Harry Steinberg

Pulmonary arteriovenous malformations: a clinical review

Pulmonary arteriovenous malformations (PAVMs) are a rare clinical entity. Most of them are associated with hereditary haemorrhagic telangiectasia. The usual clinical presentation is exertional dyspnoea and hypoxaemia. The initial test of choice for screening is the 100% oxygen method. A pulmonary angiogram is needed to define the anatomy and guide transcatheter embolisation (TCE). TCE has been shown to be effective and safe with a very low recanalisation rate and has largely replaced surgery for PAVMs. Computed tomography of the chest can be used for the follow up of asymptomatic PAVMs and TCE.

Interstitial Pneumonitis in a Patient Treated with α-Interferon and Ribavirin for Hepatitis C Infection

Hepatitis C is a common infection with worldwide prevalence. It has a variable course and can lead to chronic hepatitis, cirrhosis and hepatocellular carcinoma. Until recently alpha-interferon (IFN-alpha) was the only effective treatment available. Combination therapy with IFN-alpha and ribavirin has been found to be more efficacious than IFN-alpha alone. Various side effects have been ascribed to interferon, such as arthralgias, myalgias, fatigue, and gastrointestinal and neuropsychiatric symptoms. Interstitial pneumonitis is a rare but known complication of IFN-alpha when given at a high dosage of 6 to 10 million units per day. Ribavirin is associated with dose-dependent hemolytic anemia, cough, dyspnea, rash, depression, and dyspepsia, although a potential role in interferon-induced interstitial pneumonitis has not been described. We describe a patient with an excellent clinical response of chronic hepatitis C to combination therapy with IFN-alpha at a dosage of 3 million units per day and ribavirin. The patient developed interstitial pneumonitis that resolved after discontinuation of IFN-alpha and ribavirin. Given that interstitial pneumonitis has previously been reported with high-dose IFN-alpha, this case suggests that this complication may occur with lower dosages of IFN-alpha, although a potential role for ribavirin in this disorder at present remains speculative.

Possible Levofloxacin-Induced Acute Hepatocellular Injury in a Patient with Chronic Obstructive Lung Disease

Levofloxacin is one of the most commonly prescribed antibiotics for both inpatient and outpatient care of respiratory tract infection. It is generally well tolerated, and it has an excellent safety profile. We report a case of severe acute liver toxicity that apparently complicated intravenous administration of levofloxacin, which resolved after discontinuation of the drug.

Personal Digital Assistants: A Review of Their Application in Graduate Medical Education

Personal digital assistants (PDAs) have become widely used in medicine and may be especially useful in achieving the goals of graduate medical education. The complex challenges that residents and their program directors in graduate medical education programs confront may be met more readily with the use of these devices. The PDA’s ability to serve as an informational database, an organizer of patient-specific information, a tracking tool that can be used by program directors to enhance curriculum design, and a tool for conducting education research are some of the ways that these devices might favorably affect residency training in graduate medical education programs.

A comparison between the acute effects of nitric oxide synthase inhibition and fluid resuscitation on myocardial function and metabolism in entotoxemic dogs

PURPOSE Nitric oxide (NO) synthase inhibitors increase mean arterial pressure (MAP) and systemic vascular resistance (SVR) in animal models of sepsis and in humans with septic shock. However, NO synthase inhibitors may cause coronary vessel constriction leading to myocardial ischemia and increased mortality in endotoxemic animals. This study was designed to test the acute effect of NG-nitro-L-arginine (L-NAME) on left ventricular (LV) function and coronary blood flow in a dog model of endotoxemia. METHODS In open chest, anesthetized dogs endotoxemia was induced intravenously (IV) by Escherichia coli lipopolysaccharide at 2 mg/kg for 60 minutes. This resulted in hypotension, acidosis, and decreased SVR while cardiac index (CI) was maintained. When MAP was < or = 60 mm Hg, animals were resuscitated with either dextran (group I), or L-NAME 30 mg/kg IV bolus (group II). Group III received L-NAME only. A fourth group of dogs was given endotoxin and not resuscitated. Animals were followed up for 30 minutes after intervention. Animals in the fourth group were followed up until the MAP was approximately 30 mm Hg. Heart rate, CI, MAP, LV end systolic and diastolic pressures, dP/dt at a pressure of 40 mm Hg, left anterior descending artery coronary blood flow, regional LV contraction (sonomicrometer crystals), coronary pressures, gas tension, and lactates were continuously recorded. A catheter placed in the coronary sinus allowed measurement of coronary sinus pressure, as well as coronary sinus lactate and gas tensions. Stroke volume index, stroke work index, systemic vascular resistance index (SVRI), coronary vascular resistance, percent myocardial shortening, myocardial oxygen consumption (Mvo2) and net myocardial lactate production were calculated. RESULTS In Group I, fluid administration increased MAP, stroke work index, coronary blood flow, percent myocardial shortening, and Mvo2. In Group II, L-NAME increased MAP to the same extent as fluid administration without evidence of coronary ischemia or myocardial dysfunction. L-NAME did not alter Mvo2 in either endotoxemic or nonendotoxemic animals. In group III, L-NAME alone resulted in a significant increase in MAP and SVRI, but its effects on coronary blood flow and LV function were not significant. We did not observe net lactate production in any of the groups. Coronary blood flow increased out of proportion to Mvo2 in group I animals. CONCLUSIONS We conclude that although L-NAME at 30 mg/kg causes vasoconstriction, its effects on coronary blood flow and LV function were not significant.

Malignant pleural effusions in lymphoproliferative disorders

In order to determine variables that correlate with malignant pleural effusion and mortality in patients with lymphoproliferative disorders and pleural effusion, a retrospective study was performed. Clinical data of hospitalized patients with a lymphoid malignancy and pleural effusion who underwent thoracentesis from January 1993 to December 2002 were collected. A logistic regression analysis was carried out to determine prognostic variables that predict malignant pleural effusion and hospital mortality. There were 86 patients who were admitted on 91 occasions. The median age was 70 years (range 4 - 92) and the male:female ratio was 44:42. Sixty-four patients (74%) had advanced disease, 43 (50%) had received prior chemotherapy and 9 (10%) were in remission. Of 91 cases of pleural effusions, 44 (48%) were bilateral, 80 (88%) were exudates and 48 (53%) were due to malignant involvement of pleura. In multivariate analysis, symptomatic pleural effusion (odds ratio 10.3, 95% confidence interval 1.7 - 98.3), pleural fluid mesothelial cell count < 5% (odds ratio 8.0, 95% confidence interval 1.4 - 58.2), pleural fluid:serum lactate dehydrogenase (LDH) > or =1 (odds ratio 6.4, 95% confidence interval 1.2 - 45.6) and pleural fluid lymphocyte percentage > or =50 (odds ratio 6.4, 95% confidence interval 1.2 - 50) were significantly correlated with malignant effusion. A secondary cancer (odds ratio 11.9, 95% confidence interval 2.3 - 88.8), pleural fluid:serum LDH > or =1 (odds ratio 10.9, 95% confidence interval 2.6 - 64.9), and pneumonia (odds ratio 6.4, 95% confidence interval 1.7 - 28.6) were significantly correlated with hospital mortality. In conclusion, malignant pleural effusion is the common etiology of pleural effusion in patients with lymphoid malignancy. Many clinical and cytochemical markers have discriminatory values in identifying malignant effusion. A high pleural fluid to serum LDH level correlates with malignant pleural involvement and hospital mortality.

Ventilator Strategy for Status Asthmaticus in Pregnancy: A Case-Based Review

Asthma is a common and potentially serious condition complicating pregnancy. However, the literature available on the management of severe asthma in pregnancy is limited. We describe two episodes of respiratory failure due to asthma in pregnant women and discuss their management in the context of a review of the literature. In both patients, adequate oxygenation was maintained by using controlled hypoventilation with a permissive hypercapnia strategy. Both patients received aggressive steroid therapy, aerosolized bronchodilators, sedation, and paralysis. Aggressive asthma treatment as in a nongravid female is recommended.

Quantifying internal medicine resident clinical experience using resident-selected primary diagnosis codes†

BACKGROUND While experiential learning is a desirable goal of residency education, little is known regarding the actual clinical experience of internal medicine residents during their training. METHODS We modified an electronic patient handoff tool to include a system for resident entry of a primary diagnosis for each of their patients. Using the International Classification of Diseases, Ninth Revision (ICD-9) system, we created two methods to select the code: 1) an organ system-based dropdown list containing frequently used codes; and 2) a search option for the complete ICD-9 database. The codes were then grouped using ICD-9 categorization. RESULTS A total of 7562 resident-patient diagnostic encounters were studied. A wide spectrum of clinical conditions was observed, with symptoms and ill-defined conditions, circulatory disorders, respiratory disorders, neoplasms, genitourinary disorders, digestive disorders, diseases of the blood/blood forming organs, endocrinologic/nutritional/metabolic/immune disorders, and disorders of the skin and subcutaneous tissue accounting for about 86% of resident clinical experience. Symptoms and ill-defined conditions were noted to represent a sizable portion of resident clinical experience. Within this category, the most common conditions were fever; abdominal pain; and chest pain, unspecified. CONCLUSIONS Analysis of resident-selected ICD-9 codes might serve as a method to attempt to define resident clinical experience, and may be useful in the development of innovative experiential learning-based residency curricula. This might also be used to assess gaps in experiential learning at the program or resident level, and may serve to identify topics that require additional teaching supplementation.