of the abdomen with contrast was obtained and it revealed uterine perforation with an adjacent abscess. The patient received intravenous fluids and broad-spectrum antibiotics. A laparotomy was performed that confirmed the diagnosis of uterine perforation. The patient subsequently did very well. Conclusions Uterine perforation should be considered in any postpartum patient that presents with acute abdominal pain, especially if there are risk factors, such as previous C-sections. Appropriate evaluation, consultations, and management should be done expeditiously to avoid increased morbidity and mortality.

Correlation of hepatitis C and prostate cancer, inverse correlation of basal cell hyperplasia or prostatitis and epidemic syphilis of unknown duration

Abstract: PURPOSE: The accuracy of prostate specific antigen (PSA) to detect prostate cancer has not yet been determined. Autopsy evidence suggests one-third of men have evidence of prostate cancer. Correlation between prostate cancer and sexually transmitted infection is indeterminate. MATERIALS AND METHODS: A retrospective database was created of all men who underwent transrectal ultrasound guided prostate biopsy over 3 years. Men were 49% African or African Caribbean, and 51% Central or South American. Information about prostate specific antigen, cholesterol, hepatitis A, B and C, human immunodeficiency virus, syphilis, tuberculin skin testing and histology were collected. RESULTS: Hepatitis C antibody detection correlated with prostate cancer OR 11.2 (95% CI 3.0 to 72.4). The odds of prostate cancer increased annually (p = 0.0003). However, no correlation was found between prostate cancer and the following: PSA, biopsy date, repeat biopsy, more than 12 cores at biopsy, total cholesterol, high density lipoprotein, triglycerides, low density lipoprotein, risk measure reported with free and total PSA, hepatitis B surface antibody, high grade prostatic intraepithelial neoplasia or atypical small acinar proliferation. Histologic prostatitis and basal cell hyperplasia were inversely correlated with prostate cancer. Syphilis of unknown duration occurred in 17% of men with indeterminate correlation to prostate cancer. CONCLUSION: In inner city men of African and African-Caribbean, or Central and South American descent, prostate specific antigen levels did not correlate with prostate cancer. Hepatitis C antibody detection correlates significantly with prostate cancer. One prostate biopsy is sufficient to diagnose statistically significant prostate cancer. Histologic prostatitis and basal cell hyperplasia decrease odds of prostate cancer. Atypical small acinar proliferation may not correlate to prostate cancer and is pending further investigation. Men should be screened for epidemic syphilis of unknown duration.

Appendicitis: a rare cause.

Abstract: Acute appendicitis is the most common acute surgical condition in children. Parasitic infestations are ubiquitous on a worldwide basis and are seen in the United States because of increasing international travel and emigration from developing countries. These infestations may produce symptoms of acute appendicitis, although the role of parasitic infestation in relation to appendicitis is controversial. Intestinal parasites may cause significant morbidity and mortality. We report a patient with symptoms of acute appendicitis in whom intramural parasites were found during laparoscopic surgery. Histology of the appendix specimen revealed a normal appendix. The pertinent literature is also reviewed.

Rituximab and lupus interstitial lung disease: friend or foe?

Abstract: Dear Editor, A 29-year old Mexican male with systemic lupus erythematosus (SLE) and secondary Sjogren’s syndrome presented to the emergency room of UMDNJ University Hospital, Newark, NJ, US, with dyspnea, productive cough, fever, chills, tachycardia and bilateral pleuritic chest pain of 2 weeks’ duration. Physical examination revealed crackles on lung auscultation. The patient was admitted for presumed communityacquired pneumonia and treated with intravenous levofloxacin. Initial pulmonary function tests (PFTs) revealed a restrictive defect with impaired gas exchange. Laboratory investigations revealed lupus flare with increased titers of anti-nuclear antibodies (ANA), anti-Ro and anti-La antibodies, anti-double stranded-DNA (anti-dsDNA) antibodies, along with low complement levels, elevated C-reactive protein levels and erythrocyte sedimentation rate. Electrocardiography (ECG) showed sinus tachycardia. Echocardiogram showed normal contractility and absence of thrombi. Chest imaging revealed patchy infiltrates and high-resolution computed tomography (HRCT) scan of the chest showed right pleural effusion, groundglass opacity and basal atelectasis, consistent with the diagnosis of lupus pneumonitis. The patient received high-dose intravenous steroids and was discharged from the hospital on oral prednisone 60 mg/daily, and hydroxychloroquine 400 mg/ daily. Five days post-discharge, the patient’s oxygen saturation was normal but his complaints of dyspnea continued. Subsequently, mycophenolate mofetil (MMF) 2 g/daily was added to his treatment regimen. However, the patient continued to complain of reduced exercise tolerance associated with a progressive decline in respiratory function on spirometry. The patient was reluctant to undergo cyclophosphamide treatment and rituximab was infused at a dose of 1000 mg at weeks 0 and 2. The patient improved both in terms of subjective symptoms of dyspnea and exercise tolerance, and in terms of spirometric parameters: increase of forced expiratory volume in 1 sec (FEV1) by 25% (49% to 74%), forced vital capacity (FVC) by 15% (2.21 L or 51% to 3.1 L or 66%), and diffusion capacity of carbon monoxide (DLCO) by 17% (42% to 59%). Respiratory complications of SLE may involve every element of the respiratory tract and are relatively common as the initial manifestation of this disease occurring in 60–80% of patients during the course of the disease. The pathology involves genetic, endocrine, environmental, pharmacological and immunological factors with a cytotoxic reaction of auto antibodies against complement, a circulating immune complex reaction and a hyperactivity of B lymphocytes. Acute lupus pneumonitis (ALP) is an uncommon complication of SLE, reported to occur in 0–14% of patients, in 50% of whom it may be the presenting manifestation. The natural history and etiology of ALP remain inadequately defined and the treatment options are limited and lack the support of randomized controlled trials. Although high-dose steroids and cyclophosphamide are the most commonly used therapies, their efficacy is questionable in some cases and the toxicity and sterility risk associated with cyclophosphamide is often not acceptable to patients. In SLE specifically, B-cell depletion has been shown to be an effective treatment. Disease control and sustained remission in patients with active, multi-organ SLE has been demonstrated. The pathogenesis of ALP is unclear and therefore the exact mechanism by which B-cell depletion improves this condition is also uncertain. Rituximab is a chimeric monoclonal antibody targeting the CD20 antigen on mature B-cells, and thereby causing B-cell depletion, which has been successfully employed for a variety of autoimmune conditions with an acceptable safety profile. Moreover, it has been reported in one study to be effective toward systemic sclerosis-induced interstitial lung disease (ILD); however, limited data exists for its use in SLEinduced ILD. On the contrary, there have been isolated case reports with rituximab-induced ILD in SLE patients. Based on current observations, we speculate that B-cell depletion may be more beneficial in International Journal of Rheumatic Diseases 2011; 14: e3–e4

Ganando Confianza: Research Focus Groups with Immigrant Mexican Mothers

Abstract: Immigrant families with children with developmental disabilities must be served using culturally sensitive approaches to service and research to maximize treatment benefits. In an effort to better understand cultural issues relevant to the provision of parenting programs for immigrant Mexican mothers of children with developmental disabilities, we conducted sustained focus groups through which we could learn more about our participants and thereby improve services. This paper reports on the challenges and lessons learned from these groups. We characterize the key lessons as (a) recruitment and retention is more than agreement to participate; (b) confidentiality is not just a word but an activity; (c) the complicated nature of language; (d) cultural norms shape the group process; (e) appreciating the value of taking time; and (f) gender issues and group interaction. Service providers and researchers who work with Mexican families may benefit from our experiences as they promote and develop programs and projects in the developmental disabilities field.

Challenges and Solutions for Latin American-Trained International Medical Graduates in Psychiatry Residency

Abstract: Objective: Latin American-trained international medical graduates (IMGs) in psychiatry residency face multiple challenges that go beyond their medical training. These challenges call for innovative problem-solving. Although the professional development of IMGs has been discussed in the professional literature, little is written about their experiences. In this report, a group of IMGs reflect on their experiences and describe how they solved challenges. Method: Using cogenerative ethnography, four IMGs trained in Colombia, the Dominican Republic, and Mexico provided insights on their challenges and solutions while adapting to psychiatric residency training. Individual interviews, focused discussion, and written reports were analyzed using data reduction, data display, and conclusion-drawing techniques. Results: We illustrate the challenges of IMG training in psychiatry using their reflections and stories. We categorize these challenges into three domains: immigration and acculturation, social adjustment, a...

PCP chemoprophylaxis is essential for lymphopenic dermatomyositis patients treated with immunomodulators.

Abstract: A 48-year-old man presented with lower extremity weakness and rash. Physical examination revealed symmetrical proximal muscle weakness, extremity erythematous plaques, Gottron papules, and periorbital edema with a heliotrope hue. Serology revealed elevated titers of aminotransferases, aldolase, creatine kinase, and erythrocyte sedimentation rate. Skin biopsy suggested acute collagen vascular disease, and electromyography revealed proximal irritable myopathy. Muscle biopsy of the quadriceps was performed; however, the limited muscle tissue obtained failed to show signs of inflammation and the negative result was attributed to sampling error. The patient fulfilled the Bohan and Peter criteria for dermatomyositis (DM) based on clinical presentation and characteristic electromyography findings. His initial total lymphocyte count was 784/mm, and his CD4 cell count was 318/mm. The patient responded to 60 mg/day of prednisone over a period of 7 days, and was discharged with nearcomplete recovery of muscle strength and decreased serum levels of muscle enzymes and aminotransferases. However, 2 weeks later, he again presented with profound dyspnea, fever, cough, tachycardia, bilateral knee pain, and facial swelling. Arterial blood gas analysis revealed hypoxemia and respiratory alkalosis. Chest radiography was normal, but chest computed tomography (CT) scan showed diffuse pleural thickening with extensive peripheral reticular nodular infiltrates. The patient received antibiotics for possible hospital-acquired pneumonia. Despite treatment, he continued to complain of dyspnea associated with rapid respiratory deterioration, and he ultimately required intubation. His total lymphocyte count was 300/mm, and his CD4 cell count was 259/mm. Bronchoscopy and bronchoalveolar lavage revealed Pneumocystis jirovecii organisms by staining and cytopathology. Subsequently, he was treated with intravenous trimethoprim–sulfamethoxasole and prednisone for Pneumocystis carinii pneumonia (PCP). His clinical status remained tenuous for several days, and he died of progressive respiratory failure. PCP is an opportunistic infection that is reported frequently in DM patients treated with immunosuppressants. The incidence of PCP in immune-compromised DM patients is anywhere between 10% and 40%. The frequency of PCP may relate to the intensive immunosuppression used rather than to an inherent immune defect in DM. PCP evaluated independently in non-HIV patients with connective tissue diseases (CTDs) exhibited significant morbidity and mortality that compares directly to PCP in HIV patients. A recent review suggested a higher incidence of PCP with considerable mortality in DM patients when compared with other CTDs. However, there is currently no consensus to aid physicians in adequately identifying patients who are at high-risk for PCP infection and would benefit from prophylaxis. The total lymphocyte and CD4 subset counts may be currently the only measurable prognostic factors. Prior studies have shown that low lymphocyte counts were negatively associated with PCP occurrence in immunocompromised patients. Furthermore, the CD4 lymphocyte subset may be superior to the total lymphocyte count, as has been clearly demonstrated in HIV/AIDS. Review of the available literature showed a relative paucity of data. We identified 4 other reported cases wherein low total lymphocyte and CD4 cell counts during the course of therapy were associated with significant morbidity and even mortality (Table 1), which argues for the need for early initiation of PCP prophylaxis in susceptible individuals. Some investigators consider DM patients who receive immunosuppressants and have total lymphocyte counts <800/lL or CD4 counts <200/lL to be candidates for routine PCP chemoprophylaxis. We propose that all DM patients should be screened with peripheral lymphocyte counts at the time of diagnosis, and those with lymphopenia should receive PCP prophylaxis prior to the initiation of prednisone or other

Epidemiology of congenital syphilis in a South Bronx population: a follow-up study.

Abstract: Despite widespread prenatal serological screening, the Centers for Disease Control recently reported that from 2005 to 2008, congenital syphilis increased by 23%, many being born to black women in the southern United States. We collected data on the epidemiology of this condition in our institution for the past 18 years (January 1, 1991-December 31, 2008). There has been a marked decrease in the incidence of active infection since the 1990s. Through the 18 years period reviewed, only 21 cases of active neonatal infection were documented among 699 babies who had a positive rapid plasma reagin test. Of these 21 cases, only one was symptomatic. As compared to previous studies, poor prenatal care has still the greatest correlation with active infection. This study might contribute towards the reinforcement of current programs and the formulation of newer strategies towards control and elimination of this condition.

Lupus pernio: sarcoid-specific cutaneous manifestation associated with chronic sarcoid arthropathy.

Abstract: A 34-year-old African American man presented with bilateral hand arthritis and a flesh growth at the tip of his nose that appeared at the age of 27 years and gradually increased in size. Skin biopsy revealed noncaseating granulomatous dermatitis, consistent with the diagnosis of cutaneous sarcoidosis. Two years later, the patient developed dry cough; physical examination revealed dactylitis and bilateral proximal interphalangeal joint synovitis (Fig. 1) and a shiny, soft tissue growth over the tip of the nose (Fig. 2), consistent with lupus pernio. Chest radiography revealed paratracheal and bilateral hilar lymphadenopathy. Laboratory evaluation revealed borderline elevation of erythrocyte sedimentation rate and angiotensin-converting enzyme titers. Hand radiographs showed several circumscribed, corticated digital lytic bone lesions. The patient responded initially to a combination of methotrexate 15 mg weekly and prednisone 10 mg daily. However, the arthritis and dactylitis progressed, and the infliximab 5 mg/kg was added with resultant decrease in the activity of the arthritis and the lupus pernio lesion size.

Predicting survival of periviable fetuses using NICHD fetal heart rate categories.

Abstract: Objective: To evaluate whether National Institute of Child Health and Human Health and Development (NICHD) fetal heart rate categories were predictive of neonatal survival in periviable pregnancies. Methods: We reviewed the charts of 57 infants delivered at 23 and 24 weeks' gestation. Fetal heart rate tracings were evaluated following the NICHD 2008 criteria, using the acceleration height of 10 bpm and duration of 10 s. Multiple logistic regression analyses were performed using survival, fetal morbidities, and cord pH < 7.1 as dependent variables. Independent variables included fetal heart rate category, mode of delivery, resuscitation, and histological chorioamnionitis. Outcomes of infants delivered at 23 and 24 weeks were also compared. Results: In 23-week pregnancies, fetal heart rate category 2 was associated with improved short-term survival compared to category 3 (OR 1.3, 95% CI 0.11-15.7). Cesarean delivery and histological chorioamnionitis were not predictive of survival [(OR 0.5, 95% CI 0.04-7.1, and OR 0.4, 95% CI 0.02-6.85), respectively]. Long-term survival for infants born at 23 and 24 weeks was 8% and 56%, respectively. Conclusions: The NICHD fetal heart rate category during labor may be associated with survival for infants born at 23 and 24 weeks of gestation. Cesarean delivery was not associated with improved survival.

Pyrilamine-induced prolonged QT interval in adolescent with drug overdose.

Abstract: The widespread availability of antihistamines in many over-the-counter preparations can lead to significant hazard to the public because of their possible link to potential ventricular arrhythmias secondary to prolongation of QT interval. The effect can be further compounded by the use of other commonly used medications such as macrolides, antifungal agents, antipsychotics, and other antihistamine-containing preparations. The effect of antihistamines on QT interval is not a class effect but is unique to certain medications. Pyrilamine, a first-generation antihistaminic agent, is considered safe as there are no reports regarding its cardiac toxicity available in literature. We report a case of an adolescent with prolonged QT interval after an overdose of pyrilamine.

A common symptom of an uncommon disease.

Abstract: Cancer of the colon is the second most common visceral cancer in the United States (lung cancer is the first). It is usually diagnosed in patients older than 40 years, with a peak incidence at 70 years of age. Rarely, are cases seen in the pediatric population. In this study, we report a case of a 13-year-old girl with an 11-month history of intermittent abdominal pain whose diagnosis was delayed due to vague symptoms and a low index of suspicion for this condition.

Combined laparoscopy and transabdominal endoscopy: Case report of dislodged oesophageal stent retrieval.

Abstract: The patient is a 39-year-old male with a five-month history of progressive dysphagia and a 70 lb weight loss. On upper gastrointestinal (GI) endoscopy he was found to have a near-obstructing mass in the lower oesophagus that was proven by biopsy to be oesophageal adenocarcinoma. Stricture caused by the adenocarcinoma mass was stented with a Cook Evolution 12.5 cm / 24 Fr stent, which dislodged subsequently. We report the first case of a dislodged Cook Evolution 12.5 cm / 24 Fr oesophageal stent that was retrieved using combined laparoscopic and transabdominal endoscopy.

Complex Situations in Patients with Adult-Onset Still’s Disease

Abstract: Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology, characterized by quotidian or double quotidian fever, a peri-febrile cutaneous eruption, polyarthritis, and multiorgan involvement. AOSD is a challenging disease with protean disease manifestations and rare, albeit potentially life-threatening, complications. In such cases, prompt diagnosis and treatment may prove life-saving.

An adolescent with lower-extremity swelling.

Abstract: Lower-extremity swelling is an uncommon presentation in a pediatric emergency department. Deep venous thrombosis is one of the common differential diagnoses in a patient with an underlying predisposing factor. We report a case of a previously healthy adolescent without any risk factor for thromboembolism presented with deep venous thrombosis. The pertinent literature is reviewed.