Faculty Bibliography

Cannabinoid hyperemesis syndrome (CHS) is a rare constellation of clinical findings that includes a history of chronic heavy marijuana use, severe abdominal pain, unrelenting nausea, and intractable vomiting. A striking component of this history includes the use of hot showers or long baths that help to alleviate these symptoms. This is an underrecognized syndrome that can lead to expensive and unrevealing workups and can leave patients self-medicating their nausea and vomiting with the very substance that is causing their symptoms. Long-term treatment of CHS is abstinence from marijuana use-but the acute symptomatic treatment of CHS has been a struggle for many clinicians. Many standard medications used for the symptomatic treatment of CHS (including ondansetron, promethazine, and morphine) have repeatedly been shown to be ineffective. Here we present the use of lorazepam as an agent that successfully and safely treats the tenacious symptoms of CHS. Additionally, we build upon existing hypotheses for the pathogenesis of CHS to try to explain why a substance that has been used for thousands of years is only now beginning to cause this paradoxical hyperemesis syndrome.

BACKGROUND: Obesity is a serious disease that is associated with an increased risk of diabetes, hypertension, heart disease, stroke, and cancer, among other diseases. The United States Centers for Disease Control and Prevention (CDC) estimates a 20% obesity rate in the 50 states, with 12 states having rates of over 30%. Currently, the body mass index (BMI) is most commonly used to determine adiposity. However, BMI presents as an inaccurate obesity classification method that underestimates the epidemic and contributes to failed treatment. In this study, we examine the effectiveness of precise biomarkers and duel-energy x-ray absorptiometry (DXA) to help diagnose and treat obesity. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study of adults with BMI, DXA, fasting leptin and insulin results were measured from 1998-2009. Of the participants, 63% were females, 37% were males, 75% white, with a mean age = 51.4 (SD = 14.2). Mean BMI was 27.3 (SD = 5.9) and mean percent body fat was 31.3% (SD = 9.3). BMI characterized 26% of the subjects as obese, while DXA indicated that 64% of them were obese. 39% of the subjects were classified as non-obese by BMI, but were found to be obese by DXA. BMI misclassified 25% men and 48% women. Meanwhile, a strong relationship was demonstrated between increased leptin and increased body fat. CONCLUSIONS/SIGNIFICANCE: Our results demonstrate the prevalence of false-negative BMIs, increased misclassifications in women of advancing age, and the reliability of gender-specific revised BMI cutoffs. BMI underestimates obesity prevalence, especially in women with high leptin levels (>30 ng/mL). Clinicians can use leptin-revised levels to enhance the accuracy of BMI estimates of percentage body fat when DXA is unavailable.

BACKGROUND: We performed this study 1) to determine the prevalence of community-associated extended spectrum beta-lactamase producing Enterobacteriaceae (ESBLPE) colonization and infection in New York City (NYC); 2) to determine the prevalence of newly-acquired ESBLPE during travel; 3) to look for similarities in contemporaneous hospital-associated bloodstream ESBLPE and travel-associated ESBLPE. METHODS: Subjects were recruited from a travel medicine practice and consented to submit pre- and post-travel stools, which were assessed for the presence of ESBLPE. Pre-travel stools and stools submitted for culture were used to estimate the prevalence of community-associated ESBLPE. The prevalence of ESBLPE-associated urinary tract infections was calculated from available retrospective data. Hospital-associated ESBLPE were acquired from saved bloodstream isolates. All ESBLPE underwent multilocus sequence typing (MLST) and ESBL characterization. RESULTS: One of 60 (1.7%) pre- or non-travel associated stool was colonized with ESBLPE. Among community-associated urine specimens, 1.3% of Escherichia coli and 1.4% of Klebsiella pneumoniae were identified as ESBLPE. Seven of 28 travelers (25.0%) acquired a new ESBLPE during travel. No similarities were found between travel-associated ESBLPE and hospital-associated ESBLPE. A range of imported ESBL genes were found, including CTX-M-14 and CTX-15. CONCLUSION: ESBL colonization and infection were relatively low during the study period in NYC. A significant minority of travelers acquired new ESBLPE during travel.

Introduction: Mediastinal histoplasmosis present as mediastinal adenitis, granulomas or fibrosing mediastinitis. Whether these are different faces of a continuous spectrum of disease is not yet confirmed. Below is a case of mediastinal granulomas with evolving fibrosis. An extensive literature review from 1951 to 2011, revealing over 200 cases will also be detailed. Case Presentation: A 19 year old man non-smoker presented with dyspnea, night sweats, fever and non-productive cough. Paternal history was significant for lymphomas. His lungs were clear and there were no palpable lymphadenopathies. CXR revealed a right mediastinal mass/adenopathy. Chest CT showed extensive calcified mediastinal adenopathies, soft tissue densities encircling the right main bronchus and air space disease of the RML. His PPD, HIV test and sputum AFB smears and cultures were all negative. Inspection bronchoscopy showed bulging of the main carina and narrowing of the right main bronchus. EBUS lymph node sampling as well as BAL were negative for viral, bacterial, fungal, AFB cultures and malignancies. Mediastinoscopy with biopsy showed fibrotic lymphoid tissue with areas of caseating necrotizing granulomas, fibrosis and scattered calcifications. Therapy was initiated with itraconazole. Discussion: Primary histoplasmosis is usually a self-limited respiratory infection. Coalescence of caseous mediastinal lymph nodes results in mediastinal granulomas. These presents with cough, chest pain, dysphagia, hemoptysis, and dyspnea. Compression of the SVC, esophagus, or airways, and disruption of the capsule creating fistulas may all be seen. Cultures are usually negative, as are special stains for organisms. This was the case with our patient. Imaging reveals heavy calcifications, the presence of which may obviate the need for biopsy for tissue diagnosis as per some authorities. Urinary antigen and blood or bone marrow cultures are most useful in AIDS patients with disseminated diseases. Skin tests and serologies are not useful diagnostically because of high background rates of positivity in endemic areas. Differential diagnosis includes tuberculosis, other fungal infections, lymphomas post-radiation, metastases especially mucinous adenocarcinoma, sarcoidosis, and silicosis. Most authorities believe that neither antifungal nor anti-inflammatory treatment ameliorates the outcome of fibrosing mediastinitis. Our patient had both spectrum of diseases with mediastinal fibrosis revealed by the soft tissue densities encircling the right main bronchus. This explains his presentation with a post-obstructive pneumonia. Our case brings more questions than answers. What are the optimal tests to confirm histoplasmosis? Does treatment with anti-fungals prevent the mediastinal granulomas from evolving into the more devastating late complication of mediastinal fibrosis? (Figure Presented)

ABSTRACT Primary care is understudied as a reentry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid-dependent adults seeking buprenorphine/naloxone maintenance in an urban primary care clinic following release from jail versus community referrals. Postrelease patients were either (a) induced to buprenorphine in-jail as part of a clinical trial, or (b) seeking buprenorphine induction post release. From 2007 to 2008, N = 142 patients were new to primary care buprenorphine: n = 32 postrelease; n = 110 induced after community referral and without recent incarceration. Jail-released patients were more likely African American or Hispanic and uninsured. Treatment retention rates for postrelease (37%) versus community (30%) referrals were similar at 48 weeks. Rates of opioid positive urines and self-reported opioid misuse were also similar between groups. Postrelease patients in primary care buprenorphine treatment had equal treatment retention and rates of opioid abstinence versus community-referred patients

Background: Well-designed computer-assisted instruction (CAI) can potentially transform medical education. Yet little is known about whether specific design features such as direct manipulation of the content yield meaningful gains in clinical learning. We designed three versions of a multimedia module on the abdominal exam incorporating different types of interactivity. Methods: As part of their physical diagnosis course, 162 second-year medical students were randomly assigned (1:1:1) to Watch, Click or Drag versions of the abdominal exam module. First, students' prior knowledge, spatial ability, and prior experience with abdominal exams were assessed. After using the module, students took a posttest; demonstrated the abdominal exam on a standardized patient; and wrote structured notes of their findings. Results: Data from143 students were analyzed. Baseline measures showed no differences among groups regarding prior knowledge, experience, or spatial ability. Overall there was no difference in knowledge across groups. However, physical exam scores were significantly higher for students in the Click group. Conclusions: A mid-range level of behavioral interactivity was associated with small to moderate improvements in performance of clinical skills. These improvements were likely mediated by enhanced engagement with the material, within the bounds of learners' cognitive capacity. These findings have implications for the design of CAI materials to teach procedural skills.