Faculty Bibliography

David Oshinsky reviews "Jewish Jocks: An Unorthodox Hall of Fame," a history of Jewish sports figures edited by Franklin Foery and Marc Tracy

PURPOSE: African Americans (AA) have been shown to have lower exercise capacities and a higher prevalence of related risk for cardiovascular disease (CVD) compared to European Americans (EA). Broad biopsychosocial models that may inform the design of ethnic-specific exercise programs have not been well examined. We thus examined exercise capacity and its biopsychosocial correlates in a healthy population of AA and EA at increased risk of CVD. METHODS: Subjects underwent maximal graded treadmill testing with gated single-photon emission computed tomography (SPECT); exercise capacity was expressed in MET-minutes. Medical history, psychosocial variables, general well-being, physical activity, and anthropometrics were assessed. Peak filling rate, a measure of left ventricular function, and ejection fraction were obtained from SPECT imaging, and the presence of silent ischemia was determined from the treadmill and SPECT imaging. RESULTS: The sample (N = 1054) was 47% AA and 60% female. Mean age was 52.1 +/- 9 yr for AA and 49.9 +/- 10 yr for EA. Body mass index (BMI) was 32.5 +/- 6.7 kg.m(-2) for AA and 29 +/- 5.3 kg.m(-2) for EA. AA achieved a mean maximal exercise level of 31 MET.min less than EA did. In separate regression models by race, BMI (r(2) = 0 .30), age (r(2) = 0 .07), and sex (r(2) = 0 .03) explained 40% of the variance in MET-minutes in AA and 36% in EA, with a similar hierarchy of associated variables. The remaining variables had minimal effect on exercise capacity in either group. CONCLUSIONS: BMI, older age, and female sex together contribute most to exercise capacity in both ethnicities. Hypothetically important biopsychosocial variables that may help shape ethnic-specific exercise programs add little to the prediction of exercise capacity. Thus, programs designed to reduce disparities in exercise capacity still need to first and foremost be geared to the age and sex demographics and address obesity.

LEARNING OBJECTIVE 1: Recognize hepatosplenic lymphoma as a rare subtype of T-cell lymphoma LEARNING OBJECTIVE 2: Recognize the dangers of early diagnostic closure CASE: A 30 year-old Guinean man with no past medical history presented with cough, fever, night sweats and weight loss for two months. The patient immigrated to the US 6 years ago. Exam showed cachexia, HR 122, T 101.3, BP 105/72, RR 22, O2 96% on RA, splenomegaly, normal lung exam and no appreciable lymphadenopathy. Labs were significant for a WBC 3.0 with 73%N, Hbg of 7 and a negative rapid HIV. CXR was unremarkable. Patient was isolated for possible tuberculosis. CT revealed splenomegaly, multiple scattered low-density lesions in the liver, prominent mediastinal, hilar, axillary and retroperitoneal lymphadeopthy, with the largest node measuring 3.7 x 2.8 cm. CT-guided biopsy of the retroperitoneal lymph node revealed fibrocollagenous tissue with necrosis. AFB, fungal stains, and cultures were negative. High fevers persisted to Tmax 105.7 F. Despite three negative AFB sputums, patient was started on a liver-sparing TB regimen given clinical suspicion for extra-pulmonary tuberculosis and worsening liver function. A bone marrow biopsy was performed revealing normal bone marrow with slight megakaryocyte hyperplasia but no evidence of lymphoma. Repeat core biopsy of the retroperitoneal lymph node showed necrotic tissue with few CD3+ T cells; AFB and cultures again negative. The course was further complicated by acute hepatic failure and transfusion dependent pancytopenia. On day 20, as the risks of invasive surgical testing increased, decision was made to perform excisional biopsy of a small superficial inguinal lymph node seen on CT. Preliminary pathology showed T-cell lymphoma with cytotoxic features. TB treatment was stopped and chemotherapy with a modified EPOCH regimen was initiated. After biopsy, flank pain, severe agitation from hepatic encephalopathy and DIC developed. This was concerning for retroperitoneal bleed and led to in!

LEARNING OBJECTIVE 1: Identify indications for surgical intervention in the case of hepatic abscesses LEARNING OBJECTIVE 2: Review appropriate management of new pleural effusions CASE: A 56 year-old woman presented with weight loss, malaise and polyuria for two months. On admission, HR 135, BP 107/80, RR 22, T 101, O2 94% on RA. Exam revealed cachexia, bilateral lower extremity edema, decreased breath sounds in lower half of right lung with decreased tactile fremitis and coarse crackles superiorly. Labs were notable for WBC 33 and glucose 559. EKG showed sinus tachycardia. CXR revealed a right pleural effusion. Patient was pan-cultured and empirically started on vancomycin, piperacillin/tazobatam and azithromycin for presumed pneumonia. Despite insulin and IV fluids, she remained tachycardic. CT angiogram revealed a large pulmonary embolus in the left basal pulmonary artery and a large loculated right pleural effusion with no pleural enhancement. Abdominal CT revealed 8 cm septated hepatic mass, hepatic vein thrombus extending into the IVC, and a small amount of air in the wall of the gallbladder. Heparin drip was started and patient was taken for percutaneous drainage of hepatic mass and thoracentesis. Only small samples were obtained given loculation. Pleural fluid was exudative, gram stain showed white cells but no organisms, pH 7.22, glucose 169. Chest tube was placed. Strep viridans grew from pleural and hepatic fluid; blood cultures grew strep anginosus and c. albicans. Antibiotics were narrowed to ceftriaxone and caspofungin. Given pneumobilia, hepatic abscess was presumed to be from GI source with empyema formation from local spread of infection and hepatic vein thrombus from local inflammation. EGD/colonoscopy failed to find communicating track between bowel and biliary systems. Surgical intervention was deemed risky given large clot burden and patient was managed with antibiotics alone. Repeat imaging two months later at discharge showed significant resolution of hepatic and pulmonary!

OBJECTIVE: An increasing proportion of gonorrhea in the United States is diagnosed in the private sector, posing a challenge to existing national surveillance systems. We described gonorrhea epidemiology outside sexually transmitted disease (STD) clinic settings. METHODS: Through the STD Surveillance Network (SSuN), health departments in the San Francisco, Seattle, Denver, Minneapolis, and Richmond, Virginia, metropolitan areas interviewed systematic samples of men and women reported with gonorrhea by non-STD clinic providers from 2006 through 2008. RESULTS: Of 2,138 interviews, 10.0% were from San Francisco, 26.4% were from Seattle, 25.2% were from Denver, 22.9% were from Minneapolis, and 15.5% were from Richmond. A total of 1,165 women were interviewed; 70.1% (815/1,163) were