Team A: cardiology, chest diseases, neurosurgery, psychiatry & neurology, and radiology. (ABSTRACTS OF SCIENTIFIC PAPERS).

ACUTE STRUCTURAL RIGHT VENTRICULAR CHANGES IN A PORCINE MODEL OF PULMONARY EMBOLISM (PE). Norma L. Merced, MD, William C. Dixon, MD, Sheri Y. N. Boyd, MD, James L. Furgerson, MD, and Bernard J. Rubal, PhD. Brooke Army Medical Center, San Antonio, Tex.

Previous studies have shown that right ventricular (RV) dilation occurs in as many as 30% to 40% of patients presenting with moderate to large PE. RV dilation has also been shown to be adverse prognostic factor after PE. However, there have been no experimentally controlled studies evaluating the acute effect of PE on the RV. The purpose of this study was to document the acute structural changes of the RV via transthoracic echocardiography (TTE) in a swine model of PE. Acute PE was induced in eleven Yorkshire swine by injecting clotted autologous blood into the pulmonary venous circulation. Real time TTE was performed at baseline, during PE and at 1 and 2 hours post PE to evaluate acute RV changes. RV area was measured offline using commercially available software. Mean systemic arterial pressure, pulmonary arterial pressure, heart rate, arterial oxygen, and expired [CO.sub.2] were continuously monitored. PE were confirmed in all swine by angiography. TTE images were interpretable in 10 of 11 animals. Mean RV area increased from 5.47 [+ or -] 0.99 [cm.sup.2] to 12.36 [+ or -] 4.40 [cm.sup.2] immediately post PE. In addition, mean RV fractional shortening decreased from 0.33 [+ or -] 0.10 to 0.22 [+ or -] 0.16 post PE. Interestingly, RV area was not significantly different from baseline by 1 hour post PE. This study supports prior findings of RV dilation following FE. However, our data suggest that RV dilation may be transient and therefore clinically undetectable by the time of presentation.

COMPARATIVE STUDY OF PRACTICE AND HEALTH RESOURCE UTILIZATION FOR CONGESTIVE HEART FAILURE TREATMENT AT FIVE AREA HOSPITALS IN BALTIMORE. Rajiv N. Thakkar, MD, Vaishali Popat, MD, MPH, and Mark Baumel, MD. The Union Memorial Hospital, Baltimore, Md.

Congestive heart failure is the most common cause of admission to the hospital especially in patients older than 65 years. AHA/ACC Task force report periodically publishes standard guidelines to improve outcomes such as timely discharge with follow-up monitoring, reduce ER visits, and the readmission rate. Literature search also reveals that attempts have been made to establish and implement clinical pathways/guidelines within particular institute to reduce the hospital cost, duration of stay, and increase the efficiency through implementation of these guidelines. The hypothesis of this study was to determine the compliance to the AHA/ACC task force guidelines and to evaluate variability in practice and health resource utilization in treatment of patients admitted for CHF amongst five area hospitals in Baltimore. We conducted a historical cohort study of 183 patients admitted with the diagnosis of congestive heart failure at five area hospitals in Baltimore during the time period between February 1999 to May 1999. Charts were reviewed to evaluate the compliance with the multidisciplinary interventions and actions at the level of the physicians and the nursing staff. The various parameters followed during the hospitalization were use of IV diuretics in ER, daily weights, daily intake and output, use of ACE inhibitors, length of stay in the hospital, home and health care referral, and home management plans. The analysis showed that 86% patients (81-93%) received IV diuretics in the ER. Average documented weight loss during the hospitalization was 1.74 lbs. (0.33-2.43 lbs). Documentation of two days of intake and output data was only in 53.8% (39-64%). Although in 77% of patients ACE inhibitors were used during hospitalization, only 72.8% of patients were actually discharged on it. Although home health care facilities has been shown to improve the outcomes only 23% of the patients were referred. 50% (38-63%) patients were discharged within 3 days. This study shows large variability in practice, health resource utili zation, and compliance/adherence to AHA/ACC guidelines for CHF management.

CORONARY STENTING FOR MYOCARDIAL INFARCTION DUE TO VASOSPASM IN A MYOCARDIAL BRIDGE. Capt. Jason A. Mitchell, Lt. Col. Brian Schafer, Major Cynthia Gryboski, and Major Michael Ferguson. Keesler Medical Center, Keesler AFB, Miss.

A 31-year-old active duty male presented to an outside hospital with an acute myocardial infarction. On his post-infarction stress test, he exercised 11 minutes and 55 seconds of a full Bruce protocol without symptoms or EKG changes. His Sestamibi images revealed a reversible defect in his apex. Cardiac catheterization demonstrated a 30mm bridge in his mid LAD with systolic compression of 60% of the diastolic diameter. Ventriculography showed anteroapical hypokinesis in the territory distal to this bridge. The patient was referred to Keesler Medical Center for coronary stent placement. Coronary angiography at our institution confirmed the above findings. At the conclusion of the diagnostic study, the patient developed chest pain and ST elevations anteriorly. Angiography revealed severe spasm within the myocardial bridge with subtotal occlusion of the vessel and TIMI II flow distally. The patient's pain and ST segment changes resolved after a 200 [micro]g intracoronary nitroglycerin infusion. The myocardial br idge and spastic segment were stented with a 2.5 mm x 18 mm S660 stent placed distal and a 3.0 x 18 mm S670 stent placed proximal to the first in an overlapping fashion. There was no further evidence of spasm or ischemia and the patient was discharged. To date, he has remained free of chest pain. Myocardial bridges occur in 5-12% of all autopsy specimens and 1-2% of all coronary angiograms. Despite their frequency they are rarely symptomatic with only sporadic cases of ischemia and infarction due to bridging reported in the literature. Possible mechanisms of ischemia include impaired blood flow from systolic compression, accelerated atherosclerosis due to shearing forces in the bridge, or coronary spasm within the intramyocardial segment. To our knowledge, this is the first reported case of an infarction distal to a myocardial bridge due to spasm that has been treated with a coronary stent. Our experience suggests that stenting is an effective therapeutic option for patients with symptomatic myocardial bridge s.

BLOOD PRESSURE CONTROL BY CARDIOVASCULAR RISK GROUP: A MULTI-SITE ASSESSMENT WITHIN THE SOUTHERN UNITED STATES. Susan K. Maue, PhD, Eileen W. Farrelly, MPH, James H. Jackson, PharmD, and Feride Frech, MPH. Applied Health Outcomes, Novartis Pharmaceuticals.

Hypertension contributes to many serious medical conditions, including stroke, myocardial infarction, and congestive heart failure and is linked to 10% of all deaths each year in the U.S. Given these facts, the importance of hypertension control is evident. However, despite the recent advances in antihypertensive therapy, national survey data indicate that only 51% of treated hypertensive patients achieve blood pressure (BP) control of [less than]140/90 mmHg. Furthermore, the risk for cardiovascular disease is determined not only by BP control, but also by the presence or absence of target organ damage or other cardiovascular risk factors. Consideration of both factors is critical when determining an effective management strategy. The objectives of this research initiative were three-fold: (1) To identify hypertensive patients within a large, nationwide managed care database of pharmacy and medical claims; (2) To stratify patients by risk group, as defined in the sixth report by the Joint National Committee o n Hypertension (JNCVI); (3) To assess BP control by Risk Group, where control is defined by JNC-VI as BP of [less than]140/90 mmHg for non-diabetics and [less than]130/85 mmHg for diabetic patients. The risk groups are defined as follows: (A) No risk factors and no target organ disease or clinical CVD; (B) At least 1 risk factor, not including diabetes; no target organ disease or CVD; and (C) Target organ disease or CVD and/or diabetes, with or without other risk factors. Using a nationwide pharmacy and medical claims database from 1999, hypertensive patients from health plans covering approximately 3.3 million lives in the southern U.S. (Alabama, Florida and Texas) were identified. From this hypertensive population, patients were randomly selected for medical chart review. Measures of interest included blood pressure, demographic characteristics, co-morbid conditions and CV risk factors. Analyses were performed to assess overall demographic characteristics of the hypertensive population, to stratify patients according to risk group and to determine the level of BP control by risk group. Using medical and pharmacy claims, a total of 526,624 hypertensive patients were identified, indicating a prevalence of 16.1%. According to the data collected from 1493 patient charts, the hypertensive population was primarily female (59.3%) with a mean age of 63.5 years. The most common risk factors reported were age greater than 60 (57.9%), hyperlipidemia (43.3%), postmenopausal female (43.1%), male (40.7%), family history of CVD (31.6%) and diabetes mellitus (21.4%). Approximately 59% of treated hypertensive patients have uncontrolled BP, defined as [less than]140/90 mmHg, while 67% are uncontrolled according to JNC-VI criteria. The distribution of patients by Risk Group and BP control according to JNC-VI (regardless of therapy) reported by Risk Group are as follow:

               Risk     Risk     Risk
              Group A  Group B  Group C

N               68       786      639
(% of total)  (4.6%)   (52.6%)  (42.8%)
% with          50%     41.6%    29.4%
controlled    (n=34)   (n=327)  (n=188)
BP

Over 95% of the chart review patients were classified into Risk Groups B and C, indicating that over 500,000 of the hypertensive patients within the database likely have a high risk for CVD. The overall level of control for treated hypertensive patients (at [less than]140/90 mmHg) in this population was approximately 41%, which is below the national average of 51%. Additionally, as the level of risk increased, the level of BP control significantly decreased. Given the findings of this study, particularly for the higher risk patients as determined by the risk groups, more aggressive hypertension management may be considered.

CLINICAL FACTORS PREDICTING POSITIVE SERUM CARDIAC MARKERS AT A COMMUNITY MEDICAL CENTER. George M. Tadros, MD, Timothy R. McConnell, PhD, James C. Blankenship, MD, M. Ashequl Islam, MD, John M. Costello, and Elias A. Iliadis, MD. Geisinger Medical Center, Danville, Pa.

Elevated serum CK-MB and troponin T identify patients with acute coronary syndromes and predict long term cardiac events. To identify clinical factors that predict positive serum cardiac markers (CM), we prospectively analyzed patients admitted with the presumptive diagnosis of rule out myocardial infarction. Demographic, presentation and ECG criteria were analyzed to determine their likelihood of predicting positive CM (either abnormal Troponin T or CK-MB or both). Three hundred ninety-eight consecutively admitted patients were analyzed, 200 positive CM and 198 negative CM. Male sex was associated with positive CM (52 vs 41%) while females were often associated with negative CM (49 vs 59%). Positive CM were associated with hypertension (76 vs 58%), diabetes (44 vs 25%), tobacco use (37 vs 27%), prior MI (27 vs 16%) and prior CHF (43 vs 18%). Renal insufficiency (34 vs 19%) and end stage renal failure (19 vs 1%) were both associated with positive CM. Upon presentation, typical angina was associated with posit ive CM (22 vs 5%) while non specific chest pain was associated with negative CM (31 vs 67%). Ischemic ECG changes (ST depression, elevation and T wave inversion) were associated with positive CM (58 vs 18%) while nonspecific ECG changes were associated with negative CM (21 vs 69%). Multivariate logistic regression identified the strongest predictors of positive CM as ischemic EKG changes (L.R. 31.2), end stage renal disease (L.R. 25.9), chronic renal insufficiency (L.R. 16.8), typical anginal pain (L.R. 13.7), prior congestive heart failure (L.R. 8.7) and hypertension (L.R. 3.8). Our study identified various clinical variables as predictive of positive CM. However, CM are often chronically elevated in renal impaired patients, thus limiting their sensitivity in this group for defining acute myocardial injury. Therefore while recognized as a risk factor for cardiac events, patients with renal impairment may require other objective evidence of acute myocardial injury for appropriate triage. Future studies may be required to prove the efficacy of CM in predicting long term myocardial injury in renal impaired patients.

COMPARISON OF QUALITY OF LIFE (QOL) IN POSTMI PATIENTS WHO UNDERWENT PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) OR CORONARY ARTERY BYPASS SURGERY (CABG). Ozlem Soran, MD, and Tugrul Okay, MD. Dr. MU Teaching & Research Hospital, Ankara, and International Hospital, Istanbul, Turkey.

In order to asses the QOL in post MI patients who underwent PTCA or CABG, we designed a comparing study. Seventy-seven patients (PTCA = 33, and CABG = 34) were followed at least 2 years after the initial treatment. MOS Health Survey SF-36 was used for a QOL measurement. The majority of the patients were male (89%), above 50 years of age, with low-educational level and working full time before the treatment.

Although the QOL scores were good or very good (above 56) in both groups, complaints for re-MI or re-AP, and requiring PTCA or CABG were high in PTCA group. In addition, decrease in working capacity was high in PTCA group. Therefore we conclude that even if the QOL is not statistically different in post-MI patients who underwent PTCA or CABG, there is a trend to have more cardiac events and decrease in working capacity in PTCA group. As this study was relatively small, these results need to be confirmed by a larger study.

PROLONGED QT SYNDROME IN HIV PATIENTS. A SERIES OF THREE CASES. Rajiv N. Thakkar, MD, George Hennawi, MD, and David Schamp, MD. The Union Memorial Hospital, Baltimore, Md.

In the past year, three patients with known HIV disease presented to our institution with syncopal episodes. All were found to have a long QT interval on EKG and developed Torsades de Pointes during the hospitalization. Two of three patients had tox screen positive for cocaine on the date of the presentation but they continued to have a prolonged QT intervals on a follow up presentations while their tox screen were negative. None had family history of sudden death. HIV cardiomyopathy was ruled out by cardiac echocardiogram, which did not show any evidence of congestive heart failure. All electrolyte abnormalities were corrected. None of the patients were on any medications causing long QT intervals. Two patients had prior EKGs that showed normal intervals several months prior to this admission. All the patients were initially started on antiarrhythmic drugs. First patients started on Amiodarone and she did well for one year but later on had recurrent syncopal episode with documented Torsades de Pointes requir ing AICD placement. Second patient was started on Mexiletine but also required AICD placement. Third patient has been managed on Mexiletine and is doing well. Very few patients with HIV and prolonged QT interval have been reported in literature. A recent study has shown that patients with HIV disease have a significantly higher prevalence of QTc prolongation than the general population. This has been correlated to autonomic neuropathy and appears to be related to sodium channels abnormalities. In any HIV patient presenting with syncopal episode, prolonged QT syndrome should always be strongly considered. Although antiarrhythmic drugs have been recommended as a first line therapy for Torsades de Pointes with prolonged QT syndrome in HIV patients, in our group, two of three patients required AICD placement which questions the long term efficacy of antiarrhythmic drugs. More studies are needed to weigh the risk and benefit of these two modalities of treatment.

PREDICTORS OF 30-DAY CORONARY EVENTS AT A COMMUNITY MEDICAL CENTER. George M. Tadros, MD, Timothy R. McConnell, PhD, James C. Blankenship, MD, M. Ashequl Islam, MD, John M. Costello, and Elias A. Iliadis, MD. Geisinger Medical Center, Danville, Pa.

To determine predictors of coronary events (cardiac death, acute myocardial infarction, and unstable coronary syndromes) within 30 days after admission, we prospectively collected data on 400 patients admitted through our ER for chest pain. One hundred thirty five patients had coronary events within 30 days while 263 did not. Univariate analysis of demographic presentation and ischemic assessment was performed. Statistically significant variables associated with coronary events were advanced age (76 vs 63 years), diabetes mellitus (42% vs 31%), tobacco use (42% vs 26%), prior CHF (41% vs 25%), prior MI (33% vs 18%), and history of CAD (67% vs 41%). Absence of events was associated with the black population (23% vs 36%). Symptoms at presentation associated with cardiac events were typical angina (33% vs 3%) and shortness of breath (77% vs 50%) while atypical chest pain was associated with absence of events (11% vs 50%). Objective measures of ischemia associated with cardiac events were elevated troponin T (92% vs 29%), elevated CK-MB (73% vs 15%), and ischemic EKG changes (71% vs 21%). Nonspecific EKG changes were associated with an absence of events (28% vs 78%). Multiple logistic regression analysis identified independent predictors of coronary events: elevated troponin T (OR = 12.2), ischemic EKG changes (OR= 3.7), typical angina (OR = 3.7), elevated CK-MB (OR = 3.1), and history of CAD (OR = 2.1). Using forward stepwise regression, these factors generated a model to predict cardiac events within 30 days. The strongest predicting variable was serum troponin T (accounting for 35% of predicting value R2) followed by typical angina (R2 increasing to 40%), ischemic EKG changes (45%), CK-MB (47%) and prior CAD (48%). Positive predictive power of the model R2 = 48%, P[less than] .001. Our model incorporating demographic presentation and ischemic assessment identified 48% of patient suffering cardiac events within 30 days of admission. While the strongest predictor was identified as serum troponin T, clinical criteria offered modest improvement in predictive abilities. Therefore, serum markers and other objective evidence of cardiac disease such as non-invasive imaging may be necessary to Improve identification of high-risk patients and direct resources toward these patients.

THREATENED VIOLENCE AND ASSAULTS BY PATIENTS AGAINST CLINICIANS AT DIFFERENT LEVELS OF PSYCHIATRIC TRAINING AND PRACTICE. Melanie Robles Fuertes, MD, and Nilima Paresh Thakkar, MD. East Tennessee State University, Johnson City, Tenn.

In the United States, from 1998 to 1999 the nation's primary sources of information for criminal victimization reported a 10% decrease in violent crime, the lowest level in its survey history. Violence in the workplace, however, continues to be a prominent concern for Americans today. Of selected occupations examined, health care workers were among the most vulnerable. Although violence epidemiology faces limitations of underreporting and variable definitions of terms, research is based on reports of causes and inhibitors of violent crime, which may help society reinforce these factors and stop the violence. In particular violence against health care workers has alerted investigators and professional organizations to formally address clinician safety in the workplace. Studies have shown mental health practitioners are at increased risk of violence by patients compared with other medical specialties. About 40% of psychiatrists are assaulted during their careers and approximately 50% of psychiatric residents ar e physically victimized. An even greater percentage of both reported threats of violence. One study found that a third of psychiatric residents report not receiving training in managing violent patients while another third described their training as inadequate. This information suggests that the level of clinical experience attained may not play a protective role when addressing the question of personal safety. Rather, while training recommendations were previously oudined for psychiatric residents, the introduction of such elements in early medical education among students as well as continuing education for licensed practitioners is less established. This study to obtain site-specific data of the experience of threats and assaults from medical students, residents, and psychiatrists in the Department of Psychiatry and Behavioral Science at East Tennessee State University, James H. Quillen College of Medicine, and its multiple training sites. We plan to conduct a survey by administering a questionnaire exami ning respondents sex, age, level of training, or years of experience, number and type of threats or assaults, and sense of preparedness. Also to be obtained is information about the perpetrators such as sex, age, diagnosis, previous contact, and clinical setting of contact. Conclusions and recommendations can then be made regarding experiences of threatened violence and assaults as well as implications on instituting safety training for clinicians at all levels of practice.

AFFORDABLE TELEMEDICINE TECHNOLOGY TO ENHANCE PSYCHIATRY PRACTICE AND EDUCATION. Debra A. Katz, MD, Rob Sprang, MBA, and Tagalie Heister, MSLS. University of Kentucky College of Medicine, Lexington, Ky.

Utilizing affordable telemedicine systems may provide a practical method for physicians to evaluate and treat patients at distant sites and for training programs to access learning opportunities from national experts. Traditional telemedicine technologies, which are typically large, cumbersome and complex, are not often financially practical due to expensive capital equipment investment and the ongoing expense of high bandwidth communication lines. The system that will be presented, one of those used at the University of Kentucky's Kentucky TeleCare, costs approximately $3000 and operates via standard telephone lines. Particpants will understand the types and costs of telemedicine equipment, specifically comparing traditional systems with Kentucky TeleCare's low cost equipment. Participants will also see videotaped telemedicine sessions, understand how telemedicine systems can be used to overcome barriers of time and distance, and be provided with resources that will help them utilize existing telemedicine te chnology or develop new telemedicine solutions in their practices. Clinical applications of this new telemedicine technology being used at the University of Kentucky Department of Psychiatry include psychiatric consultations to local schools, consultation to distant juvenile justice facilities, and ongoing treatment of patients in their homes. The utilization of this technology to enhance learning has been demonstrated in several courses in the Psychiatry residency program. The experience from a two year telemedicine course in psychodynamic psychiatry taught by psychoanalysts from Cincinnati and New York will be discussed and shown. Research data regarding satisfaction with telemedicine technology, the impact of the course on career interests, on the development of psychotherapy skills and the ability to create psychodynamic formulations will be presented. Two additional courses, one in Child Psychopharmacology (from Miami) and one in Brief Psychotherapy (from San Francisco) have been taught using this system . Psychiatrists from the University of Kentucky have also been able to offer paid, educational programs via this technology to distant sites, thus providing much needed teaching without travel time for teachers or students and increased revenue for the deparment. Utilizing affordable telemedicine technology may enable. physicians to provide valuable clinical services to patients who are limited by distance, to enhance their own learning through telemedicine teaching and to offer their own expertise to students or trainees at distant sites.

PSYCHOSIS AND FOLIE A DEUX ASSOCIATED WITH OCD. Juan Francisco Rodriguez, MD, and Andres J. Pumariega, MD. East Tennessee State University, Johnson City, Tenn.

Obsessive-compulsive disorder (OCD) is one of the most severe and incapacitating disorders. It affects approximately 2.5% of youth and adults, not only in the United States but worldwide regardless of cultural setting and often leads to moderate to severe morbidity and incapacitation in psychosocial and cognitive function and even in activities of daily living. In some individuals with severe OCD, the extent of lack of insight associated with this disorder can approach delusional properties, and psychotic symptoms have indeed been reported to be associated with this disorder. The neurobiologic underpinnings of OCD have begun to be elucidated by recent research into function neuroanatomic, neurochemical, and even the autoimmune mechanisms associated with this disorder. Some recent attention has been focused on the interpersonal and familial morbidity of OCD. Calvocaresai et al especially have focused on the "family accommodation" paradigm. This involves inadvertent and adaptations that family members engage in both to avoid conflict with the impaired individual and to preserve their functionality in the family in the face of severe symptoms. They have outlined a number of such cognitive and behavioral adaptations that family members engage in. However, such accommodation cannot only lead to the reinforcement of OCD symptoms in the primary patient, but also the development and/or aggravation of OCD symptoms in family/household members. In many respects, the family accommodation paradox, parallels what is termed "folie a deux" in individuals suffering with psychosis and their family/household members. In this paper, we report on a case of severe OCD with psychosis in the head of a household that was associated with family accommodation that reached the proportions of a shared delusional disorder or folie a deux. The patient's symptomatic presentation, including psychotic symptoms, course of illness, and degree of functional impairment is reported. The family accommodation among family members is described observatio nally for each family member, as well as through symptom rating instruments administered to family members (including the Y-BOCS, the CY-BOCS, and the Family Accommodation Scale). Additionally, we discuss the relevance of this case to the literature on OCD and psychosis, family accommodation, and folie a deux. Treatment of this case will also be discussed in the context of the available literature on the treatment of OCD and of shared delusions.

DOES MIGRAINE PHENOTYPE PREDICT PREVENTATIVE TREATMENT? Steve D. Wheeler, MD. Miami, Fla.

The purpose of this study is to show that migraine preventatives can be selected on the basis of migraine phenotype. The genetic nature of migraine is not well defined, however the spectrum of clinical characteristics, the phenotypes, is well appreciated. The most widely recognized phenotypes include migraine without aura (M), migraine with aura (MWA), basilar migraine, hemiplegic migraine, and cluster-migraine or migraine with cluster features (MWCF). When migraine preventative treatment is necessary, specific preventative agents are typically selected on the basis of comorbid and co-existing medical illnesses, safety, tolerability and adverse event profile. However, recent review of openlabel, clinical experiences with topiramate (TPM) and lamotrigine (LTG) suggest that headache phenotype may help determine the most appropriate migraine preventative. Open label clinical experiences with TPM and LTG were reviewed. Efficacy was defined by at least a 50% reduction in headache frequency two or three months afte r treatment initiation. The LTG trial was consecutive, consisted of 65 patients prescribed LTG between September 1999 and August 2000, but only 35 were assessable; 30 were excluded because of adverse events (11), non-compliance (10), lost to follow-up (8) and lack of efficacy (one). The TPM trial was retrospective and consisted of all patients (15) with MWCF treated with TPM from October 1997 to October 2000. These trials were add-on or adjunctive in 13/15 TPM and 34/35 LTG treated patients. The TPM dose ranged from 25-400 mg/day, mean 112.5 mg; and LTG 25-200 mg/day, mean 55.1 mg. 80% (12/15) of TPM treated patients and 48.6% (17/35) of LTG treated patients had at least a 50% reduction in headache frequency. Of migraineurs with aura, 66.7% (12/18) responded to LTG and 100% (3/3) to TPM. 75% (3/4) of hemicrania continua (HC) patients responded to LTG. These open-label clinical experiences, although limited, suggest that there are some migraine phenotypes, that are prone to be responsive to certain preventativ e agents. TPM appears to be the agent of choice for MWCF and an appropriate choice for MWA. LTG appears to be appropriate for HC and MWA. Thus, migraine phenotype, in certain situations, can help determine the appropriate preventative agent.

THE DROPPED HEAD SYNDROME: AN UNUSUAL PRESENTATION OF MYASTHENIA GRAVIS. Michael Puruckherr, MD, Daniel Dube, MD, Alan Peiris, MD, Ryland P. Byrd, Jr., MD, and Thomas Roy, MD. Department of Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tenn.

A 78-year-old Caucasian male presented with a 2-month history of not being able to hold up his head when he walked. He could still partly lift up his head when sitting. During the preceding 3 weeks, he also experienced progressive weakness of his legs and limb girdle muscles which hindered him from rising from a chair without significantly using his arms, ptosis of his left eye, slurring of speech and intermittent diplopia. The remaining history was negative. Neurologically the neck flexors had a mild weakness 4-5/5 neck extensors 3-4/5, both upper extremities had a muscle strength of 5/5, the r and l lower extremity 4-5/5, DTR's were symmetrically with +2/4 in biceps, triceps, brachiora-dialis and patella, +1/4 Achilles. Sensitivity was intact throughout (temperature, sharp-dull discrimination, vibration, temperature and position). Romberg +, gait was shuffling and patient needed help to get out of the chair. He was completely unable to raise head when walking. Laboratory analysis confirmed an acetylcholine receptor antibody: 6.5 (0.0-0.5 normal range), an anti striated skeletal muscle antibody: 1:40 ([less than]40), an aldolase: 9.0 (1.2-7.6), and a FANA: 1:1280 ([less than]1;40) in nucleolar pattern. Tensilon 2 mg followed by 8 mg was given I.V. with resolution of the neurologic abnormalities within minutes. Forward sagging of the head due to weakness of the cervical extensor muscles is commonly seen at the late stage of a variety of neuromuscular diseases. In some cases, however, the head drop is the initial manifestation or remains isolated as benign nonprogressive condition. Neurologists use the term "dropped head syndrome" or "floppy head syndrome" to designate this situation. The neck extensor muscles are innervated by the dorsal roots of C1 to C8. The head sags forward onto the sternum and cannot be raised by the patient, who must either adopt unusual postures to carry out the activities of daily living or wear a hard collar with a chin rest. Passive extension of the neck is normal. This syndrome may be due to a variety of neurogenic, myopathic or neuromuscular junction disorders. When considering "dropped head syndrome", the clinician must investigate for myasthenia gravis or Eaton-Lambert syndrome, since the distinctive feature is at least partially reversible with treatment in these two conditions.

OPEN DECOMPRESSION-COBLATION NUCLEOPLASTY FOR COMBINED SPINAL STENOSIS AND DEGENERATIVE DISK DISEASE. David E. Tomaszek, MD. Conroe, Tex.

Patients with combined spinal stenosis and degenerative disk disease usually present with both back and leg pain. When conservative treatment fails, surgical options for these patients are limited. Simple surgical decompression, though effective for radicular pain, usually fails to help back pain. Some combination of decompression and fusion is usually required. Since November 2000, we have offered these patients a more conservative surgical alternative, namely decompression with coblation nucleoplasty. Nucleoplasty involves the oblation of disk tissue via a low temperature molecular dissociation, followed by thermal coagulation. We will present indications and results for the first 20 patients so treated. The surgery is rapid, bloodless, and involves far less hospital stay and postoperative recuperation than decompression with fusion. Back and leg pain are improved in 80% of patients. No operative morbidity or complications have been encountered, and patients return to active lifestyles within 2 months. Open decompression with coblation nucleoplasty appears to be a safe and effective alternative to more major surgical procedures in selected patients. A larger prospective study with long-term follow-up is currently in progress.

ENDOSCOPIC ASSISTED VERSUS OPEN STRIP CRANIECTOMY FOR SAGITTAL CRANIOSYNOSTOSIS? A RETROSPECTIVE REVIEW. Donnie R. Tyler, MD, and Andrew D. Parent, MD. Department of Neurosurgery, University of Mississippi, Jackson, Miss.

A retrospective comparison of two different techniques in the treatment of sagittal craniosynostosis employed at the University of Mississippi Medical Center between the years 1991 and 1999. From 1991 to 1996 operative exposure consisted of a single midline incision extending roughly from the anterior to the posterior fontanelle. A strip craniectomy was then performed under direct visualization. After 1996, the exposure was through two separate incisions placed in the coronal plane at the level of the lambda and bregma. The endoscope was used to assist with the subgaleal and extradural bony dissection. The placement of a post-operative molding helmet was not used with either technique. Multiple aspects of this procedure were compared: operative time, blood loss, follow-up anterior-posterior/lateral ratio, and age at time of surgery. The endoscopic assisted method resulted in lower average blood loss compared to that of the open technique, 76cc compared to 118cc. The surgical time was nearly the same for both techniques. The ICU and hospital length of stay was the same for both techniques. The average age of patients in the endoscopically assisted method was 3.5 months versus 5.2 months in the open method, and follow up AP/Lateral skull ratios were nearly equal. We conclude that this endoscopically assisted method is associated with a lower blood loss, and similar follow up AP/Lateral skull ratios without additional operative time.

SARCOIDOSIS: IMAGING OF UNUSUAL AND RARE PATTERNS. Jennifer M. Turner, MD, Kendrick Davidson, MD, Kenneth Rall, MD, and Alex Mendez, MD. Department of Radiology, University of Missouri - Columbia.

Sarcoidosis is not an uncommon idiopathic generalized granulomatous disease which principally affects the lung parenchyma and the various interstitial and mediastinal lymph nodes in over 90% of patients. Less commonly nodular organ or body tissue masses, non-specific in type are seen. Multiple other organs and body tissues unusually or rarely affected by sarcoidosis have been reported. Diagnosis often is dependent on presentations of signs and symptoms, evolution of disease, and biopsy of non-caseating granulomas with negative bacterial and fungal studies of these biopsy specimens. This study represents the review of 347 patients classified by medical record and/or biopsy record as definite or possible sarcoidosis, from the years 1989-2000. All illustrated cases were verified as sarcoidosis based on pulmonary and/or specific tissue biopsy results with clinical course, supportive laboratory data and a lack of possible pathogens by tissue staining and/or laboratory culture. Several radiographs (plain films and computed tomography) of proven sarcoid in this study show involvement of various organ systems including salivary glands, lacrimal glands, skeletal manifestations, liver and spleen non-caseating granulomas, as well as pericardial nodes, pleural involvement and renal sarcoidosis. The unusual or rare radiographic presentations of sarcoidosis as above illustrated may consist of organomegaly, organ masses or nodularity due to accumulated granulomas. These same radiographic patterns can be seen with infections and in patients with primary or secondary tumors such as reticuloendothelial diseases. Fine-needle asiration biopsies have been shown to be effective in establishing the definitive diagnosis of sarcoidosis. This is especially true when evaluating unusual and rare patterns of sarcoidosis, in the absence of the more common pulmonary presentations.

REACTIVE AIRWAYS DYSFUNCTION SYNDROME PRECIPITATED BY INHALATION OF METAL FUMES. Daniel Dube, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. Division of Pulmonary and Critical Care Medicine, Quillen College of Medicine, Johnson City, Tenn.

A previously healthy 62-year-old black male complained of acute onset of wheezing, shortness of breath, cough, fever, chills, and myalgia. These symptoms appeared shortly after exposure to metal fumes at work. He had no upper respiratory tract symptoms and denied nausea and diarrhea. His temperature was 101[degrees]F, respiratory rate 24 BPM, heart rate 100 BPM, and blood pressure 140/86 mmHg. Auscultation of his chest revealed wheezes but no crackles or rhonchi. Chest radiographs were normal. Pulmonary function tests demonstrated a severe obstructive ventilatory defect that responded to bronchodilators. A serum immunoglobulin E (IgE) level was 337 mg/dL. His fever, chills and myalgia resolved quickly. However, he has continued to require oral corticosteroids and inhaled bronchodilators to control his bronchial hyper-responsiveness. Metal fumes fever (MEF) is an acute self-limiting illness that occurs when a metal that has been heated above its melting point is aerosolized and inhaled. MFF presents acutely as a metallic taste in the mouth with fever, chills, and myalgia. Symptoms typically abate 36 hours after exposure. MFF is mediated by cytokines. Tumor necrosis factor (TNF) is released when heated metal fumes are inhaled. TNF subsequently stimulates the release of interleukin 6 (IL6). Injected IL6 and TNF cause fever and myalgia similar to MFF. Heavy metal fumes also increase the production of free oxygen radicals. Reactive airways dysfunction syndrome (RADS) occurs after inhalation injury to the bronchial airways from a variety of irritants. Symptoms of RADS follow a single exposure and but may persist for months. This insult to the airways stimulates IL6, prostaglandin (PG), and interleukin (LT), production, all of which are proposed to play a role in RADS. IL6 promotes IgE production. IgE then mediates mast cell degranulation, histamine release, and expression of cell adhesion molecules allowing basophils, monocytes, and eosinophil infiltration. Since both MFF and RADS result from inhalation of noxious mate rial and share the cytokine IL6 as part of their pathophysiological pathways, it might be expected that RADS would follow MFF with some regularity. In addition, free oxygen radicals that are present in MFF can lead to PG and LT release, both of which may play a role in RADS. Despite these observations RADS is infrequently reported to occur in association with MFF. More research is clearly necessary to further delineate the pathophysiological mechanisms of these two disease processes.

COMPARISON OF CRITERIA FOR PLEURAL FLUID ANALYSIS. CPT S. N. Dooley, MC, CPT L. L. Horvath, MC, MAJ R. A. Gallup, MC, and LTC M. J. Morris, MC. Brooke Army Medical Center, Ft. Sam Houston, Tex.

Pleural fluid (PF) analysis is essential for evaluation of pleural effusions. Numerous parameters other than Light's criteria exist for PF analysis with similar efficacy in distinguishing transudates and exudates. These criteria, PF/serum (S) ratios of bilirubin and cholesterol, and the S to PF albumin gradient, have not been evaluated for variability in the same patient. We attempted to determine if the reported accuracy of these parameters in PF analysis was reproducible by direct comparison in the same patient. All patients undergoing thoracentesis were eligible for our study. PF and S samples were obtained from 113 patients from 1997 to 2000. Cutoff values for determining an exudate for the various laboratory indices were used as previously reported and were as follows: Light's criteria (anyone of the following: PF LDH [greater than or equal to]2/3 the upper limits of normal of S value; PF/S LDH ratio [greater than]0.6, or PF/S protein ratio [greater than]0.5), a PF/S cholesterol ratio [greater than]0.3, a PF/S bilirubin ratio [greater than]0.6, and a S to PF albumin gradient [less than]1.2. Values were statistically analyzed and compared against the clinical diagnosis established on the basis of chart and lab review. Measurement of cholesterol ratio and bilirubin ratio in the same patient demonstrated similar findings as previously reported but did not improve clinical utility over Light's criteria. Albumin gradient was significantly different than previously reported. Combinations of these criteria improved the sensitivity but decreased the specificity of detecting clinically diagnosed exudates from transudates.

RHABDOMYOLYSIS ASSOCIATED WITH BACTEREMIC PNEUMOCOCCAL PNEUMONIA: AN EARLY INDICATOR OF INCREASED MORDIBITY? Maria Carmina C. Carcia, MD, Celso T. Ebeo, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. Division of Pulmonary and Critical Care Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, Tenn.

A 42-year-old known human immunodeficiency virus (HIV) positive male complained of fever and cough productive of yellow sputum for one week. He had no musculoskeletal complaints. He denied upper respiratory tract infection symptoms. He also denied recent trauma, ingestion of alcohol, drug use, and seizure activity. His past history was significant for HIV infection but due noncompliance he was not taking any antiretroviral medications or prophylactic therapy. His temperature was 103[degrees]F, his respiratory rate 18 BPM, pulse 128 BPM, and blood pressure 110/60 mmHg. The patient was cachectic. His mucous membranes were dry. There were crackles present in the right upper lung field. His cardiovascular examination was normal except for tachycardia. There was no tenderness of his major muscle groups. His white blood cells were 1,200 mm3 with 15% band forms. His serum electrolytes were normal but his blood urea nitrogen (BUN) and creatinine were elevated at 50 mg/dL and 2.6 mg/dL, respectively. Urinalysis demons trated a large amount of blood but microscopic examination of the urine revealed only 7 red blood cells per high power field. Serum creatinine phosphokinase (CPK) was 46,928 U/L and serum myoglobin was 5,083 ng/mL. A chest radiograph (CXR) documented right upper and middle lobe consolidation. Gram positive cocci were identified on sputum stains. The patient was treated with intravenous penicillin and prophylaxis for HIV-related infections with oral difluconazole and trimethoprim/sulfamethoxazole. He was aggressively hydrated intravenously and bicarbonate was added to his fluids to alkalinize his urine. Antiretroviral therapy however was withheld due to the patient's request. Both sputum and blood cultures grew Streptococcus pneumoniae. His renal function and CPK gradually returned to normal and his CXR cleared with this treatment. Rhabdomyolysis most commonly results from crushing injuries, the toxic effects of drugs and alcohol, seizures, and strenuous physical activity. Rhabdomyolysis has been rarely identi fied with bacterial pneumonia. It has recently been recognized, however, that rhabdomyolysis in the setting of Legionella pneumophila pneumonia has important prognostic implications. There are eight well documented cases of rhabdomyolysis associated with S pneumoniae pneumonia in the English literature. Interestingly all of these patients, including our patient, grew S pneumoniae from their blood. Bacteremia in patients with S pneumoniae doubles the death rate. Eight of nine patients, ours included, with S pneumoniae pneumonia associated rhabdomyolysis developed renal dysfunction as evidenced by an elevation in their BUN and serum creatinine. Uremia is also a sign of poor prognosis in patients with pneumococcal pneumonia. Bacteremic S pneumoniae pulmonary infections and rhabdomyolysis, therefore, appear to be at an increased risk of morbidity and mortality. Serum CPK may provide an early indicator for bacteremia, renal failure, and uremia in patients with pneumonic infection with this organism. This simple te st may allow for early recognition of patients with S pneumoniae pneumonia who are at an increased risk for a poor outcome and permit timely therapeutic intervention.

GEMELLA MORBILLORUM: A RARE CAUSE OF EMPYEMA THORACIS. Sujatha Goli, MD, Mathew G. Mathai, MD, Ryland P Byrd, Jr., MD, and Thomas M. Roy, MD. Division of Pulmonary and Critical Care Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City.

A 50-year-old white male complained of 2 weeks of a cough productive of yellow blood streaked sputum, fever with chills, and right-sided pleuritic chest pain. He had not completed a previously prescribed antibiotic course as an outpatient. His medical history was significant for alcohol abuse with numerous admissions for detoxification, marijuana abuse, and 40 pack years of cigarette use. His temperature was 101.6[degrees]F, respiratory rate 24/min, pulse rate 92/min, and blood pressure 117/66 mmHg. Dental caries were present, but there was no other oral lesion or abscess. There were decreased breath sounds and dullness to percussion in the right posterior lung field. His heart had a regular rhythm, with no evidence of a murmur. His white cell count was 24.8 mm (3) with 85% granulocytes. Chest roentgenogram documented a moderately large collection of pleural fluid with a subpulmonic component. Computed tomography of the chest demonstrated a loculated effusion with an air fluid level in the right posterior che st. He was empirically started on azithromycin and clindamycin. A diagnostic thoracentesis revealed exudative effusion. Gram-positive cocci in pairs and chains were identified by Gram stain. Culture of the pleural fluid grew Gemella morbillorum. Blood cultures were negative. His antibiotics were changed to ceftriaxone and clindamycin. He underwent tube thoracostomy and decortication of the right pleural space with a good outcome. Gemella morbillorum was until 1988 known as Streptococcus morbillorum, but was reclassified based on homology of DNA and 16S r RNA oligonuclotide. Gemella morbillorum is a Gram-positive cocci and facultative anaerobic bacteria. It is considered to be normal flora of the upper respiratory tract, gastrointestinal, and genitourinary tract. It is well known that endocarditis due to G morbillorum may follow dental or perianal surgery. However, other infections such as meningitis, bone and joint infection, and periodontal disease, though less common, have been reported. Septic shock caused by G morbillorum has been observed mostly in immunocompromised patients. There has been only one other case of empyema thoracis due to this organism reported in the English literature. Treatment includes [beta]-lactam or vancomycin and an aminoglycoside as initial therapy. Alternative therapy with a cephalosporin and clindamycin may be utilized to avoid nephrotoxicity. Surgery may be necessary in selected cases. The clinician should be aware that this organism might be resistant to penicillin. Our patient serves as a reminder that empyema thoracis can be caused by G morbillorum.

MYCOBACTERIUM XENOPI PNEUMONIA: A NOVEL INFECTION IN THE SOUTHEAST UNITED STATES. Jihane Faress, MD, Maroun Semaan, MD, Ryland P. Byrd, Jr., MD, Jay B. Mehta, MD, and Thomas M. Roy, MD. Department of Pulmonary and Critical Care Medicine, Quillen College of Medicine, Johnson City, Tenn.

A 67-year-old white male presented to the VAMC in Johnson City, TN with a cough productive of whitish sputum for 3 months. He gave a vague history of fevers and night sweats and admitted to a 20-pound weight loss. He had not traveled recently. His past history was significant for tobacco use, alcohol dependence, and vitamin B12 deficiency. His temperature was 96.6[degrees] F, pulse 72 BPM, blood pressure 133/72 mmHg, and respiratory rate 20 BPM. Auscultation of his lungs revealed poor air movement in all lung fields but no crackles, wheezes, or rhonchi. The remainder of his physical examination was essentially normal. His white blood cell count was 8,000/[mm.sup.3]. His hemoglobin, hematocrity, serum electrolytes, and biochemical survey were normal. Chest radiographs demonstrated a focal airspace infiltrate in the right upper lobe. Computerized tomography confirmed the infiltrate and documented fluid filled cavities in the same area. His sputum stained positive for acid fast organisms. Polymerase chain reacti on testing was positive for Mycobacterium genus but was negative for M tuberculosis, M avium, and M intracellulare. The patient was treated with oral rifampin, isoniazid, pyrazinamide, and ethambutol. High performance liquid chromatography identified M xenopi from 3 separate sputum samples. After M xenopi was identified his treatment was changed to clarithormycin, rifampin, and ethambutol. He responded well to this therapy. M xenopi is a slow growing non-tuberculous mycobacterium (NTM). It was first isolated from skin granulomata of the toad, Xenopus leavis, in 1959. This organism is found in fresh water but has been isolated in water samples collected from homes and from hospital hot water systems. M xenopi can cause pulmonary disease in immunocompetent patients with preexisting lung disease but may disseminate in patients with acquired immunodeficiency syndrome (AIDS). The classic chest radiologic appearance is cavitary apical pulmonary disease which mimics tuberculosis. Before the AIDS epidemic the frequen cy of M xenopi infection was low and occurred in clusters. M xenopi is now one of the most common NTM pathogens in parts of England and is increasingly recovered from clinical material from northwestern Europe, Canada, France, Japan, Austria, and Israel. Its isolation in the United States (US) is uncommon but infection due to this organism has been recognized in patients residing in New York, Connecticut, and Michigan. Our patient represents the first case to be reported from the southeastern US. Whether the isolation of M xenopi from our patient represents a new geographic distribution of this organism or tech nologic advancements that now allows for its identification is debatable. The optimal therapy for M xenopi infection has not been established, but the use of at least two medications has been advocated to avoid acquired resistance. Our patient serves as a reminder to the clinician that the incidence of NTM infection is rising in the US and that unusual NTM are capable of causing disease in even the non -immunocompromised patient.

SPONTANEOUS PULMONARY HEMATOMA: A RARE CAUSE OF PSEUDOTUMOR. Lisa A. McKinney, DO, M. Carmina C. Garcia, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. Quillen College of Medicine, East Tennessee State University, Johnson City, Tenn.

An 86-year-old man with hypertension and mild chronic obstructive pulmonary disease (COPD) complained of a nonproductive cough of three weeks duration. He denied fever, chills, hemoptysis, weight loss, and night sweats. He also denied recent and past chest trauma. He was afebrile and his vital signs and physical examination were normal. His prothrombin time (PTT) was 27.2 seconds, protime (PT) 11.5 seconds, and INR 0.92. His platelets numbered 161,000. His hemoglobin and hematocrit were 14.5 g/dL and 41%, respectively. His serum creatinine and blood urea nitrogen were normal. A chest radiograph (CXR) documented a 6 cm ovoid-shaped lesion in his right upper lobe. Computerized tomography (CT) demonstrated this 6 cm well circumscribed lesion to be homogenous and nonenhancing. The density of this lesion was similar to water. Flexible fiberoptic bronchoscopy failed to identify an endobronchial lesion. A needle was placed into the lesion under CT guidance and a large amount of material was aspirated that contained only degenerated blood cells. A repeat CT after 3 month of follow up documented complete resolution of the lesion. Pulmonary hematomas (PH) are collections of blood within the lung parenchyma but can simulate neoplasms. PH are most commonly associated with blunt chest trauma. Our patient, however, developed a non-traumatic PH. To our knowledge, there is only one other case of a non-traumatic PH reported in the English literature. There are two additional descriptions of intra-bullous hematomas that occurred during mechanical ventilation of COPD patients. Positive pressure ventilation (PPV) may have stretched and subsequently ruptured blood vessels embedded in the wall of the bullae. Although our patient bad mild obstructive pulmonary disease there was no evidence of bullous emphysema and he had not undergone PPV. PH on CXR are usually spherical with well-defined margins. CT demonstrates that PH mature into solid non-enhancing masses that are rounded and homogeneous. Magnetic resonance imaging shows PH to be h yperintense mass, consistent with lysis of red blood cells and oxidation of hemoglobin. Resolution of PH usually occurs within 2 to 8 weeks. In most cases of PH no specific treatment is indicated. Antibiotics are not indicated unless the hematoma becomes secondarily infected. Our patient illustrates that although rare non-traumatic PH can occur spontaneously and it must be considered in the differential diagnosis of a pulmonary pseudotumor.

                     PTCA (n=33)  CABG (n=34)

PF                   79.7 + 20.5  83.1 + 14.2
RP                   78.8 + 38.5  63.9 + 40.9
BP                   74.3 + 25.1  72.5 + 21.9
GH                   65.7 + 15.9  66.9 + 21.8
V                    65.4 + 16.6  62.1 + 23.3
SF                   84.5 + 23.7  79.4 + 23.6
RE                   75.7 + 37.9  61.7 + 45.8
MH                   67.3 + 16.2  67.3 + 20.9
Re-MI                  5 (15%)      1 (3%)
Re-AP                 11 (33%)      3 (9%)
Re-PTCA                8 (24%)      1 (3%)
CABG                   3 (9%)       -
Decrease in working      64%          53%
capacity