Paru Patrawalla

Elevated Peripheral Eosinophils Are Associated with New-Onset and Persistent Wheeze and Airflow Obstruction in World Trade Center-Exposed Individuals

Background. Exposure to World Trade Center (WTC) dust and fumes is associated with the onset of asthma-like respiratory symptoms in rescue and recovery workers and exposed community members. Eosinophilic inflammation with increased lung and peripheral eosinophils has been described in subpopulations with asthma. We hypothesized that persistent asthma-like symptoms in WTC-exposed individuals would be associated with systemic inflammation characterized by peripheral eosinophils. Methods. The WTC Environmental Health Center (WTC EHC) is a treatment program for local residents, local workers, and cleanup workers with presumed WTC-related symptoms. Patients undergo a standardized evaluation including questionnaires and complete blood count. Between September 2005 and March 2009, 2462 individuals enrolled in the program and were available for analysis. Individuals with preexisting respiratory symptoms or lung disease diagnoses prior to September 2001 and current or significant tobacco use were excluded, Results. One thousand five hundred and seventeen individuals met the inclusion criteria. Patients had a mean age of 47 years, were mostly female (51%), and had a diverse race/ethnicity. Respiratory symptoms that developed after WTC dust/fume exposure and remained persistent included dyspnea on exertion (68%), cough (57%), chest tightness (47%), and wheeze (33%). A larger percentage of patients with wheeze had elevated peripheral eosinophils compared with those without wheeze (21% vs. 13%, p < .0001). Individuals with elevated peripheral eosinophils were more likely to have airflow obstruction on spirometry (16% vs. 7%, p = .0003). Conclusion. Peripheral eosinophils were associated with wheeze and airflow obstruction in a diverse WTC-exposed population. These data suggest that eosinophils may participate in lung inflammation in this population with symptoms consistent with WTC-related asthma.

Application of the Asthma Phenotype Algorithm from the Severe Asthma Research Program to an Urban Population

Rationale Identification and characterization of asthma phenotypes are challenging due to disease complexity and heterogeneity. The Severe Asthma Research Program (SARP) used unsupervised cluster analysis to define 5 phenotypically distinct asthma clusters that they replicated using 3 variables in a simplified algorithm. We evaluated whether this simplified SARP algorithm could be used in a separate and diverse urban asthma population to recreate these 5 phenotypic clusters. Methods The SARP simplified algorithm was applied to adults with asthma recruited to the New York University/Bellevue Asthma Registry (NYUBAR) to classify patients into five groups. The clinical phenotypes were summarized and compared. Results Asthma subjects in NYUBAR (n = 471) were predominantly women (70%) and Hispanic (57%), which were demographically different from the SARP population. The clinical phenotypes of the five groups generated by the simplified SARP algorithm were distinct across groups and distributed similarly to those described for the SARP population. Groups 1 and 2 (6 and 63%, respectively) had predominantly childhood onset atopic asthma. Groups 4 and 5 (20%) were older, with the longest duration of asthma, increased symptoms and exacerbations. Group 4 subjects were the most atopic and had the highest peripheral eosinophils. Group 3 (10%) had the least atopy, but included older obese women with adult-onset asthma, and increased exacerbations. Conclusions Application of the simplified SARP algorithm to the NYUBAR yielded groups that were phenotypically distinct and useful to characterize disease heterogeneity. Differences across NYUBAR groups support phenotypic variation and support the use of the simplified SARP algorithm for classification of asthma phenotypes in future prospective studies to investigate treatment and outcome differences between these distinct groups. Trial Registration Clinicaltrials.gov NCT00212537

TARGET PRACTICE: SIMULATION-BASED MASTERY LEARNING FOR ULTRASOUND-GUIDED PERIPHERAL IV INSERTION

PURPOSE: Ultrasound use for peripheral IV (PIV) insertion has been shown to improve success rates and decrease overall time to placement [1,2]. Residents are often relied on to obtain venous access in patients with difficult access or an urgent need for intravenous medications; however, few studies have assessed competency-based training methods for internal medicine residents in ultrasound-guided (USG) PIV placement. We evaluated the effectiveness of simulation-based mastery learning of USG-PIV through a “train-the-trainer” approach.

Duplicated Renal Collecting System

CLINICAL PRESENTATION A 27-year-old man with a history of chronic abdominal distention of unclear etiology presented with 1 week of fever, dysuria and increased abdominal girth. Examination revealed a distended, tender abdomen with shifting dullness and absence of the left testicle. A loculated fluid collection noted on abdominal ultrasound was sampled, suggesting bacterial peritonitis. Cultures from urine and ascitic fluid grew Enterococcus faecalis. Computed tomography of the abdomen (Figure 1) revealed a duplicated left kidney and collecting system with an obstructed upper pole moiety that inserted ectopically into the prostatic urethra. After completing a course of antibiotics, the patient underwent left percutaneous nephrostomy tube insertion. His follow-up computed tomography scan 8 weeks later (Figure 2) revealed decompression of the dilated collecting system and ureter. Presenting symptoms of ureteral anomalies are determined by the location of the distal urethral implantation site. Congenital giant megaureter may be associated with other genitourinary abnormalities, including cryptorchidism, duplex renal systems and megacalicosis. Our patient had all 3 of these associated findings. Abdominal masses or distension due to massive or cystic dilatation of the ureter are rare and present a challenge to clinical and radiological diagnosis. In our case, the patient underwent partial nephrectomy and uretherectomy, confirming the diagnosis of a congenital duplicated left kidney and collecting system. He remains well postoperatively.