Medicine and Health Sciences Commons^™

Impact Of Ivig Vs. Scig On Igg Trough Level And Infection Incidence In Primary Immunodeficiency Diseases: A Systematic Review And Meta-Analysis Of Clinical Studies., Pragya Shrestha, Paras Karmacharya, Zhen Wang, Anthony Donato, Avni Y Joshi

Reading Hospital Internal Medicine Residency

Background: Monthly intravenous immunoglobulin (IVIG) and weekly subcutaneous immunoglobulin (SCIG) have been regarded as therapeutically equivalent treatments for primary immunodeficiency diseases (PIDD). Immunoglobulin G (IgG) trough level is used as a monitoring measure for infection prevention.

Objective: A systematic review and meta-analysis were performed to elucidate the relationship between IgG dosing, trough IgG levels with overall infection incidence in patients with PIDD receiving IVIG and SCIG therapy.

Methods: Medline, EMBASE, Cochrane, Central, and Scopus were searched for studies published from Jan 2010-June 2018, fulfilling the inclusion criteria. DerSimonian and Laird random-effects method were used to pool the difference of IgG …

Yearly Trend Of Acute Venous Thromboembolism In Patients Admitted With Heart Failure In The United States., Sijan Basnet, Rashmi Dhital, Biswaraj Tharu, Dilli Ram Poudel, Anthony Donato

Reading Hospital Internal Medicine Residency

Introduction: Heart failure (HF) patients are at risk for venous thromboembolism (VTE) during the hospital stay. We aim to study the recent trend of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE in heart failure patients from years 2000-2013. Methods: We utilized the National (Nationwide) Inpatient Sample database and selected non-pregnant patients over the age of 18 years for this purpose. We selected HF, DVT, PE, and VTE based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We used STATA for analysis. Results: We noted an increase in prevalence of DVT, PE and composite …

A Case Of Essential Thrombocythemia And Iga Nephropathy With Literature Review Of The Concurrence., Shoja Rahimian, Timothy Johnson, Ronald Herb

Reading Hospital Internal Medicine Residency

Myeloproliferative neoplasms such as essential thrombocythemia (ET) have been associated with glomerular disease on rare instances. A case of ET associated with immunoglobulin A nephropathy (IgAN) is described in a 57-year-old man with a history of hypertension. Progressively worsening renal function was noted in the patient along with unexplained mild thrombocytosis. Pathological review of renal biopsy identified IgAN concurrently with newly diagnosed JAK2-mutated ET. The patient was started on aspirin therapy and closely monitored for his renal function. A literature review of the association of ET and renal disease revealed nine cases of ET associated with IgAN, focal segmental glomerulosclerosis, …

Systematic Review And Meta-Analysis Of The Efficacy And Safety Of Apixaban Compared To Rivaroxaban In Acute Vte In The Real World., Madan Raj Aryal, Rohit Gosain, Anthony Donato, Han Yu, Anjan Katel, Yashoda Bhandari, Rashmi Dhital, Peter A. Kouides

Reading Hospital Internal Medicine Residency

Both apixaban and rivaroxaban have been approved for use in acute venous thromboembolism (VTE). Although indirect comparison through network meta-analyses of randomized trials have been performed to compare the efficacy and safety of these agents, further comparison between these agents was lacking until recently. We sought to systematically review and carry out a meta-analysis of studies to further compare apixaban with rivaroxaban from multiple studies done in the real-world settings. Studies comparing rivaroxaban with apixaban in patients with acute VTE were identified through electronic literature searches of MEDLINE, EMBASE, Scopus, and the Cochrane library up to May 2019. Study-specific risk …

Symmetrical Peripheral Gangrene Associated With Low Output Cardiac Failure., Sijan Basnet, Priya Rajagopalan, Rashmi Dhital, Ataul Qureshi

Reading Hospital Internal Medicine Residency

Symmetrical peripheral gangrene (SPG) is a rare entity characterized by ischemic changes of the distal extremities with maintained vascular integrity. We present the case of a 64-year-old man with bilateral necrotic toes and deranged liver function tests. This was thought to be related to severely depressed ejection fraction from non-ischemic etiology, presumably chronic alcohol ingestion. We hope that awareness of SPG and association with a low output state will aid in early detection and prevention.

Low Voltage Criteria Ekg As A Harbinger Of Systemic Disease., Ian Garrahy, Daniel Forman, Sharon Swierczynski

Reading Hospital Internal Medicine Residency

AL amyloidosis is due to deposition of protein derived from immunoglobulin light chain fragments. It is a systemic disorder in which deposition of plasma proteins can adversely affect function of the heart, liver, kidneys, and peripheral nerves. Deposition in the heart results in a decrease in the amplitude of the electrical activity of the heart and can be an early clue to the diagnosis. A 63-year-old male admitted for volume overload was found to have nephrotic range proteinuria, progressive renal insufficiency (Creatinine 4.0 increased from his baseline 0.9), and hypoalbuminemia. On exam, he had diffuse anasarca and peripheral neuropathy. A …

Autoimmune Polyglandular Syndrome Type 1: A Case Report And Brief Review., Ifeanyi Nwosu, Oreoluwa Oladiran, Chinyere Ogbonna-Nwosu, Anulika Anyata

Reading Hospital Internal Medicine Residency

Autoimmune polyglandular syndrome (APS) type 1 is a rare autoimmune disorder inherited in an autosomal recessive pattern due to loss of function of the AIRE gene and defective removal of self-reactive T-lymphocytes during the process of thymic T cell maturation. Its manifestation starts early in life with the cardinal clinical disorders being one of muco-cutaneous candidiasis, Addison's disease, and hypoparathyroidism. Recognizing the syndromic nature of one autoimmune disease will facilitate an active search for other conditions which would allow early detection, management, follow-up, and most importantly patient education and counselling to avoid potential complications. We present the case of a …

The Trend Of Osteoporosis And Osteoporotic Fragility Fractures In Inpatients: Results From A National Database., Rashmi Dhital, Theresa Lynn, Niranjan Tachamo, Dilli Ram Poudel

Reading Hospital Internal Medicine Residency

Osteoporosis is associated with an increased risk of pathologic fractures; however, most patients do not receive diagnosis and adequate treatment. The aim of our study was to compare the yearly trends of osteoporosis and osteoporotic fragility fractures in the USA (US) inpatients. We used National (Nationwide) Inpatient Sample database to identify adults ≥18 years with diagnoses of osteoporosis and pathologic fractures and excluded pathologic fractures due to other etiologies. We then studied the annual trends, in terms of annual percentage change (APC), of osteoporosis and osteoporotic fractures. Among overall hospitalizations, osteoporosis was noted to have an increasing trend from 2000 …

Acute Generalized Exanthematous Pustulosis: A Rare Side Effect Of Clindamycin., Sijan Basnet, Rashmi Dhital, Biswaraj Tharu

Reading Hospital Internal Medicine Residency

Acute generalized exanthematous pustulosis (AGEP) is a rare adverse effect of clindamycin characterized by widespread papules and pustulosis 1 - 3 weeks of its use. Case description: We present a case of a 71-year-old woman diagnosed with AGEP after clindamycin use for a tooth infection. She had been started on empiric prednisone without benefit. She did not have any systemic involvement and had an unremarkable blood work . Her rash resolved completely in a month.

Acute Tubulointerstitial Nephritis: A Case Report On Rare Adverse Effect Of Pembrolizumab., Sijan Basnet, Rashmi Dhital, Biswaraj Tharu

Reading Hospital Internal Medicine Residency

Pembrolizumab is a novel immune checkpoint inhibitor approved for use in non-small cell lung carcinoma. There have been a few cases that have associated adverse renal outcomes with pembrolizumab. We present a case of acute kidney injury in a patient on pembrolizumab who was noted to have acute tubulointerstitial nephritis on renal biopsy. Pembrolizumab was discontinued and the patient was started on long-term corticosteroids with a taper. Her renal function improved partially with treatment.

Severe Anion Gap Metabolic Acidosis Associated With Initiation Of A Very Low-Carbohydrate Diet., Sijan Basnet, Niranjan Tachamo, Salik Nazir, Rashmi Dhital, Asad Jehangir, Anthony Donato

Reading Hospital Internal Medicine Residency

Low carbohydrate diets have been popularized as an effective solution for weight loss. Although rare, life-threatening anion gap metabolic acidosis has been reported in patients on these diets. We present a case of a 31-year-old man with atypical symptoms of chest pain and shortness of breath found to have severe metabolic acidosis after starting low carbohydrate diet for a week.

Stroke Risk Stratification In Atrial Fibrillation: A Review Of Common Risk Factors., Oreoluwa Oladiran, Ifeanyi Nwosu

Reading Hospital Internal Medicine Residency

Atrial Fibrillation (AF) has become a major global health concern being the most common sustained arrhythmia in clinical practice. Risk factors for AF include congestive heart failure, hypertension, increasing age and diabetes. Many of these factors also increase the risk for thromboembolism and ischemic stroke in AF patients. Great efforts have been made from the latter part of the 20

Influence Of Abnormal Potassium Levels On Mortality Among Hospitalized Heart Failure Patients In The Us: Data From National Inpatient Sample., Sijan Basnet, Rashmi Dhital, Biswaraj Tharu, Sushil Ghimire, Dilli Ram Poudel, Anthony Donato

Reading Hospital Internal Medicine Residency

Abnormalities in serum potassium levels have been associated with variable mortality risk among hospitalized patients with heart failure (HF). We aim to use a large database study to further characterize risk of mortality, demographic factors, and associated comorbidities among heart failure inpatients. Methods: Our sample population was from the US National Inpatient Sample database from the year 2009-2011. The inclusion criteria used to identify patients was those with a diagnosis of heart failure as per ICD-9 classification. Other demographic factors considered in data collection included income, and cardiac risk factors. Taking these factors into consideration, a univariate association of …

Quadricuspid Aortic Valve: Report Of Two Cases And Brief Review., Oreoluwa Oladiran, Ifeanyi Nwosu, Rashmi Dhital, Gbujie Ezioma

Reading Hospital Internal Medicine Residency

Quadricuspid aortic valve (QAV) is a rare congenital cardiac defect characterized by the presence of four aortic valve leaflets of equal or varying sizes. Even rarer is its clinical presentation with aortic stenosis. Diagnosis of QAV could be challenging but is of great importance as patients often present with progressive aortic regurgitation. We present 2 cases of QAV presenting differently: one with aortic stenosis requiring valve replacement and the other with aortic regurgitation requiring close monitoring.

Atraumatic Splenic Rupture Associated With Apixaban., Sijan Basnet, Elan Mohanty, Izza Mir, Rashmi Dhital, Ajay Koirala, Niranjan Tachamo

Reading Hospital Internal Medicine Residency

Apixaban is a direct oral anticoagulant that works by inhibiting factor Xa. It has been associated with adverse bleeding outcomes including atraumatic splenic rupture. We present the case of an 86-year-old man who presented with features of left upper abdominal pain and hemorrhagic shock found to have atraumatic splenic rupture and hemoperitoneum on imaging.

Assessing The Effect Of Patient To Provider Language Discordance On Depression Screening Utilizing The Patient Health Questionnaire: An Epidemiology Study., Luis A. Murillo, Georgi Alex Grekoff, John C. Sheffield

Reading Hospital Family Medicine Residency

Background: As depression screening becomes a standard in primary care, the question remains of how effective and equitable screening can be implemented to avoid cultural and language-related disparities.

Methods: In this retrospective cohort study, rates of depression screening were compared for 3626 adult patients at a family medicine residency-based health centre in Pennsylvania, USA. The PHQ-2/PHQ-9 modality was verbally administered by nursing staff at the time of patient intake as part of a universal screening initiative. Chi-square analysis was used to determine the univariate associations of performed depression screening with variables of language, ethnicity, gender and number of office visits. …

Hyperautofluorescent Dots Are Characteristic In Ceramide Kinase Like-Associated Retinal Degeneration., Jesse D Sengillo, Galaxy Y Cho, Maarjaliis Paavo, Winston Lee, Eugenia White, Ruben Jauregui, Janet R Sparrow, Rando Allikmets, Stephen H Tsang

Reading Hospital Internal Medicine Residency

There is a lack of studies which seek to discern disease expression in patients with mutations that alter retinal ceramide metabolism, specifically in the ceramide kinase like (CERKL) gene. This cross-sectional case series reports a novel phenotypic manifestation of CERKL-associated retinopathy. Four unrelated patients with homozygous CERKL mutations underwent a complete ocular exam, spectral-domain optical coherence tomography, short-wavelength fundus autofluorescence (SW-AF), quantitative autofluorescence (qAF), and full-field electroretinogram (ffERG). Decreased visual acuity and early-onset maculopathy were present in all patients. All four patients had extensive hyperautofluorescent foci surrounding an area of central atrophy on SW-AF imaging, which has not been previously …

Assessing The Effect Of Patient To Provider Language Discordance On Depression Screening Utilizing The Patient Health Questionnaire: An Epidemiology Study., Luis A. Murillo, Georgi Alex Grekoff, John C. Sheffield

Reading Hospital Family Medicine Residency

Background: As depression screening becomes a standard in primary care, the question remains of how effective and equitable screening can be implemented to avoid cultural and language-related disparities.

Methods: In this retrospective cohort study, rates of depression screening were compared for 3626 adult patients at a family medicine residency-based health centre in Pennsylvania, USA. The PHQ-2/PHQ-9 modality was verbally administered by nursing staff at the time of patient intake as part of a universal screening initiative. Chi-square analysis was used to determine the univariate associations of performed depression screening with variables of language, ethnicity, gender and number of office visits. …

Nitrofurantoin-Induced Radiation Recall Dermatitis., Ian Garrahy, Daniel Forman

Reading Hospital Internal Medicine Residency

Radiation recall dermatitis (RRD) is an inflammatory skin reaction that develops in a previously quiescent radiation field triggered most commonly by chemotherapy, particularly anthracyclines and taxanes. Radiation-recall dermatitis secondary to antibiotic therapy is quite rare. The patient is 61-year-old female with a history of squamous cell carcinoma of the left breast treated with neoadjuvant carboplatin, paclitaxel, and anthracycline chemotherapy followed by surgery and subsequent whole breast radiation 6040 cGy. Eight years after completion of her radiation she developed diffuse redness of the left breast after two doses of nitrofurantoin taken for a urinary tract infection. On examination, vital signs were …

A Case Of Multisystem Langerhans Cell Histiocytosis Presenting As Central Diabetes Insipidus, P. Daniel Nicholas Iii, Ian Garrahy

Reading Hospital Internal Medicine Residency

Langerhans cell histiocytosis (LCH) is a rare malignancy most commonly characterized by histiocytic infiltration of bone. LCH lesions in the skull place the adjacent central nervous system (CNS) at risk for involvement, which can manifest as central diabetes insipidus (CDI) when there is infiltration of the hypothalamic-pituitary axis. We present a case of a 39-yearold female who presented with polyuria and polydipsia for 1 year and left-sided hearing loss, gait instability, and nystagmus for 5 days. She was found on laboratory evaluation to have CDI and underwent left cortical mastoidectomy for a destructive peripherally enhancing mastoid lesion seen on MRI …

Interventions To Increase Research Publications In Graduate Medical Education Trainees: A Systematic Review., Ryan Zimmerman, Richard Alweis, Alexandra Short, Tom Wasser, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Introduction: Competency-based educational models recommend trainee exposure to research, but the best methods for Graduate Medical Education (GME) programs to accomplish this have not been clarified. The objective of this study was to quantify published interventions to generate resident research and compare effectiveness among those interventions.

Material and methods: A systematic review of English-language articles of studies of GME programs was performed, describing resident research interventions and quantifying the number of publications as an outcome.

Results: The search produced 13,688 potentially relevant articles, and included 47 articles in the final synthesis. Publication effectiveness was calculated as publications per year. The …