Severe Hypomagnesemia Caused by Proton-Pump Inhibitors in a Patient With an Ostomy.

Proton pump inhibitors (PPIs) are commonly used for many gastrointestinal issues, such as gastroesophageal reflux disease (GERD), peptic ulcer disease, and Zollinger-Ellison syndrome. Many patients are on life-long daily therapy with this class of medications. The adverse effects of long-term use of PPI have been studied, and over the last two decades, a link between hypomagnesemia and PPI has been established. In addition, other electrolyte derangements can also ensue, such as hypokalemia and hypocalcemia. Losses through the gastrointestinal or renal systems may also be responsible for this electrolyte disturbance. In this case, we present a "perfect storm" of a patient who, in addition to having ongoing gastrointestinal losses through an ostomy, had severe hypomagnesemia to less than 1 mg/dL compounded by PPI use. Through its unique mechanism of action on intestinal epithelial cells, PPI use in certain settings can potentially be catastrophic. Severe hypomagnesemia may manifest as tetany, convulsions, tremors, arrhythmias, or torsades de pointes.

Severe Lymphoma-Associated Hemophagocytic Syndrome in a Young Woman.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome characterized by profound immune system activation. In adults, most cases of HLH are due to an underlying pathology- such as infection, malignancy, or autoimmune disease. It is a disease that can progress to rapid clinical deterioration and be difficult to diagnose. Nevertheless, regardless of etiology, most patients with HLH benefit from treatment. This paper highlights the challenges involved in diagnosing and managing this condition in practice, with an emphasis on how young, previously healthy young adults can present in a critically ill state.

The Effect of Dapagliflozin on Platelet Function Testing Profiles in Diabetic Patients: The EDGE Pilot Study.

INTRODUCTION: This prospective pharmacodynamic (PD) study assessed the effect of the sodium-glucose co-transporter-2 inhibitor (SGLT2i), dapagliflozin, on platelet reactivity. METHODS: Patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) (n = 27) who were on maintenance dual antiplatelet therapy (DAPT) of aspirin 81 mg daily, and clopidogrel 75 mg daily were recruited. Platelet function was evaluated with the VerifyNow™ P2Y12 assay (Werfen, Bedford, MA, USA) and assessed prior to initiation of and after 10 days of treatment with dapagliflozin 10 mg once-daily dose regimen. Results were compared with a paired t test. RESULTS: Treatment with dapagliflozin significantly decreased P2Y12 reaction units (PRU) by 20%, (95% confidence interval (CI) 8.5-32.6%, p value 0.002). The mean difference in PRU was 36.70 (95% CI 16.66-56.75). No patients experienced any serious adverse events (SAEs). CONCLUSIONS: Significantly diminished platelet reactivity was observed on dapagliflozin as compared to without dapagliflozin. This dedicated pharmacodynamic study could be potentially informative and applicable for Trinidadian stable CAD patients with T2DM on DAPT. Further studies are required to confirm these exploratory findings. CLINICAL TRIAL REGISTRATION: EDGE ClinicalTrials.gov number NCT04400760.

Sodium-Glucose Co-transporter-2 Inhibitor-Induced Pruritus: Itching for Answers.

Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) have revolutionized the treatment of type 2 diabetes mellitus during the last decade. It has not only proven to be very effective for glycemic control but also has adjunctive effects in the management of heart failure, hypertension, and diabetic nephropathy, and even contributes to weight loss. Another benefit is the apparent lack of major side effects, particularly hypoglycemia, apart from euglycemic diabetic ketoacidosis. The most well-known side effects are genital mycotic infections and urinary tract infections (UTI). Although pruritus is less well known, we highlight in this case study this side effect as notable albeit uncommon so as to sensitize clinicians to its possibility.

Posterior Reversible Encephalopathy Syndrome: Tips for Diagnosis and Treatment.

Often described as a clinico-radiological entity, posterior reversible encephalopathy syndrome (PRES) is being increasingly diagnosed nowadays. However, mystery still surrounds its exact etiology. Though there are no standardized diagnostic criteria for this syndrome, there is a consistent feature associated with it: brain vasogenic edema in combination with neurotoxicity. The nonspecific nature of this condition leaves room for the diagnosis to be overlooked, leading to delays in providing appropriate treatment and unfavorable patient outcomes. PRES is associated with a variety of medical conditions including hypertension, eclampsia, autoimmune conditions, renal failure, sepsis, and an immunocompromised state, such as that secondary to the use of immunosuppressive therapy, human immunodeficiency virus (HIV), and organ transplants. Treatment by a multidisciplinary team and prompt identification and reversal of the underlying cause can lead to beneficial outcomes, as in the case we present in this report.

The Effect of Empagliflozin on Platelet Function Profiles in Patients with Stable Coronary Artery Disease in Trinidad: The EFFECT Pilot Study.

INTRODUCTION: This prospective pharmacodynamic (PD) study aimed to assess the effect of the sodium-glucose cotransporter 2 inhibitor (SGLT2i) empagliflozin on platelet reactivity. METHODS: Patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) (n = 20) who were actively treated with dual antiplatelet therapy (DAPT) of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow™ P2Y12 assay (Instrumentation Laboratory, Massachusetts, USA) and assessed before the initiation of and after 10 days of treatment with empagliflozin 25 mg once daily maintenance dose regimen. Results were compared with a paired t test. RESULTS: The mean P2Y12 reaction units (PRU) on empagliflozin was significantly less than without empagliflozin at baseline (187.35, 95% confidence interval (CI) 155.38-219.32 vs. 217.25, CI 180.60-253.90; p < 0.030). The mean difference in PRU was 29.90 (95% CI 3.17-56.63). No patients experienced any serious adverse events (SAEs). CONCLUSIONS: Significantly attenuated platelet reactivity was observed on empagliflozin as compared to without empagliflozin. This dedicated pharmacodynamic study could be clinically pertinent for Trinidadian patients with stable CAD and T2DM on DAPT. Further studies are required to confirm these exploratory findings. (Funded by the University of the West Indies, St. Augustine; EFFECT). CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov number NCT04342819.

COVID-19 and ethnicity: Does reduced responsiveness to glucocorticoids explain the more aggressive nature of disease among minorities?

Marked ethnic variations in complications and mortality have been noted following infection with COVID-19, with Black, Asian, and minority ethnic groups (BAME) being particularly hard hit. We hypothesise that glucocorticoid resistance stemming from several intrinsic reasons such as chronic social stress and lower circulating levels of Vitamin D may contribute to the exaggerated inflammatory response, more severe disease and poorer outcomes observed in BAME.

COVID-19 and ethnicty: Does reduced responsiveness to glucocorticiods explain the more aggressive nature of disease among minorities?

Marked ethnic variations in complications and mortality have been noted following infection with COVID-19, In the United States, the age-adjusted mortality rate among Blacks is 3.8 times, Hispanics 2.5 times, and Asians 1.5 times higher than Whites. In the United Kingdom, the age-adjusted mortality rate among Blacks is 2.9 times, Pakistani and Bangladeshi 2.2 times, and South Indians 1.8 times than that of Whites. One should consider that the increased mortality seen in BAME may be a consequence of impaired glucocorticoid sensitivity stemming from several intrinsic reasons such as chronic social stress and lower circulating levels of Vitamin D. This study aims to evaluate the effect, or lack thereof, of glucocorticoids on Black, Asian and Minority ethnic groups (BAME) when compared to White populations in the setting of COVID-19 treatment.

The impact of air pollution on the incidence and mortality of COVID-19.

Air pollution is the most significant environmental risk factor for all-cause mortality, and it has caused substantial disability-adjusted life-years and economic loss. Air pollution intensified the mortality during past pandemics, Spanish flu in 1918 and SARS-CoV-1 in 2003. It increases host susceptibility and virulence of respiratory infections and reduces viral clearance. Thus, a question arises whether there will be any impact of air pollution on the current pandemic coronavirus disease 2019 (COVID-19)? Thus far, history and science are directing towards an immense potential impact of air pollution on the COVID-19 pandemic. Some of the devastated countries with the current pandemic are those with a poor air quality index. Further epidemiological and ecological studies are necessary to confirm this association. Also, countries must mobilize funding for mitigation of air pollution to benefit environmental health and ameliorate its potential effects on pandemics of the future.

COVID-19: Social Displacement and Glucocorticoid Resistance

This study aims to evaluate the effect or lack thereof, of glucocorticoids on Black, Asian, and Minority ethnic groups (BAME) when compared to white populations in the setting of COVID-19 treatment