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Dexamethasone is used to treat bronchopulmonary dysplasia in premature infants. Previous studies indicate this drug may produce ventricular dysfunction and cardiomyopathy during a 6 week course of therapy (Bensky et al., Pediatrics,97;1996). We studied the incidence, characteristics, and potential mechanisms for cardiac dysfunction in infants receiving dexamethasone (JCMC IRB#95-13). We also studied the effects of dexamethasone on contractions in human cardiac myocyte clusters (ETSU IRB#97-076e). Patients were hospitalized in the newborn intensive care unit at Johnson City Medical Center between April 1995 and February 1998 (n=37). Gestational age was 26±2.5 weeks (mean±SD), and birthweight was 842±318 grams. We initially administered dexamethasone at 0.5 mg/kg/day, and tapered over 23.6±11.7 days. Changes in ventricular function, dimensions, and wall thicknesses were measured with echocardiograms. Systemic blood pressures were measured by cuff, or using arterial lines when available. Evidence for glucose intolerance was determined by elevated serum glucose levels. Myocyte clusters (n=5, from 3 hearts), were obtained by enzymatically digesting cardiac pathologic specimens from 8-9 weeks gestation human fetuses. The clusters, contracted spontaneously and responded to field-stimulation after 12-24 h in enriched culture media. The myocyte clusters were bathed in normal Tyrode's solution, and dexamethasone was administered in 1, 5, 10, 20 and 45 μM concentrations. Contractions were measured using a video edge detector. Cardiomyopathy developed in 24 of 37 patients receiving dexamethasone (64.9%), and was observed in patients receiving ≥ 14 days of therapy. The incidence of systemic hypertension and glucose intolerance was similar in patients with and without cardiomyopathy. Contractions in cardiac myocyte clusters decreased after 20 μM and 45 μM dexamethasone, but returned to baseline after rinsing the clusters with dexamethasone-free Tyrodes solution. There is a high incidence of cardiomyopathy in premature infants treated for bronchopulmonary dysplasia with ≥ 14 days of dexamethasone. The cardiomyopathy is not related to elevated systemic arterial pressures or blood glucose. In myocyte clusters from immature fetal hearts, contractions decrease after acute exposure to dexamethasone, but the decrease is reversible.

The purpose of this study was to determine which factors affect the accuracy of blood pressures measured by patients using their own equipment. 91 patients were solicited through a general internal medicine practice, newspaper, television, and radio ads to participate in the study. Participants completed a written questionnaire regarding their own blood pressure monitoring. Blood pressures were recorded first by the patient using their own equipment and subsequently by a trained technician using a mercury sphygmomanometer. Results were considered accurate if both the systolic and diastolic pressures recorded by the patient were within 10 mmHg of the technician's recording. Data were analyzed using chi square. Two-thirds of the participants recorded accurate blood pressures using their own equipment. The following factors were examined: instrument type, instrument cost, instrument age, patient educational level, whether or not the patient received instruction in use of the equipment, whether or not the equipment had been calibrated. None of these factors showed a significant relationship with blood pressure accuracy. The power to detect differences of 25% or more varied from 60% to 80% for the different variables with the exception of educational level for which the power was only 40%. In this study of educated patients motivated to participate in a study of blood pressure measurement accuracy, one third were not able to record an accurate blood pressure. No factors could be identified which predicted the ability to record accurate blood pressures with home blood pressure equipment. In a general population inaccurate measurements by patients may be even more frequent. We suggest physician oversight of home blood pressure monitoring.

Independent risk factors for fracture include advanced age, preexisting fractures, and low bone mineral density. Risedronate has been shown in several large trials to be safe and effective for patients with osteoporosis, but its effects in populations at high risk are not well characterized. To determine the effect of risedronate on vertebral fracture in high-risk subjects, we pooled data from two randomized, double-blind studies [Vertebral Efficacy with Risedronate Therapy (VERT) Multinational (VERT-MN) and VERT-North America (VERT-NA)] in 3684 postmenopausal osteoporotic women treated with placebo or risedronate 2.5 or 5 mg/d and analyzed fracture risk in subgroups of subjects at high risk for fracture due to greater age or more prevalent fractures (vs. median for overall study population), or lower bone mineral density (T-score, -2.5 or less). Fractures were diagnosed by quantitative and semiquantitative assessment of radiographs at baseline and 1 yr. In the overall population, treatment for 1 yr with risedronate 5 mg/d reduced the risk of new vertebral fractures by 62% vs. control (relative risk, 0.38; 95% confidence interval, 0.25, 0.56; P < 0.001) and of multiple new vertebral fractures by 90% vs. control (relative risk, 0.10; 95% confidence interval, 0.04, 0.26; P < 0.001). Consistent risk reductions were observed at 1 yr in the risedronate-treated high-risk subgroups. Significant reduction in fracture risk after 1 yr is an important benefit in patients at high risk for fracture because, without treatment, these patients are likely to sustain new fractures in the near term.

Background: Concerns have been raised about the role that hospitalists may have in changing the educational process for medical students and residents, especially with regard to the primary care specialties. Methods: We implemented rotating hospital and office duties within our five-physician group. Results: Resident and student satisfaction increased, and additional faculty members could be added without expanding office space. Financial benefits then also ensued. Conclusion: Rotating hospital with office duties among a small group of internists has resulted in most of the advantages with few of the drawbacks related to the hospitalist approach.

Mycobacterium avium-intracellulare (MAI) rarely causes disease of the spine in healthy individuals. We describe an elderly woman who had isolated skeletal involvement with MAI, mimicking Pott's disease. She responded well to surgical excision of the inflamed tissue and antibiotic therapy. Osteomyelitis due to MAI must be differentiated from that due to Mycobacterium tuberculosis because the treatment regimens are different.

A 65-year-old man with a 3-month history of intractable back pain had previously received cytotoxic curative chemotherapy for non-Hodgkin's lymphoma. His postchemotherapy course had been complicated by febrile neutropenia, recurrent coagulase-negative staphylococcal bacteremia, and gastrostomy site infections. He was admitted with severe intractable lower back pain requiring high doses of intravenous narcotic analgesia. Magnetic resonance imaging of the spine was highly suggestive of disk infection. Fluoroscopically guided needle aspiration of the disk space was confirmatory, and both tissue and blood cultures were positive for coagulase-negative Staphylococcus species. Treatment included IV vancomycin and oral levofloxacin. The most common organism causing disk space infection is Staphylococcus aureus, but Staphylococcus epidermis should be considered in immuno-compromised patients. Septic discitis is an important differential diagnosis of back pain and should be considered in any clinical situation associated with bacteremia.

The Ommaya reservoir system has been used for the treatment of chronic central nervous system infections and intracranial tumors for more than three decades. The majority of reported Ommaya reservoir infections occur proximate to the time the device is accessed. A review of the literature reveals that late onset of reservoir infection is quite rare. We report a case of Ommaya reservoir infection due to Staphylococcus aureus that was diagnosed seven years after its insertion and usage for intracerebral non-Hodgkin's lymphoma and review the literature on the microbiology and management of Ommaya reservoir infections.

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