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Rhode Island Chapter Abstracts Rhode Island Chapter Abstracts April 1, 2015 Abdin, Ahmad Last Name: Abdin First Author: Resident First Name: Ahmad Category: Clinical Vignette PG Year: PGY-1 or MS Year: ACP Number: 2888549 Medical School or Residency Program: Warren Alpert Medical School of Brown University Hospital Affiliation: Memorial Hospital of Rhode Island, Providence VA Medical Center Additional Authors: Ahmad Abdin, MD, Mohammed Salhab, MD, Amos Charles, MD, Mazen Al-Qadi, MD Abstract Title: Amiodarone-Induced Cerebellar Dysfunction Abstract Text: Introduction: Amiodarone is a class III antiarrhythmic agent that is widely used to treat ventricular and supraventricular tachycardias. Several side-effects of the drug have been recognized including thyroid dysfunction, photosensitivity, hepatotoxicity, parenchymal lung disease, corneal deposits, and peripheral neuropathy. Cerebellar dysfunction is rarely seen in patients receiving amiodarone. We are reporting a rare case of amiodarone-induced cerebellar dysfunction that resolved completely upon discontinuation of the drug. Case Presentation: A 73-year-old man with a past medical history significant for paroxysmal atrial fibrillation, coronary artery disease, diabetes and hypertension who presented with worsening lower extremity weakness and unsteady gait with recurrent falls for the last 6 months. Two days prior to admission, his symptoms got worse and caused him to seek medical attention. Two years ago he was started and maintained on amiodarone 200 mg daily for rhythm control. On physical examination, vital signs were normal. A wide-based unsteady gait was noted. He had dysmetria bilaterally on finger-to-nose and heel-to-shin testing. The rapid alternating movements of the hands were irregular. The remainder of the general and neurologic examinations were unremarkable. His laboratory data revealed mild chronic transaminitis, but otherwise normal. His electrocardiogram demonstrated normal sinus rhythm with no acute changes. His brain magnetic resonance imaging was negative for acute or chronic pathology. Reviewing his medications did not reveal any neurotoxicity as a side effect except for amidarone; hence, amiodarone was discontinued. Four days later, his ataxia significantly improved and he was discharged home. Six weeks later, all his neurological symptoms had resolved. Discussion: Amiodarone is a thyroxine-like agent that is derived from benzofuran and is commonly prescribed for arrhythmia control. It blocks the potassium channels, causing slow repolarization and prolonged action potential (refractory period). Amiodarone has sodium- and calcium-blocking activities in addition to some alpha- and beta-blocking effect. It has a very long elimination half-life of several (up to 6) months. Despite its efficacy, approximately 50% of patients receiving the drug suffer more than mild adverse events and 10-15% discontinue the drug due to intolerance. Amiodarone-induced neurotoxicity develops in 3-30% of patients and mainly involves the peripheral nervous system to cause sensorimotor neuropathy. Although amiodarone crosses the blood brain barrier, involvement of the central nervous system is rarely encountered and may include cerebellar ataxia. The pathogenesis of cerebellar injury remains unknown. Rapid resolution of cerebellar symptoms is common (within few days of discontinuation), and complete recovery is to be expected within few months. Cerebellar dysfunction is an uncommon manifestation of amiodarone-induced neurotoxicity. Elderly patients are at high risk of developing amiodarone-induced cerebellar dysfunction and should receive the lowest possible dose to control their arrhythmia. Adjei, Naomi Last Name: Adjei First Author: Medical Student First Name: Naomi Category: Research PG Year: or MS Year: MS-2 ACP Number: 2209413 Medical School or Residency Program: Warren Alpert Medical School of Brown University Hospital Affiliation: Additional Authors: Naomi Adjei, Dorothy Liu*, Kunal Sindhu*, Michael Yacovelli*, Vinay Rao, and Susanna Magee, MD (* th Abstract Title: Changing the face of sex education in Rhode Island Abstract Text: Introduction: Despite progress in recent years, the teenage pregnancy rate in the United States remains the highest in the industrialized world: in 2011, there were 31.3 births per 1000 women aged 15-19 nationwide. This often reported figure, however, masks vast regional disparities. For example, while the states of New England possess some of the lowest teenage pregnancy rates in the country, Rhode Island has historically lagged behind its neighbors. In fact, in the state’s most affected city, Central Falls, the teenage pregnancy rate is nearly three times higher than the national average. While the consequences of early and risky sexual activity can be devastating, a large proportion of sexually active teenagers are not informed of the risks of their behavior. Of the women aged 15-19 who gave birth nationwide in 2011, for example, nearly half were not using any form of birth control when they conceived; within this group, 31% did not believe that they could get pregnant at the time.1 These shocking figures justify the need for immediate intervention. Methods: Previous work has shown that early and comprehensive sexual health education is effective in promoting healthy sexual decision making among adolescents. With this in mind, five medical students from The Warren Alpert School of Medicine at Brown University founded Sex Ed by Brown Med with the express aims of improving adolescents’ knowledge of and influencing their attitudes towards sexual health. With assistance from the Rhode Island Department of Health and the Board of the Central Falls School District, 41 first- and second-year medical students volunteered to teach seven lessons to 168 8th grade students at a middle school in Central Falls in the fall of 2014. Results: To assess baseline knowledge and knowledge acquisition, the middle school students were administered a 17-question, mixed format assessment both before and after the lessons were delivered. Over the course of the semester, the students’ average assessment score rose from 68.3% to 78.1%, a difference that was statistically significant (p<0.001). In addition, the students also scored significantly better in both the sexual health and reproductive anatomy sections of the post-assessment (76.3% vs 66.7%, p<0.001 and 91.1% vs 80.1%, p<0.01). Conclusion: While the students enrolled in our course demonstrated statistically significant improvements in sexual health knowledge, we recognize that our mission to eradicate teenage pregnancy in Rhode Island is by no means accomplished. However, we have established a nascent educational infrastructure that we hope to build upon going forward. For the upcoming semester, we have expanded our program to include seventh grade students and will seek to broaden our impact in the years to come. Afari, Maxwell Last Name: Afari First Author: Resident First Name: Maxwell Category: Research PG Year: PGY-3 or MS Year: ACP Number: 1706139 Medical School or Residency Program: Alpert Medical School of Brown University Hospital Affiliation: Memorial Hospital of Rhode Island Additional Authors: Hammad Shafqat, Muhammad Shafi, Fady Marmoush, Taro Minami Abstract Title: Hypertriglyceridemia Induced Pancreatitis: A Decade of Experience In A Community- Based Teaching Hospital Abstract Text: Background: Hypertriglyceridemia is the third most common cause of acute pancreatitis. The current evidence on the management of hypertriglyceridemia induced pancreatitis (HIP) is mainly derived from case series suggesting an adjunctive role for insulin, heparin, and plasmapheresis in addition to the conventional therapies (statins and fibrates). We present a retrospective review of patients seen at the Memorial Hospital of Rhode Island from 2005 to 2015. Methods: Patients aged 18 years or greater, with clinical diagnosis of acute pancreatitis and serum triglyceride >1000mg/dL were included in this study. The following data were collected: patients’ demographics, clinical presentation, laboratory, treatment method, length of hospital stay, and complications. This study was given an exempt status by the local Institutional Review Board. Results: Out of the 549 admissions for acute pancreatitis, only 14 patients met our inclusion criteria. The mean age was 39± 8 years and there were more men (57%) than women (43%). More than two- thirds of the patients were admitted to the Intensive Care Unit. Majority of the patients were treated with insulin drip (n=8), and the rest by subcutaneous insulin (n=3) and insulin drip+ plasmapheresis (n=3). In the insulin drip group we noted a gradual decrease of the admission serum triglycerides by 50.6 ±16.0 % (at 24hours), 65.9±16.9% (at 48 hours) and 85.2± 7.1% at discharge. At the time of discharge, the triglyceride had decreased by 79.8% and 92.6 % in the subcutaneous insulin and insulin+plasmapheresis cohorts respectively. Patients treated with insulin+Plasmapheresis stayed longer in the hospital (20.7±3.1 days) compared to those on insulin drip (10.3±5.4 days) and subcutaneous insulin (5.7 ± 1.2 days). No mortality was recorded in this review. While there were no complications in subcutaneous insulin group, two- thirds of the Insulin+plasmapheresis group and half of the insulin drip cohort had complications such as small bowel obstruction, spontaneous bacterial peritonitis, and respiratory failure. Discussion: The mechanism of HIP is through the stimulation of pancreatic lipase in the presence of excess triglycerides.
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