Systems

Outbreak: Toxic Tacos

December 7, 2006
Outbreak: Toxic Tacos

Update 12/12/06  Download new NY DOH Alert

Several Taco Bell restaurants in our area have been shut down recently due to an outbreak of E. Coli O157:H7.  At least 22 people are infected, and most are under age 18.  Interestingly, at least 2 Taco Bell employees have been found to carry the bacteria but are asymptomatic.

The vector is usually undercooked infected meat.  Symptoms usually present within 3-4 days of ingestion. The department of health has issued a warning to physicians to consider this diagnosis if…

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How do you approach a patient with asymptomatic primary hyperparathyroidism?

December 6, 2006
How do you approach a patient with asymptomatic primary hyperparathyroidism?

56 year old  Hispanic female with a history of hypertension, type 2 diabetes on oral medications, hyperlipidemia  and normal renal function. Over the past 2 years she has been noted to have mild hypercalcemia (11.0-11.5) on several basic metabolic panels. On her last visit, intact PTH was checked and was elevated at 66 (normal range 7-57). In patients such as this, with apparent asymptomatic primary hyperparathyroidism, what further diagnostic tests should be done and in whom is surgery indicated?…

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Pfizer Shutting Lights on ILLUMINATE Study

December 4, 2006
Pfizer Shutting Lights on ILLUMINATE Study

Low HDL is a well known independent risk factor for atherosclerotic disease.  As a result, there have been several attempts to develop medications to raise HDL.  Specific targets include the inhibition of cholesteryl ester transfer protein, which plays an essential role in HDL metabolism by facilitating the transfer of cholesterol esters from HDL cholesterol to apolipoprotein B-containing lipoproteins.

Pfizer created just that drug.  Known as Torcetrapib, it was seen as a promising therapeutic to increase HDL and potentially…

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Fast Facts-Rheumatology

November 30, 2006
Fast Facts-Rheumatology

Bellevue Morning Report Teaching Points 11/27

CC: Left knee swelling and pain x 1 week

54 yo male without past medical history in his usual state of health until 5 weeks prior when he had painful ejaculation and intermittent dysuria, denies penile discharge. Treated for a urinary tract infection with unknown antibiotic. 3 weeks later develops recurrent symptoms and again treated with another course of unknown abx by outside physician. However he develops left knee pain and swelling and is unable to…

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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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