Palestro C.J.,North Shore Long Island Jewish Health System
Seminars in Nuclear Medicine | Year: 2015
Radionuclide procedures frequently are performed as part of the diagnostic workup of osteomyelitis. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. Degenerative joint disease, fracture, and orthopedic hardware decrease the specificity of the bone scan, making it less useful in these situations. Gallium-67 scintigraphy was often used as an adjunct to bone scintigraphy for diagnosing osteomyelitis. However, now it is used primarily for spinal infections when 18F-FDG imaging cannot be performed. Except for the spine, in vitro-labeled leukocyte imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. Leukocytes accumulate in bone marrow as well as in infection. Performing complementary bone marrow imaging with 99mTc-sulfur colloid facilitates the differentiation between osteomyelitis and normal marrow and improves test overall accuracy. Antigranulocyte antibodies and antibody fragments, such as 99mTc-besilesomab and 99mTc-sulesomab, were developed to eliminate the disadvantages associated with in vitro-labeled leukocytes. These agents, however, have their own shortcomings and are not widely available. As biotin is used as a growth factor by certain bacteria, 111In-biotin is useful to diagnose spinal infections. Radiolabeled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, can differentiate infection from sterile inflammation and may be useful to monitor response to treatment. 18F-FDG is extremely useful in the diagnostic workup of osteomyelitis. Sensitivity in excess of 95% and specificity ranging from 75%-99% have been reported. 18F-FDG is the radionuclide test of choice for spinal infection. The test is sensitive, with a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of 18F-FDG for diagnosing diabetic pedal osteomyelitis are contradictory, and its role for this indication remains to be determined. Initial investigations suggested that 18F-FDG accurately diagnoses prosthetic joint infection; more recent data indicate that it cannot differentiate infection from other causes of prosthetic failure. Preliminary data on the PET agents gallium-68 and iodine-124 fialuridine indicate that these agents may have a role in diagnosing osteomyelitis. © 2015 Elsevier Inc. All rights reserved.
Palestro C.J.,North Shore Long Island Jewish Health System
Seminars in Nuclear Medicine | Year: 2013
Diagnosing musculoskeletal infection is challenging and imaging procedures are part of the diagnostic workup. Although the most commonly performed radionuclide procedures include bone, gallium-67, and labeled leukocyte imaging, FDG-PET (PET/CT) is assuming an increasingly important role in the diagnostic workup of musculoskeletal infection. FDG offers advantages over conventional radionuclide techniques. PET, a high-resolution tomographic technique, facilitates precise localization of abnormalities. Semiquantitative analysis potentially could be used to differentiate infectious from noninfectious conditions and monitor response to treatment. FDG is a small molecule entering poorly perfused regions rapidly; the procedure is completed in hours not days. Degenerative changes usually show faintly increased FDG uptake. FDG uptake usually normalizes within 3-4 months following trauma or surgery. Sensitivities higher than 95% and specificities ranging from 75% to 99% have been reported in acute and subacute bone and soft tissue infection. The test is also useful for diagnosing chronic and low-grade infection because FDG accumulates in activated macrophages. No one tracer is equally efficacious in all regions of the skeleton and the utility of FDG varies with the indication. One area in which FDG imaging clearly is useful, and should be the radionuclide study of choice, is in the evaluation of spinal osteomyelitis. The test has a high negative predictive value and is a useful adjunct to MRI for differentiating degenerative from infectious end plate abnormalities. The role of FDG imaging in the evaluation of diabetic foot infection has yet to be clarified, with some investigators reporting high accuracy and others reporting just the opposite. Although initial investigations suggested that FDG accurately diagnoses lower extremity joint-replacement infection subsequent studies indicate that this test cannot differentiate aseptic loosening from infection. This is not surprising because aseptic loosening and infection both can be accompanied by an intense inflammatory reaction. A recent meta-analysis found that the sensitivity and specificity of FDG-PET for diagnosing lower extremity prosthetic joint infection was 87% and 82%, respectively, lower than what has been reported for combined leukocyte-marrow imaging over the past 30 years. Data about FDG-PET in septic arthritis are limited. FDG accumulates in inflammatory arthritis and its role for diagnosing septic arthritis likely would be limited. © 2013 Elsevier Inc. All rights reserved.
Bernstein D.L.,North Shore Long Island Jewish Health System |
Hulkova H.,Charles University |
Bialer M.G.,North Shore Long Island Jewish Health System |
Desnick R.J.,Mount Sinai School of Medicine
Journal of Hepatology | Year: 2013
Cholesteryl ester storage disease (CESD) is caused by deficient lysosomal acid lipase (LAL) activity, predominantly resulting in cholesteryl ester (CE) accumulation, particularly in the liver, spleen, and macrophages throughout the body. The disease is characterized by microvesicular steatosis leading to liver failure, accelerated atherosclerosis and premature demise. Although CESD is rare, it is likely that many patients are unrecognized or misdiagnosed. Here, the findings in 135 CESD patients described in the literature are reviewed. Diagnoses were based on liver biopsies, LAL deficiency and/or LAL gene (LIPA) mutations. Hepatomegaly was present in 99.3% of patients; 74% also had splenomegaly. When reported, most patients had elevated serum total cholesterol, LDL-cholesterol, triglycerides, and transaminases (AST, ALT, or both), while HDL-cholesterol was decreased. All 112 liver biopsied patients had the characteristic pathology, which is progressive, and includes microvesicular steatosis, which leads to fibrosis, micronodular cirrhosis, and ultimately to liver failure. Pathognomonic birefringent CE crystals or their remnant clefts were observed in hepatic cells. Extrahepatic manifestations included portal hypertension, esophageal varices, and accelerated atherosclerosis. Liver failure in 17 reported patients resulted in liver transplantation and/or death. Genotyping identified 31 LIPA mutations in 55 patients; 61% of mutations were the common exon 8 splice-junction mutation (E8SJM-1G>A), for which 18 patients were homozygous. Genotype/phenotype correlations were limited; however, E8SJM-1G>A homozygotes typically had early-onset, slowly progressive disease. Supportive treatment included cholestyramine, statins, and, ultimately, liver transplantation. Recombinant LAL replacement was shown to be effective in animal models, and recently, a phase I/II clinical trial demonstrated its safety and indicated its potential metabolic efficacy. © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
News Article | November 17, 2015
Exactly what can happen if a woman misses one or more days of her birth control pills is highlighted by a new lawsuit: A company that allegedly mislabeled its birth control pills is being sued by more than 100 women who say they became pregnant because of the error. Pregnancy is especially possible for women who miss birth control pills while using these pills as their only form of birth control, doctors said. The women involved in the lawsuit reportedly took their birth control pills as instructed on the packaging. Normally, packs of this type of pills include "active" pills that contain hormones, as well as "reminder" pills that contain no active ingredients, but are aimed at helping women to adhere to their daily habit of taking a pill at the same time every day. However, the pills involved in the lawsuit were packaged "rotated 180 degrees," from their normal position, according to court documents. In other words, the pill packs were labeled upside down — and the reminder pills that should have been taken during the last week of the cycle were instead placed into the first week of the cycle. As a result, some women took the placebo pill when they were supposed to be taking active pills containing birth control ingredients, such as the hormones estrogen or progestin. [7 Surprising Facts About the Pill] Among the women involved in the lawsuit, 94 had unexpected pregnancies and gave birth, 17 became pregnant but did not carry to term, and two did not become pregnant, according to CNN. Normally, among women who take the pill as directed, less than 1 out of 100 women will get pregnant each year, according to Planned Parenthood. But if the pills aren't taken as directed, then about 9 out of 100 women will become pregnant each year, the organization says. Birth control pills protect against pregnancy in three ways, said Dr. Jill Rabin, the co-chief of ambulatory care and of Women's Health Programs at North Shore Long Island Jewish Health System in New York. One way is that the pills prevent a woman from ovulating because they maintain a steady level of estrogen and progesterone in the body — a woman needs to have a 24-hour-long spike of estrogen in order to ovulate, Rabin said. The pill also thickens the cervical mucus, making it difficult for the sperm to get through and reach the egg. And finally, the pill slows the normal movement inside fallopian tubes, making any egg cell that does get released move through the tube more slowly, "so the sperm and the egg just can't get together as easily," Rabin said. This threefold effect makes pregnancy very unlikely. "Let's say the sperm got by the first step — the thick mucus. But then the movement of the tube is so slow, it's not going to allow the sperm to meet the egg," she said. However, birth control pills contain low doses of hormone, so it's important to take them daily, Rabin said. Women need to take the progestin-only pill at the same time every day, but the estrogen-progestin pills have a higher dosage, and can be taken within three hours of a designated daily time, she said. If a woman misses a pill, she should take it as soon as she remembers. However, if she misses two pills, then she should double up for two days, Rabin said. For example, if a woman goes on a trip and forgets her pills on Saturday and Sunday, then she should take two pills on Monday and two pills on Tuesday before going back to her regular schedule, Rabin said. [11 Big Fat Pregnancy Myths] If multiple pills are missed, then a woman's body might start a new menstrual cycle, experience a spike of estrogen and ovulate, Rabin said. Moreover, if the woman has unprotected sexual intercourse, sperm from her partner can survive in her body for several days, and could fertilize an available egg, Rabin said. (According to Planned Parenthood, sperm can survive up to six days in a woman's body, but that time varies from person to person, Rabin said.) She encouraged women to call their doctor if they're concerned about a potential pregnancy. "If you think you might be pregnant from an unintended pregnancy, you should see your doctor so that they can help you," Rabin said. "If you would like to continue the pregnancy, you can get prenatal vitamins and, if not, they can talk to you about other options."
Nosseir S.B.,North Shore Long Island Jewish Health System
Obstetrics and Gynecology | Year: 2010
Background: Osteomyelitis associated with using synthetic mesh for laparoscopic sacral colpopexy is rare. Case: We present a patient who developed Staphylococcus sacral osteomyelitis after sacral colpopexy with synthetic mesh and titanium tack fixation to the sacral promontory in the absence of mesh erosion or fistula formation. The patient presented with low back pain 6 weeks postoperatively. Magnetic resonance imaging, bone aspirate, and culture confirmed sacral osteomyelitis and discitis 10 weeks after surgery. The patient underwent 8 weeks of outpatient antibiotic treatment. Six months after surgery, serial laboratory values have demonstrated excellent response to antibiotic treatment, and the patient has clinically improved without the need for mesh removal. Conclusion: We recommend a high index of suspicion for osteomyelitis in patients who present with back pain after sacral colpopexy. Osteomyelitis can occur as a complication of laparoscopic, robotic sacral colpopexy using mesh in the absence of abscess or fistula formation. © 2010 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins.
Pomeranz H.D.,North Shore Long Island Jewish Health System
Journal of Neuro-Ophthalmology | Year: 2016
Background: A cause and effect relationship between phosphodiesterase-5 inhibitor (PDE5I) use and nonarteritic anterior ischemic optic neuropathy (NAION) has been hypothesized based on case reports. Evidence Acquisition: Review of literature. Results: Thirty-nine case reports in the peer-reviewed medical literature have documented a possible relationship between PDE5I consumption and NAION. However, pertinent details, such as the dose and frequency of PDE5I use, and elapsed time between ingestion and onset of vision loss, are lacking from many of these reports. Investigations regarding alterations in ocular perfusion in research subjects who ingested sildenafil have been inconclusive because they have not been performed on subjects with "disc at risk" or risk factors for NAION. One case-crossover study demonstrated a 2-fold increase in risk of NAION after ingestion of PDE5I. Conclusions: When a diagnosis of NAION is made, an inquiry should be made as to whether any PDE5I was ingested before the onset of vision loss. If so, the patient should be counseled regarding the possibility that continued PDE5I use may increase the risk of NAION in the fellow eye. Patients with a known history of previous NAION should be cautioned regarding the use of PDE5I for erectile dysfunction or pulmonary hypertension because of the potential increased risk of fellow eye involvement. © 2016 by North American Neuro-Ophthalmology Society.
Barilla-LaBarca M.-L.,North Shore Long Island Jewish Health System |
Toder K.,North Shore Long Island Jewish Health System |
Furie R.,North Shore Long Island Jewish Health System
Clinical Immunology | Year: 2013
The importance of the complement system in the pathogenesis of systemic lupus erythematosus (SLE) has long been recognized. However, despite an unprecedented amount of SLE clinical trial activities ongoing at this time, complement inhibitors have been omitted from the therapeutic assault on this disease. We review data generated from murine lupus that provide scientific support for the study of human SLE. Also reviewed is the sole study of a complement inhibitor, eculizumab, performed in patients with SLE. We conclude with a review of other inflammatory diseases where ongoing programs might provide the groundwork for the development of complement inhibitors in SLE. © 2013.
Wagner B.,North Shore Long Island Jewish Health System
Journal for healthcare quality : official publication of the National Association for Healthcare Quality | Year: 2012
A comprehensive perinatal safety initiative (PSI) was incrementally introduced from August 2007 to July 2009 at a large tertiary medical center to reduce adverse obstetrical outcomes. The PSI introduced: (1) evidence-based protocols, (2) formalized team training with emphasis on communication, (3) standardization of electronic fetal monitoring with required documentation of competence, (4) a high-risk obstetrical emergency simulation program, and (5) dissemination of an integrated educational program among all healthcare providers. Eleven adverse outcome measures were followed prospectively via modification of the Adverse Outcome Index (MAOI). Additionally, individual components were evaluated. The logistic regression model found that within the first year, the MAOI decreased significantly to 0.8% from 2% (p<.0004) and was maintained throughout the 2-year period. Significant decreases over time for rates of return to the operating room (p<.018) and birth trauma (p<.0022) were also found. Finally, significant improvements were found in staff perceptions of safety (p<.0001), in patient perceptions of whether staff worked together (p<.028), in the management (p<.002), and documentation (p<.0001) of abnormal fetal heart rate tracings, and the documentation of obstetric hemorrhage (p<.019). This study demonstrates that a comprehensive PSI can significantly reduce adverse obstetric outcomes, thereby improving patient safety and enhancing staff and patient experiences. © 2011 National Association for Healthcare Quality.
Harden C.L.,North Shore Long Island Jewish Health System
CONTINUUM Lifelong Learning in Neurology | Year: 2014
Purpose of review: This review encompasses issues regarding the management of women with epilepsy and pregnancy, including preconception planning, antiepileptic drug (AED) effects on the exposed offspring, and consequences of seizures during pregnancy, with an emphasis on counseling points and risk management. Recent findings: In utero valproate exposure continues to show the highest risk of congenital malformations and of adverse cognitive outcomes, including autism, compared to other AEDs. In utero topiramate exposure is associated with facial clefts. In utero exposure to lamotrigine, carbamazepine, phenytoin, and levetiracetam has been evaluated in large numbers of offspring, and all of these AEDs have a low risk of major congenital malformations, near 2.5%. The risk of major congenital malformations due to in utero AED exposure is dose associated. Folic acid taken at the time of conception decreases the risk of adverse cognitive outcomes. AED polytherapy may adversely affect fertility, and in utero exposure of AED polytherapy is associated with infants who are small for their gestational age. Seizure freedom before pregnancy is a good predictor of remaining seizure free during pregnancy. Summary: Counseling points are complex for managing women with epilepsy contemplating pregnancy, including evaluation of AED choice and dose. The physician must have knowledge of the issues to enable an honest discussion and appropriate decision making in partnership with the patient. Copyright © 2014 American Academy of Neurology.
Love C.,Yeshiva University |
Palestro C.J.,North Shore Long Island Jewish Health System
Seminars in Nuclear Medicine | Year: 2013
Although infection may be suggested by signs and symptoms such as fever, pain, general malaise, and abnormal laboratory results, imaging tests often are used to confirm its presence. Morphologic imaging tests identify structural alterations of tissues or organs that result from a combination of microbial invasion and the inflammatory response of the host. Functional imaging studies use minute quantities of radioactive material, which are taken up directly by cells, tissues, and organs, or are attached to substances that subsequently migrate to the region of interest. Bone scintigraphy is extremely sensitive and can be positive within 2 days after the onset of symptoms. With an accuracy of more than 90%, 3-phase bone scintigraphy is the radionuclide procedure of choice for diagnosing osteomyelitis in unviolated bone. In patients with acute renal failure, gallium imaging facilitates the differentiation of acute interstitial nephritis from acute tubular necrosis. Gallium imaging also is useful in the evaluation of pulmonary infections and inflammation. Many opportunistic infections affect the lungs, and a normal gallium scan of the chest excludes infection with a high degree of certainty, especially when the chest x-ray is negative. In the human immunodeficiency virus positive patient, lymph node uptake usually is associated with mycobacterial disease or lymphoma. Focal pulmonary parenchymal uptake suggests bacterial pneumonia. Diffuse pulmonary uptake suggests an opportunistic pneumonia. Gallium imaging provides useful information about other acute respiratory conditions, including radiation pneumonitis and hypersensitivity pneumonitis. In vitro labeled leukocyte imaging with indium-111 and technetium-99m labeled leukocytes is useful in various acute care situations. The test facilitates the differentiation of normal postoperative changes from infection and is useful for diagnosing prosthetic vascular graft infection. In inflammatory bowel disease, labeled leukocyte imaging is useful for initial screening, monitoring treatment response, detecting recurrent disease, and evaluating patients with discordant physical presentation and laboratory test results. Labeled leukocyte imaging, combined with bone marrow scintigraphy accurately diagnoses complicating osteomyelitis. Fluorine-18-fluorodeoxyglucose, imaging is rapidly completed and provides high-resolution images. This test is especially valuable in patients with fever of unknown origin, patients in septic shock, and mechanically ventilated patients suspected of harboring infection. Fluorine-18-fluorodeoxyglucose imaging also shows promise in inflammatory bowel disease. © 2013 Elsevier Inc.