Clinical Questions

Analgesia for Cirrhotics: A Practical Approach

November 20, 2008
Analgesia for Cirrhotics:  A Practical Approach

Commentary by Albert B. Knapp MD, NYU Clinical Professor of Medicine (Gastroenterology)

THE CASE:
WS, a 49 yo year old Caucasian male with a known 35 year history of alcohol abuse, now presents with jaundice, tense ascites and a left shoulder fracture following a bar room brawl last night. He is admitted to the orthopedic service for elective pinning but is presently in great pain. You are consulted in regards to pain management….

THE QUESTION:
How should you approach the use…

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How Do You Approach a Patient with Arthritis and Hepatitis C?

August 7, 2008
How Do You Approach a Patient with Arthritis and Hepatitis C?

Commentary by Peter Izmirly MD, NYU Division of Rheumatology

A 54 year old male with a past medical history significant for hepatitis C genotype 1a s/p ifn/ribavarin 2003-2004 with HCV Qual negative in 2005 presents with 3 weeks of bilateral wrist pain. The pain is worst with extension. His exam is notable for diffuse tenderness when pressure is applied to his wrists. He has no obvious swelling, erythema, deformity or subcutaneous nodules. The remainder of his musculoskeletal exam in unremarkable. In addition, he has no stigmata of cirrhosis. Labs…

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Admission screening cultures for MRSA: Is it time?

July 9, 2008
Admission screening cultures for MRSA: Is it time?

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

Pressure continues to build for healthcare facilities to act to decrease hospital-acquired infections, particularly those associated with MRSA. This is partly data-driven, with one study reporting that 25% of patients acquiring MRSA colonization during a hospitalization subsequently become infected . The call to act is also partly a political response to concerns in the lay press about “superbugs” wreaking havoc both in hospitals and in the community. Seven states have…

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Aspirin Use in the Primary Prevention of Cardiovascular Disease

June 25, 2008
Aspirin Use in the Primary Prevention of Cardiovascular Disease

Commentary by Daniel Frenkel, MD PGY-2 and Aleksandar Adzic, MD PGY-2 (in consultation with Greg Mints, MD Attending Physician, General Internal Medicine)

Case #1: A 47 year old man with no significant medical history, nonsmoker, and no family history of CAD. Blood pressure 124/72 Cholesterol 202, LDL 129, HDL 35, Triglycerides 190.
Case #2: A 36 year old man history of hypertension controlled with hydrochlorothiazide, smoker, with no family history of CAD. Blood pressure 134/72 Cholesterol 168, LDL 91, HDL 46, Triglycerides 155.

Would you…

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Should H. pylori Eradication Be Confirmed?

June 12, 2008
Should H. pylori Eradication Be Confirmed?

Commentary by Fritz Francois, MD, MS, NYU Division of Gastroenterology

Humans are essentially the only reservoir for Helicobacter pylori, which is estimated to colonize the stomach of about half the world’s population (1). Although the bacteria generally do not invade the mucosa, attachment to the epithelium leads to an inflammatory reaction with neutrophils, lymphocytes, plasma cells, and macrophages. Over time, the persistent inflammation leads to changes in the gastric mucosa that may predispose to the development of dysplasia(2).

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How do you approach male patients with osteoporosis?

February 28, 2008
How do you approach male patients with osteoporosis?

Commentary by Carrie Mahowald MD

Case: GS, a 65 year old man with only a history of severe OA, is seen in pre-op clinic for medical clearance before his hip replacement. On his pre-op x-ray, an incidental finding of a lumbar vertebral compression fracture is noted. After his hip replacement, how would you work him up for osteoporosis?

Osteoporosis, defined as low bone mass and the deterioration of bone micro-architecture which leads to the compromise of bone strength and the increased risk of fracture,…

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SSRIs: Do They Increase Rates of Suicide?

January 25, 2008
SSRIs: Do They Increase Rates of Suicide?

Commentary by Arthur Sinkman MD, NYU Department of Psychiatry

Three years ago the FDA began requiring that all selective serotonin reuptake inhibitors (SSRIs) carry a black-box warning stating that their use in children and adolescents is associated with an increase in risk for suicidal thinking, feelings and behavior. Recently the FDA ordered that this warning be extended to include treatment for young adults aged 18 to 24.

The 2004 order had a dramatic impact on the treatment of depression in children. The use of SSRIs dropped…

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Why Does Hypertriglyceridemia Lead to Pancreatitis?

October 4, 2007
Why Does Hypertriglyceridemia Lead to Pancreatitis?

Commentary by Daniel Frenkel, PGY-2

Case: A 46 year old male with diabetes on oral hypoglycemic medications is admitted to the hospital with one day of constant epigastric pain, nausea, vomiting, and an inability to tolerate oral intake. You are concerned about pancreatitis but laboratory analysis reveals amylase levels that are within the normal reference range. You notice that his glucose level is 410mg/dL and that the specimen is described as lactescent. Should you still be concerned about acute pancreatitis?

Lactescent or lipemic blood samples…

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Part II- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

August 8, 2007
Part II- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

Commentary by Melissa Freeman MD, PGY2

Please also see Part I of this series

In 2002, the American Association of Clinical Endocrinologists (AACE), the American Thyroid Association (ATA), and The Endocrine Society (TES) sponsored an evidence- based Consensus Development Conference with a panel of thirteen experts to address unresolved issues about subclinical thyroid dysfunction. Though these sponsors agreed with many of the recommendations made by the consensus, they felt that they relied too heavily on evidence-based medicine that did not yet exist. Two years later,…

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Are beta blockers indicated in cirrhotics with small varices?

August 1, 2007
Are beta blockers indicated in cirrhotics with small varices?

Commentary by Bani Chander MD, PGY-2

Esophageal varices are a common complication of cirrhosis and approximately one-third of all cirrhotic patients with varices will develop a variceal bleed . Each episode of variceal hemorrhage is associated with a 15 to 20 percent risk of mortality in patients with severe liver dysfunction.  The risk of bleeding is related to the location, size, and appearance of the varix, presence of red wale markings, variceal pressure, prior history of variceal bleeding, as well as the severity…

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Part I- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

July 31, 2007
Part I- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

Commentary by Melissa Freeman MD, PGY2

Modern day science has revealed to us the intricate relationships that thyroid hormones have with multiple systems of the human body.  Many of today’s physicians find themselves checking patients’ thyroid function tests (TFTs) almost as reflexively as a baseline basic metabolic panel. Yet, what seems to the physician to be a harmless bit of thoroughness can often turn into hours of inquisitive head scratching if the TFTs reveal subclinical thyroid dysfunction, especially since automated assays for TFTs are more…

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Clinical Question: How do you manage plantar fasciitis?

July 19, 2007
Clinical Question: How do you manage plantar fasciitis?

Commentary by Cathy Cruise, M.D. Director Department of Veterans Affairs Care Coordinator, Chair Rehabilitation Council

Case: A 25 year old woman with no significant past medical history presents to walk-in clinic complaining of several days of right heel pain. She notes that the pain is quite sharp and worst when walking. It is so severe that she has skipped her morning run for three consecutive days. She has tried taking acetaminophen which has provided minimal symptom relief. Physical exam reveals mild swelling and…

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