North Shore-Long Island Jewish Health Research Articles

The Correlation of APOBEC Gene Family Member Expression with Worse CLL Patient Outcome Suggests a Role in CLL Mutational Evolution

A mutational signature consistent with APOBEC (apolipoprotein B mRNA editing enzyme, catalytic polypeptide) activity has been identified in somatic mutations found in large-scale surveys of ultra-deep sequencing data from many human cancers including chronic lymphocytic leukemia (CLL). APOBEC is a cytidine deaminase family made up of eleven genes, including AID (activation-induced cytidine deaminase) and APOBEC3B, both of which have been implicated in somatic mutation in various cancers, including CLL. These observations have led to the hypothesis that APOBEC cytidine deaminases may be driving somatic mutations leading to the development of more aggressive cancers. Therefore, we examined APOBEC gene family member RNA expression levels in CLL to test for correlations with expression levels and patient outcome. We further examined if CLL cells generated de novo APOBEC family member mutational patterns in the immunoglobulin variable region gene (IGHV) after implantation in a mouse xenograft model of CLL.CLL peripheral blood mononuclear cells (PBMCs) and associated clinical data were collected from patients after informed consent as approved by the Institutional Review Board at the North Shore-Long Island Jewish Health System and in accordance with the Helsinki Declaration. CLL samples were chosen based on availability with no pre-established inclusion/exclusion criteria. CLL RNA expression levels were examined by microarray or quantitative real-time PCR (qPCR). For microarray studies, CLL B cells were purified prior to RNA isolation and acquisition of microarray expression data using Illumina Human WG6 and HT12 bead chips, followed by quantile normalization using GenomeStudio software (Illumina). For qPCR, RNA expression from CLL PBMCs was measured relative to glyceraldehyde 3-phosphate dehydrogenase gene expression by Taqman assay with Roche UPL probes and LightCycler 480. To examine de novo mutations in CLL, the IGHV region was ultra-deep sequenced (Roche 454 FLX system) from human CLL cells recovered from the NOD/Shi-scid,γcnull (NSG) xenograft mouse model of CLL as approved by the Institutional Animal Care and Use Committee at the North Shore-Long Island Jewish Health System.CLL patient (N = 65) RNA expression by microarray showed very low levels of APOBEC1, 2, 3A, 3B, 3D, 4, and AID, modest levels of APOBEC3C and 3H, and high levels of APOBEC3F and 3G. Higher AID expression levels significantly correlated (P <0.05) with shorter time to first treatment (TFT), which was anticipated based on previous reports. Interestingly APOBEC3B and APOBEC3F expression differences showed possible trends correlating with worse patient outcome. Therefore, we tested select APOBEC gene family members by qPCR. For qPCR, we utilized the CLL patient cohort (N= 83) previously found to indicate that AID expression was a risk factor for worse patient outcome in a multivariate analysis (Patten et al. 2012 Blood 120:4802). RNA expression by qPCR followed the same pattern as the microarray data: AID and APOBEC3B had very low levels, APOBEC3H had modest levels, and APOBEC3F and 3G had high levels. Similar to AID, patients could be grouped based on the presence or absence of detectable APOBEC3B, with its presence showing a significant correlation (P <0.05) with worse TFT and overall survival. Higher levels of APOBEC3F and 3H showed a trend towards a correlation with shorter TFT, while differences in APOBEC3G expression had no significant correlation with patient outcome. Thus, not only did we confirm the correlation of AID expression with worse patient outcome, but we also found APOBEC3B and potentially APOBEC3F and 3H correlate with worse patient outcome.To test if CLL cells can acquire de novo mutations indicative of APOBEC gene family member activity, human CLL cells were transferred into NSG mice. After CLL cells proliferated for 4-14 weeks in this xenograft model, the IGHV region was amplified, ultra-deep sequenced, and analyzed for specific mutational characteristics of various APOBEC gene family members. The results of these ongoing analyses will be presented.In conclusion, the expression levels of the APOBEC gene family members AID, APOBEC3B, and potentially APOBEC3F and 3H, correlate with worse patient outcome. These data are consistent with the hypothesis that APOBEC gene family member activity may promote new mutations at sites outside the IG gene loci leading to the evolution of aggressive CLL. DisclosuresBarrientos:Pharmacyclics, Celgene, and Genentech: Membership on an entity's Board of Directors or advisory committees; Gilead, Pharmacyclics, and AbbVie: Research Funding.

The successful treatment of a recurrent intracranial, dural-based plasmacytoma with lenalidomide

A 75 year old woman presented in October of 2008 with new onset symptoms of headaches, difficulty with penmanship, forgetfulness and vertigo. Her past medical history includes sarcoidosis and osteoporosis. As a result of the sarcoidosis, she has chronic interstitial pulmonary fibrosis but refused treatment with chronic steroids. The physical exam was unremarkable and her Karnofsky performance status was 80. She was evaluated for vestibular abnormalities and a magnetic resonance imaging (MRI) with and without gadolinium was obtained. This demonstrated an enhancing extra-axial, dural-based mass in the high biparietal region, measuring 3.0 cm 9 6.6 cm in the axial plane and encasing the superior sagittal sinus. This was initially thought to represent a meningioma. She underwent a stereotactic biopsy of the mass. The Haematoxylin & Eosin (HE whereas the majority of cells were positive for EMA, and all were strongly positive for MUM-1 (Fig. 1b–d). IHC stains were strongly positive for kappa light chains and negative for lambda chains demonstrating the clonality of the plasma cells in the specimen (Fig. 1e, f). Both serum and urine immunofixation showed no evidence of a monoclonal protein. Serum free light chain ratio was also normal. The blood counts, serum creatinine and calcium are normal. A bone marrow biopsy revealed no evidence of a plasma cell dyscrasia and a skeletal survey showed no destructive lytic lesions, thus effectively ruling out multiple myeloma. Due to the solitary location of the tumor, she was treated with image-modulated radiation therapy (IMRT) in November of 2008, receiving a total of 4,500 cGy. Following this treatment, her MRI normalized and her symptoms improved including the resolution of her headaches. In August 2009, a repeat MRI revealed a new area of dural thickening in a region that had not previously received radiotherapy. She received a second course of IMRT of 4,500 cGy in 25 fractions in September of 2009. A post-treatment MRI showed another complete response. In June 2010, an MRI revealed a new, third homogeneously enhancing lesion measuring approximately 5.3 cm in cranial-caudal dimension (Fig. 2a). Due to the extent of prior radiation therapy and her advanced age, alternatives to radiotherapy were considered in an attempt to avoid excessive neurotoxicity. Given the dural nature of the lesion, it was thought that systemic therapy could access and treat the lesion. A previously published study evaluated the use of low dose dexamethasone combined with lenalidomide (Revlimid ; Celgene Corp., Summit, NJ) for multiple myeloma, and demonstrated an improved time to progression and overall C. E. Devoe (&) Monter Cancer Center, Hofstra North Shore-LIJ School of Medicine, North Shore-Long Island Jewish Health System, 450 Lakeville Road, Lake Success, NY 11042, USA e-mail: CDevoe@NSHS.edu

Olanzapine for the Treatment of Psychiatric Illness and Urticaria: A Case Report

Received September 3, 2013; revised March 16, 2014; accepted March 17, 2014. FromDepartment of Psychiatry, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, NY. Send correspondence and reprint requests to Yankel J. Girshman, DO, Department of Psychiatry, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, NY 11004; e-mail: ygirshman@nshs.edu & 2014TheAcademy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Introduction

Schizophrenia: mechanism of action of current and novel treatments.

Article Abstract Click to enlarge page Antipsychotics are effective for managing the positive symptoms of schizophrenia. When prescribing these agents, clinicians should consider pharmacokinetics, pharmacodynamics, and the interaction between the drug and the individual patient's unique genetics, age, disease variables, and environment. All antipsychotics are D2 receptor-antagonists; however, only 1 of the 6 dopamine pathways in the brain is implicated in psychosis. Dopamine blockade in the other pathways can cause a wide range of side effects, and unfortunately, a medication cannot target only 1 dopamine pathway. Therefore, other strategies, such as agents that also act at other neurotransmitter systems, could be used to balance D2 blockade in the other 5 pathways. Aiming at a novel treatment target, N-methyl-d-aspartate (NMDA) receptors, may also help to mediate the downstream release of dopamine as well as other neurotransmitters, such as glutamate and γ-aminobutyric acid (GABA), which are thought to be involved in the pathophysiology of schizophrenia. Because noncompetitive NMDA receptor agonists, such as ketamine and phencyclidine (PCP), induce schizophrenia-like positive, negative, and cognitive symptoms, dysfunctional NMDA receptor-mediated neurotransmission in the glutamate pathway may underlie the pathogenesis of schizophrenia. From the Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks; the Department of Psychiatry, Hofstra North Shore-Long Island Jewish School of Medicine, Hempstead; and Behavior Health Services, North Shore-Long Island Jewish Health System, New Hyde Park, New York (Dr Kane); and the Recognition and Prevention Program (RAP), The Zucker Hillside Hospital, Glen Oaks; the Department of Psychiatry and Molecular Medicine, Hofstra-North Shore-Long Island Jewish School of Medicine, Hempstead; and the Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York (Dr Correll).†‹

Commentary on “Off-clamp vs. complete hilar control laparoscopic partial nephrectomy: Comparison by clinical stage.” Rais-Bahrami S, George AK, Herati AS, Srinivasan AK, Richstone L, Kavoussi LR, Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, NY: BJU Int 2012;109(9):1376–81 (Epub 2011 Oct 12)

Study type-therapy (case series). Level of evidence 4. What's known on the subject? And what does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp (OC) laparoscopic partial nephrectomy (LPN) have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated OC LPN for tumors with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared with a contemporary cohort of standard LPN with complete hilar clamping performed by a single surgeon. To compare the operative outcomes and oncological efficacy of OC LPN vs. complete hilar control (HC) LPN for stage T1a-T2 renal cell carcinoma. Retrospective review of all LPNs between June 2006 and March 2010 was performed, stratifying 390 patients by clinical T stage (cT1a = 313, cT1b = 62, cT2 = 15). Perioperative and postoperative parameters were analyzed comparing patients who underwent OC LPN (n = 126) with those who had HC LPN (n = 264) collectively and within each clinical stage cohort. There was no significant difference in the proportion of OC LPN for cT1a tumors compared with cT1b and cT2, P = 0.21. OC vs. HC LPN patients had a greater estimated blood loss but with no significant difference in perioperative blood transfusion rates. When compared by clinical stage, estimated blood loss was greater only for clinical stage T1a disease (P = 0.02) but not cT1b (P = 0.91) or cT2 (P = 0.42) tumors. There was no difference in the operative time or length of hospitalization between OC and HC LPN by stage: cT1a (P = 0.77 and P = 0.17), cT1b (P = 0.77 and P = 0.07) and cT2 (P = 0.42 and P = 0.66), respectively. In our series, 1 case (0.3%) of HC LPN had a positive margin on final pathology, 1 case was converted to open partial nephrectomy (0.3%), and 2 cases of OC LPN (1.6%) were intraoperatively converted to HC LPN. OC LPN is a feasible surgical option for patients with cT1-T2 renal cell carcinoma that completely avoids renal ischemic injury, with the benefits of minimally invasive surgery. LPN can be performed OC in patients with larger, more complex renal tumors without compromising the operative time, blood loss requiring transfusions, length of hospitalization, complication rates, or positive surgical margin rates compared with HC LPN.

Central nervous system lymphoma in immunocompetent patients: The North Shore-Long Island Jewish Health System experience

Of the 74 immunocompetent patients diagnosed between July 2004 and June 2011 at the North Shore University Hospital and Long Island Jewish Medical Center with primary central nervous system lymphoma, 71 (95.9%) had diffuse large B-cell lymphomas (DLBCL). The median patient age was 68years (range: 19–87years) with a slight male preponderance (1.1:1). The overall median survival time was 21months. For patients older than 70years, the median survival time was 8months while for those 70years or younger, the median survival time was 27months (p<0.01). Female patients had a worse prognosis than male patients (p<0.05, median survival time, 17months compared to 23months). We had enough data from 52 of these 71 patients to define the lymphomas as either germinal center B-cell-like (GCB) or activated B-cell-like (ABC) DLBCL. Of these 52 patients, 42 (80.8%) had ABC DLBCL while only 10 (19.2%) had GCB DLBCL. The patients in the GCB subgroup seemed to survive longer than the patients in the ABC subgroup, although the difference did not reach statistical significance. No statistically significant difference in overall survival was seen between patients with BCL-6 positive or negative DLBCL; or between patients with BCL-2 positive or negative DLBCL.

Maureen White, MBA, RN, NEA-BC

Maureen White, MBA, RN, NEA-BC

Combination of CFTR Gene Mutation and Autoimmune Pancreatitis Presenting as Necrotizing Pancreatitis

Division of Pediatric Gastroenterology and Nutrition, Cohen Children’s Medical Center North Shore-Long Island Jewish Health System 269-01 76th Ave New Hyde Park, NY 11040 [email protected] Division of Pediatric Gastroenterology and Nutrition, Cohen Children’s Medical Center North Shore-Long Island Jewish Health System New Hyde Park, NY

PC-FACS

PC-FACS

630: Comparing international guidelines on hypertensive disorders in pregnancy

630 Comparing international guidelines on hypertensive disorders in pregnancy Melanie Wiegerinck, Sigrid Huigen, Teus van Barneveld, Ben Willem Mol, Hans Duvekot Academic Medical Centre, Obstetrics and Gynaecology, Amsterdam, Netherlands, Erasmus Medical Center, Obstetrics and Gynaecology, Rotterdam, Netherlands, Netherlands Association of Medical specialists, Department of guideline development, Utrecht, Netherlands, Dutch consortium AMPHIA trial, Netherlands, Erasmus Medical Center, Department of Obstetrics and Gynaecology, Rotterdam, Netherlands OBJECTIVE: To compare international guidelines on Hypertensive disorders in pregnancy in order to assess the quality of guideline development in this field. STUDY DESIGN: We contacted the official Obstetric Societies of all European countries, the US, Canada and Australia, regarding the availability of a guideline on Hypertensive disorders in pregnancy. All retrieved guidelines were systematically reviewed on 7 topics that were identified as important by professionals: definitions of hypertensive disorders, methods for assessing proteinuria, top 3 antihypertensive agents, criteria for starting treatment (antihypertensive, anticonvulsive, termination of pregnancy), and target blood pressure after delivery. In addition, the methodologic quality of the guidelines was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE-II) Instrument. RESULTS: We approached professional societies in 41 European countries, and obtained guidelines from the US, Canada, and Australia (figure 1). Since 21 European countries did not reply and 4 had no guidelines, we analyzed a total of 19 guidelines. Nearly all countries had developed these guidelines themselves, and 17 dated from the last 4 years. Even though most guidelines refer to the same references, only 6 (32%) use the exact same definition for hypertension. All guidelines use the same cut-off values for proteinuria (0.3g/24 hours), but the accepted methods for assessing proteinuria differ (3 quantative 24 hour measure, 1 automated dipstick, 5 also accept protein/kreatinin ratio and visual dipstick, and in 10 it was not stated). Five guidelines agreed on initiation of antihypertensive treatment when the bloodpressure exceeds 160/110 mmHg, whereas 14 used other criteria. The remaining topics were comparable among the included guidelines. Methodological rigour and transparency of the guidelines also differed significantly. CONCLUSION: We found a wide variation in used definitions, clinical recommendations and methodology. This study emphasizes the need for international collaboration in the field of guideline development. 631 The impact of postpartum hemorrhage drill training at a single institution Noel Strong, Angela Bianco, Joanne Stone, Pozharny Zhenya, Luca Lambertini Mount Sinai Medical Center, Maternal Fetal Medicine, New York, NY, Mount Sinai School of Medicine, Maternal Fetal Medicine, New York, NY, North Shore-Long Island Jewish Health System, Maternal Fetal Medince, Manhasset, NY, Mount Sinai School of Medicine, Department of Preventive Medicine, New York, NY OBJECTIVE: To evaluate the impact of standardized postpartum hemorrhage drill training. STUDY DESIGN: In June of 2009 our institution mandated that all obstetrical providers participate in standardized postpartum hemorrhage training drills. The purpose of these drills was to improve recognition and management of post partum hemorrhage (PPH). Each drill consisted of a didactic session which emphasized accurate estimation of blood loss, early intervention, use of misoprostol as a first line agent and increased use of the Bakri Balloon and B-lynch suture. Each didactic session was followed by a simulated postpartum hemorrhage utilizing a female anthropomorphic robotic simulator. A retrospective chart review was preformed comparing all cases of PPH identified by the Labor & Delivery Quality Assurance Committee in the year preceding this mandate to all cases of PPH identified by the same committee in the year following this mandate. RESULTS: 160 patients with PPH were identified over the 2 year study period: 57 cases in the year preceding the PPH drills and 103 cases in the year following the PPH drills. The demographics of these two groups did not differ statistically, nor did their labor courses or etiologies of hemorrhage. In the first six months following the PPH training drills a trend toward increased use of misoprostol (26 %v 33% p 0.069) and Bakri Balloon (7% v 17% p 0.087) was noted. Although the rate of c-hysterectomy appeared to be reduced during this time period no trend toward significance was seen (19% v 8% p 0.220). At 6-12 months following the mandated drills these findings were no longer seen. No significant differences were noted in mean estimated blood loss, change in hemoglobin or rate of transfusion between any of the studied time periods. CONCLUSION: Training appears to improve recognition and reporting of PPH. While no statistically significant changes were noted, a trend towards increased use of misoprostol and Bakri Balloon was initially seen following the PPH training drills. This trend dissipated after 6 months. These findings seem to support a need for re-education.

Medical Malpractice in Endourology: Analysis of Closed Cases From the State of New York

Medical malpractice indemnity payments continue to rise, resulting in increased insurance premiums. We reviewed closed malpractice claims pertaining to endourological procedures with the goal of helping urologists mitigate their risk of lawsuit. All closed malpractice claims from 2005 to 2010 pertaining to endourological procedures filed against urologists insured by the Medical Liability Mutual Insurance Company of New York were examined. Claims were reviewed for plaintiff demographics, medical history, operative details, alleged complication, clinical outcome and lawsuit disposition. A total of 25 closed claims involved endourological operations and of these cases 10 were closed with an indemnity payment. The average payout was $346,722 (range $25,000 to $995,000). Of the plaintiffs 16 were women and mean plaintiff age was 51.4 years. Cystoscopy with ureteral stent placement/exchange resulted in 13 lawsuits, ureteroscopic lithotripsy 8, percutaneous stone extraction 2 and shock wave lithotripsy 2. There were 17 malpractice suits brought for alleged operative complications. Failure to arrange adequate followup was implicated in 4 cases. Error in diagnosis and delay in treatment was alleged in 3 claims. Urologists are not immune to the current medical malpractice crisis. Endourology and urological oncology generate the greatest number of lawsuits against urologists. Most malpractice claims involving endourological procedures result from urolithiasis and alleged technical errors. Therefore, careful attention to surgical technique is essential during stone procedures to reduce the risk of malpractice litigation.

Data Question Association of Antipsychotics, Cardiac Deaths

Data Question Association of Antipsychotics, Cardiac Deaths

State University of New York, Downstate Medical Center College of Medicine

State University of New York, Downstate Medical Center College of Medicine

Pressure Ulcer Awareness, Knowledge Differ by Setting

LONG BEACH, CALIF. — Less than a third of clinicians in hospitals and nursing homes were aware of current guidelines for diagnosing, preventing, and managing pressure ulcers, a survey of doctors, nurses, nursing assistants, and nurses— aides found.The anonymous survey showed that 28% of 208 employees in four hospitals and 26% of 274 employees in five nursing homes were aware of the Centers for Medicare & Medicaid Services guidelines, Dr. Sarika Sharma and her associates reported in a poster presentation at the AMDA annual symposium.Hospital clinicians were significantly more likely than were nursing home clinicians to know that pressure is not the only cause of ulcer formation (72% vs. 60%, respectively), that constant low pressure applied over a prolonged period of time is a risk factor for ulcers (53% vs. 43%), and that massaging skin will not prevent decubitus formation (61% vs. 48%), reported Dr. Sharma of North Shore-Long Island Jewish Health System, New Hyde Park, N.Y. Hospital employees also were more likely than their nursing home counterparts to know thatdtreating pressure ulcers costs more than prevention (77% vs. 63%).On the other hand, hospital employees were more likely than nursing home employees to omit skin assessment on a range of patients who should be assessed, including patients on ventilators (69% vs. 20%), comatose patients (63% vs. 16%), aggressive patients (77% vs. 23%), patients on palliative care (67% vs. 19%), and patients with morbid obesity (72% vs. 19%), spine immobilization (75% vs. 20%), and contact precautions (60% vs. 14%).Both settings need greater educational efforts focused on pressure ulcers, Dr. Sharma's team suggested. Some reasons for not routinely assessing skin were more likely to be reported by clinicians in hospitals than in nursing homes, the presenters said.These included having another physician document the patient's skin condition on the same day (75% vs. 20%), having another nurse document the patient's skin condition on the same day (76% vs. 26%), lack of awareness that skin assessment is needed (70% vs. 15%), lack of time (75% vs. 21%), lack of expertise (59% vs. 12%), perceiving that other conditions were more important (72% vs. 18%), or thinking that ulcer management would not change the ultimate clinical course of illness (62% vs. 15%).The researchers called these reasons “barriers” to preventive care. LONG BEACH, CALIF. — Less than a third of clinicians in hospitals and nursing homes were aware of current guidelines for diagnosing, preventing, and managing pressure ulcers, a survey of doctors, nurses, nursing assistants, and nurses— aides found. The anonymous survey showed that 28% of 208 employees in four hospitals and 26% of 274 employees in five nursing homes were aware of the Centers for Medicare & Medicaid Services guidelines, Dr. Sarika Sharma and her associates reported in a poster presentation at the AMDA annual symposium. Hospital clinicians were significantly more likely than were nursing home clinicians to know that pressure is not the only cause of ulcer formation (72% vs. 60%, respectively), that constant low pressure applied over a prolonged period of time is a risk factor for ulcers (53% vs. 43%), and that massaging skin will not prevent decubitus formation (61% vs. 48%), reported Dr. Sharma of North Shore-Long Island Jewish Health System, New Hyde Park, N.Y. Hospital employees also were more likely than their nursing home counterparts to know thatdtreating pressure ulcers costs more than prevention (77% vs. 63%). On the other hand, hospital employees were more likely than nursing home employees to omit skin assessment on a range of patients who should be assessed, including patients on ventilators (69% vs. 20%), comatose patients (63% vs. 16%), aggressive patients (77% vs. 23%), patients on palliative care (67% vs. 19%), and patients with morbid obesity (72% vs. 19%), spine immobilization (75% vs. 20%), and contact precautions (60% vs. 14%). Both settings need greater educational efforts focused on pressure ulcers, Dr. Sharma's team suggested. Some reasons for not routinely assessing skin were more likely to be reported by clinicians in hospitals than in nursing homes, the presenters said. These included having another physician document the patient's skin condition on the same day (75% vs. 20%), having another nurse document the patient's skin condition on the same day (76% vs. 26%), lack of awareness that skin assessment is needed (70% vs. 15%), lack of time (75% vs. 21%), lack of expertise (59% vs. 12%), perceiving that other conditions were more important (72% vs. 18%), or thinking that ulcer management would not change the ultimate clinical course of illness (62% vs. 15%). The researchers called these reasons “barriers” to preventive care.

Editorial Comment

No AccessJournal of UrologyPediatric Urology1 Jun 2010Editorial Comment Lane S. Palmer Lane S. PalmerLane S. Palmer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.2425AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 183(6), p. 2351 References 1 : Measurement of urinary flow rate using ultrasound in young boys and infants. J Urol2001; 166: 1058. Link, Google Scholar Department of Urology, Schneider Children's Hospital, North Shore-Long Island Jewish Health System, Long Island, New York© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 6June 2010Page: 2351 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lane S. Palmer More articles by this author Expand All Advertisement PDF downloadLoading ...

Laboratory Surge Response to Pandemic (H1N1) 2009 Outbreak, New York City Metropolitan Area, USA

The North Shore-Long Island Jewish Health System Laboratories serve 15 hospitals and affiliated regional physician practices in the New York City metropolitan area, with virus testing performed at a central reference laboratory. The influenza A pandemic (H1N1) 2009 outbreak began in this area on April 24, 2009, and within weeks respiratory virus testing increased 7.5 times. In response, laboratory and client service workforces were increased, physical plant build-out was completed, testing paradigms were converted from routine screening tests and viral culture to a high-capacity molecular assay for respiratory viruses, laboratory information system interfaces were built, and same-day epidemiologic reports were produced. Daily review by leadership of data from emergency rooms, hospital facilities, and the Health System Laboratories enabled real-time management of unfolding events. The ability of System laboratories to rapidly increase to high-volume comprehensive diagnostics, including influenza A subtyping, provided key epidemiologic information for local and state public health departments.

Lack of Efficacy of Citalopram in Children With Autism Spectrum Disorders and High Levels of Repetitive Behavior

Selective serotonin reuptake inhibitors are widely prescribed for children with autism spectrum disorders. To determine the efficacy and safety of citalopram hydrobromide therapy for repetitive behavior in children with autism spectrum disorders. National Institutes of Health-sponsored randomized controlled trial. Six academic centers, including Mount Sinai School of Medicine, North Shore-Long Island Jewish Health System, University of North Carolina at Chapel Hill, University of California at Los Angeles, Yale University, and Dartmouth Medical School. One hundred forty-nine volunteers 5 to 17 years old (mean [SD] age, 9.4 [3.1] years) were randomized to receive citalopram (n = 73) or placebo (n = 76). Participants had autistic spectrum disorders, Asperger disorder, or pervasive developmental disorder, not otherwise specified; had illness severity ratings of at least moderate on the Clinical Global Impressions, Severity of Illness Scale; and scored at least moderate on compulsive behaviors measured with the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders. Twelve weeks of citalopram hydrobromide (10 mg/5 mL) or placebo. The mean (SD) maximum dosage of citalopram hydrobromide was 16.5 (6.5) mg/d by mouth (maximum, 20 mg/d). Positive response was defined by a score of much improved or very much improved on the Clinical Global Impressions, Improvement subscale. An important secondary outcome was the score on the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders. Adverse events were systematically elicited using the Safety Monitoring Uniform Report Form. There was no significant difference in the rate of positive response on the Clinical Global Impressions, Improvement subscale between the citalopram-treated group (32.9%) and the placebo group (34.2%) (relative risk, 0.96; 95% confidence interval, 0.61-1.51; P > .99). There was no difference in score reduction on the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders from baseline (mean [SD], -2.0 [3.4] points for the citalopram-treated group and -1.9 [2.5] points for the placebo group; P = .81). Citalopram use was significantly more likely to be associated with adverse events, particularly increased energy level, impulsiveness, decreased concentration, hyperactivity, stereotypy, diarrhea, insomnia, and dry skin or pruritus. Results of this trial do not support the use of citalopram for the treatment of repetitive behavior in children and adolescents with autism spectrum disorders. Trial Registration clinicaltrials.gov Identifier: NCT00086645.

Using the CCMC Code of Professional Conduct As a Living Document to Uphold Ethical Practice

Vivian Campagna, MSN, RN-BC, CCM, is the Chair of the Commission for Case Manager Certification, the first and largest nationally accredited organization that certifies case managers. She is also Administrative Director, Care Coordination, at Long Island Jewish Medical Center, part of the North Shore-Long Island Jewish Health System. Address correspondence to Vivian Campagna, MSN, RN-BC, CCM, Chair, Commission for Case Manager Certification.

Several Reasons Keep Clinicians From Reporting Child Abuse

Several Reasons Keep Clinicians From Reporting Child Abuse

Parenchymal Echo Texture Predicts Testicular Salvage After Torsion: Potential Impact on the Need for Emergent Exploration

In the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof. We retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room. During this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis. In the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.