Showing papers by "New York Methodist Hospital published in 2009"
TL;DR: The purpose of the study was to count and characterize the range of stereotypies in developmentally impaired children with and without autism, and to determine whether some types are more prevalent and diagnostically useful in children with autism.
Abstract: The purpose of the study was to count and characterize the range of stereotypies--repetitive rhythmical, apparently purposeless movements--in developmentally impaired children with and without autism, and to determine whether some types are more prevalent and diagnostically useful in children with autism. We described each motor stereotypy recorded during 15 minutes of archived videos of standardized play sessions in 277 children (209 males, 68 females; mean age 4y 6mo [SD 1y 5mo], range 2y 11mo-8y 1mo), 129 with autistic disorder (DSM-III-R), and 148 cognitively-matched non-autistic developmentally disordered (NADD) comparison children divided into developmental language disorder and non-autism, low IQ (NALIQ) sub-groups. The parts of the body involved and characteristics of all stereotypies were scored blind to diagnosis. More children with autism had stereotypies than the NADD comparison children. Autism and, to a lesser degree, nonverbal IQ (NVIQ) <80, especially in females contributed independently to the occurrence, number, and variety of stereotypies, with non-autistic children without cognitive impairment having the least number of stereotypies and children with autism and low NVIQ the most. Autism contributed independently to gait and hand/finger stereotypies and NVIQ <80 to head/trunk stereotypies. Atypical gazing at fingers and objects was rare but virtually limited to autism. Stereotypies are environmentally modulated movement disorders, some highly suggestive, but not pathognomonic, of autism. Their underlying brain basis and genetic correlates need investigation.
243 citations
TL;DR: A biomarker panel of neutrophil gelatinase-associated lipocalin, interleukin-1ra, and Protein C was predictive of severe sepsis, septic shock, and death in ED patients with suspected sepsi.
Abstract: Objective: To define a biomarker panel to predict organ dysfunction, shock, and in-hospital mortality in emergency department (ED) patients with suspected sepsis. Design: Prospective observational study. Setting: EDs of ten academic medical centers. Patients: There were 971 patients enrolled. Inclusion criteria: 1) ED patients age > 18; 2) suspected infection or a serum lactate level > 2.5 mmol/L; and 3) two or more systemic inflammatory response syndrome criteria. Exclusion criteria: pregnancy, do-not-resuscitate status, or cardiac arrest. Measurements and Main Results: Nine biomarkers were assayed from blood draws obtained on ED presentation. Multivariable logistic regression was used to identify an optimal combination of biomarkers to create a panel. The derived formula for weighting biomarker values was used to calculate a "sepsis score," which was the predicted probability of the primary outcome of severe sepsis (sepsis plus organ dysfunction) within 72 hrs. We also assessed the ability of the sepsis score to predict secondary outcome measures of septic shock within 72 hrs and in-hospital mortality. The overall rates of each outcome were severe sepsis, 52%; septic shock, 39%; and in-hospital mortality 7%. Among the nine biomarkers tested, the optimal 3-marker panel was neutrophil gelatinase-associated lipocalin, protein C, and interleukin-1 receptor antagonist. The area under the curve for the accuracy of the sepsis score derived from these three biomarkers was 0.80 for severe sepsis, 0.77 for septic shock, and 0.79 for death. When included in multivariate models with clinical variables, the sepsis score remained highly significant (p < 0.001) for all the three outcomes. Conclusions: A biomarker panel of neutrophil gelatinase-associated lipocalin, interleukin-1 ra, and Protein C was predictive of severe sepsis, septic shock, and death in ED patients with suspected sepsis. Further study is warranted to prospectively validate the clinical utility of these biomarkers and the sepsis score in risk-stratifying patients with suspected sepsis.
204 citations
TL;DR: Non-central cord insertion has little measurable correlation with placental shape in observed or simulated placentas, but placenta with a displaced cord show a markedly reduced transport efficiency, reflected in a larger value of beta and hence in a smaller birth weight for a given placental weight.
109 citations
TL;DR: The findings suggest that exposure of the fetus to hydroxyurea does not cause teratogenic changes in those pregnancies that terminate in live birth whether full-term or premature, and this seems to be true whether the parent taking hydroxyUREa was the mother or the father.
Abstract: The Multicenter Study of Hydroxyurea in Sickle Cell Anemia (MSH) was a randomized double-blind placebo-controlled trial to test whether hydroxyurea could reduce the rate of painful crises in adults who had at least 3 painful crises per year. Because hydroxyurea is known to be carcinogenic, mutagenic, and teratogenic in animals, a major inclusion criterion in MSH was the use of contraceptives both by females and males in order to avoid exposure of the fetus to hydroxyurea. Despite this precautionary measure, some women became pregnant while taking hydroxyurea or their male partners were on hydroxyurea. We followed surviving patients who were enrolled in the original MSH trial for up to 17 years postrandomization. Our findings suggest that exposure of the fetus to hydroxyurea does not cause teratogenic changes in those pregnancies that terminate in live birth whether full term or premature. This seems to be true whether the parent taking hydroxyurea was the mother or the father. The same argument seems to apply for exposure to opioids. However, it will take a much longer follow-up of many more hydroxyurea-exposed sickle cell disease subjects to establish the results conclusively.
82 citations
TL;DR: In this study of 447 patients hospitalized for suspected heart failure, it was unable to demonstrate a benefit of serial testing with B-type natriuretic peptide in terms of hospital length of stay, mortality, or readmission rate.
Abstract: Background— B-type natriuretic peptide is useful to diagnose heart failure. We determined whether the use of serial B-type natriuretic peptide measurements to guide treatment improves the outcome in patients with acute heart failure.
Methods and Results— We conducted a randomized controlled trial of patients with acute heart failure in 10 academic and community emergency departments. The experimental group received serial B-type natriuretic peptide testing (at 3, 6, 9, and 12 hours then daily). The control group received usual care. Our outcomes were hospital length of stay, 30-day readmission rate, and all-cause mortality.
There were 219 controls and 228 experimental patients. Mean age was 64 years, 49% were women, 58% were blacks, and 34% were whites. Groups were similar in baseline characteristics. Comparing the serial testing with the control group, there was no difference in length of stay (6.5 days [95% CI, 5.2 to 7.9] versus 6.5 days [95% CI, 5.6 to 7.3]; difference, 0.1 [95% CI, −1.7 to 1.5]), in-hospital mortality (2.2% [95% CI, 0.9 to 5.0] versus controls, 3.2% [95% CI, 1.6 to 6.5]; difference, 1.0% [95% CI, −2.3 to 4.5]), 30-day mortality (3.7% [95% CI, 1.8 to 7.5] versus 5.5% [95% CI, 3.0 to 9.8]; difference, 1.8% [95% CI, −2.8 to 6.5]), or hospital revisit rate (20.2% [95% CI, 15.0 to 26.6] versus 23.7% [95% CI, 18.0 to 30.6]; difference, 3.5% [95% CI, −5.1 to 12.1]).
Conclusions— In this study of 447 patients hospitalized for suspected heart failure, we were unable to demonstrate a benefit of serial testing with B-type natriuretic peptide in terms of hospital length of stay, mortality, or readmission rate.
Received October 7, 2008; accepted April 2, 2009.
53 citations
TL;DR: Lowering cardiac output was strongly associated with significant ventricular arrhythmias in patients with cardiac amyloidosis undergoing SCT; continuous telemetric monitoring contributed to patient safety during SCT.
Abstract: Cardiac patients with systemic light-chain amyloidosis have a high incidence of arrhythmias and arrhythmia-related death. We aimed to describe the arrhythmias, determine patient characteristics associated with the development of ventricular arrhythmias, and the utility of telemetric monitoring in patients with cardiac involvement due to AL amyloidosis undergoing stem cell transplantation (SCT). Arrhythmia events of 24 consecutive cardiac patients with AL who underwent SCT with continuous telemetric monitoring were retrospectively reviewed. The relation between number and severity of ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]) and baseline clinical, laboratory, and echocardiographic data were determined. Atrial and ventricular arrhythmias were found in all patients. Nonsustained VT was the most frequent event (267 total events). Therapeutic intervention for arrhythmias was required in 20 patients; in 3 patients, life-threatening arrhythmias were detected and treated. There was an inverse relation between VT/VF and cardiac output (r = -0.72, p <0.0001), cardiac index (r = -0.71, p = 0.0001), and stroke volume (r = -0.59, p = 0.0029). There was also a relation between VT/VF and brain natriuretic peptide before SCT (r = 0.47, p = 0.019) and average brain natriuretic peptide levels during admission for SCT (r = 0.62, p = 0.0012), troponin I levels at diagnosis (r = 0.47, p = 0.022), and serum creatinine levels before SCT (r = 0.62, p = 0.001). In conclusion, patients with cardiac amyloidosis undergoing SCT have a high incidence of ventricular and atrial arrhythmias; decreased cardiac output was strongly associated with significant ventricular arrhythmias. Continuous telemetric monitoring contributed to patient safety during SCT.
51 citations
TL;DR: Combined percutaneous debulking of confined vertebral metastases and administration of local (153)Sm is feasible and safe and may help prevent or slow down the progression of vertebra metastatic tumors.
Abstract: Object The object of this study was to investigate the use of a minimally invasive technique for treating metastatic tumors of the vertebral body, aimed at relieving pain, preventing further tumor growth, and minimizing the adverse effects of systemic use of samarium-153 (153Sm). Methods The procedure is performed in the same fashion as a kyphoplasty, using a unilateral extrapedicular approach under local anesthesia/mild general sedation, with the patient in the lateral decubitus position. The tumor is accessed as in a standard kyphoplasty. The side is chosen according to the location of the metastasis. Prior to inflation of the balloon the tumor is debulked by percutaneous curettage. Balloon inflation is carried out as per standard kyphoplasty in an attempt to create a larger space and reduce a possible kyphotic deformity. Three mCi of 153Sm-EDTMP (ethylenediaminetetramethylenephosphonic acid) is then mixed with bone cement (polymethylmethacrylate) and injected into the void created by the balloon tamp. ...
38 citations
TL;DR: The patient was initially treated with oral antibiotics for septic bursitis and returned to the orthopedics clinic for follow-up 2 days later with interval worsening of symptoms and was subsequently admitted for parenteral antibiotics and surgical wash-out of the affected bursa.
Abstract: We describe the case of a 44-year-old man who presented to the Emergency Department (ED) complaining of pain and swelling over the left elbow of 1-week duration. After olecranon bursal aspiration, synovial fluid analysis yielded an increased white blood cell count (3040 cells/mm(3)) and the presence of bacteria. Culture of the fluid later grew Staphylococcus aureus. The patient was initially treated with oral antibiotics for septic bursitis and returned to the orthopedics clinic for follow-up 2 days later with interval worsening of symptoms. He was subsequently admitted for parenteral antibiotics and surgical wash-out of the affected bursa. This report briefly discusses the clinical history and appropriate diagnostic evaluation for septic olecranon bursitis, as well as the shortcomings of existing treatment guidelines.
33 citations
TL;DR: The two nonprivate mutations identify a genetic basis for TC I deficiency for the first time and add new approaches to studying mild and severe TC I deficiencies and to reducing confusion of its low cobalamin levels with those of cobalamina deficiency and its often dramatically different prognosis and management.
Abstract: Transcobalamin (TC) I deficiency, like the function of TC I itself, is incompletely understood. It produces low serum cobalamin levels indistinguishable from those of true cobalamin deficiency. Diagnosis is especially elusive when TC I deficiency is mild. To provide new, more substantive definition, the TCN1 gene was examined in two well-characterised families that included members with both severe and mild TC I deficiencies. A severely deficient proposita with undetectable TC I levels displayed compound heterozygosity for two mutations, each causing a premature stop codon. Relatives in both families who had mildly low or low-normal plasma levels of TC I and cobalamin were heterozygous for one or the other of these mutations. An unrelated patient with mild TC I deficiency and unknown familial TC I and cobalamin status was then tested and found to be similarly heterozygous for one of the mutations. The two nonprivate mutations identify a genetic basis for TC I deficiency for the first time. They also add new approaches to studying mild and severe TC I deficiency and to reducing confusion of its low cobalamin levels with those of cobalamin deficiency and its often dramatically different prognosis and management.
30 citations
TL;DR: The results of the study have shown that the combination of intravertebral administration of Samarium-153-ethylene diamine tetramethylene phosphonate and kyphoplasty is well tolerated with adequate pain control.
Abstract: Purpose: Kyphoplasty is an effective procedure to alleviate pain in vertebral metastases. However, it has no proven anticancer activity. Samarium-153-ethylene diamine tetramethylene phosphonate ({sup 153}Sm-EDTMP) is used for palliative treatment of bone metastases. A standard dose of 1 mCi/kg is administrated intravenously. The present study was conducted to determine the feasibility of intravertebral administration of {sup 153}Sm with kyphoplasty. Methods and Materials: A total of 33 procedures were performed in 26 patients. Of these 26 patients, 7 underwent procedures performed at two vertebral levels. The mean age of the cohort was 64 years (range, 33-86). The kyphoplasty procedure was performed using a known protocol; 1-4 mCi of {sup 153}Sm was admixed with the bone cement and administered under tight radiation safety measures. Serial nuclear body scans were obtained. Pain assessment was evaluated using a visual analog pain score. Results: All patients tolerated the procedure well. No procedure-related morbidities were noted. No significant change had occurred in the blood counts at 1 month after the procedure. One case was not technically satisfactory. Nuclear scans revealed clear radiotracer uptake in the other 32 vertebrae injected. Except for the first patient, no radiation leakage was encountered. The mean pain score using the visualmore » analog scale improved from 8.6 before to 2.8 after the procedure (p < .0001). Follow-up bone scans demonstrated a 43% decrease in the tracer uptake. Conclusion: The results of our study have shown that the combination of intravertebral administration of {sup 153}Sm and kyphoplasty is well tolerated with adequate pain control. No hematologic adverse effects were found. A reduction of the bone scan tracer uptake was observed in the injected vertebrae. Longer follow-up is needed to study the antineoplastic effect of the procedure.« less
27 citations
TL;DR: The current federal guidelines that affect the physician-industry relationship are reviewed and several illustrative cases are highlighted to show how the potential for abuse can subvert this relationship.
Abstract: The effective delivery and continued advancement of health care is critically dependent on the relationship between physicians and industry. The private sector accounts for 60% of the funding for clinical research and more than 50% of the funding sources for physician education. The nature of the physician-industry relationship and the role of the physician as a gatekeeper for health care make this association vulnerable to abuse if certain safeguards are not observed. This article will review the current federal guidelines that affect the physician-industry relationship and highlight several illustrative cases to show how the potential for abuse can subvert this relationship. The recommendations and "safe harbors" that have been designed to guide business relationships in health care are discussed.
TL;DR: Aims: To compare patients with atrial flutter and 1:1 atrioventricular conduction (AVC) with patients with AFl and higher AVC.
Abstract: Summary AFl with 1:1 AVC is an uncommon but chal-lenging arrhythmia. The best criterion for a cor-rect diagnosis is to be aware of its different pre-sentations and to always consider the diagnosisin patients with history of syncope/presyncope/palpitationswhopresentwithnarroworwideQRStachycardia at rates ≥220 beats/min. References 1. KrappM,KohlT,SimpsonJM,SharlandGK,KatalinicA,GembruchU. Review of diagnosis, treatment, and outcome of fetal atrial fluttercompared with supraventricular tachycardia. Heart 2003, 89:913–917.2. Casey FA, McCrindle BW, Hamilton RM, Gow RM. Neonatal atrialflutter: Significant early morbidity and excellent long-term progno-sis. Am Heart J 1997; 133:302–306.3. Parmeggiani L, Adamec R, Perrenoud JJ. 1:1 atrial flutter in an el-derly patient: One of the methods of discovering Wolff-Parkinson-White Syndrome. A propos of a case in an adult. Arch Mal CoeurVaiss 1984; 77: 111–117.4. Feld GK, Chen PS, Nicod P, Fleck P, Meyer D. Possible atrial proar-rhythmic affects of class IC antiarrhythmic drugs. Am J Cardiol1990; 66:378–383.5. Brembilla-Perrot B, Houriez P, Beurrier D, Claudon O, Terrier dela Chaise A, Louis P. Predictors of atrial flutter with 1:1 conduc-tion in patients treated with class I antiarrhythmic drugs for atrialtachyarrhythmias. Int J Cardiol 2001; 80:7–15.6. Greenberg HB, Antin SH. 1:1 conduction in atrial flutter afterintravenous injection of aminophylline. J Electrocardiol 1972;5:391–393.7. Finkelstein D, Gold H, Billet S. Atrial flutter with 1:1 AV conduc-tion: Report of six cases. Am J Med 1956; 20:65–76.8. Kennelly BM, Lane G. Electrophysiologic studies in four patientswith atrial flutter with 1:1 atrioventricular conduction. Am Heart J1978; 96:723–730.9. Blanc JJ, Fontalirau F, Gerbaux A, Boschat J, Penther P.Atrial flutter with 1:1 atrioventricular conduction: Electrophys-iologic and histologic correlation. Am Heart J 1984; 109:1045–1049.10. Aranda JM, Moleiro F, Castellanos A, Befeler B. Electrophysiologicstudies in a patient with atrial flutter and 1:1 atrioventricular con-duction. Chest 1975; 68:200–206.11. Pahlajani DB, Miller RA, Serratto M. Patterns of atrioventricularconduction in children. Am Heart J 1975; 90:165–171.12. Chen RH, Chen KP, Wang FZ, Hua W, Chen X, Zhang S. Incidenceand causes of inappropriate detection and therapy by implantabledefibrillators in patients with ventricular tachyarrhythmia. ChinMed J 2006; 119:557–563.13. BatsfordWP,AkhtarM,CaractaAR,JosephsonME,SeidesSF,Dam-ato AN. Effect of atrial stimulation site on the electrophysiologicalproperties of the atrioventricular node in man. Circulation 1974;50:283–292.14. Lister JW, Stein E, Kosowsky BD, Lau SH, Damato AN. Atrioven-tricular conduction in man: Effect of rate, exercise, isoproterenoland atropine on the PR interval. Am J Cardiol 1965; 16:516–523.15. Schoels W, Offner B, Brachmann J, Kuebler W, El-Sherif N. Circusmovement atrial flutter in the sterile pericarditis model. Relationof characteristics of the surface electrogram and conduction prop-erties of the reentrant pathway. J Am Coll Cardiol 1994;23:799–808.
TL;DR: A normalizing function based on eGFR eliminates the need for an age-based reference ranges for NT-proBNP levels, independent of the age of the patient.
TL;DR: The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions and using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.
Abstract: Objectives: The objective was to determine the incremental benefit of a shortness-of-breath (SOB) point-of-care biomarker panel on the diagnostic accuracy of emergency department (ED) patients presenting with dyspnea.
Methods: Adult ED patients at 10 U.S. EDs with SOB were included. The physician’s estimates of the pretest clinical probability of heart failure (HF), acute myocardial infarction (MI), and pulmonary embolism (PE) were recorded using deciles (0%–100%). Blood samples were analyzed using a SOB point-of-care biomarker panel (troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme [CK-MB], D-dimer, and B-type natriuretic peptide [BNP]). Thirty-day follow-up for MI, HF, and PE was performed. Data were analyzed using logistic regression and receiver operating characteristics (ROC) curve analysis.
Results: Of 301 patients, the mean (±standard deviation [SD]) age was 61 (±18) years; 56% were female, 58% were white, and 38% were African American. Diagnoses included MI (n = 54), HF (n = 91), and PE (n = 16) in a total of 129 (43%) of the patients. High pretest clinical certainty (≥80%) identified 60 of these 129 (46.5%) cases. The SOB point-of-care biomarker panel identified 66 additional cases of MI (n = 24), HF (n = 31), and PE (n = 11). The overall adjusted sensitivity for any diagnosis was increased from 65% to 70% with the addition of the SOB point-of-care biomarker panel (difference = 5%, 95% CI = −1.1% to 11%) while specificity was increased from 82% to 83% (difference = 1%, 95% CI = −4% to 7%). The model containing pretest probability and the results of the SOB panel had an area under the curve (AUC) of 83.4% (95% CI = 78.4% to 88.5%), which was not significantly better than the AUC of 80.4% (95% CI = 75.1% to 85.7%) for clinical probability alone.
Conclusions: The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions. Using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.
TL;DR: Age, low ejection fraction, large left atrial size, and nonuse of angiotensin blocking agents were found to be significant predictors of AF development.
TL;DR: The case of a 22-year-old man who was referred to the ED with a history of intermittent palpitations, near-syncope and electrocardiogram findings of RSR' and ST elevation in V1-V2 characteristic of Brugada syndrome is reported.
Abstract: Brugada syndrome is believed to be the cause of up to 50% of sudden cardiac death (SCD) cases due to ventricular dysrhythmias in young healthy individuals with no structural heart disease. This syndrome was first reported in 1992 and is rarely seen in the Emergency Department (ED). Given the life-threatening nature of Brugada syndrome, we hope to increase awareness in Emergency Medicine practitioners. We report the case of a 22-year-old man who was referred to the ED with a history of intermittent palpitations, near-syncope and electrocardiogram findings of RSR′ and ST elevation in V 1 –V 2 characteristic of Brugada syndrome. It is crucial that emergency physicians search for this diagnosis, as an implantable cardioverter-defibrillator is the only recognized life-saving intervention, and the risk of SCD is high if the diagnosis is missed.
TL;DR: The FAST examination, adequately completed, is a nearly perfect test for predicting a “Need for OR” in patients with blunt torso trauma.
Abstract: The Cochrane Database of Systematic Reviews published a manuscript critical of the use of the FAST examination. The reference is Stengel D. Bauwens K. Sehouli J. Rademacher G. Mutze S. Ekkernkamp A. Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews. (2):CD004446, 2005. UI: 15846717. The stated objective was the assessment of the “efficiency and effectiveness” of ultrasound-inclusive evaluative algorithms in patients with suspected blunt abdominal trauma (BAT). The primary outcome measures explored were Mortality, CT and DPL use, and laparotomy rates. Little or no benefit was seen and the conclusion was that “there is insufficient evidence from randomized controlled trials to justify promotion” of FAST in patients with BAT. While the review used the same rigorous methods employed in all Cochrane Reviews, it appears that several serious flaws plagued the manuscript. The finest methodological rigor cannot yield usable results, if it is not applied to a clinically relevant question. In a world of increasingly conservative management of BAT, do we need FAST, a rapid, repeatable screening modality at the point-of-care to visualize any amount of free fluid or any degree of organ injury? The obvious answer is no. However, quantifying the value of FAST to predict the need for immediate operative intervention (OR) is essential. To rebut this recurrent review, a systematic literature review was conducted using verbatim methodologies as described in the Cochrane Review with the exception of telephone contacts. Data were tabulated and presented descriptively. Out of 487 citations, 163 articles were fully screened, 11 contained prospectively derived data with FAST results, patient disposition and final diagnoses, and a description of cases considered false negatives or false positives. Of the 2,755 patients, 448 (16%) went to the OR. There were a total of 5 patients with legitimately false-negative diagnoses made based on the FAST: 3 involving inadequate scans and 2 of blunt trauma-induced small bowel perforations without hemoperitoneum. The FAST examination, adequately completed, is a nearly perfect test for predicting a “Need for OR” in patients with blunt torso trauma.
TL;DR: Sodium bicarbonate plus epinephrine shortens the onset and prolongs the duration of a chloroprocaine-bupivacaine sciatic block in Sprague-Dawley rats.
TL;DR: It is shown that clinically relevant concentrations of propofol induce c-Fos and Egr-1 expression through an extracellular signal-regulated kinase mediated and &ggr;-aminobutyric acid-A independent pathway.
Abstract: This study explored the effects of propofol on c-Fos and Egr-1 in neuroblastoma (N2A) cells. We demonstrate that propofol induced the expression of c-Fos and Egr-1 within 30 and 60 min of exposure time. At 16.8 microM concentration, propofol induced a 6 and 2.5-fold expression of c-Fos and Egr-1, respectively. However, at concentrations above 100 microM, propofol failed to induce expression of c-Fos or Egr-1. Propofol-induced c-Fos and Egr-1 transcription was unaffected by bicuculline, a gamma-aminobutyric acid-A receptor antagonist, but was abolished by PD98059, a mitogen-activated protein kinase/extracellular signal-regulated kinase inhibitor. Our study shows that clinically relevant concentrations of propofol induce c-Fos and Egr-1 expression through an extracellular signal-regulated kinase mediated and gamma-aminobutyric acid-A independent pathway.
TL;DR: For patients with ST-segment elevation (acute) myocardial infarction (STEMI), reperfusion with primary percutaneous coronary intervention (PCI) results in excellent short and long-term outcome.
TL;DR: Angiographic and electrocardiographic estimates of reperfusion with primary PCI in ST-segment elevation myocardial infarction provide different and complementary predictions of morbidity and mortality.
TL;DR: Although there appears to be an overall congruence on the doses and techniques of radiation delivery, the management of RISK is varied and additional efforts are warranted to standardize practices in order to practice evidence based medicine in a cost-effective manner.
Abstract: Abstract Purpose: A questionnaire was developed to explore variations among radiation oncologists in managing early-stage breast cancer, specifically radiation-induced skin reaction (RISK). Materials and methods: A survey was designed to target a database of 962 radiation oncologists, self-identified as ‘interested in treatment of breast cancer’. This database was obtained from the American Society of Therapeutic Radiology & Oncology (ASTRO). Participants submitted the survey online or by mail. Overall response to the survey was 282 out of 962 (29.3%). Data were handled as rates. Results: Out of 282 respondents, 275 (97.5%) agreed on delivering 4500–5040 cGy. The most frequently employed dose was 5040/180 cGy. Three-dimensional-conformal (3DCRT) treatment was used by 55.4%, intensity-modulated radiotherapy (IMRT) by 24.5%, and conventional by 20.1%. Almost all (92.5%) agreed on using boost in ductal carcinoma in situ (DCIS). Image-guided boost placement (IGBP) was used by 87.3%. Boost dose included variations: 50.2, 7.3, and 18% used 1000, 1200, and 1400 cGy, respectively; the remaining used higher doses. In management of RISK, Aquaphor was the most popular agent (72.1%). Other agents were utilized either alone or in combination. Almost all (99%) agreed that large breast size increases RISK. Conclusion: This survey offers a glimpse of management practices in early-stage breast cancer amongst a cross-section of radiation oncologists in the United States. Although there appears to be an overall congruence on the doses and techniques of radiation delivery, the management of RISK is varied. Additional efforts are warranted to standardize practices in order to practice evidence based medicine in a cost-effective manner.
TL;DR: Too little research has been completed at this time to recommend the clinical use of the abbrMDRD equation in pharmacy practice, and the CG-CG equation has many advantages as compared with the CG equation.
Abstract: PurposeTo examine the factors affecting drug clearance and the available evidence for drug dosing based on the Cockcroft-Gault (CG) equation and the abbreviated Modification of Diet in Renal Diseas...
TL;DR: A retrospective review of all EUS−FNA procedures performed using 22− and 25−gauge needles alternately in the same patient found no statistically significant difference be− tween needle size despite a relatively easy pass with the 25− gauge needle and higher specimen adequacy and definitive diagnosis with the 22−g Gauge needle.
Abstract: guided fine−needle aspiration (FNA), the standard size of needle used is a 22−gauge needle. Larger needles have been used to obtain actual core tissue samples [1±3], but their has failed to significantly im− prove diagnostic accuracy for malignancy [2±4], except perhaps in the case of un− usual histology [5]. On the contrary, a new, smaller−caliber (25−gauge) needle has been introduced to the market by Wilson−Cook Medical Inc. (Winston− Salem, North Carolina, USA). The purpose of this study was to compare the 22− and 25−gauge needles for adequacy of tissue acquisition and diagnostic yield. The study was a retrospective review of all EUS−FNA procedures performed using 22− and 25−gauge needles alternately in the same patient. Of a total of 132 pa− tients undergoing EUS, only 16 met the inclusion criteria. The mean age was 65.1 years. The cytotechnician was present during 75% of the procedures. The needle pass was considered by the endoscopist to be difficult in 37.5% vs. 25.0% of cases using the 22− and 25−gauge needles, respectively (P = 0.7). The specimen ade− quacy rates were: cytologic 68.6 vs. 56.3 (P = 0.7), and histologic 87.5% vs. 75.0% (P = 0.6) with 22− and 25−gauge needles, respectively. Two patients were lost to follow−up. Out of the remaining 14 pa− tients, a definitive diagnosis was obtained in 85.7% (22−gauge needle) and 50.0% (25−gauge needle) (P = 0.1). When 22− and 25−gauge needles were combined, the cytologic and histologic yields, as well as the definitive diagnosis, were higher (81.3%, 93.8%, and 92.9%, respec− tively). Hence, in conclusion we found no statistically significant difference be− tween needle size despite a relatively eas− ier pass with the 25−gauge needle and higher specimen adequacy and definitive diagnosis with the 22−gauge needle. Al− though we found the two needles to com− plement each other when used alternate− ly in the same patient, the differences did not reach statistical significance due to the small number of cases. We recom− mend large prospective trials.
TL;DR: The association of heterozygosity for 999G>T with mild TC I deficiency in 7 affected members of 4 Caucasian families and its absence in all 4 unaffected members of these families suggest that this common mutation is responsible forTC I deficiency.
Duke University1, Long Island Jewish Medical Center2, Cleveland Clinic3, University of California, Los Angeles4, University of Nebraska Omaha5, Albert Einstein College of Medicine6, University of Maryland Medical Center7, University of Chicago8, NewYork–Presbyterian Hospital9, Emory University Hospital10, Society of Thoracic Surgeons11, University of Pennsylvania12, American College of Chest Physicians13, New York Methodist Hospital14
TL;DR: In a patient with acute respiratory illness (cough, sputum production, chest pain, and/or dyspnea), the need for chest imaging depends on the severity of illness, age of the patient, clinical history, physical and laboratory findings, and other risk factors.
Abstract: In a patient with acute respiratory illness (cough, sputum production, chest pain, and/or dyspnea), the need for chest imaging depends on the severity of illness, age of the patient, clinical history, physical and laboratory findings, and other risk factors. Chest radiographs seem warranted when one or more of the following are present: age ≥ 40; dementia; a positive physical examination; hemoptysis; associated abnormalities (leukocytosis, hypoxemia); or other risk factors, including coronary artery disease, congestive heart failure, or drug-induced acute respiratory failure. Chest CT may be warranted in complicated cases of severe pneumonia and in febrile neutropenic patients with normal or nonspecific chest radiographic findings. Literature on the indications and usefulness of radiologic studies for acute respiratory illness in different clinical settings is reviewed.
TL;DR: The case of a patient found to have a cervical ectopic pregnancy is presented and a discussion of the diagnosis and management, as well as the findings on bedside sonogram are presented.
Abstract: The evaluation of first trimester vaginal bleeding or pelvic pain is an important task for the emergency physician. The early identification of an ectopic pregnancy can help prevent significant morbidity and mortality for patients seeking emergency care. The increased use of bedside sonography by the emergency physician in the evaluation of these patients requires an increased knowledge about the variants and their appearance on sonogram. We present the case of a patient found to have a cervical ectopic pregnancy. A discussion of the diagnosis and management, as well as the findings on bedside sonogram are presented.
TL;DR: A rare case of tuberculous osteomyelitis of the clavicle in an immunocompetent patient who presented with swelling of the upper chest is reported.
Abstract: Tuberculosis of the clavicular bone is a very rare clinical entity, with limited cases reported in the United States. Furthermore, sparing of the sternoclavicular joint is exceedingly unusual. A literature review of the prevalence of clavicular tuberculosis identified fewer than 80 cases reported since the discovery of the tubercular bacillus, over a century ago. To our knowledge, there have been no cases reported over the last decade in the United States. A rare case of tuberculous osteomyelitis of the clavicle in an immunocompetent patient who presented with swelling of the upper chest is reported.