Faculty Bibliography

Tumor necrosis factor alpha (TNF-alpha) antagonists are being increasingly used as maintenance therapies for rheumatic diseases, and therefore knowledge of their adverse effects is important. We report a case of fatal acute necrotizing eosinophilic myocarditis temporally related to use of a second course of the TNF-alpha antagonist, adalimumab. A 51-year-old woman with relapsing polychondritis took adalimumab 2 weeks before presenting with acute myocarditis. Within hours of presentation to the emergency department, she had cardiac arrest due to fulminant heart failure. Autopsy demonstrated necrotizing eosinophilic myocarditis. This is a rare cause of fulminant heart failure. This is the first report of a TNF-alpha antagonist potentially associated with acute necrotizing eosinophilic myocarditis.

OBJECTIVE:To establish the role of high-fidelity simulation training to test the efficacy and safety of the electronic health record (EHR)-user interface within the intensive care unit (ICU) environment. DESIGN/METHODS:Prospective pilot study. SETTING/METHODS:Medical ICU in an academic medical centre. PARTICIPANTS/METHODS:Postgraduate medical trainees. INTERVENTIONS/METHODS:A 5-day-simulated ICU patient was developed in the EHR including labs, hourly vitals, medication administration, ventilator settings, nursing and notes. Fourteen medical issues requiring recognition and subsequent changes in management were included. Issues were chosen based on their frequency of occurrence within the ICU and their ability to test different aspects of the EHR-user interface. ICU residents, blinded to the presence of medical errors within the case, were provided a sign-out and given 10 min to review the case in the EHR. They then presented the case with their management suggestions to an attending physician. Participants were graded on the number of issues identified. All participants were provided with immediate feedback upon completion of the simulation. PRIMARY AND SECONDARY OUTCOMES/METHODS:To determine the frequency of error recognition in an EHR simulation. To determine factors associated with improved performance in the simulation. RESULTS:38 participants including 9 interns, 10 residents and 19 fellows were tested. The average error recognition rate was 41% (range 6-73%), which increased slightly with the level of training (35%, 41% and 50% for interns, residents, and fellows, respectively). Over-sedation was the least-recognised error (16%); poor glycemic control was most often recognised (68%). Only 32% of the participants recognised inappropriate antibiotic dosing. Performance correlated with the total number of screens used (p=0.03). CONCLUSIONS:Despite development of comprehensive EHRs, there remain significant gaps in identifying dangerous medical management issues. This gap remains despite high levels of medical training, suggesting that EHR-specific training may be beneficial. Simulation provides a novel tool in order to both identify these gaps as well as foster EHR-specific training.

INTRODUCTION Bacteremia as a direct result of bronchoscopy is a relatively uncommon event. We report a case of an empyema and streptococcus pneumoniae bacteremia following bronchoscopy. CASE PRESENTATION A 62 year female with a distant history of extrapulmonary sarcoidosis and new autoimmune serologies suggestive of Sjogren's presents with one month history of shortness of breath and cough. A CT chest revealed patchy bilateral opacities in the lung, as well as significant lymphadenopathy. The patient underwent a bronchoscopy with bronchoalveolar lavage and transbronchial biopsy of the right lower lobe. She also underwent a transbronchial needle aspiration of the subcarinal lymph node. The patient was discharged home on the same day without significant findings on her post-bronchoscopy chest x-ray. The bronchoscopy was diagnostic for non-caseating granulomas. Two days after the procedure, the patient developed fever, shortness of breath and chest pain. CT chest revealed a loculated right pleural effusion and a new right lower lobe infiltrate. A thoracentesis was performed which revealed a pH of less than 6.8. Cultures from the pleural fluid were consistent with streptococcus. Blood cultures were positive for streptococcus pneumoniae. The patient underwent a VATS, decortication and right lower lobe wedge resection. Pathology from the wedge resection was consistent with non-necrotizing granulomatous inflammation of the lung and empyema. The patient improved after surgery and antibiotics. Upper and lower respiratory tract cultures from sputum and bronchoscopy were all negative. DISCUSSION Yigla et al report a bacteremia rate as high as 6.5% following fiberoptic bronchoscopy. Bacteremia following bronchoscopy, however, remains the exception rather than the norm. Witte et al looked at 47 patients following transbronchial needle aspiration, and 22 patients following transbronchial biopsies. Blood cultures were drawn within 24 hours post procedure, and in no patients were blood cultures found to be positive. In 1977, Beyt et al reported a case of fatal pneumonitis and septicemia following fiberoptic bronchoscopy and endobronchial biopsy. Few cases such as this highlight the rare yet serious complication of septicemia following bronchoscopy. In our patient, it is possible that the empyema and bacteremia may have resulted from bacteriologic inoculation after contamination of the bronchoscope during insertion; however, bronchoscopically obtained cultures do not confirm this theory. Although bacteremia following bronchoscopy remains a rare event, clinicians should be aware of this potentially serious complication. CONCLUSION Although rare, bacteremia as a direct result of bronchoscopy can occur. Clinicians should be aware of this potentially serious complication

Introduction Measles is a highly contagious viral illness with significant mortality. Despite vaccination efforts, measles continues to occur in the United States. Most cases are associated with importation from endemic countries. Respiratory complications of the virus are one of the leading causes of fatalities. We report a case of measles pneumonia in an immunocompetent, unvaccinated adult with no associated importation from abroad. Case Presentation A 38 year old Caucasian female, with no recent travel history, presented with 3 days of fevers, cough, facial rash, and progressive shortness of breath. Her rash spread inferiorly to her trunk and extremities. On examination she was febrile, tachycardic, and hypoxic with a Pa02 of 55mmHg on room air. An erythematous, maculopapular rash was distributed over her face, trunk, and extremities. Her buccal mucosa had 2 mm white lesions, consistent with koplik spots. A chest x-ray showed a right upper lobe infiltrate and increased interstitial markings. She was placed in isolation and a floroquinolone was empirically initiated for a possible bacterial coinfection. Acute measles serologies returned positive, with an IgM level of 11.04 AU. Over the course of 48 hours, her fever defervesced, her oxygen saturation normalized, and her cough and rash resolved. She was discharged with instructions to have her 2 children receive the MMR vaccination immediately. Her children and she had not been vaccinated previously. Discussion Measles was declared eliminated from the United States in the year 2000, but the virus continues to be imported from endemic regions [1]. Our case represents one of 118 reports of measles in the United States between January 1 and May 20, 2011. Of these 118 cases, 105 (89%) were associated with importations from other countries and only 9 developed pneumonia [2]. Uniquely, our patient had no recent travel to, or contact with, individuals from an endemic region. This case, therefore, represents one of the few instances of measles pneumonia in the United States that was not import-associated. Instead, the risk factor in our presentation was the lack of prior vaccination. This absence of immunity resulted in the potentially life threatening complication of pneumonia. Our case underscores the importance of educating reluctant individuals regarding the safety and efficacy of the measles vaccine in preventing a devastating disease

INTRODUCTION: Acute exacerbation of IPF is increasingly being recognized as a common clinical event in the IPF population. The exact etiology remains unknown. Previous reports have shown an association between lung surgery, bronchoalveolar lavage, and surgical lung biopsies as a potential trigger for exacerbations of IPF. To our knowledge, there are no known cases in the literature reporting an exacerbation of IPF following a non-thoracic surgical procedure. We report a case of acute exacerbation of IPF following orthopedic surgery. CASE PRESENTATION: 78 year old male with a history of COPD (thirty pack year smoking history) and severe osteoarthritis was admitted to the NYU Hospital for Joint Diseases to undergo evaluation for total hip arthroplasty. Pre-operative evaluation was significant for a restrictive pattern with low DLCO on pulmonary function testing, as well increased interstitial markings on chest x-ray concerning for a fibrotic process. The patient reported no pulmonary symptoms, and underwent successful total hip arthroplasty without complication. On Post op day #6, the patient developed dyspnea on exertion and at rest, requiring increasing amounts of oxygen supplementation. A Chest CT was negative for pulmonary embolism, however did show bronchiectasis and evidence of fibrosis. An echocardiogram did not show evidence of heart failure. The patient was started on broad spectrum antibiotics with Vancomycin, Zosyn and Azithromycin. He also was started on high dose IV steroids (Solumedrol 60mg IV every 6 hours) for a potential COPD exacerbation. Sputum culture was positive only for Candida glabrata, and the patient completed a course of Anidulafungin. However, the patient's respiratory status continued to deteriorate, eventually requiring noninvasive positive pressure ventilation. High dose steroids were continued, as well as therapeutic anticoagulation. A repeat CT chest showed increased groundglass opacities, worsening bronchiectasis and fibrosis diffusely in a UIP pattern. A repeat echocardiogram showed new evidence for pulmonary hypertension, however otherwise normal. A trial of diuretics was initiated without a response. The patient eventually required intubation and tracheostomy, and later passed away. An autopsy revealed evidence for diffuse alveolar damage on a background of honeycombing and bronchiectasis. DISCUSSION: The etiology and pathogenesis of IPF exacerbations remains unknown. One hypothesis involves the loss of alveolar cell integrity following injury, leading to extrusion of fibrin into the alveolar spaces and remodeling. Fibrocytes can be recruited in response to chemokines generated by infection and injury and may potentiate fibrogenesis, leading to diffuse alveolar damage. This process may be triggered by pulmonary procedures, as previously reported. However, a similar inflammatory response may occur after a non-thoracic procedure, leading to the fibrogenic process. The above patient suffered an unexplained worsening fibrotic process, as evidenced by imaging, respiratory failure, and autopsy findings. Alternative causes, such as left heart failure and pulmonary embolism, were excluded. Potential infections were treated with antibiotics. Commonly proposed diagnostic criteria for IPF exacerbation were met. This is the first case to our knowledge of a non-pulmonary procedure triggering the disease process. Cases such as this are likely more common than realized and remain underreported. Clinicians should be aware of the potential for exacerbation of IPF following non-thoracic surgical procedures. CONCLUSIONS: Acute exacerbation of IPF is increasingly being recognized as a common clinical event and may occur after non-thoracic procedures, such as orthopedic surgery

STUDY DESIGN: Retrospective case-control review. OBJECTIVE: This retrospective study explored the hypothesis that the perioperative administration of blood products is an identifiable risk factor of increased surgical site infections (SSIs) after thoracic and lumbar spine surgical procedures. SUMMARY OF BACKGROUND DATA: Surgical site infections are a significant cause of postoperative morbidity and mortality. According to the Center for Disease Control's National Nosocomial Infections Surveillance system, which monitors the rate of hospital-acquired infections in the United States, SSIs represent the third most commonly reported type of nosocomial infection, accounting for 14% to 16% of all nosocomial infections. The incidence of SSIs after spinal surgery is influenced by both preoperative and intraoperative risk factors. The relationship between blood products and SSIs has been a matter of debate for more than 2 decades. Several studies have supported the association between the use of blood products and the development of postoperative surgical site infections. METHODS: A retrospective case-control study was performed. We reviewed the charts of all patients who had undergone thoracic and/or lumbar spinal surgery at the NYU Hospital for Joint Diseases between 2002 and 2007. All patients who had developed surgical site infections following spine surgery in this 5-year period were identified. RESULTS: Data for 61 cases and 71 controls were included in this study. The analysis of the preoperative risk factors was performed for the entire population of patients. Body mass index and blood transfusions were found to be statistically significant risk factors for increased surgical site infections for this population. CONCLUSION: Our findings support current theories that blood transfusions may have modulatory effects on the immune system of the recipients. Our specific study in spine patients may contribute to the expanding literature on allogeneic blood transfusions and the risk of nosocomial infections and encourage surgeons to favor a more restrictive policy with regard to transfusions