Clinical copper deficiency is now more frequently recognized. Hematologically, it can present as anemia (microcytic, normocytic, or macrocytic) and neutropenia. Thrombocytopenia is relatively rare. ...Neurologically, it can manifest as myelopathy and peripheral neuropathy simulating subacute combined degeneration. Bone marrow findings can mimic myelodysplasia resulting in occasional inappropriate referral for bone marrow transplantation. Other conditions with similar presentations include infections, drug toxicity, autoimmunity, B
deficiency, folate deficiency, myelodysplastic syndrome, aplastic anemia, and lymphoma with bone marrow involvement. Hematological, but not neurological, manifestations respond promptly to copper replacement, making early diagnosis essential for good outcome. Common risk factors for copper deficiency are foregut surgery, dietary deficiency, enteropathies with malabsorption, and prolonged intravenous nutrition (total parenteral nutrition). We present a unique case of copper deficiency, with no apparent known risk factors.
Hypoglycemia occurs frequently in patients both in the inpatient and outpatient settings. While most hypoglycemia unrelated to diabetes treatment results from excessive endogenous insulin action, ...rare cases involve functional and congenital mutations in glycolytic enzymes of insulin regulation.
A 21-year-old obese woman presented to the emergency department with complaints of repeated episodes of lethargy, syncope, dizziness, and sweating. She was referred from an outside facility on suspicion of insulinoma, with severe hypoglycemia unresponsive to repeated dextrose infusions. Her plasma glucose was 20 mg/dl at presentation, 44 mg/dl on arrival at our facility, and remained low in spite of multiple dextrose infusions. The patient had been treated for persistent hyperinsulinemic hypoglycemia of infancy at our neonatal facility and 4 years ago was diagnosed as having an activating glucokinase (GCK) mutation. She was then treated with octreotide and diazoxide with improvement in symptoms and blood glucose levels.
Improved diagnostication and management of uncommon genetic mutations as typified in this patient with an activating mutation of the GCK gene has expanded the spectrum of disease in adult medicine. This calls for improved patient information dissemination across different levels and aspects of the health care delivery system to ensure cost-effective and timely health care.
Autoimmune statin-induced myopathy: a case report Young, Jonathan B; Ghobrial, Ibrahim I
Journal of community hospital internal medicine perspectives,
09/2015, Letnik:
5, Številka:
4
Journal Article
Recenzirano
Odprti dostop
A 58-year-old woman with a history of statin use presented with a 4-month history of progressive weakness of both shoulders and thighs. Laboratory and electromyography testing confirmed the presence ...of generalized proximal myopathy and ruled out connective tissue disease, malignancy, or active viral infection. Muscle biopsy was consistent with necrotizing autoimmune myopathy.
Meningitis retention syndrome Krishna, Abhishek; Devulapally, Pavan; Ghobrial, Ibrahim
Journal of community hospital internal medicine perspectives,
01/2012, Letnik:
2, Številka:
1
Journal Article
Recenzirano
Odprti dostop
A 50-year-old Caucasian woman presented with signs and symptoms of meningitis preceded by a 3 day history of flu-like symptoms and progressive difficulty with urination. Cerebrospinal Fluid (CSF) ...analysis was consistent with aseptic meningitis. She was found to have a significant urinary retention secondary to atonic bladder. MRI of the brain and spine were normal and CSF-PCR (polymerase chain reaction) was positive for HSV-2. Urinary retention in the context of meningitis and CSF pleocytosis is known as Meningitis Retention Syndrome (MRS). MRS is a rare but important complication of meningitis most commonly associated with HSV-2. Involvement of central pathways may have a role in the pathogenesis of MRS but this is poorly documented. MRS is different from Elsberg syndrome wherein patients display features of lumbosacral polyradiculitis or radiculomyelitis. Early treatment with antiviral therapy was associated with a favorable outcome in our patient.
Drug-induced visceral angioedema Thalanayar, Prashanth M.; Ghobrial, Ibrahim; Lubin, Fritz ...
Journal of Community Hospital Internal Medicine Perspectives,
01/2014, Letnik:
4, Številka:
4
Journal Article, Book Review
Recenzirano
Odprti dostop
Angioedema associated with angiotensin converting enzyme inhibitors (ACEIs) is due to the accumulation of bradykinin and its metabolites. Angiotensin receptor blockers (ARBs) produce ...anti-hypertensive effects by blocking the angiotensin II AT1 receptor action; hence bradykinin-related side effects are not expected. However, we notice the occurrence of ARB-induced angioedema as not a very rare side effect. Visceral drug-induced angioedema has been reported with ACEIs, not with ARBs. This underlying review will help educate readers on the pathophysiology and recent guidelines pertaining to ACEI- and ARB-induced visceral angioedema.
Misplaced Concern Krim, Selim, MD; Vivo, Rey, MD; Ghobrial, Ibrahim, MD ...
The American journal of medicine,
03/2008, Letnik:
121, Številka:
3
Journal Article
Recenzirano
Krim et al investigate a case of a 58-year-old man with history of hypertension, cigarette smoking and seizure disorder. Physical examination revealed a heart rate of 110 beats per minute, a blood ...pressure of 153/104 mm Hg, and an oxygen saturation of 96% on room air. The patient was initially diagnosed with an acute anteroseptal myocardial infarction. To further evaluate this finding, spiral computed tomography of the chest was performed. Imaging revealed filling defects in the distal portions of the right and left main pulmonary arteries.
Background:
Readmission rates are projected to serve as quality measures that have the potential to negatively impact hospital and physician reimbursement. Individual physicians and hospitals are ...developing plans to reduce readmission rates. Successful plans should be based on specific data obtained from each individual type of practice.
Objective:
To analyze the etiological factors responsible for readmissions to various teaching services in a community hospital. This will serve to identify potentially correctable factors that will be the basis for developing practice-specific plans to reduce readmissions.
Design:
Retrospective detailed chart review.
Setting:
Community teaching hospital affiliated with a large academic health care system.
Participants:
Patients admitted to teaching services at a community hospital.
Measurements:
Data are presented as descriptive analysis.
Results:
Advanced chronic medical conditions (31%), patients' lifestyle choices (28%), and new unrelated diagnoses (21%) are the major causes of readmissions. The remaining small percentage of readmissions is attributed to premature discharge, poor discharge planning, poor post-discharge follow-up, medication errors, and failure to implement medical care guidelines.
Limitations:
Retrospective study from a single center.
Conclusions:
Causes of readmission are diverse. Although most are universal, the relative contribution of each factor is unique to each population. Institutions should generate their own data in order to direct their resources toward 'high return' areas. Current studies emphasize the role of physicians and health systems in reducing readmission rates. However, the area of readmissions related to patients' behaviors is not well explored. Our study identified the role of patients' lifestyle choices as a major cause of readmission.
A 51-year-old female with a history of type 1 diabetes mellitus (DM) presented with sudden onset of pain and swelling of the left thigh. Her initial evaluation revealed mildly elevated erythrocyte ...sedimentation rate and creatine phosphokinase. Venous and arterial Doppler studies were negative for DVT and arterial thrombus. Further imaging with CT scan and then MRI revealed an irregular, enhancing space-occupying lesion of the left upper and mid-thigh. Subsequent muscle biopsy showed myonecrosis and proliferative myositis. Both findings are consistent with diabetic myonecrosis, which is a microvascular complication of long-standing poorly controlled DM. The patient was treated with analgesics, supportive care, and optimization of glycemic control. While short-term prognosis is good with adequate healing in a few weeks to several months, long-term prognosis is poor due to underlying extensive vascular disease. Although radiological findings are very suggestive of the diagnosis, most clinicians still need tissue biopsy to rule out other serious conditions such as infections and malignancy.
Human erythropoietin produced by recombinant DNA technology, is now marketed worldwide for the treatment of anemias associated with chronic renal failure and chemotherapy. No sensitive methods, which ...can determine r-HuEPO dimer or oligomer aggregate content in formulated products, have been published to date. This report describes the development and validation of a sensitive size exclusion high performance liquid chromatography (HPLC) method for the quantitation of r-HuEPO aggregates in formulations containing 0.03% polysorbate 80. A Waters Alliance 2690 HPLC system connected to a TosoHaas TSKgel G3000 SWxl (7.8
mm
×
30
cm, 250
Å pore size, 5
μm particle size) column and a Waters 474 fluorescence detector was used. The mobile phase for the SEC-HPLC method consists of isopropyl alcohol–potassium phosphate (0.1
M)/potassium chloride buffer (pH 6.8
±
0.1, 0.2
M) (25:75, v/v). The flow rate was 0.3
mL/min and the method run time was 60
min.
The SEC-HPLC method presented here was shown to be specific for r-HuEPO total aggregates (dimer and oligomers) and allows for their quantitation at 80
ng/mL or 4
ngs/injection, in the presence of r-HuEPO monomer and the pharmaceutical excipients, glycine (5
mg/mL), sodium chloride (4.3
mg/mL), and 0.03% polysorbate 80. The finalized method is stability-indicating and is suitable for determining r-HuEPO aggregates between 0.2 and 0.5% levels in the formulated product of r-HuEPO. This method offers a robust way to measure total aggregates on a routine basis with a high sensitivity for use in product quality control.
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