Systems

A New Take on Quitting Smoking…

January 26, 2007
A New Take on Quitting Smoking…

Landing on the front page of the New York Times today is a study from Science that may turn addiction medicine on its head…no pun intended.   Of 32 smokers who had suffered a brain injury, they found that 16 who had suffered damage to the insula were easily able to quit smoking almost fully disrupting their smoking behavior in comparison to the other 16 who had suffered damage elsewhere.  The insula is a region of the brain that has been previously implicated in…

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When Should You Order a T Wave Alternans Test?

January 25, 2007
When Should You Order a T Wave Alternans Test?

A 58 year old male is admitted for "presyncope".  He has not had chest  pain and his baseline ECG is unchanged.  The patient has an ischemic cardiomyopathy with an ejection fraction of 39% with mild reversible changes on a stress echo that was done 5 months prior to admission.  On telemetry, the patient has frequent  polymorphic premature ventricular contractions. The cardiology consult recommends a T wave alternans test.  What is the reason for this test?

Commentary By: Neil

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A drug for NASH that may work?

January 24, 2007
A drug for NASH that may work?

Commentary By: Sandra D'Angelo, PGY-3

Nonalcoholic steatohepatitis (NASH) is a disease in which patients have features of alcoholic hepatitis on liver biopsy without a prior history of significant alcohol consumption and negative hepatitis serologies. It is unclear how prevalent this disease is because most patients with liver function abnormalities do not undergo liver biopsy.  In those that have had a liver biopsy, the prevalence is estimated to be 7-9%.  It is most common in women between the ages of 40-60 and…

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Mystery Quiz #2

January 22, 2007
Mystery Quiz #2

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine

The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration.  As part of a preoperative evaluation for hip surgery, a routine chest x-ray was obtained as below.  Click on the thumbnails below for full size images:

   

A prior film done six months previously showed similar but less impressive findings. Upon review, the patient denied any pulmonary symptoms…

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How Aggressively Should You Treat a Patient with a Pulmonary Embolus?

January 17, 2007
How Aggressively Should You Treat a Patient with a Pulmonary Embolus?

An otherwise healthy 57 year old patient presents with shortness of breath and pleuritic chest pain.  The patient is hemodynamically stable without evidence of shock.  A chest CT reveals a pulmonary embolus.

Questions: 1. When should an echocardiogram to assess for right heart strain be performed in a patient with a pulmonary embolism?  Should stable patients without evidence of shock have a routine echo once a diagnosis of pulmonary embolism is made?

2. If the echo shows signs of right…

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Morning Report: How Do You Approach a Patient With Bronchiectasis

January 16, 2007
Morning Report: How Do You Approach a Patient With Bronchiectasis

Chief complaint: 85 year old female presents with worsening shortness of breath for one day.

History of present illness:

The patient’s history of present illness begins at the age of 60 when she was diagnosed with asthma, for which she had been treated with inhaled anticholinergics, beta agonists and intermittent oral steroids.  Twelve years prior to admission, the patient was diagnosed with diabetes, which was managed with oral medications.  Two years prior to admission, the patient was diagnosed with Mycobacterium avium complex (MAC) at an…

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To Lavage or Not to Lavage?

January 10, 2007
To Lavage or Not to Lavage?

Case and Commentary by Minisha Sood PGY-3 and Ilseung Cho Fellow, Division of Gastroenterology

The patient is a 57 year-old man with a past history of hypetension, hyperlipidemia, hepatitis B/C cirrhosis and coronary artery disease status/post a non-st-elevation mi in August 2006, during which time he was on a heparin drip and developed an upper gastrointestinal bleed. Upper endoscopy at that time revealed non-bleeding esophageal varices and he was discharged on a beta blocker. He again presented to Tisch hospital in December 2006 with complaints…

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Why Are Breast Cancer Rates Trending Down?

January 9, 2007
Why Are Breast Cancer Rates Trending Down?

The recent finding of decreasing breast cancer rates made headlines throughout the media; including a NY Times article entitled, Reversing Trend, Big Drop is seen in Breast Cancer on December 15, 2006.

Striking epidemiological facts tells us that breast cancer is the most common cancer in women in the U.S., and only second to lung cancer as the most common cause of cancer deaths. It is estimated that approximately 212,920 American women will be diagnosed with breast cancer in the year…

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A Bad Break for the Purple Pill…

January 8, 2007
A Bad Break for the Purple Pill…

Commentary By Josh Remick, PGY-2

In the December 27th 2006 issue of JAMA, Yang et al. reported the results of a nested case-control study of United Kingdom patients entitled “Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture.” Using the General Practice Research Database (GPRD), a computerized medical record system used by several of the general medical practices in the UK, new hip fracture cases were found in patients at least 50 years old (n=13,556) and matched them with…

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Links: Dermis.net-An Online Dermatology Atlas

January 5, 2007
Links: Dermis.net-An Online Dermatology Atlas

The best online dermatology atlas I have come across is dermIS.net.  The site originates from Germany and includes an excellent, easily searchable database with terrific pictures and clinical information. The most useful feature of the site however is the differential diagnosis list which appears next to the pictures that are displayed.  So if you have an educated guess what the rash you're looking at is, then you can easily review similar rashes and quickly compare and contrast them to your original diagnosis. Then you can make the fancy diagnosis, sound smart…

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Do Statins Get Along With Hepatitis C?

January 4, 2007
Do Statins Get Along With Hepatitis C?

A 53 year old male with chronic hepatitis C and type 2 diabetes is found to have a moderately elevated cholesterol.

1. Is it safe to start a statin?

2. Do statins have any effect on viral replication?

Comentary By Ed Bini, M.D. Associate Professor/Director Gastroenterology and Hepatology Research

The many benefits of statins far outweigh the risks associated with this class of medications. However, statins are known to have the potential to cause hepatotoxicity. The most common form of statin-induced hepatotoxicity is elevations in…

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Does the Existence of Community Acquired MRSA Change Empiric Therapy for Skin and Soft Tissue Infections?

January 3, 2007
Does the Existence of Community Acquired MRSA Change Empiric Therapy for Skin and Soft Tissue Infections?

A 58 year old man with type 2 diabetes and chronic venous insufficiency/recurrent lower extremity cellulitis presents with fever and a left lower extrmity ulcer with purulent drainage. He’s been successfully treated in the past with both Unasyn/Augmentin or Levaquin.  In the face of community acquired methicillin resistant staph aureus (CA-MRSA),  have guidelines for skin and soft tissue infections changed?

Commentary By Howard Leaf, M.D. Assistant Professor, Division of Infectious Diseases and Immunology

 

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