Systems

Morning Report-How Do You Approach a Patient with a Significant Transaminitis?

March 23, 2007

Consultant: Robert Raicht, MD Professor of Medicine, Chief Division of Gastroenterology

Clinical Vignette:
The patient is a 50 year old male with a past medical history notable for type II diabetes, hypertension and recently treated right foot cellulitis and c.difficile colitis who presented to the emergency room with the complaint of fevers and malaise for 1 week. His labs were notable for a significant transaminitis (AST 1997, ALT 1620, alkaline phosphatase 365, total bilirubin 3.1), INR wnl. An abdominal ultrasound was ordered with…

Will my breast cancer patient need adjuvant chemotherapy? Gene Micro array technology may help answer this question��

March 20, 2007

Commentary By Sandra D’Angelo, PGY-3

Breast cancer is the most common cancer diagnosed in women, second only to lung cancer as a leading cause of death from cancer. Experts state that approximately 210, 000 women will be diagnosed in 2006 and about 40,000 will die from the disease.1 According to data compiled by the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, 61% of breast cancer cases are diagnosed while the cancer is still confined to the primary site…

More Breaking News for the Glitazones…

March 15, 2007

Coming right on the heels of the recent warning from the FDA about the risk of fractures and Rosiglitazone, the FDA announced on March 9th that pioglitazone (Actos) has also been linked to an increased occurrence of arm, hand, and foot fractures among women taking the drug for treatment of type 2 diabetes. In an analysis of over 15,000 patients followed for up to 3.5 years, the risk of fracture was 1.9 fractures per 100 patient years in the pioglitazone group, compared to 1.0…

When Should You Order a Serum Fructosamine Level for a Diabetic Patient?

March 14, 2007

Commentary By: Christopher Johnson, MSIV and Glenn Matfin, MD Clinical Associate Professor of Medicine, Divsion of Endocrinology

When was the last time you had a diabetic patient in clinic whose hemoglobin A1C was elevated, prompting you to modify their diabetic regimen? You may have scheduled a repeat hemoglobin A1C in 3 months, since you know A1C measures glycemic control over a 3 month period. A serum fructosamine may help give you a snapshot of more recent control.

What is fructosamine?
Fructosamine is…

Does the Overuse of Macrolides Lead to Antibiotic Resistance?

March 12, 2007

Commentary By: Danise Schiliro, PGY-3

Although intuitively we always worry about creating drug resistance when using antibiotics, there is a surprising lack of well done studies that show a clear causal effect of antibiotic use on the development of subsequent drug resistance. A recent study in Lancet may however lead us to re-evaluate our use of macrolides in everyday practice.

Azithromycin and clarithromycin are two of the most commonly used macrolides for treating respiratory infections. Azithromycin has a long half-life, making it…

How Do You Approach A Patient with a Non-Ischemic Cardiomyopathy

March 7, 2007

A 26 year old woman developed uncontrolled hypertension peripartum 5 years prior to this presentation After diagnosis she was intermittently compliant with her medication although remained asymptomatic. She now presents with new onset congestive heart failure. On admission, she was in mild respiratory distress. Her physical exam was notable for tachycardia with a blood pressure ranging from 160/100-200/110. She had a jugular-venous pressure of 8cm, +S4, crackles were present bilaterally 1/2 way up, but no peripheral edema. Labs were notable only for renal insufficiency…

More Breaking News: Rosiglitazone Linked to Fractures

March 6, 2007

Commentary By: Cara Litvin PGY-3

The FDA recently informed physicians of a report issued by GlaxoSmithKline acknowledging that Avandia (rosiglitazone) has been linked to increased fractures in females (1). The report stems from a review of the safety data from ADOPT (A Diabetes Outcome and Progression Trial) (2), which was a recently published randomized trial of 4,360 patients designed to compare glycemic control with rosiglitazone relative to metformin and glyburide monotherapies. In the published study, there were no unexpected adverse events reported, although…

Safety of Long-Acting Beta-Agonists in the Treatment of Asthma: Should they be used?

February 21, 2007

Commentary By: Sarah Huen, PGY-3 and David Chong, Director of Critical Care, Bellevue Hospital, Associate NYU Internal Medicine Residency Program Director

The role of long-acting b-agonists (LABAs) in the treatment of asthma continues to be controversial. Growing evidence that LABAs may cause an increased risk of asthma exacerbations and asthma-related deaths prompted the U.S. Food and Drug Administration (FDA) to approve “black box” safety warning labels for Serevent Diskus (salmeterol xinafoate), Advair Diskus (fluticasone propionate; salmeterol xinafoate), and Foradil (formoterol fumarate). Concern about…

Should patients with Anemia and a Normal Ferritin Undergo Colonoscopy?

February 16, 2007

Commentary By: Joshua Olstein PGY-3

Second only to lung cancer, colon cancer claimed an estimated 55,000 lives in the United States in 2006. In an effort to reduce colon cancer morbidity and mortality, multiple screening tests have been developed to detect early disease among asymptomatic individuals. The 2003 American Gastroenterology Associations guidelines for screening asymptomatic individuals recommended colonoscopy as a preferred method of screening.

Due to a higher risk of colonic neoplasm, patients with unexplained iron-deficiency anemia are not included in these…

PB&J Hold the P: Salmonella Outbreak Linked to Peanut Butter

February 15, 2007

Commentary By: Cara Litvin PGY-3

The CDC has issued a public health advisory regarding a large outbreak of Salmonella infections in 39 states since August. As of Tuesday February 14, 288 cases had been reported to the CDC. Among the 120 patients for whom clinical information is available, 31 patients have been hospitalized, and no deaths have been reported. The most cases have been reported in…

What Is XDR-TB?

February 12, 2007

Commentary By: Marshall Fordyce, PGY-3

Extensively drug-resistant tuberculosis (XDR-TB) is as ominous as it sounds. As a second-year resident on the Chest service, you may have treated one or two patients with multi-drug resistant tuberculosis (MDR-TB), which is resistant to at least INH (Isoniazide) and RIF (Rifampin), the two most powerful first-line agents. However, when TB becomes designated as XDR-TB, it implies resistance to any and all Fluoroquinolones and at least one of the three injectable second-line drugs (Amikacin, Capreomycin, and Kanamycin).…

More Smoke From the Tobacco Industry

February 8, 2007

Commentary By: Elizabeth Ross, PGY-3

Cigarette manufacturers have been steadily increasing the nicotine content in cigarettes over the last 7 years. The news broke in August of this year when the Massachusetts Department of Public Health discovered that the level of nicotine that smokers typically consume per cigarette had risen about 10 percent.

The Harvard School of Public Health recently re-analyzed the data with the goal of ascertaining how the tobacco industry managed the increase in nicotine content. The investigators found…

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Clinical Correlations