Journal of Community Hospital Internal Medicine Perspectives, 2017
Thrombosis is a frequent cause of morbidity and mortality in patients with nephrotic syndrome (NS... more Thrombosis is a frequent cause of morbidity and mortality in patients with nephrotic syndrome (NS). Though venous thromboses are common in NS, arterial thromboses are relatively rare. Commonly involved arteries include coronary, iliac, femoral, renal, cerebral, pulmonary, mesenteric, and axillary arteries, and the aorta. Arterial thromboses are associated with poor prognosis; treatment options are limited and patients may not always be amenable to treatment. We present the case of a 39-year-old female with NS who presented with thigh pain and was found to have sub-acute popliteal artery thrombosis.
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associ... more Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associated with sudden emotional or physical stress. Epinephrine use has been implicated in precipitating Takotsubo cardiomyopathy in multiple case reports and case series. We sought to systematically review the current English literature on this association. We searched relevant articles on Takotsubo cardiomyopathy associated with epinephrine administration and extracted data on demographic characteristics, clinical features, investigations and clinical outcomes. We identified total of 41 cases from 36 articles. The mean age of presentation was (47.07±15.73years) with strong female preponderance (83%, P=0.0001). The most common symptom at presentation was chest pain (82%). Mean peak troponin I level was (7.12±11.22ng/ml). The most common EKG abnormality was ST elevation, seen in 40% of patients. The most common finding on echocardiography was apical hypokinesis, seen in 48.78% cases. Patients younger than 45 were less likely to have apical cardiomyopathy (n=5/20, 25%) compared to patients with age >45 (n=14/21, 66%, p value 0.001, OR 0.17). The most common route of administration of epinephrine was intravenous (65.85%). All patients except one survived with complete recovery of systolic function reported in most cases within an average of 14.7days. Exposure to epinephrine in clinical practice can trigger Takotsubo cardiomyopathy, which is rapidly reversible with good prognosis in most cases. This review further supports the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of Takotsubo cardiomyopathy.
Statins are a group of drugs that reduce the levels of triglycerides and cholesterol in blood by ... more Statins are a group of drugs that reduce the levels of triglycerides and cholesterol in blood by inhibiting HMG-CoA reductase, an enzyme involved in rate limiting step in cholesterol synthesis. About 2-20% patients on statins develop toxic myopathies, which usually resolve on discontinuation of statin. More recently, an immune-mediated necrotizing myopathy has been found to be associated with statin use which in most cases requires treatment with immunosuppressants. To perform a systematic review on published case reports and case series of statin-associated autoimmune myopathy. A comprehensive search of PUBMED, EMBASE, Cochrane library and ClinicalTrials.gov databases was performed for relevant articles from inception until March 19, 2016 to identify cases of statin-associated necrotizing myopathy and characterize their symptoms, evaluation and response to treatment. A total of 16 articles describing 100 patients with statin-associated autoimmune myopathy were identified. The mean age of presentation was 64.72 years, and 54.44% were males. The main presenting clinical feature was proximal muscle weakness, which was symmetric in 83.33% of patients. The mean creatine kinase (CK) was 6853 IU/l. Anti-HMG-CoA reductase antibody was positive in all cases tested (n = 57/57, 100%). In patients with no anti-HMG-CoA antibody results, diagnosis was established by findings of necrotizing myopathy on biopsy. Among the 83 cases where muscle biopsy information was available, 81.48% had necrosis, while 18.51% had combination of necrosis and inflammation. Most (83.82%) patients received two or more immunosuppressants to induce remission. Ninety-one percent had resolution of symptoms after treatment. Statin-associated necrotizing myopathy is a symmetric proximal muscle weakness associated with extreme elevations of CK. It is common in males and can occur after months of statin use. It is associated with necrosis on muscle biopsy and the presence of anti-HMG-CoA reductase antibodies. It usually requires discontinuation and immune suppression for resolution. Rechallenge with statin is unsuccessful in most cases.
Antiphospholipid antibody syndrome (APS) is a disorder associated with both arterial and venous t... more Antiphospholipid antibody syndrome (APS) is a disorder associated with both arterial and venous thromboembolic disease, including acute myocardial infarction (AMI). Given that management with anticoagulants is critical and differs from usual AMI care, identification of key discriminators of patients with AMI with APS is important. We performed an English-language systematic review of the literature of cases and case series of patients with AMI and APS from inception until 20 March 2016, collecting demographics, investigations, and outcomes. Forty cases of AMI because of APS were identified from 27 articles. Patients were younger than typical AMI patients (41.10±13.61 years) and 45% were women. ST-elevation myocardial infarction was the presentation in 45% (18/40) of cases. The average platelet count was 130 000±138 912 c/mm in the 10 cases reporting it and partial thromboplastin time was elevated in all four reporting it. Coronary arteries were described as normal or with acute thro...
Statins modify inflammatory cell signaling during the immune response to infection. This has been... more Statins modify inflammatory cell signaling during the immune response to infection. This has been considered as a pleotropic effect. Effects of statins in inflammatory conditions such as bacteremia have been found to be controversial. We examined the effect of statins on the mortality of bacteremia patients. Major databases were searched for the pertinent clinical trials. Six cohort studies comprising 7553 patients were included. Hospital mortality was lower (15.36% vs 22.28%) in patients on statin. There may be a potential role of statins in similar inflammatory and infective conditions.
Rivaroxaban is a novel oral anticoagulant used in the treatment of venous thromboembolism. The us... more Rivaroxaban is a novel oral anticoagulant used in the treatment of venous thromboembolism. The use of this medication has expanded over the recent years with resultant expansion of side effect profile. We present a case of a 56-year-old female who presented with shortness of breath and chest pain 12 weeks after starting rivaroxaban for left upper extremity deep vein thrombosis. She was later diagnosed with spontaneous hemopericardium requiring pericardial fluid drainage. Rarer side effects like this will be encountered more often with the increasing use of novel oral anticoagulants. The clinicians should be cognizant of this entity among patients with shortness of breath and chest pain for timely diagnosis and intervention.
Background
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequ... more Background
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associated with sudden emotional or physical stress. Epinephrine use has been implicated in precipitating Takotsubo cardiomyopathy in multiple case reports and case series. We sought to systematically review the current English literature on this association. Methods
We searched relevant articles on Takotsubo cardiomyopathy associated with epinephrine administration and extracted data on demographic characteristics, clinical features, investigations and clinical outcomes. Results
We identified total of 41 cases from 36 articles. The mean age of presentation was (47.07 ± 15.73 years) with strong female preponderance (83%, P = 0.0001). The most common symptom at presentation was chest pain (82%). Mean peak troponin I level was (7.12 ± 11.22 ng/ml). The most common EKG abnormality was ST elevation, seen in 40% of patients. The most common finding on echocardiography was apical hypokinesis, seen in 48.78% cases. Patients younger than 45 were less likely to have apical cardiomyopathy (n = 5/20, 25%) compared to patients with age > 45 (n = 14/21, 66%, p value 0.001, OR 0.17). The most common route of administration of epinephrine was intravenous (65.85%). All patients except one survived with complete recovery of systolic function reported in most cases within an average of 14.7 days. Conclusion
Exposure to epinephrine in clinical practice can trigger Takotsubo cardiomyopathy, which is rapidly reversible with good prognosis in most cases. This review further supports the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of Takotsubo cardiomyopathy.
Smoking has been found to be negatively correlated with serum uric acid levels by virtue of reduc... more Smoking has been found to be negatively correlated with serum uric acid levels by virtue of reduced production and increased consumption of endogenous antioxidant uric acid among smokers and has been reported to decrease incidence of gout. To shed further light on the question of association between active smoking and acute gout by examining this association using a large inpatient US database, using the Nationwide Inpatient Sample data from 2009 to 2011, we identified current smokers based on the International Classification of Diseases, Ninth Revision (ICD-9) code 305.1 and were assumed to have ceased smoking during hospital stay. Patients who developed acute gout inhospital were identified based on ICD-9 code 274.01 at secondary diagnosis position. Univariate and multivariate logistic regressions were used to derive odds ratio for measures of association. Statistical analysis was done using STATA version 13.0 (College Station, TX). A total of 17,847,045 discharge records were used which included 13,932 (0.08 %) inhospital acute gouty arthritis and 2,615,944 (14.66 %) active smokers. Both univariate (OR 0.59, CI 0.54–0.63, p < 0.0001) and multivariate (OR 0.64, CI 0.59–0.68, p < 0.0001) regressions showed statistically significant reduction of acute gout among hospitalized patients who were current smokers but were assumed to have ceased smoking during hospital stay. Active tobacco use was associated with a lower risk of acute inpatient gouty arthritis, even when controlling for conventional risk factors. More study is needed to correlate this finding with uric acid levels, and a better understanding of the mechanisms that explain this finding are necessary.
Journal of Community Hospital Internal Medicine Perspectives, 2015
Apixaban, a novel oral anticoagulant, is also used for deep vein thrombosis (DVT) prophylaxis. In... more Apixaban, a novel oral anticoagulant, is also used for deep vein thrombosis (DVT) prophylaxis. In this study, we sought to critically evaluate the differences in the rates of symptomatic DVT and bleeding, and analyze the rates of pulmonary embolism (PE) in subgroups of patients from ADVANCE I and II trials given their similar indication and design. Studies were identified through electronic literature searches of MEDLINE, clinicaltrial.gov, SCOPUS, and EMBASE up to January 2014. Phase III RCTs involving use of apixaban and enoxaparin for thromboprophylaxis in patients undergoing total knee or hip replacement were included. Study-specific odds ratios were calculated and between-study heterogeneity was assessed using the I (2) statistics. In three studies involving 11,659 patients, the risk of symptomatic DVT (pooled OR 0.38, 95% CI 0.16-0.90, I (2)=0%, p=0.03) and bleeding (pooled OR 0.87, 95% CI 0.77-0.99, I (2)=0%, p=0.03) was less in apixaban group compared to the enoxaparin group. However, it was interesting to note that on subgroup analysis, the risk of PE was higher with apixaban when used for thromboprophylaxis in knee replacement surgery (pooled OR 2.58, 95% CI 1.10-6.04, I (2)=0%, p=0.03). Apixaban was found to be associated with lower risk of symptomatic DVT and bleeding compared to enoxaparin when used for thromboprophylaxis in patients undergoing knee and hip replacement surgeries. However, it was associated with higher risk of PE in patients undergoing knee replacement.
The risk of venous thromboembolism (VTE) increases with age. New oral anticoagulants (NOACs) have... more The risk of venous thromboembolism (VTE) increases with age. New oral anticoagulants (NOACs) have been increasingly studied for VTE prophylaxis in patients with elective postarthroplasty. Although the elderly population accounts for a significant proportion of patients requiring VTE prophylaxis, safety and efficacy of NOACs in this subgroup for VTE prophylaxis has not been well studied. Relevant studies were identified through electronic literature searches of MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov (from inception to 12 August 2014). Phase III randomized controlled trials that compared NOACs against low-molecular-weight heparin (LMWH) in the prevention of VTE prophylaxis in patients with elective postarthroplasty were included. We defined our elderly population as adults of at least 75 years and assessed the reported safety and efficacy outcomes with NOACs in this population. Study-specific odds ratios (ORs) were calculated and between-study heterogeneity was assessed using the I statistic. In nine trials involving 29 403 patients, the risk of VTE or VTE-related deaths in elderly patients with elective postarthroplasty was similar with NOACs compared with LMWH (OR 0.62, 95% confidence interval 0.30-1.26; P = 0.18; I = 44%) but bleeding risk was significantly lower (OR 0.71, 95% confidence interval 0.53-0.94; P = 0.02; I = 0%). Analysis of individual NOACs showed superior efficacy but similar safety for apixaban when compared with LMWH. Efficacy and safety profiles of rivaroxaban and dabigatran were similar to LMWH. In elderly patients with elective postarthroplasty, NOACs have similar efficacy but superior safety when compared with enoxaparin for VTE prophylaxis.
Journal of Community Hospital Internal Medicine Perspectives, 2015
Hyperkalemia can present with a spectrum of clinical manifestations with progressive EKG changes ... more Hyperkalemia can present with a spectrum of clinical manifestations with progressive EKG changes and life-threatening arrhythmias. Although no formal guidelines exist as to when to initiate treatment for hyperkalemia, it is generally recommended in clinically symptomatic patients with or without EKG changes. Timely diagnosis and reversal can relieve symptoms and prevent life-threatening arrhythmias. We review the EKG changes associated with hyperkalemia and management principles along with an example of a case of severe hyperkalemia resulting in arrhythmia and flaccid paralysis.
Journal of Community Hospital Internal Medicine Perspectives, 2015
Late onset seroma is a rare post-operative complication occurring after various surgeries includi... more Late onset seroma is a rare post-operative complication occurring after various surgeries including thymectomy. Most cases are asymptomatic; however, seromas occurring in the mediastinal cavity may cause compression symptoms including airway compression or cardiac tamponade. We present a 62-year-old male with a history of thymectomy for myasthenia gravis who presented with cardiac tamponade several years ago. Further evaluation revealed a late onset seroma anteriorly compressing the cardiac chambers resulting in tamponade physiology.
Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a common cause of hyponatr... more Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a common cause of hyponatremia. Although it has been associated with different pulmonary infections, there have been only few case reports describing the association of SIADH with influenza. We report a case of SIADH in a patient with influenza who was successfully treated with fluid restriction. It is essential for clinicians to be aware of the association between influenza and SIADH.
A 62-year-old male with past medical history of benign prostatic hyperplasia presented to the eme... more A 62-year-old male with past medical history of benign prostatic hyperplasia presented to the emergency department with complaints of decreased urinary flow, inability to fully empty his bladder, and gross hematuria. Physical examination was unremarkable. Urinalysis revealed large amount of blood and more than 700 white blood cells suggesting a urinary tract infection. Urine culture grew group D Salmonella greater than 100,000 colony-forming units per mL. He was prescribed 6 weeks of trimethoprim/sulfamethoxazole and had resolution of symptoms. Retrospectively, he reported a 3-day history of watery diarrhea about a week prior to onset of urinary symptoms that was presumed to be the hematogenous source in this case. Urinary tract infection from nontyphoidal Salmonella (NTS) is rare and is usually associated with immunosuppression, chronic diseases, such as diabetes or structural abnormalities of the genitourinary tract. Genitourinary tract abnormalities previously reported in the literature that predispose to nontyphoidal Salmonella urinary tract infection include nephrolithiasis, chronic pyelonephritis, retrovesicular fistula, urethrorectal fistula, hydrocele, and post-TURP. We present an exceedingly uncommon case of 62-year-old male with group D Salmonella urinary tract infection predisposed by his history of benign prostatic hyperplasia.
Journal of Community Hospital Internal Medicine Perspectives, 2017
Thrombosis is a frequent cause of morbidity and mortality in patients with nephrotic syndrome (NS... more Thrombosis is a frequent cause of morbidity and mortality in patients with nephrotic syndrome (NS). Though venous thromboses are common in NS, arterial thromboses are relatively rare. Commonly involved arteries include coronary, iliac, femoral, renal, cerebral, pulmonary, mesenteric, and axillary arteries, and the aorta. Arterial thromboses are associated with poor prognosis; treatment options are limited and patients may not always be amenable to treatment. We present the case of a 39-year-old female with NS who presented with thigh pain and was found to have sub-acute popliteal artery thrombosis.
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associ... more Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associated with sudden emotional or physical stress. Epinephrine use has been implicated in precipitating Takotsubo cardiomyopathy in multiple case reports and case series. We sought to systematically review the current English literature on this association. We searched relevant articles on Takotsubo cardiomyopathy associated with epinephrine administration and extracted data on demographic characteristics, clinical features, investigations and clinical outcomes. We identified total of 41 cases from 36 articles. The mean age of presentation was (47.07±15.73years) with strong female preponderance (83%, P=0.0001). The most common symptom at presentation was chest pain (82%). Mean peak troponin I level was (7.12±11.22ng/ml). The most common EKG abnormality was ST elevation, seen in 40% of patients. The most common finding on echocardiography was apical hypokinesis, seen in 48.78% cases. Patients younger than 45 were less likely to have apical cardiomyopathy (n=5/20, 25%) compared to patients with age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;45 (n=14/21, 66%, p value 0.001, OR 0.17). The most common route of administration of epinephrine was intravenous (65.85%). All patients except one survived with complete recovery of systolic function reported in most cases within an average of 14.7days. Exposure to epinephrine in clinical practice can trigger Takotsubo cardiomyopathy, which is rapidly reversible with good prognosis in most cases. This review further supports the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of Takotsubo cardiomyopathy.
Statins are a group of drugs that reduce the levels of triglycerides and cholesterol in blood by ... more Statins are a group of drugs that reduce the levels of triglycerides and cholesterol in blood by inhibiting HMG-CoA reductase, an enzyme involved in rate limiting step in cholesterol synthesis. About 2-20% patients on statins develop toxic myopathies, which usually resolve on discontinuation of statin. More recently, an immune-mediated necrotizing myopathy has been found to be associated with statin use which in most cases requires treatment with immunosuppressants. To perform a systematic review on published case reports and case series of statin-associated autoimmune myopathy. A comprehensive search of PUBMED, EMBASE, Cochrane library and ClinicalTrials.gov databases was performed for relevant articles from inception until March 19, 2016 to identify cases of statin-associated necrotizing myopathy and characterize their symptoms, evaluation and response to treatment. A total of 16 articles describing 100 patients with statin-associated autoimmune myopathy were identified. The mean age of presentation was 64.72 years, and 54.44% were males. The main presenting clinical feature was proximal muscle weakness, which was symmetric in 83.33% of patients. The mean creatine kinase (CK) was 6853 IU/l. Anti-HMG-CoA reductase antibody was positive in all cases tested (n = 57/57, 100%). In patients with no anti-HMG-CoA antibody results, diagnosis was established by findings of necrotizing myopathy on biopsy. Among the 83 cases where muscle biopsy information was available, 81.48% had necrosis, while 18.51% had combination of necrosis and inflammation. Most (83.82%) patients received two or more immunosuppressants to induce remission. Ninety-one percent had resolution of symptoms after treatment. Statin-associated necrotizing myopathy is a symmetric proximal muscle weakness associated with extreme elevations of CK. It is common in males and can occur after months of statin use. It is associated with necrosis on muscle biopsy and the presence of anti-HMG-CoA reductase antibodies. It usually requires discontinuation and immune suppression for resolution. Rechallenge with statin is unsuccessful in most cases.
Antiphospholipid antibody syndrome (APS) is a disorder associated with both arterial and venous t... more Antiphospholipid antibody syndrome (APS) is a disorder associated with both arterial and venous thromboembolic disease, including acute myocardial infarction (AMI). Given that management with anticoagulants is critical and differs from usual AMI care, identification of key discriminators of patients with AMI with APS is important. We performed an English-language systematic review of the literature of cases and case series of patients with AMI and APS from inception until 20 March 2016, collecting demographics, investigations, and outcomes. Forty cases of AMI because of APS were identified from 27 articles. Patients were younger than typical AMI patients (41.10±13.61 years) and 45% were women. ST-elevation myocardial infarction was the presentation in 45% (18/40) of cases. The average platelet count was 130 000±138 912 c/mm in the 10 cases reporting it and partial thromboplastin time was elevated in all four reporting it. Coronary arteries were described as normal or with acute thro...
Statins modify inflammatory cell signaling during the immune response to infection. This has been... more Statins modify inflammatory cell signaling during the immune response to infection. This has been considered as a pleotropic effect. Effects of statins in inflammatory conditions such as bacteremia have been found to be controversial. We examined the effect of statins on the mortality of bacteremia patients. Major databases were searched for the pertinent clinical trials. Six cohort studies comprising 7553 patients were included. Hospital mortality was lower (15.36% vs 22.28%) in patients on statin. There may be a potential role of statins in similar inflammatory and infective conditions.
Rivaroxaban is a novel oral anticoagulant used in the treatment of venous thromboembolism. The us... more Rivaroxaban is a novel oral anticoagulant used in the treatment of venous thromboembolism. The use of this medication has expanded over the recent years with resultant expansion of side effect profile. We present a case of a 56-year-old female who presented with shortness of breath and chest pain 12 weeks after starting rivaroxaban for left upper extremity deep vein thrombosis. She was later diagnosed with spontaneous hemopericardium requiring pericardial fluid drainage. Rarer side effects like this will be encountered more often with the increasing use of novel oral anticoagulants. The clinicians should be cognizant of this entity among patients with shortness of breath and chest pain for timely diagnosis and intervention.
Background
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequ... more Background
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associated with sudden emotional or physical stress. Epinephrine use has been implicated in precipitating Takotsubo cardiomyopathy in multiple case reports and case series. We sought to systematically review the current English literature on this association. Methods
We searched relevant articles on Takotsubo cardiomyopathy associated with epinephrine administration and extracted data on demographic characteristics, clinical features, investigations and clinical outcomes. Results
We identified total of 41 cases from 36 articles. The mean age of presentation was (47.07 ± 15.73 years) with strong female preponderance (83%, P = 0.0001). The most common symptom at presentation was chest pain (82%). Mean peak troponin I level was (7.12 ± 11.22 ng/ml). The most common EKG abnormality was ST elevation, seen in 40% of patients. The most common finding on echocardiography was apical hypokinesis, seen in 48.78% cases. Patients younger than 45 were less likely to have apical cardiomyopathy (n = 5/20, 25%) compared to patients with age > 45 (n = 14/21, 66%, p value 0.001, OR 0.17). The most common route of administration of epinephrine was intravenous (65.85%). All patients except one survived with complete recovery of systolic function reported in most cases within an average of 14.7 days. Conclusion
Exposure to epinephrine in clinical practice can trigger Takotsubo cardiomyopathy, which is rapidly reversible with good prognosis in most cases. This review further supports the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of Takotsubo cardiomyopathy.
Smoking has been found to be negatively correlated with serum uric acid levels by virtue of reduc... more Smoking has been found to be negatively correlated with serum uric acid levels by virtue of reduced production and increased consumption of endogenous antioxidant uric acid among smokers and has been reported to decrease incidence of gout. To shed further light on the question of association between active smoking and acute gout by examining this association using a large inpatient US database, using the Nationwide Inpatient Sample data from 2009 to 2011, we identified current smokers based on the International Classification of Diseases, Ninth Revision (ICD-9) code 305.1 and were assumed to have ceased smoking during hospital stay. Patients who developed acute gout inhospital were identified based on ICD-9 code 274.01 at secondary diagnosis position. Univariate and multivariate logistic regressions were used to derive odds ratio for measures of association. Statistical analysis was done using STATA version 13.0 (College Station, TX). A total of 17,847,045 discharge records were used which included 13,932 (0.08 %) inhospital acute gouty arthritis and 2,615,944 (14.66 %) active smokers. Both univariate (OR 0.59, CI 0.54–0.63, p < 0.0001) and multivariate (OR 0.64, CI 0.59–0.68, p < 0.0001) regressions showed statistically significant reduction of acute gout among hospitalized patients who were current smokers but were assumed to have ceased smoking during hospital stay. Active tobacco use was associated with a lower risk of acute inpatient gouty arthritis, even when controlling for conventional risk factors. More study is needed to correlate this finding with uric acid levels, and a better understanding of the mechanisms that explain this finding are necessary.
Journal of Community Hospital Internal Medicine Perspectives, 2015
Apixaban, a novel oral anticoagulant, is also used for deep vein thrombosis (DVT) prophylaxis. In... more Apixaban, a novel oral anticoagulant, is also used for deep vein thrombosis (DVT) prophylaxis. In this study, we sought to critically evaluate the differences in the rates of symptomatic DVT and bleeding, and analyze the rates of pulmonary embolism (PE) in subgroups of patients from ADVANCE I and II trials given their similar indication and design. Studies were identified through electronic literature searches of MEDLINE, clinicaltrial.gov, SCOPUS, and EMBASE up to January 2014. Phase III RCTs involving use of apixaban and enoxaparin for thromboprophylaxis in patients undergoing total knee or hip replacement were included. Study-specific odds ratios were calculated and between-study heterogeneity was assessed using the I (2) statistics. In three studies involving 11,659 patients, the risk of symptomatic DVT (pooled OR 0.38, 95% CI 0.16-0.90, I (2)=0%, p=0.03) and bleeding (pooled OR 0.87, 95% CI 0.77-0.99, I (2)=0%, p=0.03) was less in apixaban group compared to the enoxaparin group. However, it was interesting to note that on subgroup analysis, the risk of PE was higher with apixaban when used for thromboprophylaxis in knee replacement surgery (pooled OR 2.58, 95% CI 1.10-6.04, I (2)=0%, p=0.03). Apixaban was found to be associated with lower risk of symptomatic DVT and bleeding compared to enoxaparin when used for thromboprophylaxis in patients undergoing knee and hip replacement surgeries. However, it was associated with higher risk of PE in patients undergoing knee replacement.
The risk of venous thromboembolism (VTE) increases with age. New oral anticoagulants (NOACs) have... more The risk of venous thromboembolism (VTE) increases with age. New oral anticoagulants (NOACs) have been increasingly studied for VTE prophylaxis in patients with elective postarthroplasty. Although the elderly population accounts for a significant proportion of patients requiring VTE prophylaxis, safety and efficacy of NOACs in this subgroup for VTE prophylaxis has not been well studied. Relevant studies were identified through electronic literature searches of MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov (from inception to 12 August 2014). Phase III randomized controlled trials that compared NOACs against low-molecular-weight heparin (LMWH) in the prevention of VTE prophylaxis in patients with elective postarthroplasty were included. We defined our elderly population as adults of at least 75 years and assessed the reported safety and efficacy outcomes with NOACs in this population. Study-specific odds ratios (ORs) were calculated and between-study heterogeneity was assessed using the I statistic. In nine trials involving 29 403 patients, the risk of VTE or VTE-related deaths in elderly patients with elective postarthroplasty was similar with NOACs compared with LMWH (OR 0.62, 95% confidence interval 0.30-1.26; P = 0.18; I = 44%) but bleeding risk was significantly lower (OR 0.71, 95% confidence interval 0.53-0.94; P = 0.02; I = 0%). Analysis of individual NOACs showed superior efficacy but similar safety for apixaban when compared with LMWH. Efficacy and safety profiles of rivaroxaban and dabigatran were similar to LMWH. In elderly patients with elective postarthroplasty, NOACs have similar efficacy but superior safety when compared with enoxaparin for VTE prophylaxis.
Journal of Community Hospital Internal Medicine Perspectives, 2015
Hyperkalemia can present with a spectrum of clinical manifestations with progressive EKG changes ... more Hyperkalemia can present with a spectrum of clinical manifestations with progressive EKG changes and life-threatening arrhythmias. Although no formal guidelines exist as to when to initiate treatment for hyperkalemia, it is generally recommended in clinically symptomatic patients with or without EKG changes. Timely diagnosis and reversal can relieve symptoms and prevent life-threatening arrhythmias. We review the EKG changes associated with hyperkalemia and management principles along with an example of a case of severe hyperkalemia resulting in arrhythmia and flaccid paralysis.
Journal of Community Hospital Internal Medicine Perspectives, 2015
Late onset seroma is a rare post-operative complication occurring after various surgeries includi... more Late onset seroma is a rare post-operative complication occurring after various surgeries including thymectomy. Most cases are asymptomatic; however, seromas occurring in the mediastinal cavity may cause compression symptoms including airway compression or cardiac tamponade. We present a 62-year-old male with a history of thymectomy for myasthenia gravis who presented with cardiac tamponade several years ago. Further evaluation revealed a late onset seroma anteriorly compressing the cardiac chambers resulting in tamponade physiology.
Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a common cause of hyponatr... more Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a common cause of hyponatremia. Although it has been associated with different pulmonary infections, there have been only few case reports describing the association of SIADH with influenza. We report a case of SIADH in a patient with influenza who was successfully treated with fluid restriction. It is essential for clinicians to be aware of the association between influenza and SIADH.
A 62-year-old male with past medical history of benign prostatic hyperplasia presented to the eme... more A 62-year-old male with past medical history of benign prostatic hyperplasia presented to the emergency department with complaints of decreased urinary flow, inability to fully empty his bladder, and gross hematuria. Physical examination was unremarkable. Urinalysis revealed large amount of blood and more than 700 white blood cells suggesting a urinary tract infection. Urine culture grew group D Salmonella greater than 100,000 colony-forming units per mL. He was prescribed 6 weeks of trimethoprim/sulfamethoxazole and had resolution of symptoms. Retrospectively, he reported a 3-day history of watery diarrhea about a week prior to onset of urinary symptoms that was presumed to be the hematogenous source in this case. Urinary tract infection from nontyphoidal Salmonella (NTS) is rare and is usually associated with immunosuppression, chronic diseases, such as diabetes or structural abnormalities of the genitourinary tract. Genitourinary tract abnormalities previously reported in the literature that predispose to nontyphoidal Salmonella urinary tract infection include nephrolithiasis, chronic pyelonephritis, retrovesicular fistula, urethrorectal fistula, hydrocele, and post-TURP. We present an exceedingly uncommon case of 62-year-old male with group D Salmonella urinary tract infection predisposed by his history of benign prostatic hyperplasia.
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Papers by Dilli Poudel
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associated with sudden emotional or physical stress. Epinephrine use has been implicated in precipitating Takotsubo cardiomyopathy in multiple case reports and case series. We sought to systematically review the current English literature on this association.
Methods
We searched relevant articles on Takotsubo cardiomyopathy associated with epinephrine administration and extracted data on demographic characteristics, clinical features, investigations and clinical outcomes.
Results
We identified total of 41 cases from 36 articles. The mean age of presentation was (47.07 ± 15.73 years) with strong female preponderance (83%, P = 0.0001). The most common symptom at presentation was chest pain (82%). Mean peak troponin I level was (7.12 ± 11.22 ng/ml). The most common EKG abnormality was ST elevation, seen in 40% of patients. The most common finding on echocardiography was apical hypokinesis, seen in 48.78% cases. Patients younger than 45 were less likely to have apical cardiomyopathy (n = 5/20, 25%) compared to patients with age > 45 (n = 14/21, 66%, p value 0.001, OR 0.17). The most common route of administration of epinephrine was intravenous (65.85%). All patients except one survived with complete recovery of systolic function reported in most cases within an average of 14.7 days.
Conclusion
Exposure to epinephrine in clinical practice can trigger Takotsubo cardiomyopathy, which is rapidly reversible with good prognosis in most cases. This review further supports the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of Takotsubo cardiomyopathy.
Takotsubo cardiomyopathy is a syndrome of transient cardiac dysfunction that is frequently associated with sudden emotional or physical stress. Epinephrine use has been implicated in precipitating Takotsubo cardiomyopathy in multiple case reports and case series. We sought to systematically review the current English literature on this association.
Methods
We searched relevant articles on Takotsubo cardiomyopathy associated with epinephrine administration and extracted data on demographic characteristics, clinical features, investigations and clinical outcomes.
Results
We identified total of 41 cases from 36 articles. The mean age of presentation was (47.07 ± 15.73 years) with strong female preponderance (83%, P = 0.0001). The most common symptom at presentation was chest pain (82%). Mean peak troponin I level was (7.12 ± 11.22 ng/ml). The most common EKG abnormality was ST elevation, seen in 40% of patients. The most common finding on echocardiography was apical hypokinesis, seen in 48.78% cases. Patients younger than 45 were less likely to have apical cardiomyopathy (n = 5/20, 25%) compared to patients with age > 45 (n = 14/21, 66%, p value 0.001, OR 0.17). The most common route of administration of epinephrine was intravenous (65.85%). All patients except one survived with complete recovery of systolic function reported in most cases within an average of 14.7 days.
Conclusion
Exposure to epinephrine in clinical practice can trigger Takotsubo cardiomyopathy, which is rapidly reversible with good prognosis in most cases. This review further supports the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of Takotsubo cardiomyopathy.