Mina Aknouk’s research while affiliated with Hackensack University Medical Center and other places

Oxaliplatin is widely used in chemotherapeutic regimens for colorectal carcinoma, its recurrence, and metastasis, and is associated with better outcomes. However, oxaliplatin use is associated with injury to hepatic sinusoidal endothelium and the development of nodular regenerative hyperplasia (NRH) in the liver, which can be differentiated from nodular hyperplasia of cirrhosis by the presence of diffuse micronodular transformation without a fibrous band and the lack of perinuclear collagen tissue. This causes non-cirrhotic portal hypertension (NCPH), which presents with splenomegaly and variceal bleeding and preserved synthetic liver function. Its treatment revolves around managing variceal bleeding with banding, sclerotherapy, and beta blockers. Some patients may end up requiring liver transplantation because of recurrent variceal bleeding. We present the case of a 46 years old female who presented with recurrent variceal bleeding due to NCPH and NRH six years after treatment of colon carcinoma with oxaliplatin.

Granulomatosis with polyangiitis (GPA), earlier known as Wegener's granulomatosis, is an autoimmune inflammatory disorder that causes necrotizing vasculitis of small- and medium-sized blood vessels. It primarily affects the upper respiratory tract, lungs, and kidneys. Most of the cardiac involvement tends to be subclinical and is often not clinically apparent with involvement of the conduction pathway; myocarditis, pericarditis, or coronary artery involvement are associated with increased morbidity and mortality. These present with the symptoms of shortness of breath, cough, bilateral pedal edema, orthopnea, syncope, and features of heart failure such as elevated jugular venous pressure. We report a rare case of heart involvement with profound valvular deformity involving all four cardiac valves along with renal impairment in a 76-year-old female with recently diagnosed granulomatosis with polyangiitis.

Background: Lower gastrointestinal bleeds (LGIB) is a very common inpatient condition in the United States. Gastrointestinal bleeds have a variety of presentations, from minor bleeding to severe hemorrhage and shock. Although previous studies investigated the efficacy of colonoscopy in hospitalized patients with LGIB, there is limited research that discusses disparities in colonoscopy utilization in patients with LGIB in urban and rural settings. Aim: To investigate the difference in utilization of colonoscopy in lower gastrointestinal bleeding between patients hospitalized in urban and rural hospitals. Methods: This is a retrospective cohort study of 157748 patients using National Inpatient Sample data and the Healthcare Cost and Utilization Project provided by the Agency for Healthcare Research and Quality. It includes patients 18 years and older hospitalized with LGIB admitted between 2010 and 2016. This study does not differentiate between acute and chronic LGIB and both are included in this study. The primary outcome measure of this study was the utilization of colonoscopy among patients in rural and urban hospitals admitted for lower gastrointestinal bleeds; the secondary outcome measures were in-hospital mortality, length of stay, and costs involved in those receiving colonoscopy for LGIB. Statistical analyses were all performed using STATA software. Logistic regression was used to analyze the utilization of colonoscopy and mortality, and a generalized linear model was used to analyze the length of stay and cost. Results: Our study found that 37.9% of LGIB patients at rural hospitals compared to approximately 45.1% at urban hospitals received colonoscopy, (OR = 0.730, 95%CI: 0.705-0.7, P > 0.0001). After controlling for covariates, colonoscopies were found to have a protective association with lower in-hospital mortality (OR = 0.498, 95%CI: 0.446-0.557, P < 0.0001), but a longer length of stay by 0.72 d (95%CI: 0.677-0.759 d, P < 0.0001) and approximately $2199 in increased costs. Conclusion: Although there was a lower percentage of LGIB patients that received colonoscopies in rural hospitals compared to urban hospitals, patients in both urban and rural hospitals with LGIB undergoing colonoscopy had decreased in-hospital mortality. In both settings, benefit came at a cost of extended stay, and higher total costs.

Myocarditis is associated with a wide range of infections, most commonly viral (cytomegalovirus), bacterial, and parasitic (Trypanosoma cruzi). Epstein-Barr virus (EBV) rarely causes myocarditis, which is a life-threatening complication. Autoantibodies against cardiac myocytes activate the complement system and cause diffuse myocyte necrosis. Myocarditis has a variable presentation from asymptomatic to cardiogenic shock. Over time, untreated myocarditis can progress and result in dilated ventricles. Continued dilation of ventricles leads to systolic dysfunction, conduction abnormalities, ventricular arrhythmia, heart failure, valvular abnormalities, and thromboembolism. So, we are emphasizing the importance of early diagnosis and treatment of EBV to prevent mortality. This case study represents a rare case of mortality secondary to EBV infection with resultant DCM and congestive heart failure (CHF).

Kratom is a psychoactive herb that has been gaining widespread popularity due to its ease of availability and opiate-like effects. While it has been used beneficially as a method of weaning off opiate addictions, it does have a host of toxic effects when misused or abused. There has been a wide spectrum of negative effects including renal failure, liver failure, and cardiac toxicity. While some adverse effects have been reversed with medical intervention, others left more of a detrimental long-term impact not amenable to even the most invasive therapies. We present the case of a patient who was admitted to the intensive care unit after presenting with unresponsiveness secondary to a cerebrovascular accident, rhabdomyolysis, and renal failure. The patient had begun using kratom, initially for recreational purposes, and later escalating it to abusive doses. The patient survived the episode after suffering many complications including transient reversible nonischemic cardiomyopathy and was discharged in a neurologically stable state; however, he ended up being hemodialysis-dependent at such an early age. Rhabdomyolysis is a rare complication of this herb that has not been well documented.

Licorice has been around for centuries and has been commercialized in the food, tobacco, and healthcare industry. Historically, its therapeutic benefits have been reaped in countless ways, including as a thirst sensation suppressor in battlefields, flavoring agent in medicinal preparations, antacid for gastric discomfort and peptic ulcers, and even as an estrogenic agent in postmenopausal women. Licorice and its derivatives are recognized safe by the US Food and Drug Administration (FDA). Though FDA recognized the licorice to be a food additive in certain concentrations, it has issued warnings against its use in at-risk group and in larger amount. However, it is a lesser known fact that glycyrrhizic acid, the active component in licorice, can cause a metabolic syndrome presenting as pseudohyperaldosteronism. Chronic consumption leads to the development of hypertension, metabolic alkalosis, and hypokalemia. We present a patient who developed a sinus pause on telemetry and subsequent syncope after presenting for evaluation of hypertension and hypokalemia. The patient had been ingesting a significant quantity of deglycyrrhizinated licorice for many years to alleviate postprandial epigastric pain. Although seemingly benign electrolyte disturbance, it is crucial to recognize that chronic consumption of licorice without strict regulation can lead to supraventricular and ventricular ectopics and tachyarrhythmias with the potential to develop life-threatening arrhythmias including ventricular tachycardia, ventricular fibrillation, and Torsades de Pointes.