Suspected Metformin-induced Cobalamin Deficiency Mimicking Thrombotic Thrombocytopenic Purpura.

Thrombotic thrombocytopenic purpura (TTP) can often be life threatening and requires timely diagnosis and prompt initiation of plasmapharesis. Cobalamin deficiency can closely mimic TTP and distinguishing between the two diseases can prove to be a diagnostic challenge. Previously, cobalamin-related pseudo-TTP has been associated with pernicious anemia, dietary insufficiency and hereditary disorders of cobalamin activation. Here in, we discuss the first case of suspected metformin-induced cobalamin deficiency causing pseudo-TTP. Our patient was a 36-year-old female with type 2 diabetes mellitus on metformin for eight years who presented with hemolytic anemia, thrombocytopenia, schistocytes and mild acute renal failure. The initial impression was TTP; however, further workup revealed very low serum cobalamin levels and elevated methylmalonic acid levels. Apart from metformin use, no other cause of cobalamin deficiency was identified. We recommended upper gastrointestinal endoscopy to definitively rule out pernicious anemia.

A Case Report of Foreign Body Embolization.

Prostate brachytherapy (BT) seed embolization to the lung is a rare complication, with <1% of all seeds migrating post-implantation. Here, we present the case of a 63-year-old male who presented with a history of chest pain and intermittent dyspnea at rest for the last four months.

Heart Failure Secondary to Left Ventricular Non-compaction Cardiomyopathy in a 26-Year-Old Male.

Left ventricular non-compaction (LVNC) is a genetic anomaly where the ventricular wall is replaced by thick ventricular trabeculations with deep intertrabecular recesses held together by a thin compacted layer. We present a case of a 26-year-old male who presented with dyspnea on exertion and edema in his legs for the last one week.

An Evaluation of a Modified CTAS at an Accident and Emergency Department in a Developing Country.

OBJECTIVES: To review the modified Canadian Triage and Acuity Scale used in an accident and emergency department in Trinidad and Tobago. DESIGN AND METHODS: A cross-sectional study was carried out. Times from assignment of triage category to being seen by a physician were collected from the patient notes on the days of presentation and compared to the reference standards. Times from decision to admit to obtaining a bed were also recorded. RESULTS: 200 patients were included in the study. The median waiting time for patients in the immediate/blue category was 3 minutes (range = 3); for the red category, it was 31.2 minutes (range = 121.8); in the yellow category, it was 61.8 minutes (range = 805.2). The overall admission rate was 30.5%, with an admission rate of 25% for the blue category; 20% of patients in the red category waited more than 4 hours for a hospital bed. CONCLUSION: The patients assigned to the blue category were being seen almost immediately. Less critical persons wait longer than the reference times and this may be due to structural factors such as staffing. The admission rates per category highlighted a low admission rate for the blue category (25%), which is unusual. This study highlights the need for a further study to review clinical presentation, assignment to triage category, and outcomes.

Spirometric instability - another hurdle in achieving real-world COPD diagnostic criteria?

Globally, mortality, morbidity and the economic burden of chronic obstructive pulmonary disease (COPD) are on the rise. In addition, its diagnosis continues to pose challenges to the physicians, which is compounded further by its new feature "spirometric instability." Based on the findings from the two recent observational studies, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommended repeat spirometry for the individuals with a fixed ratio between 0.6 and 0.8. In this perspective, we discuss the uncertainties and consequences of this critical update in the 2018 GOLD report.