Systems

Should You Recommend Surgery or Conservative Care for Disc Herniation?

November 29, 2006
Should You Recommend Surgery or Conservative Care for Disc Herniation?

In the November 22nd issue of JAMA, the results of two studies from the Spine Patient Outcomes Research Trial (SPORT) on lumbar disk surgery for persistent radicular pain are reported.  Both these studies sought to assess the efficacy of surgery for lumbar disk herniation as compared to nonoperative treatment, including counseling, anti-inflammatory medications, injections, and physical therapy. It is important to note that specific inclusion criteria were radicular pain as well as imaging showing disk herniation.  Because a large number of study participants declined randomization,…

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Diagnostic Dilemma #2 How Should You Approach a Low Titer +RPR?

November 28, 2006
Diagnostic Dilemma #2 How Should You Approach a Low Titer +RPR?

45 year old male with history of Hep B ( Hep B Surf Ag + but Hep E Ab+ and E Ag – and DNA viral load was not sent) and syphilis treated in the past.  He has RPRs in the past that were 1:1 for years and then negative x 2 a year apart, the last being over two years ago.  He had labs drawn last week and had an RPR of 1:4.  He does report high-risk unsafe sexual activity (with female prostitutes)…

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Fast Facts-Critical Care

November 22, 2006
Fast Facts-Critical Care

VA MICU Conference 11/22/06

56 y.o. male with PMH ETOH abuse and COPD presented with a LUL PNA and BCx positive for penicillin-resistant pneumococcus.

 

Early Goal-Directed Therapy in Severe Sepsis and Septic Shock

Early broad spectrum antibiotics. Goal directed hemodynamic resuscitation with IV fluids pressors PRBCs (for Hct <30) inotropes To maintain: Central Venous Pressure 8-12 mm Hg Arterial Pressure: MAP >65 mm Hg but <90 mm Hg Central Venous Oxygen Saturation >70% Consider cosyntropin stimulation to evaluate for relative adrenal insufficiency. Consider Recombinant Activated Protein C

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Fast Facts-Cardiology

November 20, 2006
Fast Facts-Cardiology

Welcome to Fast Facts-a new feature of Clinical Correlations.  Look for frequent posts summarizing key teaching points from Morning Reports and Noon Conferences from Bellevue, Tisch and the VA.

Bellevue 11/16/08-William Slater M.D.

34 yo female, 4 weeks post-partum, presents with progressive DOE, othopnea, and bilateral pleural effusions on CXR.  Working DDx: Postpartum Cardiomyopathy, PE, Primary Pulmonary HTN TTE with normal EF, right ventricle dilatation, and PAP >50 mmhg..

ECG changes due to PE: The classical S1Q3T3 reflects delayed rightward forces (S1) as

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Epogen and Anemia-Less is More

November 17, 2006
Epogen and Anemia-Less is More

Singh AK et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006 Nov 16; 355:2085-98.

Drüeke TB et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006 Nov 16; 355:2071-84.

It’s always been unclear what target hgb we should be shooting for in our patients on epogen/aranesp.  These 2 articles in the NEJM definitely come close to answering this question.  In the CREATE study 603 patients with…

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NYU’s Dr. Hochman Releases OAT Results

November 16, 2006
NYU’s Dr. Hochman Releases OAT Results

                          Hochman JS et al. for the Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006 Nov 14; 355.

Reperfusion via thrombolytics or PCI in patients with acute STEMI has been shown to reduce mortality and maximize myocardial salvage.  It has been less clear whether patients with late presentations of MI are afforded the same benefits.  Though there was no official consensus, late revascularization of the infarct vessel was frequently employed.  At the AHA meeting yesterday,…

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Should We Screen All Smokers for Lung Cancer?

November 15, 2006

Commentary by Deborah Shapiro, M.D.  Attending Physician, Dept. Veterans Affairs

The International Early Lung Cancer Action Program Investigators. Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med 2006;355:1763-1771

Over the last few weeks there has been major press in the lay media about this lead article in the NEJM from 10/26/06.  This study was designed to diagnose lung cancer at an earlier stage and therefore to decrease mortality rates. The authors…

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Tamiflu Patients Need Monitoring

November 14, 2006
Tamiflu Patients Need Monitoring

Over 100 cases have been reported to the FDA involving the use of Tamiflu and the development of hallucinations, delerium and other unusual behavior mainly in Japanese children.  From the Chicago Tribune article "Health officials have been sensitive about taking any action that might dissuade people from taking Tamiflu, since the drug could play an important role in an outbreak of bird flu."

Read more about it in the Chicago Tribune and FDA websites…here are the links:

FDA announcement

Chicago Tribune Story

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Improving Stroke Recovery-The EXCITE Trial

November 9, 2006
Improving Stroke Recovery-The EXCITE Trial

The EXCITE trial was the lead article in last week’s JAMA. It looks at a 2 week program of contstraint induced movement therapy vs. usual care in patients suffering a cva within the previous 3-9 months. Pt’s in the treatment arm wore a restraining mitt on the less-affected hand and engaged in tasks/behaviors with the hemiplegic hand. This group was compared to a control group with usual care. Measures of performance time and motor function ability all showed clinically relevant improvements that persisted out…

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Diagnostic Dilemma #1-Faculty Response

November 8, 2006

Commentary By Michael Poles, M.D. Gastroenterologist, Assistant Professor of Medicine, Mircrobiology and Pathology.

Welcome blog readers to this inauguration of the NYU medicine blog. If the future cases are as interesting as this one, I am sure we will be having a lot of fun, and hopefully some learning.

OK, lets dive right in. We have the case of a young-ish guy who developed abnormal LFTs after starting a statin. Fortunately, the case is more interesting than just that…

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Diagnostic Dilemma #1

November 7, 2006
Diagnostic Dilemma #1

The first in our series of clinical cases with difficult management questions… Question: 59 y.o. male with pmh notable for hyperlipidemia. Pt had normal lft's, which increased mildly when he was put on a statin. His basic hepatitis screen including A, B and C were all negative, but an iron/tibc was 61% with a nl ferritin. A hemochromatosis gene analysis was sent which revealed a single mutation c282y-and he was designated a carrier. U/s showed a midly heterogeneous hepatic echotexture with no discrete lesions.
Questions
1:…

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Statins and CHF

November 3, 2006
Statins and CHF

This week’s JAMA has an enormous study that looks at chf patients and the use of statins. Data from ~25,000 patients with chf were analyzed for use of statin in the 120 days prior to the initial chf diagnosis. Mortality risk was significantly lower for statin users than nonusers (hazard ratio 0.79), as was hospitalization (hr 0.80). Findings did not change by etiology of chf or whether the patient had cad. The press is taking this study to mean all patients with chf should be

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