Faculty Bibliography

BACKGROUND:Bilateral adrenalectomy (BLA) is a treatment option to alleviate symptoms in patients with ectopic Cushing's syndrome (ECS) for whom surgical treatment of the responsible nonpituitary tumor is not possible. ECS patients have an increased risk for complications, because of high cortisol levels, poor clinical condition, and metabolic disturbances. This study aims to evaluate the safety and long-term efficacy of endoscopic BLA for ECS. METHODS:From 1990 to present, 38 patients were diagnosed and treated for ECS in the Erasmus University Medical Center, a tertiary referral center. Twenty-four patients were treated with BLA (21 endoscopic, 3 open), 9 patients were treated medically, and 5 patients could be cured by complete resection of the adrenocorticotropic hormone (ACTH)-producing tumor. The medical records were retrospectively reviewed and entered into a database. For evaluation of the efficacy of BLA, preoperative biochemical and physical symptoms were assessed and compared with postoperative data. RESULTS:Endoscopic BLA was successfully completed in 20 of the 21 patients; one required conversion to open BLA. Intraoperative complications occurred in two (10%) patients, and postoperative complications occurred in three (14%) patients. Median hospitalization was 9 (2-95) days, and median operating time was 246 (205-347) min. Hypercortisolism was resolved in all patients. Improvements of hypertension, body weight, Cushingoid appearance, impaired muscle strength, and ankle edema were achieved in 87, 90, 65, 61, and 78% of the patients, respectively. Resolution of diabetes, hypokalemia, and metabolic alkalosis was achieved in 33, 89, and 80%, respectively. CONCLUSION/CONCLUSIONS:Endoscopic BLA is a safe and effective treatment for patients with ectopic Cushing's syndrome.

In the spring of 2009, New York City (NYC) experienced the emergence and rapid spread of pandemic influenza A H1N1 virus (pH1N1), which had a high attack rate in children and caused many school closures. During the 2009 fall wave of pH1N1, a school-located vaccination campaign for elementary schoolchildren was conducted in order to reduce infection and transmission in the school setting, thereby reducing the impact of pH1N1 that was observed earlier in the year. In this paper, we describe the planning and outcomes of the NYC school-located vaccination campaign. We compared consent and vaccination data for three vaccination models (school nurse alone, school nurse plus contract nurse, team). Overall, >1,200 of almost 1,600 eligible schools participated, achieving 26.8% consent and 21.5% first-dose vaccination rates, which did not vary significantly by vaccination model. A total of 189,902 doses were administered during two vaccination rounds to 115,668 students at 998 schools included in the analysis; vaccination rates varied by borough, school type, and poverty level. The team model achieved vaccination of more children per day and required fewer vaccination days per school. NYC's campaign is the largest described school-located influenza vaccination campaign to date. Despite substantial challenges, school-located vaccination is feasible in large, urban settings, and during a public health emergency.

Background: Having a usual source of primary care is known to improve health. Currently only two-thirds of ED patients have a usual source of care outside the ED, far short of Healthy People 2020's target of 84%. Prior attempts to link ED patients with primary care have had mixed results. Objectives: To determine if an intervention directly linking low-acuity patients with a primary care clinic at the time of an ED visit could lead to future primary care linkage. Methods: DESIGN: Pseudo-randomized controlled trial. SETTING: Urban safety-net hospital. SUBJECTS: Adults presenting to the ED 1/07-1/08 for select problems a layperson would identify as low-acuity. Patients were excluded if they arrived by EMS, had a PCP outside our hospital, were febrile, or the triage nurse felt they needed ED care. Consecutive patients were enrolled weekday business hours when the primary care clinic was open. Patients were assigned to usual care in the ED if a provider was ready to see them before they had completed the baseline study survey. Otherwise they were offered the intervention if a clinic slot was available. INTERVENTION: Patients agreeing to the intervention were escorted to a primary care clinic in the same hospital building. They were assigned a personal physician and given an overview of clinic services. A patient navigator ensured patients received timely same-day care. Intervention group patients could refuse the intervention and instead remain in the ED for care. Both clinic and ED patients were given follow-up clinic appointments, or a phone number to call for one, as per usual provider practice. ANALYSIS: The main outcome measure was primary care linkage, defined as having one or more primary care clinic visits within a year of the index ED visit for patients with no prior PCP. Results: 1,292 patients were potentially eligible and 853 were enrolled (662 intervention and 191 controls). Groups had similar baseline characteristics. Nearly 75% in both groups had no prior PCP. Using an intention to treat analysis, 50.3% of intervention group patients with no prior PCP achieved successful linkage (95%CI 45.7-54.9%) vs. 36.9% of the control group (95%CI 28.9-45.4%). Conclusion: A point-of-care program offering low-acuity ED patients the opportunity to instead be seen at the hospital's primary care clinic resulted in increased future primary care linkage compared to standard ED referral practices

Obese and underweight women who develop breast cancer may have poorer survival compared with normal-weight women. However, the optimal weight for best prognosis is still under study. We conducted a prospective investigation of pre-diagnosis body mass index (BMI) and mortality among 14,948 breast cancer patients in the After Breast Cancer Pooling Project. Breast cancer patients diagnosed from 1990 to 2006 with AJCC Stage I-III breast tumors were drawn from four prospective cohorts. Hazard ratios (HR) and 95% confidence intervals (CI) representing the associations of BMI categories (World Health Organization international classifications) with recurrence and mortality were estimated using delayed entry Cox proportional hazards models. Obese (30 to < 35 kg/m(2)), severely obese (35 to < 40 kg/m(2)), and morbidly obese (>/= 40 kg/m(2)) were examined. After a mean follow-up of 7.8 years, 2,140 deaths and 2,065 recurrences were documented. Both underweight (HR = 1.59; 95% CI: 1.18, 2.13) and morbidly obese women (HR = 1.81; 95% CI: 1.42, 2.32) had the greatest risk of overall mortality compared with normal weight (18.5-24.9 kg/m(2)) women. Severe obesity (HR = 1.09; 95% CI: 0.88, 1.36) and obesity (HR = 1.11; 95% CI: 0.97, 1.27) were related to small non-significant increased risks. Overweight (25.0-29.9 kg/m(2)) was not associated with any excess risk compared with normal weight. Similar associations were found for breast cancer death and non-breast cancer death but not recurrence. Women who were underweight and morbidly obese before breast cancer diagnosis were at the greatest risk of all-cause mortality. Morbidly obese women were also at increased risk of death from breast cancer. These results suggest that degree of obesity confers differential risk on survival.

Over 350,000 immigrants are detained by U.S. Immigration and Customs Enforcement (ICE) each year. An unknown fraction of these detainees have serious mental illnesses and are taken into ICE custody even though a criminal court has ordered them to enter inpatient mental health care. The authors report findings from 16 such cases in which they have provided advocacy over the past four years. In some cases, they were able to secure release of detainees into inpatient care in community (nonforensic) settings, which involved substantial logistical challenges. Given the well-documented concerns about securing adequate care for ICE detainees with mental illness, a logical policy change would be for ICE to allow these patients to enter court-ordered inpatient care. This move would improve care for patients and would also unburden ICE from the untenable proposition of caring for patients that the criminal justice system has deemed unfit for incarceration. (Psychiatric Services 63:377-379, 2012; doi: 10.1176/appi.ps.201100040).

Abstract The American Diabetes Association now recommends hemoglobin A(1c) (HbA(1c)) screening for the diagnosis of diabetes. It has been reported that HbA(1c) levels underestimate glycemic levels in HIV-infected persons. We examined the performance of HbA(1c) as a screening test for diabetes in a group of HIV-infected people without diabetes. We conducted a retrospective cross-sectional cohort study among HIV-infected patients determining the sensitivity and specificity of HbA(1c) as a screening test compared to fasting blood glucose (FBG). The effect of treatment regimen on the relationship between HbA(1c) and FBG was assessed by multiple linear regressions. Twenty-two of the 395 patients included in the study were newly diagnosed with diabetes based on FBG>/=126 mg/dL. Using a cutoff of HbA(1c)>/=6.5%, HbA(1c) had a sensitivity of 40.9% and specificity of 97.5% for identification of incident diabetes. At an HbA(1c) level of 5.8% the product of sensitivity and specificity was maximized, with values of 88.8% and 77.5% respectively. Higher mean cell volume (MCV) values (p=0.02) and current use of a non-nucleoside reverse transcriptase inhibitors (NNRTIs; p=0.02) significantly increased the slope, while PI use significantly decreased the slope (p<0.001), of the linear regression of HbA(1c) compared to FBG. Tenofovir use did not significantly alter the slope or y-intercept of the line. Among HIV-infected nondiabetic patients, HbA(1c) is insensitive, although highly specific for diagnosing diabetes. Current antiretroviral (ART) use has significant and variable influence on the relationship between HbA(1c) and FBG. The use of HbA(1c) in conjunction with FBG may be the best modality to screen for diabetes.

When [Julia] walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have "open and honest" communication with her, in a "patient centered" manner. But I couldn't. I couldn't bring myself to tell this young mother that she was going to die. The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the "continuous musical line of our minds, the unstoppable humming ..." This basso continuo thrums along, modulating doctors' actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions. I'd like to say that I'd handle the situation better now, with another decade of clinical experience under my belt, but I'm not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can't -- and shouldn't -- eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.