A postoperative Gerbode defect in aortic prosthesis endocarditis with non-typhoid Salmonella.

The Gerbode defect is a congenital shunt from the left ventricle to the right atrium. The type I defect (2) results in a direct shunt through a portion of the membranous septum, while a type II (indirect) defect occurs if the membranous septal defect lies below the attachment of the septal leaflet of the tricuspid valve. The shunt is directed towards the right atrium through a cleft or perforations of the septal leaflet. Acquired Gerbode defects have been identified in endocarditis, after mitral or aortic valve surgery, or may be post-traumatic. The case is presented of a 69-year-old woman with a postoperative Gerbode defect in association with aortic prosthetic endocarditis caused by non-typhoid Salmonella.

Non-typhoid Salmonellae and prosthetic valve endocarditis: more than a rare coincidence? A review of the literature.

Non-typhoid Salmonellae (NTS) commonly cause gastroenteritis but are rarely found pathogens in prosthetic heart valve endocarditis. The details of two patients from the authors' institution and 15 published cases are reviewed in terms of their risk factors, clinical findings and outcomes. Only two of eight patients with paravalvular leakage or abscess--the most serious local complications--survived, both with surgery. It appears that NTS bacteremia in patients with prosthetic valves and concomitant risk factors should be treated early with high-dose antimicrobials for up to six weeks in order to minimize the risk of endocarditis.

Is chest radiography necessary after uncomplicated insertion of a triple-lumen catheter in the right internal jugular vein, using the anterior approach?

STUDY OBJECTIVES: Chest radiographs are required in many institutions by protocol after the insertion of a right internal jugular vein triple-lumen catheter (TLC), even if the anterior approach is used. This study investigates whether correct placement can be predicted during insertion and whether a "routine" postprocedural chest radiograph can be safely omitted. DESIGN: The operators included 18 first-, second-, or third-year medical residents, 3 pulmonary fellows, and a board-certified pulmonary medicine and critical care attending, with at least 1 certified physician present during the procedure. All operators were trained in the "seven number rule." PATIENTS: One hundred consecutive patients who required central venous access. Patients with left internal jugular vein or subclavian catheters were excluded. SETTING: Single institution, medical ICU, step-down unit, and floors. INTERVENTIONS: Right internal jugular vein TLC insertion, anterior approach, with subsequent chest radiograph. MEASUREMENTS AND RESULTS: Eighty-eight patients had uncomplicated insertions, as defined by fewer than four sticks with a 22-gauge pathfinder needle and fewer than four slides with the 18-gauge introducer needle. Ninety-eight catheters were in accurate position, 1 catheter was in the distal superior cava vein, and 1 catheter was in an S-shaped position. CONCLUSIONS: It is safe to omit the routine chest radiograph after uncomplicated insertion of a TLC. i.v. treatment can be initiated early. However, if there is any doubt about the correct position, a chest radiograph should be obtained.

Smoking in contemporary American cinema.

OBJECTIVE: The true prevalence of smoking among characters portrayed in the movies is unknown. This study examines this prevalence objectively. DESIGN: The top 10 movies on the weekly box office charts were reviewed. Whether or not the top five characters in these movies smoked, was documented. It was determined prior to the start of the study that 300 male characters and 300 female characters were needed to detect any significant difference. A total of 447 movies, composed of 193 movies rated restricted (R) [children < 17 years of age must be accompanied by an adult], 131 movies rated PG13 for parental guidance suggested for children < 13 years of age (PG) and 123 movies rated PG for parental guidance suggested, were examined until the sample size was reached. RESULTS: Smoking prevalence is the same in contemporary American movies and in the general US population (23.3% vs 24.8%, respectively). However, there was more smoking in these movies among men than among women (25.5% vs 20.5%, respectively; p < 0.006), among antagonists than among protagonists (35.7% vs 20.6%, respectively; p < 0.001), lower vs middle vs upper socioeconomic class (SEC) [48.2%, 22.9%, and 10.5%, respectively; p < 0.001], among independent vs studio movies (46.2% vs 18.2%, respectively; p < 0.001); and among R-rated vs PG13-rated vs PG-rated movies (37.3%, 16.2%, and 8.1%, respectively; p < 0.001). In R-rated movies, and in both subcategories of R-rated studio movies and R-rated independent movies, smoking prevalence is higher than in the US population (37.3%, 30.5%, and 50.6% vs 24.8%, respectively; p < 0.001 for all). Additionally, compared to the US population, men, women and lower SEC members smoke more in R-rated movies, R-rated studio movies, and R-rated independent movies. In R-rated movies, antagonists smoke more than protagonists (43.9% vs 35.8%, respectively; p < 0.001), and whites smoke more than nonwhites (38.3% vs 26.4%, respectively; p < 0.001). In R-rated studio movies, antagonists smoke more than protagonists (42.6% vs 26.6%, respectively; p < 0.001), and men smoke more than women (32.0% vs 27.9%, respectively; p = 0.03). In R-rated independent movies, whites smoke more than nonwhites (51.8% vs 40.5%, respectively; p < 0.001). Smoking prevalence is higher in R-rated independent movies than in R-rated studio movies (50.6% vs 30.5%, respectively; p < 0.001). Smoking prevalence is also higher in R-rated independent movies than in R-rated studio movies in subcategories of men (32.0% vs 49.8%, respectively; p < 0.001), women (21.8 vs 51.8%, respectively; p < 0.001), protagonists (26.6% vs 51.6%, respectively; p < 0.001), whites (31.5% vs 51.8%, respectively; p < 0.001), nonwhites (24.7% vs 40.5%, respectively; p < 0.001), and all three SECs. CONCLUSIONS: In contemporary American cinema, the smoking prevalence is higher for men, antagonistic characters, lower SEC, independent movies, and R-rated movies. Smoking prevalence is higher than in the general US population in R-rated movies, and in both its subcategories of R-rated studio movies and R-rated independent movies. There is more smoking in R-rated independent movies than in R-rated studio movies. Smoking in contemporary American cinema is associated with male sex, lower SEC, and antagonistic (ie, bad) characters.

Diffuse alveolar hemorrhage after infliximab treatment of Crohn's disease.

Infliximab (Remicade), a chimeric monoclonal antibody to tumor necrosis factor-alpha (anti-TNF-alpha), is being used with increasing frequency in the treatment of Crohn's disease. Infliximab's safety profile to date has been good with reported adverse events being mild to moderate. We report a case of diffuse alveolar hemorrhage after the second infliximab infusion in a patient with Crohn's disease. The mechanism by which infliximab may have caused the observed pulmonary insult remains unknown. Physicians should be aware of the possible association between infliximab treatment and the development of alveolar hemorrhage. Future cases should be reported.

Real-time chest ultrasonography: a comprehensive review for the pulmonologist.

This review discusses real-time pulmonary ultrasonography (US) for the practicing pulmonologist. US supplements chest radiography and chest CT scanning. Major advantages include bedside availability, absence of radiation, and guided aspiration of fluid-filled areas and solid tumors. Pulmonary vessels and vascular supply of consolidations may be visualized without contrast. US may help to diagnose conditions such as pneumothorax, hemothorax, pleural or pericardial effusion, pneumonia, and pulmonary embolism in the critically ill patient who is in need of bedside diagnostic testing. The technique of US, which is cost-effective compared to CT scanning and MRI, may be learned relatively easily by the pulmonologist.

Multidrug-resistant tuberculosis in pregnancy: case report and review of the literature.

A woman at 23 weeks' gestation was treated with rifampin, isoniazid, and ethambutol for cavitary tuberculosis (TB). She did not respond within 3 weeks, and multidrug-resistant (MDR) TB was suspected. Direct plating on susceptibility media was performed immediately. Treatment was initiated with IV capreomycin, levofloxacin, para-aminosalicylic acid, pyrazinamide, cycloserine, and high-dose vitamin B(6) at 26 weeks' gestation. The patient delivered vaginally at week 35. The newborn was not infected. Following delivery, ethionamide was added as a sixth drug, and levofloxacin was replaced with moxifloxacin. The patient's sputum became smear-negative and culture-negative for TB. All reported cases of MDR-TB during pregnancy are reviewed.

Agreement between SPECT V/Q scan and CT angiography in patients with high clinical suspicion of PE.

OBJECTIVE: To track agreement between single positron emission computed tomography (SPECT) V/Q and CT angiography in patients with high clinical suspicion of pulmonary embolism (PE). If significant agreement occurs, a case could be made for more frequent use of chest radiography followed by SPECT V/Q scanning given its lower risk profile. INTRODUCTION: Diagnosis of PE can be difficult. CT pulmonary angiography (CTA) is the preferred initial test, but may be indeterminate, is a significant source of ionizing radiation, and is contraindicated in renal insufficiency. SPECT ventilation/perfusion imaging (V/Q) is therefore preferred in certain patients. METHODS: Two thousand nine hundred and twenty patients admitted to a tertiary care hospital in New York City were screened and 100 consecutive high-risk patients who required both CTA and V/Q for an initial indeterminate or negative imaging test despite a high pre-test probability were identified. The agreement between these tests was evaluated. RESULTS: There was no significant agreement between CTA and V/Q when positive, negative and indeterminate results were included (K = 0.18, SE = 0.09, p = 0.051). However, in the presence of a positive finding on either test, there was substantial agreement between the two (K = 0.62, SE = 0.27, p = 0.02). In 30 cases in which CTA was indeterminate, V/Q was diagnostic 93 % of the time. In 12 cases in which V/Q was indeterminate, CTA was diagnostic 83 % of the time and negative in 100 % of those cases. CONCLUSION: In the presence of an indeterminate CTA in patients with high clinical suspicion of PE, SPECT V/Q often provides a diagnosis.

Clopidogrel-induced hepatocellular injury and cholestatic jaundice in an elderly patient: case report and review of the literature.

In patients undergoing percutaneous coronary intervention and in those with acute coronary syndromes, clopidogrel plus aspirin is the first-line antiplatelet therapy for reducing cardiovascular events. Although clopidogrel is generally well tolerated, with rash, indigestion, vomiting, diarrhea, and bleeding being the most common adverse effects, rare but serious complications may occur. We describe a 78-year-old woman who underwent percutaneous coronary intervention with drug-eluting stents; clopidogrel and aspirin were started as antiplatelet therapy. Three weeks later, the patient developed mixed hepatocellular and cholestatic liver injury. Clopidogrel was discontinued, and her liver profile results began to improve. Her diagnostic work-up included screening for hepatitis, infectious mononucleosis, and rheumatologic diseases, as well as ultrasonography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreaticography; all results were normal. On day 5 of hospitalization, because of the patient's risk for thrombosis secondary to the drug-eluting stents, clopidogrel was reintroduced; her liver enzyme levels increased. In the absence of any biliary obstruction or other obvious causes of hepatic injury, drug-induced hepatocellular injury and cholestatic jaundice were suspected, and clopidogrel was again discontinued. The patient's liver function tests gradually improved 3 days later and showed marked improvement at her 2-week follow-up visit after discharge. Use of the Maria and Victorino scale for diagnosis of drug-induced hepatotoxicity indicated a probable (score of 14) relationship between clopidogrel and mixed hepatocellular injury and cholestatic jaundice in this patient. Although routine liver function testing is not recommended in patients who receive clopidogrel, having a high index of clinical suspicion, drug rechallenge, and excluding other obvious causes are required to establish the diagnosis of a rare drug complication such as clopidogrel-induced hepatic injury.