Faculty Bibliography

BACKGROUND: The extent of damage in New York City following Hurricane Sandy in October 2012 was unprecedented. Bellevue Hospital Center (BHC), a tertiary public hospital, was evacuated and temporarily closed as a result of hurricane-related damages. BHC's large primary care office-based buprenorphine clinic was relocated to an affiliate public hospital for three weeks. The extent of environmental damage and ensuing service disruption effects on rates of illicit drug, tobacco, and alcohol misuse, buprenorphine medication supply disruptions, or direct resource losses among office-based buprenorphine patients is to date unknown. METHODS: A quantitative and qualitative semi-structured survey was administered to patients in BHC's primary care buprenorphine program starting one month after the hurricane. Survey domains included: housing and employment disruptions; social and economic support; treatment outcomes (buprenorphine adherence and ability to get care), and tobacco, alcohol, and drug use. Open-ended questions probed general patient experiences related to the storm, coping strategies, and associated disruptions. RESULTS: There were 132 patients enrolled in the clinic at the time of the storm; of those, 91 patients were recruited to the survey, and 89 completed (98% of those invited). Illicit opioid misuse was rare, with 7 respondents reporting increased heroin or illicit prescription opioid use following Sandy. Roughly half of respondents reported disruption of their buprenorphine-naloxone medication supply post-event, and self-lowering of daily doses to prolong supply was common. Additional buprenorphine was obtained through unscheduled telephone or written refills from relocated Bellevue providers, informally from friends and family, and, more rarely, from drug dealers. CONCLUSIONS: The findings highlight the relative adaptability of public sector office-based buprenorphine treatment during and after a significant natural disaster. Only minimal increases in self-reported substance use were reported despite many disruptions to regular buprenorphine supplies and previous daily doses. Informal supplies of substitute buprenorphine from family and friends was common. Remote telephone refill support and a temporary back-up location that provided written prescription refills and medication dispensing for uninsured patients enabled some patients to maintain an adequate medication supply. Such adaptive strategies to ensure medication maintenance continuity pre/post natural disasters likely minimize poor treatment outcomes.

Doppler ultrasonography is a standard in diagnosis of deep vein thrombosis (DVT) but is often delayed. Clinician-performed focused vascular sonography (FVS) has proven to accurately diagnose DVT in the ambulatory and emergency room settings. Whether trained medical residents can perform quality FVS in the critically ill is unknown. Medical residents were trained in a 2-hour module in FVS assessing for complete compressibility of common femoral and popliteal veins. Residents imaged consecutive medical ICU and intermediate care patients awaiting comprehensive, sonographer-performed and radiologist-interpreted examinations. Sensitivity, specificity, positive and negative predictive values of the focused examination were calculated against the comprehensive study. Fleiss Kappa (kappa), the degree of agreement between resident and radiologist, was calculated. Time savings was measured. Nineteen residents performed 143 studies on 75 patients. Twelve patients had above-the-knee DVTs, a prevalence of 16 %. All 6 common femoral and 7 of 9 popliteal vein DVTs were identified. None of 6 isolated superficial femoral DVTs were identified. Sensitivity for above-the-knee DVT was 63 %, specificity 97 %. Sensitivity for common femoral and popliteal DVT was 86 %, specificity 97 %. Residents showed substantial agreement with radiologists for diagnosis of DVT (kappa = 0.70, SE 0.114, p < 0.001).Time from order of a formal ultrasound to a radiologist's read averaged 14.7 h. The two-point compression ultrasound method demonstrated insufficient sensitivity in a cohort of critically ill medical patients due to a high-incidence of superficial femoral DVT. However, residents demonstrated substantial agreement with radiologists for the diagnosis of clinically relevant DVT after a 2-hour course. FVS should include the superficial femoral vein and is associated with a significant time savings.

OBJECTIVES: Intensivist-performed focused sonography, including renal sonography, is becoming accepted practice. Whether internal medicine residents can be trained to accurately rule out renal obstruction and identify sonographic findings of chronic kidney disease is unknown. The purpose of this study was to test the ability of residents to evaluate for this specific constellation of findings. METHODS: Internal medicine residents were trained in a 5-hour module on focused renal sonography evaluating renal length, echogenicity, hydronephrosis, and cysts on a convenience sample of medical ward, intermediate care, and medical intensive care unit patients. All patients underwent comprehensive sonography within 24 hours. The primary outcome was represented by the Fleiss kappa statistic, which indicated the degree of interobserver agreement between residents and radiologists. Sensitivity, specificity, and positive and negative predictive values were calculated using the comprehensive radiologist-read examination as the reference. RESULTS: Seventeen internal medicine residents imaged 125 kidneys on 66 patients. The average number of studies performed was 7.3 (SD, 6.6). Residents demonstrated excellent agreement with radiologists for hydronephrosis (kappa = 0.73; P < .001; SE, 0.15; sensitivity, 94%; specificity, 93%), moderate agreement for echogenic kidneys (kappa = 0.43; P < .001; SE, 0.13; sensitivity, 40%; specificity, 98%), and substantial agreement for renal cysts (kappa = 0.61; P < .001; SE, 0.12; sensitivity, 60%; specificity, 96%). Residents showed sensitivity of 100% and specificity of 88% for identification of atrophic kidneys, defined as length less than 8 cm. CONCLUSIONS: After a 5-hour training course, medical residents accurately identified hydronephrosis and key sonographic findings of chronic kidney disease in a cohort of medical patients. Screening for hydronephrosis and renal atrophy can be performed by medical residents after adequate training.

BACKGROUND: : Since 2004, a new wave of synthetic cannabinoids (SCs) known as "Spice drugs" has come under scrutiny because of their suspected link to neurological and psychiatric sequelae. These "herbal incense" or "potpourri blends" have gained popularity as a result of being more potent than natural cannabinoids, are not detected with current screening tests, and are easily modified by manufacturers to bypass legal restrictions. Unfortunately, cases of withdrawal phenomena, nausea, hypertension, and psychosis are now being reported in the medical literature. In addition, after reports in lay media of seizures and coma attributed to the consumption of the drug, anecdotal reports have emerged of similar findings in the medical literature. CASE DESCRIPTION: : We report on a 48-year-old man who, after consuming the herbal blend, lost consciousness and suffered several episodes of seizures. Despite a complicated ICU stay, the patient recovered well with no subsequent neurological sequelae. CONCLUSIONS: : The authors interpreted the history and findings consistent with the consumption of a large amount of synthetic cannabinoids leading to new-onset seizures and coma. However, at the time of admission, the lack of routine laboratory testing and treatment options delayed the diagnosis and delivery of appropriate therapy.

OBJECTIVES: Ultrasound velocity criteria for the diagnosis of in-stent restenosis in patients undergoing carotid artery stenting (CAS) are not well established. In the present study, we test whether ultrasound velocity measurements correlate with increasing degrees of in-stent restenosis in patients undergoing CAS and develop customized velocity criteria to identify residual stenosis > or =20%, in-stent restenosis > or =50%, and high-grade in-stent restenosis > or =80%. METHODS: Carotid angiograms performed at the completion of CAS were compared with duplex ultrasound (DUS) imaging performed immediately after the procedure. Patients were followed up with annual DUS imaging and underwent both ultrasound scans and computed tomography angiography (CTA) at their most recent follow-up visit. Patients with suspected high-grade in-stent restenosis on DUS imaging underwent diagnostic carotid angiograms. DUS findings were therefore available for comparison with luminal stenosis measured by carotid angiograms or CTA in all these patients. The DUS protocol included peak-systolic (PSV) and end-diastolic velocity (EDV) measurements in the native common carotid artery (CCA), proximal stent, mid stent, distal stent, and distal internal carotid artery (ICA). RESULTS: Of 255 CAS procedures that were reviewed, 39 had contralateral ICA stenosis and were excluded from the study. During a mean follow-up of 4.6 years (range, 1 to 10 years), 23 patients died and 64 were lost. Available for analysis were 189 pairs of ultrasound and procedural carotid angiogram measurements; 99 pairs of ultrasound and CTA measurements during routine follow-up; and 29 pairs of ultrasound and carotid angiograms measurements during follow-up for suspected high-grade in-stent restenosis > or =80% (n = 310 pairs of observations, ultrasound vs carotid angiograms/CTA). The accuracy of CTA vs carotid angiograms was confirmed (r(2) = 0.88) in a subset of 19 patients. Post-CAS PSV (r(2) = .85) and ICA/CCA ratios (r(2) = 0.76) correlated most with the degree of stenosis. Receiver operating characteristic analysis demonstrated the following optimal threshold criteria: residual stenosis > or =20% (PSV >or =150 cm/s and ICA/CCA ratio > or =2.15), in-stent restenosis > or =50% (PSV > or =220 cm/s and ICA/CCA ratio > or =2.7), and in-stent restenosis > or =80% (PSV 340 cm/s and ICA/CCA ratio > or =4.15). CONCLUSIONS: Progressively increasing PSV and ICA/CCA ratios correlate with evolving restenosis within the stented carotid artery. Ultrasound velocity criteria developed for native arteries overestimate the degree of in-stent restenosis encountered. These changes persist during long-term follow-up and across all grades of in-stent restenosis after CAS. The proposed new velocity criteria accurately define residual stenosis >or =20%, in-stent restenosis >or =50%, and high-grade in-stent restenosis > or =80% in the stented carotid artery.