Publications by authors named "Sumit Dahal"

29 Publications

  • Page 1 of 1

Connective Tissue Disorders in Patients With Thrombotic Thrombocytopenic Purpura: A Retrospective Analysis Using a National Database.

J Clin Med Res 2019 Jul 11;11(7):509-514. Epub 2019 Jun 11.

Hospitalist Service, St. Joseph Hospital, Bangor, ME, USA.

Background: Prior reports have shown acquired thrombotic thrombocytopenic purpura (TTP) co-existing with connective tissue disorders (CTD). However, these are mainly limited to case reports and case-series reports, and the patient characteristics and clinical outcomes in these patients are not well known.

Methods: We used National Inpatient Sample and Nationwide Inpatient Sample (NIS) database for the years 2009 to 2016 to identify all adult patients with TTP and searched for either the presence or absence of any co-existing CTD. These two cohorts of TTP patients were then compared using statistical methods for baseline patient characteristics and clinical outcomes. The primary outcome of interest was the all-cause in-hospital mortality and the secondary outcomes were in-hospital length of stay, in-hospital total charge and in-hospital complications.

Results: Of the 14,400 cases of TTP diagnosed between 2009 and 2016, nearly 9% (n = 1,247) had one or more underlying CTD. Patients with TTP were more likely to be young, black, female, with more than one comorbidity and with private insurance if they had an underlying CTD than when they did not have any underlying CTD. There was no difference in regards to the size, location or type of the hospital, or the time taken to initiate plasmapheresis. Patients being managed for TTP had a longer mean length of hospital stay and a greater mean total inpatient stay charge if they had underlying CTD. There was however no difference in the risks of inpatient mortality, acute coronary syndrome, cardiac arrest, acute stroke, need for mechanical ventilation or hemodialysis.

Conclusion: TTP and CTD frequently co-existed and contributed to a longer hospital stay and a greater hospital charge.
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http://dx.doi.org/10.14740/jocmr3850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6575126PMC
July 2019

Vancomycin-Induced Leukocytoclastic Vasculitis: A Rare Case Report.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618820873. Epub 2018 Dec 21.

St. Joseph Hospital, Bangor, ME, USA.

Vancomycin causes different types of hypersensitivity reactions, ranging from localized skin reactions to generalized cardiovascular collapse. However, cases of vancomycin-induced leukocytoclastic vasculitis are rare. In this article, we present a case where the patient developed palpable purpura on his bilateral lower limbs following treatment with vancomycin. He was diagnosed with vancomycin-induced leukocytoclastic vasculitis that resolved without sequelae after withdrawal of vancomycin.
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http://dx.doi.org/10.1177/2324709618820873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304699PMC
September 2019

Risk, Outcomes, and Predictors of Infection in Lymphoma: A Nationwide Study.

South Med J 2018 Oct;111(10):628-633

From the Divisions of General Internal Medicine, Hematology and Oncology, and Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, and the Department of Internal Medicine, Interfaith Medical Center, Brooklyn, New York.

Objective: The risk of infection (CDI) has not been well studied in patients with lymphoma. We thus sought to determine the risk of CDI in hospitalizations with lymphoma along with its trend, outcomes, and predictors using a large database.

Methods: Hospital discharge data from the Nationwide Inpatient Sample (NIS) from 2007 to 2011 were used for the study. Using the codes, all adult patients aged 18 years or older having a primary diagnosis of lymphoma were queried for the presence of CDI as any of the secondary diagnoses. The risk of CDI in lymphoma and its yearly trend were assessed. We performed multivariate logistic regression to determine the independent risk factors of CDI in lymphoma. Furthermore, we studied mortality and other adverse outcomes of CDI in patients with lymphoma.

Results: There were 236,312 discharges (weighted) with the primary diagnosis of lymphoma. CDI was present in 2.13% of patients with lymphoma versus 0.8% in the nonlymphoma group ( < 0.001). On multivariate analysis, the significant predictors of CDI in lymphoma were presence of infection (odds ratio [OR] 3.1, 95% confidence interval [CI] 2.7-3.6), stem cell transplant (OR 2.7, 95% CI 2.3-3.4), graft-versus-host disease (OR 1.9, 95% CI 1.4-2.8), race (Asian vs white, OR 1.6, 95% CI 1.1-2.4), chemotherapy (OR 1.6, 95% CI 1.4-1.8), gastrointestinal surgery (OR 1.4, 95% CI 1.2-1.7), and Charlson Comorbidity Index (CCI) (CCI of 2 vs 0-1: OR 1.2, 95% CI 1.1-1.4; CCI of 3 vs 0-1: OR 1.3, 95% CI 1.03-1.6). CDI in lymphoma was associated with worse hospital outcomes such as increased mortality (17% vs 8%), increased length of stay (23.6 vs 9.9 days), mean total hospital charges ($197,015 vs $79,392), rate of intubation (13% vs 4% vs 13%), and rate of total parenteral nutrition (11% vs 3%).

Conclusions: Hospitalization with lymphoma was associated with an increased risk of CDI. The significant predictors for CDI in lymphoma were infection, stem cell transplant, graft-versus-host disease, race, chemotherapy, gastrointestinal surgery, and Charlson Comorbidity Index. CDI in lymphoma was associated with increased mortality and other adverse outcomes warranting a need of more vigilance for CDI in patients with lymphoma.
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http://dx.doi.org/10.14423/SMJ.0000000000000872DOI Listing
October 2018

Hot and malignant - a case of invasive papillary carcinoma in hyperthyroid patient with hot nodules.

J Community Hosp Intern Med Perspect 2018 23;8(4):220-222. Epub 2018 Aug 23.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

: Malignant thyroid nodules are clinically euthyroid and appear as cold nodules on scintigraphy. Malignancy in hyper-functioning thyroid nodule is rare. : A 48-year-old male with painless swelling on the right side of his neck for the last 4 months complained of feeling hot all the time, sweating and unintentionally losing about 20 pounds. On physical examination, there was a 3-cm mobile, non-tender mass on the right supra-clavicular area biopsy of which was consistent with metastatic papillary carcinoma of thyroid. Neck imaging showed a cystic mass in the right supra-clavicular fossa region, bilateral neck adenopathy and multiple thyroid nodules. Subsequent thyroid radionuclide scans showed three hyper-functioning nodules, which were later demonstrated to be a follicular variant of papillary microcarcinoma. He was treated with total thyroidectomy followed by radioactive iodine thyroid ablation therapy. : Physicians need to be aware and vigilant for the possibilities of malignancy in a hyper-functioning thyroid nodule when evaluating any thyroid nodule.
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http://dx.doi.org/10.1080/20009666.2018.1490139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116287PMC
August 2018

A Case of Pseudoinfarction Pattern in Diabetic Ketoacidosis: A Diagnostic and Therapeutic Dilemma.

Cardiol Res 2018 Aug 10;9(4):250-252. Epub 2018 Aug 10.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Diabetic ketoacidosis (DKA) is regularly associated with hyperkalemia that results in well-described changes on the electrocardiogram (EKG). However, ST-segment elevations on EKG mimicking acute myocardial infarction have rarely been described in the setting of DKA. Here we present a case of a 43-year-old male with DKA who had pseudoinfarction pattern of ST-segment elevation on EKG that resolved with treatment of DKA and discuss the diagnostic and therapeutic dilemma around the condition.
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http://dx.doi.org/10.14740/cr747wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089466PMC
August 2018

Hyperacute liver injury following intravenous fluconazole: A rare case of dose-independent hepatotoxicity.

J Family Med Prim Care 2018 Mar-Apr;7(2):451-454

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Fluconazole is a triazole antifungal medication used in the treatment of various fungal infections. It is available in both oral and parenteral formulations. Liver damage has been reported with fluconazole use, but most commonly it is benign elevated liver transaminases. Acute liver failure (ALF) in fluconazole use is rare, with cases being reported sporadically in literature and large cohorts describing incidence rates of acute liver injury ranging from 0.0 to 31.6/10,000 patients. We present a case of a 45-year-old African-American male with no history of liver disease who presented with superficial candidiasis and superimposed bacterial cellulitis. He was subsequently started on intravenous fluconazole and clindamycin. Shortly after he developed ALF and a drug-induced liver injury (DILI) was suspected. Fluconazole was stopped, and the clinical picture improved shortly afterward, leading to a diagnosis of fluconazole-induced ALF. Patient underwent laboratory and clinical evaluation to exclude competing etiologies of liver injury as well as a standardized assessment for causality and disease severity such as Roussel Uclaf Causality Assessment Method/Council for International Organizations of Medical Sciences score, which concluded a "Highly Probable" DILI, and a Naranjo score identifying adverse drug reaction (ADR) which concluded a "Definite ADR." Due to the severity of ALF and the routine use of fluconazole in clinical practice, clinicians should be aware that fluconazole can be a causative agent of ALF, even in low-risk populations.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_330_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6060922PMC
August 2018

The Characteristics and Trends in Adrenocortical Carcinoma: A United States Population Based Study.

J Clin Med Res 2018 Aug 27;10(8):636-640. Epub 2018 Jun 27.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Background: Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis. Data on the incidence of ACC, however, are scarce and not recent. The purpose of this study was to characterize the tumor and the patients developing ACC over the last four decades using a large population based database.

Methods: We identified all cases of ACC diagnosed between 1973 - 2014 from the Surveillance, Epidemiology, and End Results-18 registry. Descriptive analyses were used for all extracted demographic, clinical, pathological, therapeutic and survival data, and were compared between the four time periods of 1973 to 1984, 1985 to 1994, 1995 to 2004 and 2005 to 2014 using Chi-square tests for categorical variables and one-way analysis of variance for continuous variables.

Results: There were a total of 2,014 cases of ACC between 1973 and 2014 with an age-adjusted incidence of 1.02 per million populations. The median age at diagnosis was 55 years with the majority of them being females and whites. The proportion of cases by different genders, races and age at diagnosis had not changed significantly over time. These malignancies were mostly the only primary malignancy, unilateral and of high grades at diagnosis. Surgical resection of the tumor remained the mainstay of treatment. However, there was a significant increase in the use of adjuvant radiotherapy, adjuvant chemotherapy and chemotherapy alone in recent times. The median survival time was 17 months, but continues to decrease in recent time periods.

Conclusions: ACC continues to be a rare malignancy in the United States. However, most cases continue to be diagnosed only in advanced stages and are associated with poor survival. These findings underline the need for specific diagnostics tools with new and more effective treatment options.
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http://dx.doi.org/10.14740/jocmr3503wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031252PMC
August 2018

Real-World Clinical Efficacy and Tolerability of Direct-Acting Antivirals in Hepatitis C Monoinfection Compared to Hepatitis C/Human Immunodeficiency Virus Coinfection in a Community Care Setting.

Gut Liver 2018 11;12(6):694-703

Division of Gastroenterology and Hepatology, Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York, NY, USA.

Background/aims: Limited data exist comparing the safety and efficacy of direct-acting antivirals (DAAs) in hepatitis C virus (HCV) monoinfected and HCV/human immunodeficiency virus (HIV) coinfected patients in the real-world clinic practice setting.

Methods: All HCV monoinfected and HCV/HIV coinfected patients treated with DAAs between January 2014 and October 2017 in community clinic settings were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy, factors affecting sustained virologic response at 12 weeks (SVR12) after treatment, and adverse reactions were compared between the groups.

Results: A total of 327 patients were included in the study, of which 253 were HCV monoinfected, and 74 were HCV/HIV coinfected. There was a statistically significant difference observed in SVR12 when comparing HCV monoinfection and HCV/HIV coinfection (94% and 84%, respectively, p=0.005). However, there were no significant factors identified as a predictor of a reduced response. The most common adverse effect was fatigue (27%). No significant drug interaction was observed between DAA and antiretroviral therapy. None of the patients discontinued the treatment due to adverse events.

Conclusions: In a real-world setting, DAA regimens have lower SVR12 in HCV/HIV coinfection than in HCV monoinfection. Further studies involving a higher number of HCV/HIV coinfected patients are needed to identify real predictors of a reduced response.
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http://dx.doi.org/10.5009/gnl18004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6254621PMC
November 2018

Predictors of hospital stay in normotensive acute pulmonary embolism: a retrospective pilot study.

J Community Hosp Intern Med Perspect 2018 12;8(3):95-100. Epub 2018 Jun 12.

Department of Pulmonology, Interfaith Medical Center, Brooklyn, USA.

: The aim of our study is to determine the clinical, biochemical, and imaging factors that affect the duration of hospital stay in patients admitted with normotensive acute pulmonary embolism. : This was a single-center retrospective study conducted in a community hospital in New York metropolitan area for patients admitted from October 2015 to October 2017. : A total of 79 patients were included, the mean age was 55.76 ( = 17.33), 29 cases were males (37%) and 50 cases were females (63%). Among all patients, 17 cases had short length of stay (LOS) (≤2 days) and 62 cases had long LOS (>2 days). There were statistically significant differences in age ( = .041), presence of lung disease ( = .036), number of comorbidities ( = .043), and pulmonary embolism severity index (PESI) scores (original and simplified;  = .002 and .001, respectively). Logistic regression analysis showed that PESI score significantly predicted long LOS ( 1.067, 95% [1.001, 1.137],  = .048). Similarly, sPESI significantly predicted long LOS ( 0.223, 95% [0.050, 0.999],  = .050). Both regression models were adjusted for age, lung disease, and number of comorbidities. : Both original and simplified PESI scores were statistically significant predictors of duration of hospital stay. Patients with multiple comorbidities or with chronic lung disease were also likely to have prolonged hospital stay. None of the cardiac biomarkers affected the duration of hospital stay, neither did the presence of right ventricular dysfunction nor treatment modality.
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http://dx.doi.org/10.1080/20009666.2018.1466602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5998290PMC
June 2018

Secondary Salivary Gland Malignancy in Thyroid Cancer: A United States Population Based Study.

J Clin Med Res 2018 Jul 4;10(7):601-605. Epub 2018 Jun 4.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Background: There is an increased risk of second primary malignancies with thyroid cancer. However, the risk and characters of secondary salivary gland malignancy (sSGM) in patients with thyroid cancer have not been evaluated before.

Methods: We used the Surveillance Epidemiology and End Results (SEER) 18 registry to identify thyroid cancer patients from 1973 to 2014. We then calculated the risk of sSGM using standardized incidence ratio and excess risk. Separately, all cases of primary salivary gland malignancy (pSGM) diagnosed between 1973 - 2014 were extracted from the SEER 18 registry, and their characteristics compared with sSGM using independent samples -test for continuous variables and Chi-square tests for categorical variables.

Results: There were a total of 68,339 cases of primary thyroid cancer. Of these, 18 patients developed sSGM with the observed to expected ratio being 3.58 (95% CI: 2.12 to 5.65; P < 0.05) and excess risk being 0.48 per 10,000 population. The incidence of sSGM remained higher between 6 months to 10 years from the time of diagnosis of thyroid carcinoma. The risk of developing sSGM was significantly higher if they were below 60 years of age (O/E: 4.51; 95% CI: 2.33 - 7.88; P < 0.05), were females (O/E: 4.91; 95% CI: 2.80 - 7.97; P < 0.05), were whites (O/E: 3.04; 95% CI: 1.62 - 5.1 9; P < 0.05), had well-differentiated thyroid carcinoma (O/E: 9.70; 95% CI: 3.90 - 19.98; P < 0.05) or were treated with radioactive iodine (O/E: 5.26; 95% CI: 2.72 - 9.19; P < 0.05). While the proportion of females developing sSGM was significantly greater than those developing pSGM (88.9% vs. 44%; P < 0.05), there was no statistical difference between pSGM and sSGM in terms of the age at diagnosis, the proportion of patients diagnosed before 60 years of age, anatomic site of origin or the histological grade of tumor.

Conclusions: Patients with thyroid cancers are at an increased risk of developing sSGM than the general population. This risk is greater if the person is below 60 years of age, female, white, with well-differentiated thyroid carcinoma or is treated with radioactive iodine.
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http://dx.doi.org/10.14740/jocmr3475wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5997411PMC
July 2018

Myocardial Infarction as an Early Presentation in Thrombotic Thrombocytopenic Purpura: A Rare Case Series.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618773789. Epub 2018 May 2.

Interfaith Medical Center, Brooklyn, NY, USA.

Renal and neurological involvements are frequently seen in thrombotic thrombocytopenic purpura (TTP). Cardiac involvement, however, has been rarely reported. In this article, we present 2 cases of myocardial infarction in patients with TTP. In the first case, a young man presented with non-ST-segment elevation myocardial infarction that resolved promptly with plasmapheresis. The second patient developed ST-segment elevation myocardial infarction early in the course of the disease and died before plasmapheresis could be initiated. Hence, a high degree of suspicion with prompt diagnosis and treatment is needed to prevent mortality associated with cardiac involvement in TTP.
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http://dx.doi.org/10.1177/2324709618773789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946356PMC
May 2018

Acquired Amegakaryocytic Thrombocytopenia and Pure Red Cell Aplasia in Thymoma.

Case Rep Hematol 2018 11;2018:5034741. Epub 2018 Mar 11.

Interfaith Medical Center, Brooklyn, NY, USA.

Association of thymoma with myasthenia gravis, pure red cell aplasia, and aplastic anemia is well documented. However, thymoma complicated by acquired amegakaryocytic thrombocytopenia (AAMT) is rarely reported. Here, we present a case of a 60-year-old male with past medical history of recurrent invasive thymoma who presented with cough and blood in sputum. He was found to have severe normocytic normochromic anemia and thrombocytopenia that did not improve with intravenous steroids or multiple transfusions of red cells and platelets. Subsequent bone marrow biopsy showed severely depleted megakaryocytes and erythroid precursor cells with relative myeloid hyperplasia suggestive of amegakaryocytic thrombocytopenia and red cell aplasia. He was started on oral cyclosporine but subsequently developed leukopenia and refused any further treatment or diagnostic procedures and left the hospital against medical advice. AAMT, thus, may be a very early presentation of impending aplastic anemia, and treating physicians need to be aware of this entity.
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http://dx.doi.org/10.1155/2018/5034741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866878PMC
March 2018

Lung consolidation as a rare presentation of lymphoplasmacytic lymphoma with extramedullary Waldenström's macroglobulinemia.

J Community Hosp Intern Med Perspect 2018 17;8(2):68-72. Epub 2018 Apr 17.

Medicine Department, Pulmonary and Critical Care Division, Interfaith Medical Center, Brooklyn, NY, USA.

: Lymphoplasmacytic lymphoma (LPL) is a mature B cell lymphoma that usually involves the bone marrow, spleen and lymph nodes. Extramedullary involvement, including the lung, is rarely reported. : A 73-year-old female initially presented to our hospital complaining of productive cough of white-colour sputum for three weeks duration. She reported unintentional weight loss of ten pounds over the last five months. There was no history of haemoptysis, fever, night sweats, chills, recent infections or hospitalization. Chest imaging showed right lower lobe consolidation, small right pleural effusion. She was treated with oral antibiotic for pneumonia. After two months, a follow up chest imaging revealed persistent right lower lobe consolidation. Therefore, she was worked up for the possibility of malignancy. Bronchoscopy showed polypoid nodularities surrounded by black discoloured mucosa in the sub-segmental bronchi of the right lower lobe, and biopsy specimen revealed atypical B cell lymphocytic infiltrate. Polymerase chain reaction confirmed a clonal B-cell gene rearrangement supportive for a low-grade B-cell Lymphoma. Subsequently; serum immunofixation showed IgM of 1491 mg/dL (normal range 26-217 mg/dl) with normal levels of IgG and IgA. Urine contained free kappa light chains. Cytology with immunophenotyping of pleural fluid revealed lymphoplasmacytic lymphocytes. This combination of lab and bronchoscopy findings established the diagnosis of extramedullary Waldenström's macroglobulinemia. : Waldenström's macroglobulinemia, a manifestation of LPL, is associated with an IgM monoclonal gammopathy in the blood. Extramedullary involvement including the lung is rarely seen in LPL. Physicians need to be aware of this rare presentation.
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http://dx.doi.org/10.1080/20009666.2018.1440854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5906769PMC
April 2018

Hypereosinophilic Syndrome Complicated by Eosinophilic Myocarditis With Dramatic Response to Steroid.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618764512. Epub 2018 Mar 19.

Interfaith Medical Center, Brooklyn, NY, USA.

Eosinophilic myocarditis is an infiltrative disease that affects the myocardium leading to various presentations. It can be precipitated by medications, helminthiasis, or hypereosinophilic syndrome. We present the case of a young, male patient who presented with palpitations and dyspnea and was found to have heart failure with reduced ejection fracture of 12%. His past medical history was significant for recent lung problem treated with steroids. Based on his history and laboratory findings, he was started on intravenous steroids for treatment of eosinophilic myocarditis. Within 3 days, his ejection fracture improved to 35%. Given the nonspecific clinical presentations, mimicking other diseases, high index of suspicion is warranted to diagnose eosinophilic myocarditis. This is crucial as early detection and treatment with steroids can lead to a dramatic response.
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http://dx.doi.org/10.1177/2324709618764512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862364PMC
March 2018

Drug-Induced Liver Injury: An Institutional Case Series and Review of Literature.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618761754. Epub 2018 Mar 14.

Interfaith Medical Center, Brooklyn, NY, USA.

Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the USA. DILI can be broadly classified as Intrinsic and Idiosyncratic. Identifying predictors and at-risk patients are challenging but can have a substantial clinical implication. This case report series demonstrates the importance of valproic acid, fluconazole, and amiodarone as potential hepatoxic agents of drug-induced liver injury leading to acute hepatic failure. The causality in all cases was established by Roussel Uclaf Causality Assessment Method/Council for International Organizations of Medical Sciences score and Naranjo Algorithm. Obesity, hypo-perfusion state, and concurrent hepatotoxic agent might identify at-risk patients. Further studies are required to understand the risk factors.
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http://dx.doi.org/10.1177/2324709618761754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858623PMC
March 2018

Fatal Acute Liver Failure With Intravenous Amiodarone: A Case Report and Literature Review.

Gastroenterology Res 2018 Feb 23;11(1):62-63. Epub 2018 Feb 23.

Interfaith Medical Center, 1545 Atlantic Ave, Brooklyn, NY 11213, USA.

Amiodarone is a drug which frequently causes elevated transaminases. However, acute liver failure has been rarely reported. Here, we present a case of fatal acute liver failure following the administration of intravenous amiodarone. It is important to be aware of this rare but potentially fatal complication of intravenous amiodarone so that it can be withdrawn immediately at the first sign of hepatic impairment.
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http://dx.doi.org/10.14740/gr911wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827905PMC
February 2018

Assessment of Knowledge, Attitudes, and Practices Regarding Chronic Hepatitis C Treatment and Its Challenges: A Survey of Internal Medicine Residents in a Community Hospital.

Gastroenterology Res 2018 Feb 23;11(1):31-35. Epub 2018 Feb 23.

Department of Gastroenterology, Interfaith Medical Center, Brooklyn, NY, USA.

Background: Despite recent advances in chronic hepatitis C (CHC) treatment, only a small proportion of patients are connected with care and receive treatment. Internal medicine (IM) residents spend nearly one-third of their training in primary care settings and play a crucial role in diagnosing and counseling patients as well as linking patients with care and following up.

Methods: IM residents in a community hospital completed an anonymous questionnaire regarding their knowledge, attitude, and practice associated with CHC treatment and its challenges.

Results: Descriptive analysis of the survey showed that there is a substantial gap in knowledge regarding the newer treatment of CHC between IM residents' perceptions of patient awareness and IM residents.

Conclusion: Updated education regarding CHC that is geared towards medical residents and focused on new modalities of treatment can narrow the gap and lead to considerable increases in the rates of diagnosis and treatment and decreases in morbidity and mortality.
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http://dx.doi.org/10.14740/gr963wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827899PMC
February 2018

Rare case of presenting as asymptomatic cavitary lung lesion.

J Community Hosp Intern Med Perspect 2018 6;8(1):32-34. Epub 2018 Feb 6.

Pulmonary and critical care, Interfaith Medical Center, Brooklyn, NY, USA.

: is a rare nontuberculous mycobacterial infection. The first isolate of the species was from human sputum at University of Nebraska Medical Center. There are only a few cases have been reported and the exact behavior of the disease is not clearly described. Here, we present a case from New York City incidentally found to have a cavitary lung lesion due to . : An 82-year-old female with a history of diabetes mellitus, hypertension, and dementia presented with constipation and urinary retention for 1 day. She had no fever, cough, shortness of breath, nausea, vomiting, appetite change, or weight loss. Computed tomography (CT) scan of abdomen and pelvis revealed retained fecal material in the colon, non-obstructing left renal calculus, and bilateral small pleural effusion with right-sided lung infiltrates. Subsequent CT scan of the chest showed 4.5 cm pleural-based opacity in right lung base with a small cavity. Sputum smear for Acid-fast bacilli was positive. Mycobacterial culture reported positive growth of , while polymerase chain reaction returned negative for complex and . With the patient asymptomatic and her constipation improved, she was discharged with plans for close follow-up as outpatient. is a very rare nontuberculous mycobacterial infection. From only a few cases reported in the USA, the exact presentation of infection, disease progression, and treatment have not been described well. Asymptomatic cavitary lung disease caused by has not been reported before.
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http://dx.doi.org/10.1080/20009666.2017.1418120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804722PMC
February 2018

Sickle Cell Beta-Plus Thalassemia with Subcapsular Hematoma of the Spleen.

Case Rep Hematol 2017 14;2017:3819457. Epub 2017 Dec 14.

Maimonides Medical Center, Brooklyn, NY, USA.

While splenic complications like hypersplenism, sequestration crisis, and infarction are commonly reported in sickle cell variants like sickle cell beta-plus thalassemia, splenic rupture with hematoma is rare. We present a case of a 32-year-old young male who presented with dull left upper quadrant pain who was found to have multiple subcapsular splenic lacerations and hematoma on abdominal imaging. Hemoglobin electrophoresis confirmed sickle cell beta-plus thalassemia in the patient. There was no history of trauma, and rest of the workup for possible cause of spontaneous rupture of spleen was negative. With the patient refusing splenectomy, he was managed conservatively. Clinicians need to be aware of this rare complication of sickle cell variants.
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http://dx.doi.org/10.1155/2017/3819457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5745719PMC
December 2017

Fatal pulmonary cavitary disease secondary to in a patient with sarcoidosis.

J Community Hosp Intern Med Perspect 2017 14;7(6):372-377. Epub 2017 Dec 14.

Pulmonary and Critical Care Department, Interfaith Medical Center, Brooklyn, NY, USA.

: () has low pathogenicity and usually requires either host immune impairment or structural lung disease to cause clinical disease. Fatal cavitary infection in a patient without immunosuppression is rarely presented. : A 62-year-old female with history of sarcoidosis and hypertension presented with cough, fever and dyspnea for one week. Chest imaging showed irregular opacification of upper lung zones. The sputum samples tested positive for acid-fast bacilli (AFB) and the subsequent testing identified . She was started on rifampin, isoniazid, pyrazinamide and ethambutol along with azithromycin, and was discharged with plans to continue the same. A follow up sputum test was negative for AFB. She was, however, readmitted ten months later with sepsis due to pneumonia. Chest imaging revealed worsening cavitary lung lesions. Despite starting her on intravenous antibiotics while continuing anti-tubercular therapy, she developed severe respiratory distress and had to be intubated. Her condition continued to deteriorate and she expired the following day. Fatal cavitary infections with M. xenopi have been reported in the absence of established optimal management. Well-designed studies with sufficient power are needed to establish new treatment guidelines.
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http://dx.doi.org/10.1080/20009666.2017.1407211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5738639PMC
December 2017

Acquired Thrombotic Thrombocytopenic Purpura in a Patient with Pernicious Anemia.

Case Rep Hematol 2017 4;2017:1923607. Epub 2017 Apr 4.

Interfaith Medical Center, Brooklyn, NY, USA.

. Acquired thrombotic thrombocytopenic purpura (TTP) has been associated with different autoimmune disorders. However, its association with pernicious anemia is rarely reported. . A 46-year-old male presented with blood in sputum and urine for one day. The vitals were stable. The physical examination was significant for icterus. Lab tests' results revealed leukocytosis, macrocytic anemia, severe thrombocytopenia, renal dysfunction, and unconjugated hyperbilirubinemia. He had an elevated LDH, low haptoglobin levels with many schistocytes, nucleated RBCs, and reticulocytes on peripheral smear. Low ADAMTS13 activity (<10%) with elevated ADAMTS13 antibody clinched the diagnosis of severe acquired TTP, and plasmapheresis was started. There was an initial improvement in his hematological markers, which were however not sustained on discontinuation of plasmapheresis. For his refractory TTP, he was resumed on daily plasmapheresis and Rituximab was started. Furthermore, the initial serum Vitamin B12 and reticulocyte index were low in the presence of anti-intrinsic factor antibody. So with the concomitant diagnosis of pernicious anemia, Vitamin B12 was supplemented. The rest of the immunological workups were negative. Subsequently, his symptoms resolved and his hematological parameters improved. . While pernicious anemia can masquerade as TTP, an actual association between the two can also occur and needs further evaluation and characterization.
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http://dx.doi.org/10.1155/2017/1923607DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394407PMC
April 2017

Thrombocytopenia in Patients with Chronic Hepatitis C Virus Infection.

Mediterr J Hematol Infect Dis 2017 1;9(1):e2017019. Epub 2017 Mar 1.

University of Nebraska Medical Center, Department of Internal Medicine, Division of Hematology-Oncology, Omaha, Nebraska, USA.

Thrombocytopenia in patients with chronic hepatitis C virus (HCV) infection is a major problem. The pathophysiology is multifactorial, with auto-immunogenicity, direct bone marrow suppression, hypersplenism, decreased production of thrombopoietin and therapeutic adverse effect all contributing to thrombocytopenia in different measures. The greatest challenge in the care of chronic HCV patients with thrombocytopenia is the difficulty in initiating or maintaining IFN containing anti-viral therapy. Although at present, it is possible to avoid this challenge with the use of the sole Direct Antiviral Agents (DAAs) as the primary treatment modality, thrombocytopenia remains of particular interest, especially in cases of advanced liver disease. The increased risk of bleeding with thrombocytopenia may also impede the initiation and maintenance of different invasive diagnostic and therapeutic procedures. While eradication of HCV infection itself is the most practical strategy for the remission of thrombocytopenia, various pharmacological and non-pharmacological therapeutic options, which vary in their effectiveness and adverse effect profiles, are available. Sustained increase in platelet count is seen with splenectomy and splenic artery embolization, in contrast to only transient rise with platelet transfusion. However, their routine use is limited by complications. Different thrombopoietin analogues have been tried. The use of synthetic thrombopoietins, such as recombinant human TPO and pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMDGF), has been hampered by the development of neutralizing antibodies. Thrombopoietin-mimetic agents, in particular, eltrombopag and romiplostim, have been shown to be safe and effective for HCV-related thrombocytopenia in various studies, and they increase platelet count without eliciting any immunogenicity Other treatment modalities including newer TPO analogues-AMG-51, PEG-TPOmp and AKR-501, recombinant human IL-11 (rhIL-11, Oprelvekin), recombinant human erythropoietin (rhEPO), danazol and L-carnitine have shown promising early result with improving thrombocytopenia. Thrombocytopenia in chronic HCV infection remain a major problem, however the recent change in DAAs without IFN, as the frontline therapy for HCV, permit to avoid the dilemmas associated with initiating or maintaining IFN based anti-viral therapy.
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http://dx.doi.org/10.4084/MJHID.2017.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333732PMC
March 2017

Secondary acute myeloid leukemia in survivors of Hodgkin lymphoma.

Future Oncol 2016 Jul 15;12(13):1565-75. Epub 2016 Apr 15.

Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE 68198, USA.

Background: This large population-based study determined the epidemiology and outcomes of secondary acute myeloid leukemia (sAML) developing in Hodgkin lymphoma survivors.

Methods: We utilized the Surveillance Epidemiology and End Results (SEER) 9 database to identify 104 cases of sAML.

Results: Patients with sAML (median age: 47 years; 82% <60 years) were significantly younger than de novo AML cases (66 years; p < 0.01). sAML had worse overall survival (OS) than de novo AML (p < 0.01). OS was better in younger patients and in more recent years.

Conclusion: Older patients with sAML have a dismal OS and should be enrolled in trials of novel therapies. Younger patients have improved OS and hence may benefit from curative intent intensive therapy and allogeneic transplant.
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http://dx.doi.org/10.2217/fon-2016-0048DOI Listing
July 2016

Demographic and other characteristics of nodal non-Hodgkin's lymphoma managed in academic versus non-academic centers.

Ther Adv Hematol 2015 Oct;6(5):223-7

Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA.

Background: Cancer therapy and outcomes are known to be affected by various demographic features and hospital types. We aimed to identify the characteristics of non-Hodgkin's lymphoma (NHL) patients associated with receipt of care at academic centers.

Method: This is a retrospective study of all patients diagnosed with nodal NHL between 2000 and 2011 in the National Cancer Database (NCDB), who received the diagnosis, and all or part of their initial therapy in the reporting hospital (n = 243,436). Characteristics of patients receiving care in academic versus nonacademic centers were compared using the Chi-square test.

Results: Approximately 27% received care in academic centers. Patients receiving care in nonacademic centers, compared with academic centers, were more likely to be ⩾60 years (69% versus 58%, p < .0001), White (89% versus 80%, p < .0001) and have lower educational attainment (>12% without high school diploma: 72% versus 69%, p < .0001) and economic status (household income <$49,000: 66% versus 61%, p < 0.0001). Patients receiving care in nonacademic centers were less likely to travel ⩾25 miles (21% versus 26%, p < 0.0001). White patients, compared with non-Whites, were more likely to be ⩾60 years (70% versus <50%, p < 0.0001), which probably explains less care in academic centers.

Conclusions: Patients ⩾60 years and those with poorer educational attainment and economic status were less likely to receive care in academic centers. Care in academic centers required a longer commute. Elderly patients frequently have inferior outcomes and may benefit from clinical trials with novel agents and expertise at academic centers.
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http://dx.doi.org/10.1177/2040620715592568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556968PMC
October 2015

Fondaparinux for Management of Heparin-induced Thrombocytopenia after Cardiovascular Intervention: A Systematic Review.

Cardiovasc Hematol Agents Med Chem 2015 ;13(2):82-6

University of Nebraska Medical Center, Department of Internal Medicine, Division of Hematology- Oncology, 987680 Nebraska Medical Center, Omaha, NE 68198-7680, USA.

Objectives: The efficacy and safety of fondaparinux, an emerging therapeutic option for heparin-induced thrombocytopenia (HIT), remain unclear in cardiac surgery patients with HIT.

Methods: Using several search criteria, we reviewed all cases of fondaparinux use in patients who developed HIT after any cardiovascular intervention and were indexed in MEDLINE by August 2014. Based on pre-specified criteria, cases were divided into confirmed HIT, probable HIT and possible HIT. The outcome of fondaparinux use in each group was compared using Chi-square test.

Results: Of 43 total cases, 22 had confirmed HIT and 21 had possible HIT. Valve replacement or repair (39%) and heart transplant or ventricular assist device placement (21%) were the most common preceding cardiovascular interventions. Creatinine clearance <30 ml was present in 27% and 52% of confirmed and possible HIT respectively. Overall the risk of new thrombosis and bleeding with fondaparinux were 4.6% and 7% respectively, without any differences in the two subgroups. The majority (86%) of cases improved clinically; of the remainder patients, similar percentage of cases with possible HIT and confirmed HIT died (24% vs. 5%; p= 0.102). None of the deaths were attributed to HIT or complications of bleeding.

Conclusion: Within the limitations of this study, the risk of thrombosis and bleeding with fondaparinux use in cardiac surgery patients with HIT are low and largely comparable to outcomes reported in literature with other agents.
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http://dx.doi.org/10.2174/1871525713666150911113811DOI Listing
October 2016

Chemotherapy use in stage III colon cancer: a National Cancer Database analysis.

Ther Adv Med Oncol 2015 Sep;7(5):244-51

Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA.

Background: Although adjuvant chemotherapy in stage III colon cancer improves overall survival, prior studies have shown that it is underused. We analyzed different factors that may influence its use.

Methods: This is a retrospective study of stage III colon cancer patients (n = 207,718) diagnosed between 2000 and 2011 in the National Cancer Data Base (NCDB). The NCDB contains ~70% of new cancer diagnosis from >1500 American College of Surgeons accredited cancer programs in the United States and Puerto Rico. The chi-squared test was used to determine any difference in characteristics of patients who did or did not receive chemotherapy.

Results: A total of 35% of all stage III colon cancer patients, and 38% of stage III cases undergoing surgery, did not receive adjuvant chemotherapy. The use of chemotherapy had increased in recent years (64% in 2007-2011 versus 59% in 2000-2002; p < 0.0001). Its use was lower in whites (61%), females (60%), patients ⩾60 years (55%), patients with one or more comorbidities (55%), nonacademic centers (62%), those with medicare insurance (52%), lower education (61%) and income levels (59%, all p < 0.0001). The nonwhite and uninsured were more likely to be <60 years old.

Conclusion: More than one-third did not receive adjuvant chemotherapy, although its use has increased in more recent years. Age was one of the most important determinants of chemotherapy use, which may explain higher rates in nonwhite and uninsured. In addition to patient characteristics, race, gender and socioeconomic factors influence chemotherapy use. These findings have important implications for healthcare reform.
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http://dx.doi.org/10.1177/1758834015587867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4543852PMC
September 2015

Myxedema Coma with Reversible Cardiopulmonary Failure: a Rare Entity in 21 Century.

Maedica (Bucur) 2015 Sep;10(3):268-271

Department of Internal Medicine, Division of Hematology-Oncology, Nebraska Medical Center, University of Nebraska Medical Center, Omaha, Nebraska, United States of America.

Myxedema coma, a rare entity in 21st century in developed nations, is a decompensated phase of hypothyroidism with high mortality rates. We describe a young woman with myxedema, who developed respiratory failure, congestive heart failure and significant pericardial effusion, some of the uncommon manifestations. Decreased cardiac contractility can result in cardiomyopathy and heart failure. As illustrated by this case, myxedema can also result in significant pericardial effusion due to increased vascular permeability. Myxedema can further be complicated by alveolar hypoventilation and respiratory failure secondary to the lack of central drive as well as respiratory muscle weakness. Prompt therapy with thyroid hormone replacement, glucocorticoid therapy, aggressive supportive care and management of the precipitating event can save lives and reverse the cardiopulmonary symptoms, as in our patient. Hence, physicians should have a high index of suspicion for myxedema coma in patients with unexplained cardiopulmonary failure. Our report is, therefore, aimed at bringing awareness about the rare but fatal manifestations of myxedema coma.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5327827PMC
September 2015

Differentiating malignant hypertension-induced thrombotic microangiopathy from thrombotic thrombocytopenic purpura.

Ther Adv Hematol 2015 Jun;6(3):97-102

Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA.

Objectives: Malignant hypertension can cause thrombotic microangiopathy (TMA) and the overall presentation may mimic thrombotic thrombocytopenic purpura (TTP). This presents a dilemma of whether or not to initiate plasma exchange. The objective of the study was to determine the clinical and laboratory manifestations of malignant hypertension-induced TMA, and its outcomes.

Methods: Using several search terms, we reviewed English language articles on malignant hypertension-induced TMA, indexed in MEDLINE by 31 December 2013. We also report a new case. All these cases were analyzed using descriptive statistics.

Results: A total of 19 patients, with 10 males, had a median age of 38 years at diagnosis; 58% had a history of hypertension. Mean arterial pressure at presentation was 159 mmHg (range 123-190 mmHg). All had prominent renal dysfunction (mean creatinine of 5.2 mg/dl, range 1.7-13 mg/dl) but relatively modest thrombocytopenia (mean platelet count of 60 × 103/µl, range 12-131 × 10(3)/µl). Reported cases (n = 9) mostly had preserved ADAMTS-13 activity (mean 64%, range 18-96%). Following blood pressure control, the majority had improvement in presenting symptoms (100%) and platelet counts (84%); however, only 58% had significant improvement in creatinine. More than half (53%) needed hemodialysis. One patient died of cardiac arrest during pacemaker insertion.

Conclusion: Prior history of hypertension, high mean arterial pressure, significant renal impairment but relatively modest thrombocytopenia and lack of severe ADAMTS-13 deficiency (activity <10%) at diagnosis are clues to diagnose malignant hypertension-induced TMA. Patients with malignant hypertension respond well to antihypertensive agents and have favorable nonrenal outcomes.
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http://dx.doi.org/10.1177/2040620715571076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480518PMC
June 2015

Systemic therapy in stage IV pancreatic cancer: a population-based analysis using the National Cancer Data Base.

Ther Adv Med Oncol 2015 Jul;7(4):198-205

Department of Internal Medicine, Division of Hematology-Oncology, Creighton University Medical Center, Omaha, NE, USA.

Background: Pancreatic cancer accounts for approximately 7% of all cancer deaths. More than half of all pancreatic cancers are stage IV at diagnosis, where systemic chemotherapy is used with the goal of life prolongation as well as palliation. The patient characteristics and health system factors that drive the use of systemic therapy are unknown.

Method: This is a retrospective study of stage IV pancreatic cancer patients (n = 140,210) diagnosed between 2000 and 2011 in the NCDB. NCDB contains approximately 70% of new cancer diagnosis from more than 1500 accredited cancer programs in the United States and Puerto Rico. Chi-squared test was used to determine any differences in characteristics of patients who did or did not receive systemic therapy.

Results: Our study demonstrated that only 49.1% of stage IV pancreatic cancer patients received systemic therapy. The use of systemic therapy is significantly lower in female, African American/Hispanic, patients older than 40 years, those without insurance or with Medicare and Medicaid, higher Charlson Comorbidity Score, poor economic and educational status and in nonacademic centers.

Conclusions: This is the largest study to evaluate the determinants of systemic therapy use in stage IV pancreatic cancer. The use of systemic therapy was significantly lower in patients older than 40 years, lower educational status, nonprivate insurance and with higher Charlson Comorbidity Scores. In addition, the use of systemic therapy was lower with female sex, African Americans/Hispanic, and lower socio-economic status. Understanding the barriers in the use of systemic therapy as well as appropriate utilization of systemic therapy can both optimize cancer care.
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http://dx.doi.org/10.1177/1758834015579313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480523PMC
July 2015