A Rare Case of Acquired Factor VIII Inhibition in an Elderly Female.

Acquired hemophilia A is a rare condition characterized by the development of autoantibodies against coagulation factor VIII. It often initially presents as serious bleeding in the absence of risk factors and carries high morbidity and mortality if not diagnosed early. Due to its rare nature, data is limited, and guidelines are primarily based on expert opinion. Here we present a case of an elderly patient with severe gastrointestinal bleeding found to have activated partial thromboplastin times, plasma mixing studies, and coagulation factor activity levels consistent with acquired hemophilia A. We hope to bring awareness of this rare disease and promote its consideration in the differential of unexpected bleeding to improve safety outcomes.

A Rare Case of Junctional Bradycardia Secondary to Oral Phenytoin.

Phenytoin is a commonly used anti-seizure agent, which stabilizes neuronal membranes by blocking voltage-gated sodium channels to inhibit the propagation of action potentials during convulsions. However, phenytoin has also been shown to have antiarrhythmic effects as it can prolong the effective refractory period of ventricular pacemaker cells. Adverse cardiac effects such as junctional bradycardia are usually seen with intravenous use. Cardiovascular dysfunction is not well recognized in oral phenytoin toxicity. Here we present a case of junctional bradycardia due to oral phenytoin toxicity, which resolved spontaneously with the discontinuation of phenytoin. This case report will serve to increase awareness of the adverse cardiovascular effects of oral phenytoin toxicity to improve the recognition and treatment of these adverse effects.

How High Can You Get: A Case Report of an Unusual Cause of Ascending Paralysis.

Secondary hyperkalemic paralysis is a life-threatening manifestation of hyperkalemia seen with a potassium level of 7 or above 7 milliequivalents per liter (Meq/L) in an acute or chronic state. Standard hyperkalemic treatment should be initiated upon diagnosis with emergency dialysis in refractory cases. Here we present the case of a patient with end-stage renal disease (ESRD) compliant with dialysis three times a week. The patient presented with generalized ascending flaccid paralysis and was found to have serum potassium of 9.6 Meq/L. Spontaneous resolution of the paralysis was observed shortly after the completion of one hemodialysis session. The goal of this case report is to raise awareness of a life-threatening complication of electrolyte imbalances in ESRD even in patients that are compliant with dialysis.

A Novel Team-Based Learning Approach for an Internal Medicine Residency: Medication-Assisted Treatments for Substance Use Disorders.

Introduction: It is estimated that approximately one-tenth of the US population suffers from substance use disorders (SUD), a problem that is compounded when one considers the impact that drug addiction could have on treatment outcomes for many other chronic diseases. Thus, addiction medicine has become an important component of many successful urban primary care practices and residencies across the country. Our program sought to improve the confidence of our residents in managing SUD by instituting a team-based learning (TBL) activity that focused on the diagnosis and medication-assisted treatment of these illnesses. Methods: The class of 80 internal medicine residents were divided into groups of approximately 16 residents, and during the TBL sessions further divided into teams of three to four. Each TBL session consisted of an individual readiness assurance test, a group discussion of the correct answers, and a PowerPoint-based team application activity. Surveys were conducted for each group to assess the residents' attitudes after completing the activity. Results: Of residents, 69 of 80 completed the survey. The response to the TBL exercise was overwhelmingly positive, with most residents in agreement that the activity increased their knowledge and confidence in diagnosing and treating patients with SUD. Discussion: Overall, this TBL activity was well received by the residents and subjectively increased their competence in managing patients with SUD. In addition, our modification to the traditional TBL format suggested that the theories and spirit behind TBL can be successfully adapted to meet the challenges and intricacies of internal medicine residency education.

Phospholipase D mediates nutrient input to mammalian target of rapamycin complex 1 (mTORC1).

The mammalian target of rapamycin (mTOR) is a critical sensor of nutritional sufficiency. Although much is known about the regulation of mTOR in response to growth factors, much less is known about the regulation of mTOR in response to nutrients. Amino acids have no impact on the signals that regulate Rheb, a GTPase required for the activation of mTOR complex 1 (mTORC1). Phospholipase D (PLD) generates a metabolite, phosphatidic acid, that facilitates association between mTOR and the mTORC1 co-factor Raptor. We report here that elevated PLD activity in human cancer cells is dependent on both amino acids and glucose and that amino acid- and glucose-induced increases in mTORC1 activity are dependent on PLD. Amino acid- and glucose-induced PLD and mTORC1 activity were also dependent on the GTPases RalA and ARF6 and the type III phosphatidylinositol-3-kinase hVps34. Thus, a key stimulatory event for mTORC1 activation in response to nutrients is the generation of phosphatidic acid by PLD.