Systems

Epogen and Anemia-Less is More (Part 2)

December 14, 2006
Epogen and Anemia-Less is More (Part 2)

Commentary By David Goldfarb, M.D. Professor of Medicine, NYU Medical Center, Chief Nephrology Section VA New York Harbor

 

2 weeks ago we reported on 2 lead articles in the New England journal that suggested that our targets for hemoglobin values when treating with erythropoietin were too high.

Last week, the New York Times reported that based on those NEJM articles (CHOIR and CREATE), the National Kidney Foundation, which publishes…

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Mystery Quiz-Radiology

December 13, 2006
Mystery Quiz-Radiology

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

62 year old male smoker with past medical history notable for hypertension, copd, comes to clinic complaining of chronic cough x 6 months with minimal sputum, no wheezing.  Lung exam shows decreased breath sounds throughout.  Pt had the following CXR performed:

    

Click on Thumbnail to Enlarge

What's your diagnosis and the next step in his evaluation?  Please submit your answers by clicking on the "comments" link below this post. …

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FDA Warns of Methadone Dangers When Used for Chronic Pain

December 12, 2006
FDA Warns of Methadone Dangers When Used for Chronic Pain

Last week, the FDA issued a public health advisory regarding the use of methadone (trade name Dolophine) for chronic pain. Death and life threatening side effects have been reported in patients newly starting methadone treatment and patients who have switched to methadone after taking other narcotics for pain control.  According to the advisory, prescribing methadone is complex and should only be used when moderate to severe pain is not relieved by other non-narcotic pain relievers.

Although pain relief from a…

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What Is Sezary Syndrome?

December 11, 2006
What Is Sezary Syndrome?

Morning Report-Tisch Hospital

Case Presentation: 83 year old with a past medical history of hypertension noted erytematous plaques with scale about 1 year ago.  The rash was associated with diffuse pruritis at that time.  The patient subsequently underwent several inconclusive biopsies.  She was eventially diagnosed with mycosis fungoides and treated with UV therapy.  Her rash progressed to a diffuse pruritic erythema covering the vast majority of her body, including palms and soles.  (erythroderma).  She was noted to have Sezary cells on peripheral smear and diagnosed…

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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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