Abdominal Physical Signs and Medical Eponyms: Part II. Percussion and Auscultation, 1924-1980

BACKGROUND

Percussion and auscultation are derived from the Latin words to touch and hear, respectively. Covered are abdominal percussion signs and ausculatory signs discovered from 1924 to 1980. Signs ascribed as medical eponyms pay homage to these physicians who provided new and unique insights into disease.

DATA SOURCES

PubMed, Medline, online Internet word searches, textbooks, and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign.

CONCLUSION

Many of these signs have been discarded because of modern imaging and diagnostic techniques. When combined with a high clinical suspicion, positive results using percussion combined with palpation is a useful bedside technique in detecting splenic enlargement. Thus, some of these maneuvers remain important bedside techniques that skilled practitioners should master, and along with a meaningful history, provide relevant information to diagnosis. It is through learning about these signs that we gain a sense of humility on the difficulty physicians faced prior to the advent of techniques that now allow us an easier way to visualize and diagnose the underlying disease processes.

Abdominal Physical Signs and Medical Eponyms: Part I. Percussion, 1871-1900

BACKGROUND

Percussion is derived from the Latin word to hear and to touch. Percussion of the abdomen is used to detect areas of tenderness, dullness within an area of tenderness suggestive of a mass, shifting dullness representing fluid or blood, splenic, hepatic and bladder enlargement, and free air in the peritoneum. Covered are abdominal signs of percussion attributed as medical eponyms from the time-period beginning in the mid-late nineteenth century. Described is historical information behind the sign, descriptions of the sign, and implication in modern clinical practice.

DATA SOURCES

PubMed, Medline, online Internet word searches, textbooks, and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign.

CONCLUSION

Percussion signs defined as medical eponyms were important discoveries adopted by physicians prior to the advent of radiographs and other imaging and diagnostic techniques. The signs perfected during this time-period provided important clinical cues as to the presence of air within the peritoneum or rupture of the spleen.

Abdominal Physical Signs of Inspection and Medical Eponyms

BACKGROUND

An eponym in clinical medicine is an honorific term ascribed to a person(s) who may have initially discovered or described a device, procedure, anatomical part, treatment, disease, symptom, syndrome, or sign found on physical examination. Signs, although often lacking sufficient sensitivity and specificity, assist in some cases to differentiate and diagnose disease. With the advent of advanced technological tools in radiological imaging and diagnostic testing, the importance of inspection, the initial steps taught during the physical examination, is often overlooked or given only cursory attention. Nevertheless, in the era of evidence-based and cost-effective medicine, it becomes compelling, and we contend that a meticulously performed history and physical examination, applying the basic tenets of inspection, remains paramount prior to obtaining appropriate diagnostic tests.

DATA SOURCES

PubMed, Medline, online Internet word searches and bibliographies from source text and textbooks. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign.

CONCLUSIONS

We describe the historical aspect, clinical application, and performance of medical eponymous signs of inspection found on physical examination during the 18th to 20th centuries.

Abdominal Physical Signs and Medical Eponyms: Part III. Physical Examination of Palpation, 1926-1976

BACKGROUND

This paper describes medical eponyms associated with abdominal palpation from the period 1926-1976. Despite opposition by some, eponyms are a long standing tradition and widely used in medicine. The techniques may still be useful in some cases, assisting in the selection of an appropriate and cost-effective approach to patient care. In this piece, we cover signs named in honor of physicians who contributed to medicine by developing new palpatory techniques in an attempt to better diagnose disease of the abdominal wall, umbilicus, gallbladder, pancreas, and appendix.

DATA SOURCES

PubMed, Medline, online Internet word searches, textbooks, and references from other source texts. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign.

CONCLUSION

We describe brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication into today's medical practice.

Pentostatin, Cyclophosphamide, and Rituximab Followed by Alemtuzumab for Relapsed or Refractory Chronic Lymphocytic Leukemia: A Phase 2 Trial of the ECOG-Acrin Cancer Research Group (E2903)

Patients with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL) may benefit from salvage chemoimmunotherapy (CIT). To explore further the use of CIT in the pre-novel agent era, ECOG-ACRIN undertook a phase 2 trial (E2903) for R/R CLL utilizing pentostatin, cyclophosphamide, and rituximab (PCR) followed by a consolidation course of alemtuzumab. This trial enrolled 102 patients with a median age of 64 years. Treatment consisted of 6 cycles of PCR followed by alemtuzumab for either 4 or 18 weeks depending on the initial response to PCR. The overall response after PCR (complete remission, CR, nodular partial remission, nPR, and partial remission, PR) was 55%. Major responses (CR or nPR) were achieved in 6%. The median overall survival (OS) and the median progression-free survival were 28 and 12 months, respectively. The most serious nonlethal adverse events were myelosuppression, febrile neutropenia, fatigue, nausea, and hyponatremia. PCR is an effective and well-tolerated nucleoside-based regimen for heavily pretreated CLL patients with R/R disease. The addition of alemtuzumab to CLL patients with a minor response (PR) or stable disease did not result in a significant number of higher responses (CR or nPR) nor an improvement in OS.

Venothromboembolic signs and medical eponyms: Part I

Eponyms are honorific terms ascribed to individuals who discovered a sign, test, syndrome, technique, or instrument. Despite some contentions, eponyms continue to be widely ingrained and incorporated into the medical literature and contemporary language. Physical signs are considered unreliable methods alone for detecting deep venous thrombosis (DVT). The accuracy of the majority of these signs is unknown. For those signs that have been studied, there are a number of methodological limitations hindering the ability to draw meaningful conclusions about their accuracy and validity in clinical practice. Nevertheless, some findings when present and used in conjunction with other key signs, symptoms, and aspects of the patients history may be useful in further supporting the clinical suspicion and likelihood of DVT and/or pulmonary embolism (PE) or venothromboembolism (VTE). These signs also provide the means to better recognize the relationship between clinical findings and VTE. The acquisition of historical knowledge about these signs is important as it further enhances our understanding and appreciation of the diagnostic acumen that physicians were required to employ and to diagnose VTE prior to the advent of advanced imaging methods. Described in this paper is a brief overview of thrombosis as enumerated by Rudolf Virchow, and eponymous signs described in the late eighteenth and nineteenth centuries.

Abdominal Physical Signs and Medical Eponyms: Part II. Physical Examination of Palpation, 1907-1926

BACKGROUND

Abdominal palpation is an important clinical skill used by physicians to detect the cause of the underlying disease. Abdominal physical signs reported as medical eponyms are sometimes helpful in supporting or confirming clinical suspicion of a diagnosis. With the advent of advanced and rapid imaging techniques physicians often know the diagnosis prior to setting their hands on patients. Nevertheless, knowledge of these signs may still remain important in settings where imaging may not be readily available and importantly provide deeper insights into the mechanism of disease. In this paper, described are medical eponyms associated with abdominal palpation from the period 1907-1926.

DATA SOURCES

PubMed, Medline, on-line Internet word searches, textbooks, and references from other source text were used as the data source. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign.

CONCLUSION

We describe brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication into today's medical practice.

Abdominal Physical Signs and Medical Eponyms: Movements and Compression

BACKGROUND

Prior to the advent of modern imaging techniques, maneuvers were performed as part of the physical examination to further assess pathological findings or an acute abdomen and to further improve clinicians' diagnostic acumen to identify the site and cause of disease. Maneuvers such as changing the position of the patient, extremity, or displacing through pressure a particular organ or structure from its original position are typically used to exacerbate or elicit pain. Some of these techniques, also referred to as special tests, are ascribed as medical eponym signs.

DATA SOURCES

PubMed, Medline, online Internet word searches, textbooks and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign.

CONCLUSION

These active and passive maneuvers of the abdomen, reported as medical signs, have variable performance in medical practice. The lack of diagnostic accuracy may be attributed to confounders such as the position of the organ, modification of the original technique, or lack of performance of the maneuver as originally intended.

Abdominal Physical Signs and Medical Eponyms: Physical Examination of Palpation Part 1, 1876-1907

BACKGROUND

Abdominal palpation is a difficult skill to master in the physical examination. It is through the tactile sensation of touch that abdominal tenderness is detected and expressed through pain. Its findings can be used to detect peritonitis and other acute and subtle abnormalities of the abdomen. Some techniques, recognized as signs or medical eponyms, assist clinicians in detecting disease and differentiating other conditions based on location and response to palpation. Described in this paper are medical eponyms associated with abdominal palpation from the period 1876 to 1907.

DATA SOURCES

PubMed, Medline, on-line Internet word searches, textbooks and references from other source text were used as the data source. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign.

CONCLUSION

We present brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication in today's medical practice.

Flushing Disorders Associated with Gastrointestinal Symptoms: Part 2, Systemic Miscellaneous Conditions

Flushing disorders with involvement of the gastrointestinal tract represent a heterogeneous group of conditions. In part 1 of this review series, neuroendocrine tumors (NET), mast cell activation disorders (MCAD), and hyperbasophilia were discussed. In this section we discuss the remaining flushing disorders which primarily or secondarily involve the gastrointestinal tract. This includes dumping syndrome, mesenteric traction syndrome, rosacea, hyperthyroidism and thyroid storm, anaphylaxis, panic disorders, paroxysmal extreme pain disorder, and food, alcohol and medications. With the exception of paroxysmal pain disorders, panic disorders and some medications, these disorders presents with dry flushing. A detailed and comprehensive family, social, medical and surgical history, as well as recognizing the presence of other systemic symptoms are important in distinguishing the different disease that cause flushing with gastrointestinal symptoms.

The Clinical Significance of Relative Bradycardia

INTRODUCTION

Relative bradycardia is a poorly understood paradoxical phenomenon that refers to a clinical sign whereby the pulse rate is lower than expected for a given body temperature.

OBJECTIVE

To provide an overview and describe infectious and noninfectious causes of relative bradycardia.

METHODS

PubMed and Medline databases were searched using individual and Medical Subject Headings terms including relative bradycardia, fever, pulse-temperature dissociation and pulsetemperature deficit in human studies published from inception to October 2, 2016. The causes and incidence of relative bradycardia were reviewed.

RESULTS

Relative bradycardia is found in a wide variety of infectious and noninfectious diseases. The pathogenesis remains poorly understood with proposed mechanisms including release of inflammatory cytokines, increased vagal tone, direct pathogenic effect on the myocardium, and electrolyte abnormalities. The incidence of this sign varies widely, which may be attributable to multiple factors, including population size, time course for measuring pulse and temperature, and lack of a consistent definition used. The fact that this sign is not consistently identified in case series suggests that relative bradycardia is caused by mechanisms presumably involving or influenced by pathogen and host factors.

CONCLUSIONS

Relative bradycardia is a sensitive but nonspecific clinical sign that may be an important bedside tool for narrowing the differential diagnosis of potential infectious and noninfectious etiologies. Recognizing this relationship may assist the clinician by providing bedside clinical clues into potential etiologies of disease, particularly in the setting of infectious diseases and in circumstances when other stigma of disease is absent.

Flushing Disorders Associated with Gastrointestinal Symptoms: Part 1, Neuroendocrine Tumors, Mast Cell Disorders and Hyperbasophila

Flushing is the subjective sensation of warmth accompanied by visible cutaneous erythema occurring throughout the body with a predilection for the face, neck, pinnae, and upper trunk where the skin is thinnest and cutaneous vessels are superficially located and in greatest numbers. Flushing can be present in either a wet or dry form depending upon whether neural-mediated mechanisms are involved. Activation of the sympathetic nervous system results in wet flushing, accompanied by diaphoresis, due to concomitant stimulation of eccrine sweat glands. Wet flushing is caused by certain medications, panic disorder and paroxysmal extreme pain disorder (PEPD). Vasodilator mediated flushing due to the formation and release of a variety of biogenic amines, neuropeptides and phospholipid mediators such as histamine, serotonin and prostaglandins, respectively, typically presents as dry flushing where sweating is characteristically absent. Flushing occurring with neuroendocrine tumors accompanied by gastrointestinal symptoms is generally of the dry flushing variant, which may be an important clinical clue to the differential diagnosis. A number of primary diseases of the gastrointestinal tract cause flushing, and conversely extra-intestinal conditions are associated with flushing and gastrointestinal symptoms. Gastrointestinal findings vary and include one or more of the following non-specific symptoms such as abdominal pain, nausea, vomiting, diarrhea or constipation. The purpose of this review is to provide a focused comprehensive discussion on the presentation, pathophysiology, diagnostic evaluation and management of those diseases that arise from the gastrointestinal tract or other site that may cause gastrointestinal symptoms secondarily accompanied by flushing. This review is divided into two parts given the scope of conditions that cause flushing and affect the gastrointestinal tract: Part 1 covers neuroendocrine tumors (carcinoid, pheochromocytomas, vasoactive intestinal polypeptide, medullary carcinoma of the thyroid), polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes (POEMS), and conditions involving mast cells and basophils; while Part 2 covers dumping syndrome, mesenteric traction syndrome, rosacea, hyperthyroidism and thyroid storm, anaphylaxis, panic disorders, paroxysmal extreme pain disorder, and food, alcohol and medications.

A systematic review of mobility/immobility in thromboembolism risk assessment models for hospitalized patients

Hospitalized patients are at risk of venous thromboembolism (VTE) and prophylaxis is often suboptimal due to difficulty in identifying at-risk patients. Simple and validated risk-assessment models (RAMs) are available to assist clinicians in identifying patients who have a high risk for developing VTE. Despite the well-documented association of immobility with increased risk of thrombosis, immobility is not consistently defined in clinical studies. We conducted a systematic review of published VTE RAMs and used objective criteria to determine how the term immobility is defined in RAMs. We identified 17 RAMs with six being externally validated. The concept of immobility is vaguely described in different RAMs, impacting the validity of these models in clinical practice. The wide variability in defining mobility in RAMs precluded its accurate clinical application, further limiting generalization of published RAMs. Externally validated RAMs with clearly defined qualitative or quantitative terms of immobility are needed to assess VTE risk in real-time at the point-of-care.

Erythrocyte Sedimentation Rate and C-reactive Protein Measurements and Their Relevance in Clinical Medicine

INTRODUCTION

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are widely used laboratory markers of systemic inflammation.

OBJECTIVE

A thorough understanding of the similarities and differences between these two serological markers, including factors that affect measurements, is necessary for the proper utilization and interpretation of ESR and CRP.

METHODS

This review summarizes the current published literature (searched on MEDLINE through February 2016) surrounding the history and utilization of ESR and CRP, and examines factors that affect ESR and CRP measurements and discordance amongst these two inflammatory markers.

RESULTS

As ESR and CRP lack sensitivity or specificity, these tests should be used only in combination with clinical history and physical exam for diagnosis and monitoring of pathological conditions. The clinical application of these tests in diagnosis is best applied to conditions in which there is high or low clinical probability of disease. Importantly, discrepancies between ESR and CRP measurements commonly have been reported in both inpatient and outpatient settings and this problem may be particularly prevalent in chronic inflammatory diseases. Numerous physiological factors, including noninfectious conditions and resolution of inflammation can contribute to abnormally high ESR/low CRP readings or vice versa.

CONCLUSIONS

Although discordance may be encountered in certain settings, proper utilization of ESR and CRP measurements continues to play an important role in clinical management of many inflammatory and other conditions.

A Review of Clinical Signs Related to Ecchymosis

Ecchymosis is a large area of discoloration caused by extravasation of blood into the subcutaneous tissue. It is an objective physical finding that may provide valuable clues as to its possible etiology. Ecchymosis is associated with eponyms based on the physician who first described the physical findings, which can be divided into 4 anatomical categories: base of the skull, abdominal wall and retroperitoneum, groin and scrotum, and lower extremity. Classic external signs and eponyms associated with ecchymosis are reviewed. Knowledge of these signs on physical examination may prove to be a useful clue directing the examiner to consider potentially serious causes of disease.

Reinitiating warfarin: relationships between dose and selected patient, clinical and hospital measures

BACKGROUND

Warfarin is an oral anticoagulant used in the long-term treatment/prevention of venothromboembolic disease. Patients undergoing elective surgical and non-surgical procedures may require temporary warfarin discontinuation followed by reinitiation after their procedure. Because little information is available regarding best methods for warfarin reinitiation, we investigated current practices to inform management decisions.

METHODS

Subjects were required to have a known and stable warfarin dose prior to discontinuation, which was operationalized by requiring, within 7-days prior to discontinuation, that they have at least one INR in therapeutic range (2.0-3.5), no INR(s) out of range, and no more than a 15% change in warfarin dose. Stable dose prior to discontinuation was defined as the average daily dose received in the 7 days immediately prior to discontinuation. Reinitiation dose was defined as the average daily dose received in the first 3 days after warfarin was restarted. Subjects were divided into three groups based on whether they received approximately the same, a higher, or a lower dose at reinitiation and were also grouped by calendar time into three distinct periods that reflected differing levels of availability of electronic and patient care data that may impact reinitiation dose decisions. These groupings facilitated analyses and descriptions of trends in reinitiation dosing and supported other analyses, including tests for association between dose group and selected subject demographic, clinical, medication and hospitalization measures. All study data were abstracted from Marshfield Clinic electronic patient care and administrative databases and electronic patient care databases from Ministry St. Joseph's Hospital (Marshfield, WI).

RESULTS

We identified 205 subjects with warfarin temporarily discontinued between 1994 and 2012: 99 subjects in same dose group, 32 subjects in the low group, and 74 subjects in the high group. Because relatively wide differences were observed in the proportion of same dose subjects during more recent years (2007-2012) compared to earlier years (54% vs 35%), we focused our analyses on this recent period, which included 140 subjects. Review of physician notes and other documents yielded virtually no information about reasons for reinitiation dose decisions. In addition, tests for association between reinitiation dose group and subject demographic, clinical, medication and hospital measures were uniformly uninformative.

CONCLUSIONS

We observed varied dosing strategies for reinitiating patients on warfarin and, in more recent years, an apparent trend toward reinitiating patients on the same dose. However we could not associate dosing strategy with specific patient demographic, clinical, medication or hospital factors. Many factors influence whether a physician reinitiates a patient at a different dose than his/her prior stable warfarin dose. However, in the absence of clinical indications for modification, we believe patients with a previously established effective dose should be reinitiated at that same dose following temporary warfarin discontinuation.

Symptomatic factor XIII deficiency with normal urea solubility test

BACKGROUND

Factor XIII deficiency is a rarely encountered bleeding disorder traditionally identified by clot dissolution in 5 molar urea (urea solubility test).

METHODS

We report a patient with delayed post-surgical bleeding characteristic of factor XIII deficiency with a normal urea solubility test.

RESULTS

Factor XIII deficiency was identified by an automated assay that measured factor XIII antigen. The patient was successfully treated with cryoprecipitate.

CONCLUSIONS

Patients with excessive bleeding with normal screening tests should be tested for factor XIII using a sensitive assay procedure. The urea solubility assay for factor XIII should be discontinued due to its lack of sensitivity.

Factors that affect rate of INR decline after warfarin discontinuation

BACKGROUND

Despite vast literature on warfarin, optimal strategies for temporarily discontinuing and restarting warfarin have not been established. To improve warfarin discontinuation processes, we investigated known medical and genetic factors that influence stable warfarin dose to determine how well they predict the time until patients become subtherapeutic after discontinuing warfarin.

METHODS

This was a retrospective cohort study of patients who temporarily discontinued warfarin before an elective procedure andhad at least 2 international normalized ratio (INR) values available during the discontinuation period. Data abstracted included date of discontinuation, warfarin dose, INR values, body surface area, gender, age, indication for warfarin, current medications, eGFR, and presence of bridging therapy with heparin. DNA variants were tested in CYP2C9, VKORC1, and CYP4F2 genes. Subjects were excluded if they received vitamin K, fresh frozen plasma, or prothrombin complexes to reverse anticoagulation. Asymptotic regression models were used to approximate decline in INR during warfarin clearance. Spearman correlations and Kruskal-Wallis tests were used to characterize associations of model estimates with quantitative variables and for group comparisons, respectively.

RESULTS

Other than the expected association with baseline INR, correlations of model parameter estimates with clinical variables were generally weak and not statistically significant. The strongest associations with slope were with serum creatinine and eGFR. There were no significant associations with CYP2C9, VKORC1, or CYP4F2 DNA variants, but there were few subjects combined in the nonwild groups for CYP2C9. Estimated slope showed moderate correlation with observed dose.

CONCLUSION

Known clinical and genetic predictors of therapeutic dose were not found to be strongly associated with the slope of INR decline after warfarin discontinuation.

Mirtazapine and mefloquine therapy for non-AIDS-related progressive multifocal leukoencephalopathy

Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection of the human nervous system caused by the JC virus. We report what is, to the best of our knowledge, the second reported case using a combination of mefloquine and mirtazapine in a patient with non-AIDS-related PML with a good clinical outcome. Conversely, the recent trial of mefloquine in 21 patients with AIDS and 3 without AIDS failed to show a reduction of JC viral DNA levels in the cerebral spinal fluid. However, the positive clinical response seen in our patient after the initiation of this combination therapy suggests that further studies in the form of randomized controlled trials for the treatment of non-AIDS-related PML are warranted.

The Emeritus Clinical-Researcher Program

BACKGROUND

For some physicians, retirement means leaving their practice and severing ties with their institution, while others may wish to maintain a more active role within their institution. Many institutions have designed programs that enable these individuals to maintain an academic relationship and provide services to their institution.

OBJECTIVES

This manuscript provides a brief experience of the Marshfield Clinic (MC) and Marshfield Clinic Research Foundation (MCRF) recent development of an emeritus program for research and education.

RESULTS

The program is designed to provide opportunities for physicians, clinical PhDs, dentists, and other clinicians with terminal degrees and the necessary qualifications as researchers, to continue to contribute to the MC/MCRF research mission after retirement from clinical practice. Assignment to various aspects of the program is determined by the individual's expertise, experience and institutional needs. Expectations and performance of each individual is evaluated. The infrastructure of the program was assembled by reviewing institutes that have had an emeritus program in operation and integrating the unique aspect of MC/MCRF resources.

CONCLUSION

Alignment of the unique skills, expertise, knowledge, and wealth of experience of emeritus faculty along institutional needs has provided added value to the institution without major financial investment.

Rhabdomyolysis-induced acute kidney injury secondary to Anaplasma phagocytophilum and concomitant statin use

We report the case of a patient with rhabdomyolysis-induced acute renal failure occurring in the setting of Anoplasma phagocytophilum infection based on the presence of morulae in neutrophils and concomitant statin use. Although the pathogenesis is unknown, we believe the combination of concurrent statin use in the setting of the infection promoted this complication. We describe proposed mechanisms including cytokine activation, alteration of the muscle membrane components, and ionic balance as contributing factors.

Multilocular thymic cyst with epithelioid granulomata of unknown etiology: a radiologic and histopathologic correlation

Thymic cysts (congenital or acquired) are believed to account for 3% to 5% of all mediastinal masses. Multilocular thymic cysts are an acquired reactive inflammatory process arising within the thymus gland and are less common than the congenital unilocular type. Multilocular cysts have been reported in association with a variety of neoplastic, autoimmune, and infectious conditions. We report a case of a 23-year-old white man who presented with a 2-week history of progressive right-sided shoulder and chest pain. He was found to have an anterior mediastinal mass involving the thymus. This case of multilocular thymic cyst is particularly unique due to the presence of abundant epithelioid granulomata within the cyst, a finding that has not previously been emphasized as a histologic feature of these lesions, and one that expands the histopathologic differential diagnosis, warranting exclusion of infectious and autoimmune etiologies.

The impact of serum glucose on clinical outcomes in patients hospitalized with community-acquired pneumonia

PURPOSE

Community-acquired pneumonia (CAP) is a common medical condition resulting in excess morbidity, mortality, and high rates of hospitalization. Despite high hospitalization rates for CAP, the relationship between abnormal glucose levels (hyperglycemia and hypoglycemia) and the seriousness of the illness as measured by length of stay (LOS) is not well established. We examined relationships of CAP to multiple factors that impact predictability and severity of the disease process. They include glycemic control; hospital utilization, including LOS; 30-day hospital readmission; intensive care unit (ICU) admissions, adjusting for comorbidities; illness severity; and timing of antibiotic treatment.

METHODS

We conducted a retrospective observational cohort study of adult patients hospitalized for CAP between January 1, 1992 and June 23, 2007. Case screening was conducted electronically using International Classification of Diseases, 9th Revision (ICD-9) codes 480.0-487.9. Subsequent medical record abstraction yielded 969 qualifying cases with comprehensive data on past and current medical problems.

RESULTS

Serum glucose levels at admission were independently associated with LOS for CAP patients. Patients with levels between 90 mg/dL and 140 mg/dL on admission had shorter LOS compared to those with levels of < 90 mg/dL and > 140 mg/dL (median 3.9 vs 4.2 days, P = .04). Multivariate analyses confirmed the univariate results. Serum glucose levels at initial hospitalization were not associated with 30-day hospital readmission (P =.34) or ICU admission (P = .48).

CONCLUSIONS

Abnormal glucose levels are an independent predictor of increased LOS for CAP. Control of blood glucose may lead to improved outcomes, including shortened LOS, and should be a priority in CAP management.

Infectious disease and cancer

With the recent advances in molecular biology and genetics over the past several decades, we have grad-ually uncovered the elusive cause of some of the malignant diseases that have been, and continue to be, a major factor in human mortality. Infectious disease agents, so ubiquitous in our environment, have now become the most credible link in our search for the cause of cancer. The number of malignancies associated with specific infectious disease agents continues to grow and now represents approximately 20% of all cancers. This perspective represents a brief summary of those cancers that have been associated with or caused by infectious disease agents. Hopefully, knowledge of this relationship can be translated into more effective means of treatment.

New oral anticoagulants: a brief review

This manuscript represents a brief review of the current oral anticoagulants that have come on the scene over the past decade and that are now in various stages of development through the process of phase II and III clinical trials. A brief review of the oral thrombin and direct factor Xa inhibitors is presented to apprise the practicing clinician of the status of these new agents. Efficacy and safety issues are mentioned as they relate to each agent and the need for alternative agents to replace the vitamin K antagonists for long-term anticoagulation therapy. Although none of the agents discussed in the review have been approved for clinical use, data accumulated thus far from the clinical studies have provided some degree of encouragement and optimism for their future approval.

Extrahepatic portal hypertension following abdominal surgery

We present a case of non-cirrhotic extrahepatic portal hypertension in a 31-year-old woman following extensive abdominal laparotomy for the drainage of multiple retroperitoneal and liver abscesses following a perforated appendix. Chronic portal, splenic, and mesenteric vein thrombosis with portal hypertension was caused by a hypercoagulable state due to the abdominal infection and abdominal surgery. Various etiological aspects of chronic extraheptic venous thrombosis have not been documented due to the low incidence of these events. We discuss these aspects in the context of our patient.

A phase II trial of arsenic trioxide for relapsed and refractory acute lymphoblastic leukemia

We designed a phase II trial of arsenic trioxide (AT) for the treatment of relapsed and refractory acute lymphoblastic leukemia (ALL). The dose administered was 0.25 mg/kg/day intravenously for 5-7 days per week for up to 60 days. Of 11 patients eligible, eight had B-cell and three T-cell ALL and two were Philadelphia chromosome-positive. The median duration of therapy was 21 days (range 7-28). One patient died of an infection. There were no responses. Ten patients have died. The median survival was 3.2 months (range 1.2-4.1). We conclude that AT is not active in the treatment of ALL.

Recurrent venous thromboembolism in patients with and without anticoagulation after inferior vena caval filter placement

AIM

The aim of this study was to compare the rate of recurrent venothromboembolic (VTE) events and factors contributing to VTE events in patients with inferior vena caval (IVC) filters on chronic anticoagulation to those in whom anticoagulation was discontinued.

METHODS

Retrospective cohort study of 353 patients who received IVC filters between 1986 and 2002.

RESULTS

Anticoagulation status was available for 304 patients (132 on coumadin anticoagulation therapy and 172 who did not receive any anticoagulation therapy) whose IVC filters were placed within 30 days of their qualifying thromboembolic event. Two-year event-free survival for the anticoagulated group was 80.6% (95% confidence interval--CI--76.9, 84.3] and was 67.8% (95% CI 63.2, 72.3) for the non-anticoagulated group. Patients who had Greenfield filter had a higher, but not statistically significant different, rate of recurrence compared to those with other types of filters (hazard ratio 1.4; 95% CI 0.9, 2). The rate of recurrent VTE events was independent of age, gender, smoking status, or underlying medical condition.

CONCLUSIONS

Among those with IVC filters, long-term anticoagulation therapy prolonged event-free survival for up to 2 years but did not prevent recurrent VTE events.

Efficacy of the influenza vaccine in patients with malignant lymphoma

BACKGROUND

The benefits and efficacy of the influenza vaccine have been controversial and have had mixed reviews in the recent literature. Immunosuppressed patients and those receiving chemotherapy are particularly at risk for infectious complications and are therefore given high priority to receiving prophylactic vaccines.

METHOD

We administered the influenza vaccine to 29 patients with malignant lymphoma who were receiving chemotherapy or had recently completed therapy during the flu season of 2003-2004. An aged-matched control group received the same vaccine during the same period. The ability of both groups to mount a protective titer of antibodies to the antigens in the vaccine was measured.

RESULTS

Three of 29 patients (10%) in the lymphoma group were able to mount a 4-fold titer to at least one of the influenza A antigens. One patient developed a protective titer to both influenza A and B antigens and 3 of 29 responded to the influenza B antigen. In the control group 13 of 29 (45%) responded to an influenza A antigen and 14 of 29 (48%) had a 4-fold response to the B antigen. Seven of 29 controls (24%) had a 4-fold increase in their titers to both the A and B antigens.

CONCLUSIONS

This study confirmed the low incidence of response or efficacy to the influenza vaccine reported in previous studies. Only a small percentage (10%) of immunosuppressed patients with malignant lymphoma responded with a 4-fold increase in their antibody titer to the major antigens of the 2003 influenza vaccine. Most interestingly, less than 50% of the aged-matched control population studied responded with a 4-fold increase in their antibody titer. Additional studies are needed to determine methods for improving the efficacy of the vaccine and the effectiveness of the influenza vaccination program in preventing influenza infections in the United States.

Risk assessment model for venothromboembolism in post-hospitalized patients

AIM

Venothromboembolism (VTE) is an important condition in hospitalized patients accounting for significant morbidity and mortality, and the risk of VTE often continues post-hospitalization. Although risk assessment models have been developed to predict the risk of deep venous thrombosis (DVT) in hospitalized patients, no models have been developed that determine the risk of DVT during the post-hospitalization period. The objective of this study was to create a risk profile using risk factor assessment that could be used to predict which patients are at highest risk of developing DVT within 60 days following hospital discharge.

METHODS

The computerized medical records of 380 patients (190 with DVT and 190 without DVT) who received care from 1995-2002 and were subsequently re-hospitalized within 60 days of discharge were retrospectively reviewed. Univariate and multivariate logistic regression analyses were conducted to identify risk variables related to VTE. A novel risk assessment model was created using risk factors from the logistic regression analyses.

RESULTS

The prevalence of VTE was found to be 93.2% (69/74) in the high-risk category, 52.9% (109/206) in the moderate-risk category, and 12% (12/100) in the low-risk category.

CONCLUSIONS

Once validated, this risk assessment model may be applied to identify patients who may be at increased risk of developing VTE post-hospitalization. Those at high risk should be considered for anticoagulation therapy during the post-hospitalization period. Availability of a risk profile using risk factor assessment to guide decisions related to anticoagulation therapy will have important ramifications relative to patient outcomes including morbidity, mortality, and reductions in VTE-associated cost.

Auer rods galore! Acute promyelocytic leukemia

The diagnostic intracellular inclusions (Auer rods) found in this touch preparation of a core bone marrow biopsy helped provide basis for the diagnosis in this case. The patient, a 48-year-old man, presented with increasing fatigue and pancytopenia. A bone marrow biopsy demonstrated a marked increase in hypergranular, immature myeloid cells, as well as a plethora of Auer rods. The diagnosis was confirmed by cytogenetic studies which showed a C15:17 translocation [t(15:17)].

Disorders of flushing

Disorders of flushing encompass a broad spectrum of diverse acquired and inherited conditions. Chemical mediators involved in the flushing response are incompletely understood. Flushing episodes rarely can be associated with significant morbidity and mortality. The goal of the physician is to separate benign from potentially life-threatening conditions. Accurate diagnosis requires a thorough history and physical examination emphasizing the age of the patient, temporal association of flushing with occupation, environmental, stress, food, or drug exposure, and the duration of the episode. In some cases, despite a thorough evaluation, the etiology for flushing remains unknown. Understanding the distinct mechanisms that lead to flushing helps provide a rational approach to treatment.

Hypercoagulability and venous thromboembolism: a review

This review addresses the numerous factors that predispose individuals for venous thromboembolic events (VTE). Both acquired and genetically inherited factors are reviewed with their approximate relative risk of developing VTE. Oral contraceptive use and hormone replacement therapy, as well as the prevalence of VTE associated with pregnancy, are also addressed. Particular attention is directed to the frequency of more than 1 predisposing factor being present, further increasing the risk of VTE or its recurrence.

Hematologic and metabolic abnormalities in a patient with anorexia nervosa

Anorexia nervosa is a common problem in young adults that may present with a variety of metabolic and hematologic abnormalities, as well as weight loss and psychological disturbances. We present a young man with a long history of anorexia nervosa who developed pancytopenia associated with decreased bone marrow cellularity and abnormal architecture and marrow infiltration with an amorphous, gelatinous substance characteristic of anorexia nervosa. The patient also developed osteopenia with evidence of excessive calcium excretion. The pancytopenia and marrow function reverted to normal with therapeutic and dietary intervention. The effects of eating disorders can result in serious consequences with respect to an individual's health and well-being. A host of hematologic abnormalities that are associated with anorexia nervosa have the potential of increasing the risk of infection and bleeding. Additionally, because of the insidious development of anemia in some patients, decreased performance status and chronic fatigue can pose significant compromises in one's daily activities and work effort. Anorexia nervosa is a chronic illness that is distinctly more common in females than in males (ratio of 10 to 1), but can affect males in an equally debilitating manner, requiring multiple modalities of therapeutic intervention and consultation. We present the case of a male referred to the hematology department because of pancytopenia, chronic fatigue, and back pain. A diagnosis of anorexia nervosa had been made 10 years prior at the age of 18 years.

Tumor lysis syndrome (TLS) following fludarabine therapy for chronic lymphocytic leukemia (CLL): case report and review of the literature

Adenosine deaminase inhibitors have proven superior to alkylating agent-based therapies in inducing clinical and hematologic remissions in treated and previously untreated chronic lymphocytic leukemia (CLL) patients, and they have become increasingly accepted as a standard for therapy. We report the case of a 66-year-old patient with a 7-year history of CLL who had been previously treated with alkylating agents. Upon presentation with abdominal lymphadenopathy, a 5-day course of the nucleoside analogue, fludarabine, was administered. Two days after completion, the patient developed acute tumor lysis syndrome (TLS) that induced renal failure with hyperkalemia and hyperuricemia. This resulted in critical, life-threatening complications requiring hospitalization, aggressive hemodialysis and fluid replacement therapy. While only 5 other cases of TLS associated with fludarabine therapy have been reported since 1989, we recommend that adenosine deaminase inhibitor therapy be initiated with the addition of allopurinol, and that hydration with copious amounts of oral fluids during therapy be encouraged in order to help protect against the renal effects of potential TLS induced by these agents.

Regulation of colony-stimulating factor-induced human myelopoiesis by transforming growth factor-beta isoforms

Transforming growth factor-beta (TGF-beta) proteins are multifunctional regulators of cell growth and differentiation. The three isoforms, TGF-beta1, -beta2, -beta3 share approximately 70% identical amino acid sequence and are coded by three distinct genes. Growth and differentiation functions in which the isoforms have differential activity include: inhibition of colorectal cancer cell growth, migration of aortic endothelial cells, survival of ciliary ganglionic neurons, and binding to cell surface receptors. A previous paper reported that TGF-beta1 and TGF-beta2 had bimodal dose-dependent stimulatory and inhibitory effects on granulocyte-macrophage colony-stimulating factor induced Day 7 granulocyte-macrophage colony-forming units. The effects of TGF-beta3 were only inhibitory. At low concentrations, TGF-beta1 and -beta2 stimulated growth, whereas at higher concentrations both isoforms inhibited growth. We now report that TGF-beta1, TGF-beta2, and TGF-beta3 are similar to each other at low concentrations; at higher concentrations TGF-beta1 and TGF-beta3 inhibit growth, but TGF-beta2 stimulates growth. Our results are consistent with the known affinities of the TGF-beta isoforms with the Type II TGF-beta signaling receptor, which has greater affinity for TGF-beta1 and TGF-beta3 than TGF-beta2.

Activity involvement among suicidal and nonsuicidal high-risk and typical adolescents

The purpose of this study was to compare weekly activities among four groups of randomly selected high-risk and typical high school students: (1) potential dropouts at suicide risk, (2) typical youth at suicide risk, (3) potential dropouts not at suicide risk, and (4) typical youth not at suicide risk. Of the 1,286 participants, 39.4% of the high-risk and 30.1% of typical high school students screened in at suicide risk. Weekly activity comparisons across the four groups showed that suicide-risk adolescents, regardless of potential dropout status, engaged in more solitary activities on weekdays and weekends than did their nonsuicide risk peers. High-risk potential dropout youth engaged in less homework and more social activities during weekdays and weekends than did the typical high school students. These results provide important insight into the weekly activity involvement of at-risk youth while helping to gain a better understanding of suicide-risk adolescents. Implications of these findings are discussed for identifying youth at risk for suicidal behavior and for prevention programming.

Approach to diagnosing lower extremity edema

Edema, a sign of a localized or systemic disease process, results from a disruption in the normal physiological forces controlling extracellular fluid volume. This review utilizes an anatomical approach in discussing the various causes of edema.