Coney Island Hospital

OBJECTIVE: To estimate the incidence of tympanostomy tube sequelae based on systematic review of published case series and randomized studies. DATA SOURCES: English-language MEDLINE search from 1966 through April 1999 with manual reference search of proceedings, articles, reports, and guidelines. STUDY SELECTION: Cohort studies with otitis media as the primary indication for tube placement. DATA EXTRACTION: Two reviewers independently extracted data from 134 articles. DATA SYNTHESIS: Transient otorrhea occurred in 16% of patients in the postoperative period and later in 26%; recurrent otorrhea occurred in 7.4% of patients and chronic otorrhea in 3.8%. Sequelae of indwelling tubes included obstruction (7% of ears), granulation tissue (5%), premature extrusion (3.9%), and medial displacement (0.5%). Sequelae after tube extrusion included tympanosclerosis (32%), focal atrophy (25%), retraction pocket (3.1%), cholesteatoma (0.7%), and perforation (2.2% with short-term tubes, 16.6% with long-term tubes). Meta-analysis showed that long-term tubes increased the relative risk of perforation by 3.5 (95% CI, 1.5 to 7.1) and cholesteatoma by 2.6 (95% CI, 1.5 to 4.4). Similarly, intubation increased the relative risk of tympanosclerosis by 3.5 (95% CI, 2.6 to 4.9) and focal atrophy by 1.7 (95% CI, 1.1 to 2.7) over nonintubated control ears (baseline tympanosclerosis and atrophy rates of 10% and 14%, respectively). CONCLUSIONS: Sequelae of tympanostomy tubes are common but are generally transient (otorrhea) or cosmetic (tympanosclerosis, focal atrophy). Nonetheless, the high incidence suggests a need for ongoing otologic surveillance of all patients with indwelling tubes and for a reasonable time period after tube extrusion. Long-term tubes should be used on a selective and individualized basis.

Morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer is gaining momentum as evidence strengthens the clinical relevance of this immunological biomarker. TILs in the post-neoadjuvant residual disease setting are acquiring increasing importance as a stratifying marker in clinical trials, considering the raising interest on immunotherapeutic strategies after neoadjuvant chemotherapy. TILs in ductal carcinoma in situ, with or without invasive carcinoma, represent an emerging area of clinical breast cancer research. The aim of this report is to update pathologists, clinicians and researchers on TIL assessment in both the post-neoadjuvant residual disease and the ductal carcinoma in situ settings. The International Immuno-Oncology Working Group proposes a method for assessing TILs in these settings, based on the previously published International Guidelines on TIL Assessment in Breast Cancer. In this regard, these recommendations represent a consensus guidance for pathologists, aimed to achieve the highest possible consistency among future studies.

OBJECTIVE/HYPOTHESIS: Data from cohort studies and untreated groups in randomized controlled trials can be identified through systematic literature review and synthesized with meta-analysis to estimate natural history of acute otitis media (AOM) and otitis media with effusion (OME). STUDY DESIGN: Systematic literature review and meta-analysis. METHOD: Source articles were identified by MEDLINE search through August 2002 plus manual crosschecks of bibliographies and published meta-analyses. Data were abstracted independently by two investigators and combined with random effects meta-analysis to estimate spontaneous resolution, 95% confidence intervals (CI), and heterogeneity. Sensitivity analysis was performed. RESULTS: Sixty-three articles met inclusion criteria. AOM symptoms improved within 24 hours without antibiotics in 61% of children (95% CI, 50-72%), rising to 80% by 2 to 3 days (95% CI, 69-90%). Suppurative complications were comparable if antibiotics were withheld (0.12%) or provided (0.24%). Children entered recurrent AOM trials with a mean rate of 5.5 or more annual episodes but averaged only 2.8 annual episodes while on placebo (95% CI, 2.2-3.4). No AOM episodes occurred in 41%, and only 17% remained otitis prone (3 or more episodes). OME after untreated AOM had 59% resolution by 1 month (95% CI, 50-68%) and 74% resolution by 3 months (95% CI, 68-80%). OME of unknown duration had 28% spontaneous resolution by 3 months (95%, CI 14-41%), rising to 42% by 6 months (95% CI, 35-49%). In contrast, chronic OME had only 26% resolution by 6 months and 33% resolution by 1 year. CONCLUSIONS: The natural history of otitis media is very favorable. Combined estimates of spontaneous resolution provide a benchmark against which to judge new or established interventions. The need for surgery in children with recurrent AOM or chronic OME should be balanced against the likelihood of timely spontaneous resolution and the potential risk of learning, language, or other adverse sequelae from persistent middle ear effusion. Further research is needed to identify prognostic factors that can target children unlikely to improve spontaneously for earlier intervention.

To assess the efficacy of supervised disulfiram as an adjunct to out-patient treatment of alcoholics, a randomised, partially blind, six-month follow-up study was conducted in which 126 patients received 200 mg disulfiram or 100 mg vitamin C under the supervision of a nominated informant. In the opinion of the (blinded) independent assessor, patients on disulfiram increased average total abstinent days by 100 and patients on vitamin C by 69, thus enhancing by one-third this measure of treatment outcome. Mean weekly alcohol consumption was reduced by 162 units with disulfiram, compared with 105 units with vitamin C, and the disulfiram patients reduced their total six-month alcohol consumption by 2572 units compared with an average reduction of 1448 units in the vitamin C group. Serum gamma-GT showed a mean fall of 21 IU/I in patients on disulfiram but rose by a mean of 13 IU/I with vitamin C. Unwanted effects in the disulfiram group led to a dose reduction in seven patients and to treatment withdrawal in four (and in one vitamin C patient). Two-thirds of the disulfiram group asked to continue the treatment at the end of the study. There were no medically serious adverse reactions.

We reviewed the long-term natural history of 21 adult-onset Still's disease patients. Patient subsets were identified according to clinical course patterns. These included monocyclic systemic disease in 4, polycyclic systemic disease in 2, chronic articular monocyclic systemic disease in 10, and chronic articular polycyclic systemic disease in the remaining 5 patients. Functional outcome differed according to course patterns and the extent of articular involvement. Systemic manifestations, per se, did not contribute to poor functional prognosis. Chronic articular disease had the worst outcome: 27% evolved to functional class III status, compared with none in the cyclic systemic groups. Those patients who had a chronic articular pattern or a polyarticular onset and course were at higher risk to develop disabling arthritis. An aggressive approach to therapy, including the early use of remittive agents, should be considered in these patient subsets.

Among 257 isolates of Klebsiella pneumoniae collected in Brooklyn, NY, 24% were found to possess bla(KPC). Clinical microbiology laboratories that used automated broth microdilution systems reported 15% of the KPC-possessing isolates as susceptible to imipenem. The imipenem MIC was found to be markedly affected by the inoculum. For accurate detection of KPC-possessing K. pneumoniae, particular attention should be paid to proper inoculum preparation for broth-based susceptibility methods. In addition, using ertapenem or meropenem for class reporting of carbapenem susceptibility will improve detection.

ABSTRACT A highly sensitive specific radioimmunoassay (RIA) method for the measurement of arginine vasopressin (AVP) is described. The sensitivity of the assay is 0.1 pg/ml. A simple extraction technique from plasma is described with a consistent recovery of about 65–70%, and without alteration in the immunoreactivity of the extracted hormone. AVP levels, uncorrected for recovery, ranged between 1.3 and 8.5 pg/ml (mean 3.7 pg/ml) in humans after 12–25 hr of water deprivation, and were consistently less than 1.2 pg/ml after water loading. AVP levels were undetectable in 6 patients with diabetes insipidus. Smoking was followed by up to several hundred-fold increases in plasma AVP. Plasma AVP levels in animals also rose with dehydration, increased plasma hypertonicity and hypovolemia and fell with hydration.

OBJECTIVE: To test the safety and efficacy of fluoxetine in patients with renal failure on dialysis. METHOD: Fourteen patients with major depression and end stage renal disease on hemodialysis were randomized into two groups for an eight-week study. Subjects as well as investigators were blinded as to which subject received fluoxetine and which placebo. Patients were carefully monitored concerning adverse events, serum fluoxetine and norfluoxetine levels, and psychological measurements of degree of depression. RESULTS: No patients discontinued treatment because of adverse events, all of which were minor. All psychological tests showed improvement in depression at the four-week and eight-weeks point, although statistical significance could only be demonstrated at the fourth week of this study. All patients in the active group had serum plasma concentrations of fluoxetine and norfluoxetine less than 250 ng/ml at eight weeks, similar to levels in patients with normal renal function in a previous open label study. CONCLUSIONS: This study confirms the relative safety of fluoxetine in depressed patients in renal failure on hemodialysis. It also suggests that fluoxetine may be efficacious in depressed patients on dialysis.

OBJECTIVES: To review and evaluate the role of vitamin D in autoimmune diseases based on current studies. METHOD: We searched PubMed using keywords such as 'vitamin D', 'autoimmune disease', and 'autoimmunity'. We compiled and reviewed various studies including prospective cohorts, cross-sectional studies, longitudinal evaluations, genetic studies, and experimental models that investigated the role of vitamin D in autoimmune diseases. RESULTS: There is evidence based on these various studies that several key autoimmune diseases are modulated by vitamin D. These diseases include, but are not limited to, multiple sclerosis (MS), scleroderma or systemic sclerosis (SSc), autoimmune thyroid diseases, rheumatoid arthritis (RA), and primary biliary cirrhosis (PBC). CONCLUSIONS: Although there is evidence for vitamin D as a factor in the pathophysiology of autoimmune diseases, the mechanism for this association has yet to be elucidated. Additional data are needed to corroborate these findings.

Nocturnal sleep EEG stages and concomitant plasma growth hormone (GH) and cortisol concentrations were examined in subjects with endogenous or exogenous elevation of plasma corticosteroid or ACTH concentrations, and in patients with hypothalamic tumors. These studies were designed to determine whether central nervous system (CNS) function was uniquely altered in Cushing's disease, independent of the effects of hypercortisolemia per se. Marked reductions of sleep EEG stages III-IV and of the nocturnal GH rise were present in 4 treated (remission 5 months to 2 yr) and 6 untreated patients with Cushing's disease (clinically active 2 months to 10 yr duration) as well as in 4 “eu-corticoid” patients with hypothalamic tumors. In contrast, similar EEG and hormonal changes, present in a patient with Cushing's syndrome secondary to an adrenal adenoma, returned to normal 16 months following removal of the adenoma. These findings suggest that altered CNS function may be involved in the pathophysiology of Cushing's disease. The return of normal percentages of Stages III-IV sleep and normal nocturnal growth hormone increments following removal of the adrenal adenoma, suggest, however, that cortisol excess plays some role in the observed sleep EEG and GH changes. Suppression of Stage III-IV sleep in the patient with the adrenal adenoma prior to treatment, and lack of suppression in patients receiving chronic prednisone therapy (15–60 g. daily for 4 months to 10 yr) suggests either differential effects of synthetic and natural steroids, or different effects of intermittent exogenous steroid therapy as compared to continuous endogenous secretion. Normal sleep EEG stages in 4 patients with Cushing's disease who subsequently developed Nelson's syndrome also suggests a possible role for ACTH in the genesis of sleep EEG stages.

Natural language processing (NLP) aims to program machines to interpret human language as humans do. It could quantify aspects of medical education that were previously amenable only to qualitative methods. The application of NLP to medical education has been accelerating over the past several years. This article has three aims. First, we introduce the reader to NLP. Second, we discuss the potential of NLP to help integrate FOAM (Free Open Access Medical Education) resources with more traditional curricular elements. Finally, we present the results of a systematic review. We identified 30 articles indexed by PubMed as relating to medical education and NLP, 14 of which were of sufficient quality to include in this review. We close by discussing potential future work using NLP to advance the field of medical education in emergency medicine.

The distribution of thyroid hormones between free solution and their several protein-binding sites during pregnancy was studied under physiological conditions of temperature and pH. Single serum specimens were obtained from individual women at different stages of pregnancy. During the first 5 weeks of pregnancy, mean serum free T4 and free T3 concentrations were 50% higher than in nonpregnant women or women during the third trimester. Free T4 was increased significantly throughout the first trimester, but because of wide variance, free T3 was significantly above control values only during the first 5 weeks. Free T4 and free T3 concentrations decreased to control levels in the third trimester. These changes in free T4 concentrations are consistent with a weak thyrotropic action of hCG, which attained maximal concentrations early in the first trimester and then decreased markedly in the second and third trimesters. TRH testing of women scheduled for abortion in the first and second trimesters revealed marked inhibition of TSH response to TRH in those first trimester women who had elevated free T4 concentrations. The percent free T4 did not decrease during the first 5 weeks, but then declined progressively to term as T4-binding globulin (TBG) affinity, defined as the product of the capacity and affinity constant, progressively increased. T4 bound to TBG (T4-TBG) increased from early in the first trimester to term, and then decreased in postterm pregnancy and postpartum. T4 bound to prealbumin (T4-PA) and to albumin (T4-Alb) decreased significantly in the third trimester compared with either control or first trimester concentrations. The concentration of free T3 was positively correlated with T4-PA (r = 0.25) and T4-Alb (r = 0.31), but not with free T4 (r = 0.18) or T4-TBG (r = -0.30) concentrations. These results suggest that 1) only the high concentrations of hCG present in the first trimester of pregnancy have a thyrotropic effect in excess of normal levels of TSH, and this can be sufficient to suppress the TSH response to TRH; 2) hepatic TBG secretion continues to respond to the continuously rising estrogen levels throughout pregnancy; and 3) T4-PA and T4-Alb, but not free T4 or T4-TBG, are possible precursors for the extrathyroidal generation of T3.

UNLABELLED: Emergency contraception (EC) is the use of a method of contraception after unprotected intercourse to prevent unintended pregnancy. Although first described over 20 years ago, physician awareness of EC has been limited and many feel uncomfortable prescribing it. OBJECTIVE: To assess the knowledge, attitudes, and opinions of practicing pediatricians regarding the use of EC in adolescents. METHODS: An anonymous questionnaire was mailed to all 954 active members of New York Chapter 2, District II of the American Academy of Pediatrics. The questionnaire assessed basic knowledge, attitudes, and opinions regarding EC in adolescents. Data were analyzed by physician age, gender, year completed residency, and practice type. RESULTS: Two hundred thirty-three practicing pediatricians (24.4%) completed the survey. Of the respondents, 23.7% had been asked to prescribe EC to an adolescent and 49% of these cases involved a rape victim. Only 16.7% of pediatricians routinely counsel adolescent patients about the availability of EC, with female pediatricians more likely to do so. Most respondents (72.9%) were unable to identify any of the Food and Drug Administration-approved methods of EC. Only 27.9% correctly identified the timing for its initiation and only 31.6% of respondents felt comfortable prescribing EC. Inexperience with use was cited as the primary reason for not prescribing EC by 70% of respondents. Twelve percent cited moral or religious reasons and 17% were concerned about teratogenic effects. There were no differences in comfort level based on age, gender, or practice type. Twenty-two percent of respondents believed that providing EC encourages adolescent risk-taking behavior and 52.4% would restrict the number of times they would dispense EC to an individual patient. A minority of respondents (17%) believed that adolescents should have EC available at home to use if necessary and only 19.6% believed that EC should be available without a prescription. The vast majority (87.5%) were interested in learning more about EC. CONCLUSIONS: Despite the safety and efficacy of EC, the low rate of use is of concern. Pediatricians are being confronted with the decision to prescribe EC but do not feel comfortable prescribing it because of inadequate training in its use. Practicing pediatricians are aware of their lack of experience and are interested in improving their knowledge base.

Malaria continues to be a cause of high mortality and morbidity. Imported cases of malaria are increasing in New York City. Yet, New York physicians, when evaluating patients for fever, frequently missed the diagnosis of malaria. We evaluated the role of platelet count for predicting malarial infection. The study included patients seen between 1996 and 2000 in a New York community hospital for fever who had traveled to a malaria-endemic area. Forty patients with malaria were identified. Our study found the sensitivity of platelet count for diagnosing malaria was 100%, and the specificity was 70%. The negative predictive value was 100% and the positive predictive valve was 86%. Hence, we propose that in any patient with fever and recent travel history, platelet count is an important clue to the diagnosis of malaria. A finding of thrombocytopenia should increase the suspicion of malaria and lead to performance of more specific tests, including multiple peripheral smears and ELISA for parasite-specific antigen, etc.

BACKGROUND: Elevated histone deacetylase (HDAC) isoenzyme levels have been described in patients with carcinomas and leukemias. HDAC inhibitors (HDACi) have shown promise in the treatment of carcinomas and are currently under intense research. To make better use of HDACi in treating chronic lymphocytic leukemia (CLL), HDAC isoenzyme levels were studied. METHODS: Quantitative reverse transcriptase polymerase chain reaction for HDAC isoenzyme was measured in 32 patients with CLL and compared with 17 normal volunteer controls. ZAP-70, CD38 and CD44 were also assayed and correlated to HDAC isoenzyme levels. RESULTS: The results showed: (1) HDAC isoenzyme levels in CLL were significantly increased in class I including HDAC1 and HDAC3, in class II including HADC6, HDAC7, HDAC9 and HDAC10, and in class III including SIRT1 and SIRT6; (2) higher expression of HDAC isoenzyme levels was found in ZAP-70+ compared to ZAP-70- patients, and CD44 expression levels were correlated with HDAC isoenzyme expression levels in the majority of HDAC classes. CONCLUSIONS: These results suggest: (1) in CLL, elevated HDAC isoenzyme activity is not restricted to one class, and therefore, HDACi therapy may need to be directed to more than one specific class of HDAC; (2) higher HDAC expression activity may indicate a poor prognosis and more advanced disease stage (through indirect evidence), since higher values were found in patients with ZAP-70+ and higher CD44 expression levels.

Despite 30 years of advocacy, the prevalence of non-therapeutic female genital alteration (FGA) in minors is stable in many countries. Educational efforts have minimally changed the prevalence of this procedure in regions where it has been widely practiced. In order to better protect female children from the serious and long-term harms of some types of non-therapeutic FGA, we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia. We offer a revised categorisation for non-therapeutic FGA that groups procedures by effect and not by process. Acceptance of de minimis procedures that generally do not carry long-term medical risks is culturally sensitive, does not discriminate on the basis of gender, and does not violate human rights. More morbid procedures should not be performed. However, accepting de minimis non-therapeutic f FGA procedures enhances the effort of compassionate practitioners searching for a compromise position that respects cultural differences but protects the health of their patients.

OBJECTIVE: Several therapeutic agents have been assessed for the treatment of COVID-19, but few approaches have been proven efficacious. Because leukotriene receptor antagonists, such as montelukast have been shown to reduce both cytokine release and lung inflammation in preclinical models of viral influenza and acute respiratory distress syndrome, we hypothesized that therapy with montelukast could be used to treat COVID-19. The objective of this study was to determine if montelukast treatment would reduce the rate of clinical deterioration as measured by the COVID-19 Ordinal Scale. METHODS: We performed a retrospective analysis of COVID-19 confirmed hospitalized patients treated with or without montelukast. We used "clinical deterioration" as the primary endpoint, a binary outcome defined as any increase in the Ordinal Scale value from Day 1 to Day 3 of the hospital stay, as these data were uniformly available for all admitted patients before hospital discharge. Rates of clinical deterioration between the montelukast and non-montelukast groups were compared using the Fisher's exact test. Univariate logistic regression was also used to assess the association between montelukast use and clinical deterioration. A total of 92 patients were analyzed, 30 who received montelukast at the discretion of the treating physician and 62 patients who did not receive montelukast. RESULTS: = 0.022). Our findings suggest that montelukast associates with a reduction in clinical deterioration for COVID-19 confirmed patients as measured on the COVID-19 Ordinal Scale. CONCLUSIONS: Hospitalized COVID-19 patients treated with montelukast had fewer events of clinical deterioration, indicating that this treatment may have clinical activity. While this retrospective study highlights a potential pathway for COVID-19 treatment, this hypothesis requires further study by prospective studies.

OBJECTIVE: The objectives were (1) to compare the morbidity and mortality of patients with hip fractures surgically repaired within and after 48 hours of the occurrence of fracture and (2) to establish whether timing of repair alone had a major role in determining how the patients fared after the surgical repair or whether comorbidities also affected outcomes. SAMPLE: The study involved the medical records of 49 patients (aged 51 to 99 years) admitted to Coney Island Hospital between January 2003 and January 2004 with a primary diagnosis of hip fracture who underwent surgical repair. DESIGN: Analysis of data was done by retrospective chart review of patients admitted with the diagnosis of hip fracture to an acute care hospital setting. Follow-up continued until the patients were transferred to a rehabilitation facility for physical or occupational therapy after surgery. OUTCOME MEASURES: The preoperative health status of each patient was assessed by cardiopulmonary risk index score, based on comorbid conditions, and postoperative outcome was determined by complications (such as bed sores, pneumonia, urinary tract infection, deep vein thrombosis, or pulmonary embolism) or death. RESULTS: Patients who underwent early surgical repair (within 48 hours) had fewer postoperative complications (14.7%, as compared with 33.3% in the group undergoing surgery >48 hours after fracture). CPRI scores in the early and delayed surgery groups were also compared with regard to postoperative mortality and morbidity. It appeared that there was a higher statistical correlation between CPRI scores and complications among patients in the early surgery group (P=0.39) and an insignificant correlation among patients in the delayed surgery group (P=0.07). CONCLUSION: Surgical repair of hip fractures within the first 48 hours was associated with better health outcomes in a nationally representative sample, as observed in an acute care facility, irrespective of comorbid conditions.

BACKGROUND: The rising prevalence of obesity and metabolic syndrome (MetS) has received increased attention since both place individuals at risk for Type II diabetes and cardiovascular disease. Insulin resistance (IR) has been implicated in the pathogenesis of obesity and MetS in both children and adults and is a known independent cardiovascular risk factor. However measures of IR are not routinely performed in children while MetS or severe obesity when present, are considered as clinical markers for IR. OBJECTIVE: The study was undertaken to assess the utility of ATPIII defined metabolic syndrome (MetS) and severe obesity as predictors of insulin resistance (IR) in a group of 576 overweight children and adolescents attending a pediatric obesity clinic in Brooklyn. METHODS: Inclusion criteria were children ages 3-19, and body mass index > 95th percentile for age. MetS was defined using ATP III criteria, modified for age. IR was defined as upper tertile of homeostasis model assessment (HOMA) within 3 age groups (3-8, n = 122; 9-11, n = 164; 12-19, n = 290). Sensitivity, specificity, positive predictive values and odds ratios (OR) with 95% confidence intervals (CI) were calculated within age groups for predicting IR using MetS and severe obesity respectively. RESULTS: MetS was present in 45%, 48% and 42% of the respective age groups and significantly predicted IR only in the oldest group (OR = 2.0, 95% CI 1.2, 3.4; p = .006). Sensitivities were <55%; specificities <63% and positive predictive values < or = 42% in all groups. Severe obesity was significantly associated with IR in both the 9-11 (p = .002) and 12-18 (p = .01) groups but positive predictive values were nonetheless < or = 51% for all groups. CONCLUSION: The expression of IR in overweight children and adolescents is heterogeneous and MetS or severe obesity may not be sufficiently sensitive and specific indicators of insulin resistance. In addition to screening for MetS in overweight children markers for IR should be routinely performed. Further research is needed to establish threshold values of insulin measures in overweight children who may be at greater associated risk of adverse outcomes whether or not MetS is present.

PPARgamma is a therapeutic target that has been exploited for treatment of type II diabetes mellitus (T2DM) with agonist drugs. Since PPARgamma is expressed by many hematopoietic, mesodermal and epithelial cancers, agonist drugs were tested and shown to have both preclinical and clinical anticancer activities. While preclinical activity has been observed in many cancer types, clinical activity has been observed only in pilot and phase II trials in liposarcoma and prostate cancer. Most studies address agonist compounds, with substantially fewer reports on anticancer effects of PPARgamma antagonists. In cancer model systems, some effects of PPARgamma agonists were not inhibited by PPARgamma antagonists, suggesting noncanonical or PPARgamma-independent mechanisms. In addition, PPARgamma antagonists, such as T0070907 and GW9662, have exhibited antiproliferative effects on a broad range of hematopoietic and epithelial cell lines, usually with greater potency than agonists. Also, additive antiproliferative effects of combinations of agonist plus antagonist drugs were observed. Finally, there are preclinical in vivo data showing that antagonist compounds can be administered safely, with favorable metabolic effects as well as antitumor effects. Since PPARgamma antagonists represent a new drug class that holds promise as a broadly applicable therapeutic approach for cancer treatment, it is the subject of this review.