Richard Snyder

Catastrophic antiphospholipid syndrome and heparin-induced thrombocytopenia-related diseases or chance association?

Antiphospholipid syndrome (APS) and heparin-induced thrombocytopenia (HIT) are thrombotic disorders due to specific autoimmune-mediated antibodies. Catastrophic APS (CAPS), also known as Ashermans syndrome, is a life-threatening severe form of APS. Diagnostic criteria for CAPS include the development of a thrombotic event of three or more organs in less than a week with the presence of antiphospholipid antibodies and microvascular thrombosis on histology. Thrombocytopenia is seen in more than 60% of cases of CAPS. HIT is a life-threatening disorder with the clinical presentation of thrombocytopenia and arterial or venous thrombosis in patients who develop antibodies to heparin and platelet factor 4 typically within 10 days after starting heparin treatment. Due to the multiple similarities in clinical features and pathophysiology of CAPS and HIT, it has been postulated that these two antibody-mediated disorders may be related. We report two cases in which patients diagnosed with CAPS developed HIT very soon during the same admission as well as a case of a patient initially diagnosed with HIT who presented with CAPS years later.

Long-term use of proton pump inhibitors: are they really safe? A case of delayed acute interstitial nephritis.

missions for transient ischemic attack. A retrospective population-based study in the Emilia Romagna region of Italy. Clin Appl Thromb Hemost, 2009 Feb 16. [Epub ahead of print]. 7. Willich SN, Lowel H, Lewis M et al. Weekly variation of acute myocardial infarction: Increased Monday risk in the working population. Circulation 1994;90:87–93. 8. Murakami S, Otsuka K, Kubo Yet al. Repeated ambulatory monitoring reveals a Monday morning surge in blood pressure in a community-dwelling population. Am J Hypertens 2004;17(12 Pt 1):1179–1183. 9. Urdal P, Andressen SA, Holme I et al. Monday and non-Monday concentration of lifestyle-related blood components in the Oslo Diet and Exercise Study. J Intern Med 1998;244:507–513. 10. Kostis WJ, Demissie K, Marcella SW et al. Weekend versus weekday admission and mortality from myocardial infarction. N Engl J Med 2007;356: 1099–1109. 11. Manfredini R, Salmi R, Boari B. Higher stroke mortality on weekends: Are all strokes the same? Stroke 2007;38:e112.

An Under-Recognized and Under-Reported Cause of Adrenal Insufficiency

We report a unique case of potentially life-threatening secondary adrenal insufficiency in a 58year-old female who was maintained on a high dose fentanyl patch and hydrocodone for many years for chronic back pain. She presented to the emergency room (ER) with severe hypotension, weight loss and fatigue. We suspected hypothalamic-pituitary-adrenal (HPA) axis suppression induced by chronic use of opioids. Subsequently, after appropriate laboratory investigations, she was diagnosed with secondary adrenal insufficiency attributed to chronic opiate use. We discontinued the hydrocodone, decreased the dose of her fentanyl patch and began oral prednisone. The patient responded to treatment and her symptoms were resolved as seen on an outpatient follow up visit three months later. Currently, she is off prednisone and is doing well without demonstrating any symptoms or signs of adrenal insufficiency. Physicians must be aware of this potentially life- threatening side effect of opioid medications and should discourage long term opiate use. To the best of our knowledge, this is the first case report in the United States showing opioid-induced secondary adrenal insufficiency.

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care

The incorporation of a clinical pharmacist in daily rounding can help identify and correct errors related to anticoagulation dosing. Inappropriate anticoagulant dosing increases the risk of developing significant bleeding diathesis. Conversely, inappropriate dosing may also fail to produce a therapeutic response. We retrospectively reviewed electronic medical records of 41 patients to confirm and analyze the errors related to various anticoagulants. A clinical pharmacist in an integrated rounding between the period of February 2016 and April 2016 collected this data. We concluded that integrated rounding improves patient safety by recognizing anticoagulant dosage error used for the purpose of prophylaxis or treatment. It also allows us to make dose adjustments based on renal function of the patient. We think that it is prudent for physicians to pay particular attention to creatinine clearance when dosing anticoagulants in order to achieve the intended dosing effect and reduce the risk of adverse drug events.

Determining the role of intravenous hydration on hospital readmissions for acute congestive heart failure

The role of intravenous hydration on hospital readmissions due to acute exacerbation of congestive heart failure (CHF) has not been studied sufficiently to the best of our knowledge. We sought to determine the possible role of intravenous hydration on hospital readmissions for acute CHF and fluid overload and explain how an intravenous fluid (IVF) restriction strategy may help reduce hospital readmission rates. We retrospectively studied the electronic medical records of 98-patient cohort who had hospital readmission due to acute decompensated congestive heart failure (ADHF) during the period of January 1, 2016 to July 9, 2016. These patients were admitted with reasons other than ADHF during the index admission. The patients were divided into two groups; those with ADHF readmissions within 15 days of index admission (group A) and those after 15 days (group B). Various factors affecting CHF readmissions as outlined in the results were compared between these two groups. Cohort of 98 patients (53 females, 54.1%; 76.4±11.6 years) re-admitted during the study period of 1/1/2016 to 7/9/2016 were analyzed. 71 patients had only received IVF during index admission. These were subdivided into group A (12 females, 54.5 %; mean age 75.9±12.9 years) and group B (25 females, 51.02%; mean age 76.08±11.90 years) based on readmission ≤15 days or >15 days from the index admission. There was no statistically significant difference (P=0.97) in amount of IVF prescribed between two subgroups but the duration of prescribed IVF significantly affected readmission in group A compared to group B (P=0.03). While the drop in albumin and rise in creatinine were not significant, the mean hemoglobin (Hb) drop in group A compared to group B was significant at P=0.008. Type of IVF and nature of CHF (heart failure with reduced ejection fraction, HFrEF/heart failure with preserved ejection fraction, HFpEF) were not found to significantly affect early readmissions associated with IV hydration. In patients with history of CHF, duration of IVF prescribed during the index admission seems to play important role in early CHF readmission (defined as <15 days in our study).

Omnious T-wave inversions: Wellens’ syndrome revisited

Wellens’ syndrome is characterized by T-wave changes in electrocardiogram (EKG) during pain-free period in a patient with intermittent angina chest pain. It carries significant diagnostic and prognostic value because this syndrome represents a pre-infarction stage of coronary artery disease involving proximal left anterior descending (LAD) artery, which can subsequently lead to extensive anterior myocardial infarctions (MIs) and even death without coronary angioplasty. Therefore, it is crucial for every physician to recognize EKG features of Wellens’ syndrome in order to take appropriate immediate intervention to reduce mortality and morbidity for MI. Here, we report a case of an overweight man with 35 pack-year of smoking history who presented to Easton Hospital with intermittent pressing chest pain of 5/6 times within 10 day-period and was found to have type A Wellens’ sign, which was biphasic T-waves in precordial leads V2 and V3 during pain-free period with no cardiac enzymes elevation. He was given therapeutic lovenox and subsequently underwent coronary angioplasty and had 95–99% occlusion in proximal LAD artery. The unique feature of our case was that Wellens’ type B EKG changes were seen after reduction of stenosis with LAD artery stent, which was likely explained by the reperfusion of the ischemic myocardium. Therefore, it is important for physicians to recognize EKG features of Wellens’ syndrome in order to take appropriate therapy to reducing mortality and morbidity form impending MI.

Thyroid storm presenting as psychosis: masked by diabetic ketoacidosis

Introduction While extremely uncommon, diabetic ketoacidosis (DKA) and thyroid storm (TS) are endocrine emergencies that can coexist. We describe a case with a confounding clinical presentation that identifies these two emergencies within the setting of sepsis and influenza. Case A 69-year-old diabetic female was found by the paramedic staff to be disoriented. She demonstrated tachycardia and had a foul-smelling abdominal wound. Laboratory evaluation revealed DKA, leukocytosis, influenza B, and urinary tract infection. After appropriate management in the intensive care unit, the DKA resolved the following morning. However, the patient developed a fever, and her psychosis became more pronounced. Extensive analysis was performed but did not explain her mental status. The patient was found to have thyroid stimulating hormone of 0.06 mIU/mL, free T4 (thyroxine) of 2.38 ng/dL, and total T3 (triiodothyronine) of 72 ng/dL. Based on the Burch and Wartofsky criteria (score of 65), TS was diagnosed. Based on more recent diagnostic criteria suggested by Akamizu et al., the patient met criteria for TS grade 1. Within several hours of initiating treatment, the patients mental state and tachycardia improved, and her psychosis resolved by the third day. Conclusion This case highlights the importance of recognizing the clinical diagnosis of TS, as the magnitude of thyroid hormone derangements may not correlate with clinical severity. While rare, DKA and TS can simultaneously occur and are associated with increased morbidity and mortality if not promptly recognized and treated.