Ali A Alsaad

Rare allergic reaction of the kidney: sitagliptin-induced acute tubulointerstitial nephritis

A 56-year-old man with a history of diabetes mellitus type-2 and stage-2 chronic kidney disease secondary to diabetic nephropathy presented with an acute deterioration of kidney function. Non-invasive work-up failed to reveal the underlying aetiology for the acute kidney failure. Kidney biopsy revealed acute tubulointerstitial nephritis (ATIN) which was attributed to sitagliptin use. Only few case reports have shown this correlation. Our aim is to alert physicians and other providers of the potential effect of sitagliptin to cause ATIN with this biopsy-proven case.

A multidisciplinary approach to reducing alarm fatigue and cost through appropriate use of cardiac telemetry

Background Alarm fatigue (AF) is a distressing factor for staff and patients in the hospital. Using cardiac telemetry (CT) without clinical indications can create unnecessary alarms, and increase AF and cost of healthcare. We sought to reduce AF and cost associated with CT monitoring. Methods After implementing a new protocol for CT placement, data were collected on telemetry orders, alarms and bed cost for 13 weeks from 1 January 2015 through 31 March 2015. We also retrospectively collected data on the same variables for the 13 weeks prior to the intervention. A survey was administered to nurses to assess past and present perceptions of AF. Interventions included protocol creation and education for participants. Results At baseline, 77% of patients were monitored with CT. A total of 145 (31%) order discrepancies were discovered during data collection, of which 72% had no indication for CT, so CT was discontinued. The other 28% had indications, so orders were placed. A total of 8336 alarms were recorded during 4 weeks of data collection, of which 333 (4%) were classified as true actionable alarms. Postintervention data showed 67% CT assignment with 10% reduction in CT usage, with no increase in mortality (p<0.001 and >0.05, respectively). A 42% cost reduction was achieved after adjusting the patient status. Nurses reported 27% perceived reduction in AF. One-year follow-up revealed that 69% of patients were being monitored by CT, and the rate of order discrepancies due to lack of indication was 9%. Conclusion All hospital units may benefit from the protocols created during this study. If applied appropriately, these protocols can lead to reduced AF and cost per episode of care.

Pacemaker Placement in Patients with Stroke-Mediated Autonomic Dysregulation

Lateral medullary syndrome (LMS) is an ischemic disease of the medulla oblongata, which involves the territory of the posterior inferior cerebellar artery. Lateral medullary syndrome is often missed as the cause of autonomic dysregulation in patients with recent brain stem stroke. Due to the location of the baroreceptor regulatory center in the lateral medulla oblongata, patients with LMS occasionally have autonomic dysregulation-associated clinical manifestations. We report a case of LMS-associated autonomic dysregulation. The case presented as sinus arrest and syncope, requiring permanent pacemaker placement. A dual-chamber pacemaker was placed, after failure of conservative measures to alleviate the patients symptoms. Our case shows the importance of recognizing LMS as a potential cause for life-threatening arrhythmias, heart block, and symptomatic bradycardia. Placement of permanent pacemaker may be necessary in some patients with LMS presenting with syncope, secondary to sinus arrest.

Renal cell carcinoma with isolated breast metastasis

Renal cell carcinoma (RCC) is a highly prevalent disease worldwide with many cases being metastasised to various organs during the time of initial presentation. Metastatic RCC to the breast is a rare entity and can mimic primary breast carcinoma. In this article, we present a 63-year-old Caucasian woman presented with a breast mass that was detected by screening mammography and found to have a biopsy proven grade-II clear RCC in the breast tissue. Despite the high incidence and prevalence of primary breast cancer, metastasis from extramammary should be suspected in patients with a prior history of other cancers. In this brief literature review, we also highlight the survival benefit from surgery and close follow-up in selected group of patients with metastatic, metachronous and solitary RCC.

Collapsing glomerulopathy in systemic lupus erythematosus

Collapsing glomerulopathy (CG) is a rare disease that can be associated with multiple other disorders. It usually leads to poor prognosis with a high percentage of patients progressing to end-stage renal disease. In this article, we illustrate a clinical case of CG associated with systemic lupus erythematosus that had a prompt response to mycophenolate and prednisone. The condition started after sudden cessation of the already established mycophenolate treatment regimen. The patient then presented with acute kidney injury due to kidney biopsy-proven CG. In that circumstance, we hypothesised that mycophenolate may play a role in prevention and development of CG.

High-risk echocardiographic features predict mortality in pulmonary arterial hypertension

Aims Echocardiography is the most common imaging modality for assessment of the right ventricle in patients with pulmonary arterial hypertension (PAH). Echocardiographic parameters were identified as independent risk factors for mortality in the Registry to Evaluate Early and Long‐term PAH Disease Management (REVEAL) and other PAH cohorts. We sought to identify readily obtained echocardiographic features associated with PAH survival. Methods and results Retrospective analysis of 175 patients with Group 1 was performed. Baseline clinical and laboratory assessment including REVEAL risk criteria were obtained and standard 2‐Dimensional and Doppler echocardiography performed at baseline was reviewed. Univariate and multivariate analyses of echocardiographic parameters were performed. Estimated right atrial pressure> 15 mmHg (HR 2.39, P = .02), tricuspid regurgitation ≥ moderate (HR 2.16, P = .04), and presence of pericardial effusion (HR 1.8, P = .05) were identified as independent, high‐risk echocardiographic features in PAH. A validation cohort of 677 patients was identified and Kaplan–Meier survival analysis was performed in both cohorts. High‐risk echocardiographic features stratified survival curves of both cohorts (P < .01 for all). The presence of 3 high‐risk echocardiographic features greatly increased risk of 1‐year (RR 4.86) and 3‐year (RR 3.35) mortality (P < .05 for both). Conclusion Estimated right atrial pressure> 15, tricuspid regurgitation ≥ moderate, and presence of pericardial effusion are high‐risk echocardiographic features in PAH. When seen in combination, these features greatly increase risk of mortality in PAH and may lead to more timely enhanced therapy for patients identified as having an increased risk for death.

Assessing the performance and satisfaction of medical residents utilizing standardized patient versus mannequin-simulated training

Background Conducting simulations of rapidly decompensating patients are a key part of internal medicine (IM) residency training. Traditionally, mannequins have been the simulation tool used in these scenarios. Objective To compare IM residents’ performance and assess realism in specific-simulated decompensating patient scenarios using standardized patients (SPs) as compared to mannequin. Methods Nineteen IM residents were randomized to undergo simulations using either a mannequin or an SP. Each resident in the two groups underwent four different simulation scenarios (calcium channel blocker overdose, severe sepsis, severe asthma exacerbation, and acute bacterial meningitis). Residents completed pretest and post-test evaluations as well as a questionnaire to assess the reality perception (realism score). Results Nine residents completed mannequin-based scenarios, whereas 10 completed SP-based scenarios. Improvement in the post-test scores was seen in both groups. However, there were significantly higher post-test scores achieved with SP simulations in three out of the four scenarios (P=0.01). When compared with the mannequin group, the SP simulation group showed a significantly higher average realism score (P=0.002). Conclusions Applying SP-based specific-simulation scenarios in IM residency training may result in better performance and a higher sense of a realistic experience by medical residents.

Apixaban-induced liver injury.

An 81-year-old woman with well-controlled hypertension presented to the emergency department with new-onset atrial fibrillation with rapid ventricular response. Treatment for atrial fibrillation was initiated, including rate control and anticoagulation with 5 mg of apixaban two times per day for primary stroke prophylaxis. Three days after initiation of apixaban, the patient noted new-onset abdominal pain, worsening shortness of breath and weakness. Laboratory results showed elevated liver enzymes. Workup for elevated transaminase did not reveal any underlying infectious or autoimmune process. Apixaban, a probable cause for the hepatocellular injury, was discontinued and replaced with intravenous unfractionated heparin to bridge anticoagulation with warfarin. The patients symptoms resolved as her transaminases improved by discontinuation of apixaban. We illustrate this case of drug-induced hepatotoxicity secondary to treatment with apixaban. It is important for physicians to be aware of this rare adverse effect caused by a widely used novel oral anticoagulant.

Recurrent Syncope, a Clue in Amyloid Cardiomyopathy

Infiltrative cardiomyopathies include a variety of disorders that lead to myocardial thickening resulting in a constellation of clinical manifestations and eventually heart failure that could be the first clue to reach the diagnosis. Among the more described infiltrative diseases of the heart is amyloid cardiomyopathy. The disease usually presents with subtle, nonspecific symptoms. Herein, we illustrate a case of recurrent syncope as the initial presenting symptom for systemic amyloid with polyneuropathy and cardiomyopathy as a cause of syncope. The article illustrates the role of advanced cardiac imaging in the diagnosis of the disease with a focused literature review. We also highlight the role of early, shared decision-making between patient, family, and medical team in the management of cardiac amyloidosis.

Appropriately testing patients with intermediate risk for coronary artery disease: how well are we doing?

Background Cardiovascular risk assessment and stratification of stable coronary artery disease represents a pivotal component of coronary artery disease management. The introduction of risk stratification tools has advanced the detection of patients with intermediate to high risk for coronary artery events. These patients will ultimately undergo non-invasive and invasive cardiovascular testing. Objective To synthesise evidence illustrating risk stratification tools and non-invasive testing for patients with intermediate risk for coronary artery disease and suggest a simple method for clinicians to follow prior to ordering non-invasive cardiovascular testing. Study selection Literature review of PubMed and MEDLINE Central on studies and evidence highlighting the appropriate use criteria for radionuclide myocardial perfusion imaging. Findings and conclusions Overtestingusing myocardial perfusion imaging is well documented in several studies in the literature. Few studies highlighted the importance of the appropriate use criteria for radionuclide myocardial perfusion imaging, which can reduce unnecessary testing in patients with suspected coronary artery disease. Herein, we propose ‘Simple Steps to Follow’ to be considered by clinicians prior to ordering radionuclide myocardial perfusion imaging. The target audience of this article is internal and family medicine primary care physicians and other non-cardiologist physicians.