Acute Worsening Research Articles

Modeling ventilation of patients with interstitial lung disease at rest and exercise: a bench study.

The ventilatory physiopathology of patients with interstitial lung disease (ILD) remains poorly understood. We aimed to personalize a mechanical simulator to model healthy and ILD profiles ventilation, and to evaluate the effect of spontaneous breathing on respiratory mechanics at rest and during exercise. In a 2-compartment lung simulator (ASL 5000®), we modeled 1 healthy and 3 ILD profiles, at rest and during exercise, based on physiological data from literature and patients. Measurements were: tidal volume, end-expiratory lung volume, driving pressure, transpulmonary driving pressure, dynamic alveolar strain, mechanical power, and time lag of inspiratory flow between compartments 1 and 2. Healthy and ILD models were validated: maximum differences between real and simulated tidal volume were 5% (96ml) and 6% (54ml) at rest and during exercise respectively, considered clinically negligible. When we simulated lung inhomogeneity (compliance in compartment 1 > compartment 2), tidal volume, end-expiratory lung volume, driving pressure and mechanical power increased in compartment 1 and decreased in compartment 2. Driving transpulmonary pressure and dynamic alveolar strain increased in compartment 2 and decreased in compartment 1. Time lag of inspiratory flow between compartments 1 and 2 was positively correlated with a difference of compliance between compartments (r = 0.98, CI95% (0.9106; 0.9962), p < 0.0001). In this bench study, we personalized a mechanical simulator thatmodels the lung inhomogeneity and spontaneous breathing of healthy subjects and ILD patients at rest and during exercise. Our results suggest that lung inhomogeneity could increase lung vulnerability to volo-atelec-trauma mechanisms in ILD. Further physiological studies are needed to evaluate the impact of this vulnerability on acute or chronic ILD worsening.

VS 01 - BN Chronic loop gastrojejunostomy volvulus masquerading as a Crohn’s stricture

Abstract Background A video presentation of a case of chronic loop gastrojejunostomy volvulus masquerading as a Crohn's stricture. Method 61 year old female with a previous loop gastrojejunostomy and subsequent ileocaecal resection for Crohn's related pyloric stenosis and terminal ileal stricture. Acute worsening of post-prandial pain and vomiting 5 years later, re-investigation revealed a stenosed gastrojejunostomy thought to be Crohn's related. Results Intraoperative volvulus of the gastrojejunostomy was demonstrated related to traction forces resulting in the migration of the duodeno-jejunal flexure to the right of midline. The gastrojejunostomy was revised to a Roux-en-Y configuration with relief of mechanical obstruction. Conclusion An ileocaecal resection may create unexpected traction forces

Anemia and sideropenia in patients with decompensated heart failure

Abstract Introduction Anemia is highly prevalent in patients with heart failure (HF). In the latest ESC guidelines, intravenous. iron supplementation is recognized as substantial for improving quality of life, exercise capacity and reducing the risk of future hospitalizations in patients diagnosed with HF of reduced ejection fraction (HFrEF). We hypothesized that patients diagnosed with HF of preserved EF (HFpEF) and midly reduced EF (HFmrEF), who also exhibit iron deficiency, may benefit from intravenous iron supplementation. Method We evaluated the prevalence and parameters of anemia from medical histories of hospitalized patients with HFrEF and HFmrEF/HFpEF, from March 2023 to January 2024, and compared them to NTproBNP levels. Results We included 134 hospitalized patients with HF, mean age 71 ± 10 (41% women). Of total 134, 77 patients exhibited acute worsening of chronic HFrEF or were newly diagnosed HFrEF (group A), whereas 57/134 patients had decompensated HFmrEF/HFpEF (11 and 46, respectively - group B) whose iron status was analyzed on admission. General prevalence of anemia in all HF patients was 50.8% (cut off value - hemoglobin concentration less than 12 g/dL in women, and less than 13 g/dL in men), 54.4% of HFpEF/HFmrEF group and 48.1% of HFrEF group had anemia, 46.6% patients with anemia had EF&amp;gt;40%, without any statistical difference among groups (hemoglobin concentration group A/group B – 12.33±2.54/11.89­±2.63 g/dL, CV 0.2). Reduced transferrin saturation, which is defined as less than 20.0%, had 44.0% of all HF patients, and that was more common in HFrEF patients (62.0%), but statistically insignificant (group A/group B - 0.1843±0.10/0.1877±0.11, CV 0.6). Among group A and group B - 63.6% and 62.5% had transferrin saturation less than 0.2, respectively. There was no difference in the prevalence of serum ferritin &amp;lt;100 μg/L in group A and B (41.6% and 47.4% respectively; group A/group B – 177.26±176.7/137.01±126.6, CV 0.9). Spearman’s rank test implied no correlation between NTproBNP levels and serum ferritin or transferrin saturation. Serum iron had a mild negative (coefficient -2.8) correlation with NTproBNP levels (p&amp;lt;0.01). Hemoglobin concentration was associated with strong negative correlation with NTproBNP levels but with less statistical significance (coefficient -0.9 p&amp;lt;0.05). Conclusion Results of our study suggest that anemia and sideropenia are common in our HF population, with no difference between the spectrum of HF subgroups based on EF. There seems to be a correlation between anemia and serum iron and level of NTproBNP which may imply that anemia and low iron worsen the degree of HF decompensation.

The Role of Viral Infections in the Development and Progression of COPD.

Chronic obstructive pulmonary disease (COPD) is a common chronic disease seen in smokers associated with poor functional status, quality of life, and morbidity and mortality from acute worsening of chronic symptoms, also called exacerbations. As a disease, the risk factors for COPD are well defined; however, there is room for innovation in identifying underlying biological processes, or "endotypes," that lead to the emergence and/or progression of COPD. Identifying endotypes allows for more thorough understanding of the disease, may reveal the means of disease prevention, and may be leveraged in novel therapeutic approaches. In this review, we discuss the interface of viral infections with both cellular and epithelial immunity as a potential endotype of interest in COPD.

Diagnostic and Therapeutic Approach to the Major Secondary Causes of Arterial Hypertension in Young Adults: A Narrative Review

Arterial hypertension in young adults, which includes patients between 19 and 40 years of age, has been increasing in recent years and is associated with a significantly higher risk of target organ damage and short-term mortality. It has been reported that up to 10% of these cases are due to a potentially reversible secondary cause, mainly of endocrine (primary aldosteronism, Cushing’s syndrome, and pheochromocytoma/paraganglioma), renal (renovascular hypertension due to fibromuscular dysplasia and renal parenchymal disease), or cardiac (coarctation of the aorta) origin. It is recommended to rule out a secondary cause of high blood pressure (BP) in those patients with early onset of grade 2 or 3 hypertension, acute worsening of previously controlled hypertension, resistant hypertension, hypertensive emergency, severe target organ damage disproportionate to the grade of hypertension, or in the face of clinical or biochemical characteristics suggestive of a secondary cause of hypertension. The 2023 Guideline of the European Society of Hypertension recommends starting pharmacological therapy from grade 1 hypertension (BP ≥140/90 mm Hg), with the aim of achieving BP control of less than 130/80 mm Hg. It is important to highlight that the prevalence of secondary hypertension in these patients could be underestimated, given that there is little evidence available on the management of high BP in young adults, which is why we developed this narrative review on the diagnostic and therapeutic approach to the major secondary causes of arterial hypertension in young adults.

12355 An Adolescent Female With Congenital Lipodystrophy Presenting With Repeated Acute Metabolic Decompensations Rescued By A Novel Leptin Receptor Agonist

Abstract Disclosure: D.M. Chambers: None. Y. Chan: None. M.K. Crocker: None. Patient SH is a now 17-year-old female treated for generalized congenital lipodystrophy with a course complicated by severe hypertriglyceridemia, type 2 diabetes mellitus, hypertension, hepatosteatosis, and intermittent menstrual irregularity. She had been managed successfully with metreleptin for 2 years, but in 2022-2023, she developed repeated episodes of pancreatitis (4 times over a 14-month period) secondary to severe hypertriglyceridemia (serum triglycerides &amp;gt;8000 mg/dL). During her admissions, she had markedly increased insulin requirements (up to 12 units/kg/day) with refractory hyperglycemia despite maximal treatment with metreleptin, empagliflozin, and oral semaglutide. In the clinical context of her acute metabolic worsening, she was suspected of having a neutralizing antibody against metreleptin. Serum leptin was undetectable 1 hour after observed metreleptin doses; direct measurement of neutralizing antibodies is pending. She was transitioned from metreleptin to mibavademab, an investigational leptin receptor agonist, on an expanded use IND. She subsequently experienced significant improvements in her fasting triglyceride levels (&amp;lt;300 mg/dL) with no subsequent episodes of pancreatitis since starting therapy in August 2023. She has also had improvements in other aspects of her metabolic health including decreased insulin requirements with decreasing hemoglobin A1c, decreased need for adjunctive lipid and hypertension therapy, and improving menstrual regularity. Her clinical course demonstrates: 1) clinical indicators of a rare but serious loss of efficacy of metreleptin therapy; 2) adjunctive options for management of generalized lipodystrophy; and, 3) an individual experience with a novel leptin agonist therapy in the treatment of generalized lipodystrophy. Presentation: 6/3/2024

Posterior interosseous nerve lesion due to lipoma. Review of the literature and rare case presentation.

Posterior interosseous nerve lesion is a rare mononeuropathy of the upper limb. Atraumatic posterior interosseous nerve lesions are commonly caused by lipomas of the forearm, manifesting as slow-progressing wrist and finger drop. In this review and case report study, we present a systematic review of the literature for patients presenting with posterior interosseous palsy due to lipomas and a rare case of patient with acute posterior interosseous nerve lesion caused by a lipoma. Our primary interest was in the timing of clinical presentation. For the review process, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. After reviewing the literature, we identified thirty patients with posterior interosseous nerve lesions caused by lipomas. In 28 patients, the symptoms presented progressively, ranging from 1 month to a maximum of 240 months. We found only one case of a patient with acute presentation and another patient with acute worsening of chronic weakness due to trauma. Atraumatic posterior interosseous nerve lesions are frequently secondary to forearm lipomas. In the majority of cases, the symptoms will develope progressively. However, in this study, we also report a rare case of a patient presenting with acute posterior interosseous nerve lesion due to a lipoma.

The natural course of an iridoschisis: A case report.

Iridoschisis is a rare ophthalmological disorder that presents with the separation of the anterior fibers of the iris from the posterior ones at the level of the stromal layer. Fibers resulting from the disintegration of the anterior iris layers can be encountered in the anterior chamber of the affected eyes. This condition mostly affects females and has been associated with both open-angle and angle-closure glaucoma. The pathogenesis has not been clarified yet, and the treatment is still a matter of discussion. We want to contribute to the understanding of the pathogenesis and natural course of the disease as well as to document with multimodal imaging a new case of this very rare disease. We present a case of a 71-year-old woman affected by iridoschisis in both eyes followed by 3 consecutive visits every 4 months. We performed an extensive ophthalmologic examination, including gonioscopy, endothelial cell microscopy, and optical coherence tomography of the anterior segment. In our report, we documented a possible natural course of iridoschisis, characterized by an acute worsening followed by a phase of stability, and formulated some hypotheses on the pathogenesis of this rare disease.

Acute decompensation and acute-on-chronic liver failure

Acute decompensation is defined as the development of ascites, bleeding due to portal hypertension, jaundice, or hepatic encephalopathy in the presence of known or unknown chronic liver disease. Acute-on-chronic liver disease is defined as a clinical entity reflecting acute worsening in liver function along with extrahepatic organ failure with significantly higher 28-day mortality. In the common pathogenesis, severe systemic inflammation and portal hypertension and varying degrees of reaction to these conditions play a major role. Triggering factors act as accelerators in the development of acute decompensation and acute-on-chronic liver failure. The extrahepatic organ failure in acute-on-chronic liver failure is mainly due to tissue hypoxia due to decreased perfusion and cellular edema. The number of organ failure in acute-on-chronic liver failure is considered to be the most important prognostic indicator. Liver transplantation remains the most appropriate treatment option for selected patients, even though supportive therapies based on the severity of the disease and the clinical findings that have developed are at the forefront.

Paraneoplastic glomerulonephritis and kidney infiltration by mantle cell lymphoma: A diagnostic challenge.

Mantle cell lymphoma (MCL) is a rare and aggressive type of lymphoma that can affect the kidneys. The disease can lead to kidney impairment, and glomerulonephritis (GN) is a rare but serious complication of MCL. We report a case of MCL with kidney interstitial infiltration and membranoproliferative glomerulonephritis with focal and segmental glomerulosclerosis. A 75-year-old man presented recurrent acute kidney failure and worsening of nephrotic syndrome. Kidney biopsy revealed membranoproliferative glomerulonephritis presented immunoglobulin and complement deposition, focal and segmental glomerulosclerosis of not otherwise specified type, and infiltration by mantle cell lymphoma. Bone marrow biopsy and PET/CT scan confirmed the diagnosis of mantle cell lymphoma. The patient was treated with R-CHOP21 chemotherapy with cyclophosphamide dose adjustment for nephroprotection. He achieved complete remission with normalization of hematological parameters, improvement of kidney function, and reduction of proteinuria and albuminuria. This case shows the importance of considering alternative diagnoses in patients with recurrent chronic kidney disease and worsening nephrotic syndrome. Early diagnosis and treatment of mantle cell lymphoma can lead to favorable outcomes.

Reversible Increased Anxiety Following Left-Sided Stellate Ganglion Block to Treat Posttraumatic Stress Disorder: A Case Report.

Describe a 2-patient case report of a rare occurrence of significantly increased anxiety after a left-sided stellate ganglion block (SGB) and the subsequent improvement of that anxiety through a right-sided SGB. Right-sided SGB to treat post-traumatic stress disorder (PTSD) has over 23 supporting publications in the peer-reviewed medical literature, including level 1 evidence. A published case series of 285 patients showed that two-level SGB may improve anxiety-related symptoms in patients. However, a recently published study indicates that some patients only respond to a left-sided SGB. The patients had an ultrasound-guided right-sided SGB for the treatment of PTSD and experienced a reduction in anxiety symptoms based on Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) scores. Later, a left-sided SGB was performed. Clinically, the addition of a left-sided SGB is typically associated with further anxiety reduction, but in these 2 cases, the patients had a significant reversal of the improvements experienced after a right-sided SGB. Following this unusual response to a left-sided SGB, these patients were offered another right-sided SGB, after which, they experienced a significant and durable improvement in anxiety symptoms beyond the original baseline PCL-score. In rare cases and for unknown reasons, a left-sided SGB may result in acute worsening of anxiety symptoms, which can be addressed and significantly improved with the application of a subsequent right-sided SGB.

Expert consensus on the diagnosis and treatment of respiratory diseases exacerbated by nonsteroidal anti-inflammatory drugs （2024, Chengdu）

Non-steroidal anti-inflammatory drugs-exacerbated respiratory disease （N-ERD） is a chronic respiratory disease characterized by eosinophilic inflammation, featuring chronic rhinosinusitis （CRS）, asthma, and intolerance to cyclooxygenase 1 （COX-1） inhibitors. The use of these medications can lead to an acute worsening of rhinitis and asthma symptoms. This condition has not yet received sufficient attention in China, with a high rate of misdiagnosis and a lack of related research. The Chinese Rhinology Research Group convened a group of leading young experts in otolaryngology from across the country, based on the latest domestic and international evidence-based medical practices to formulate this consensus.The consensus covers the epidemiology, pathogenesis, clinical manifestations, diagnostic methods, and treatment strategies for N-ERD, including pharmacotherapy, surgery, biologic treatments, and desensitization therapy. The goal is to improve recognition of N-ERD, reduce misdiagnosis, and enhance treatment outcomes.

Nebulised interferon beta-1a (SNG001) in the treatment of viral exacerbations of COPD

BackgroundRespiratory viral infections are major drivers of chronic obstructive pulmonary disease (COPD) exacerbations. Interferon-β is naturally produced in response to viral infection, limiting replication. This exploratory study aimed to demonstrate proof-of-mechanism, and evaluate the efficacy and safety of inhaled recombinant interferon-β1a (SNG001) in COPD. Part 1 assessed the effects of SNG001 on induced sputum antiviral interferon-stimulated gene expression, sputum differential cell count, and respiratory function. Part 2 compared SNG001 and placebo on clinical efficacy, sputum and serum biomarkers, and viral clearance.MethodsIn Part 1, patients (N = 13) with stable COPD were randomised 4:1 to SNG001 or placebo once-daily for three days. In Part 2, patients (N = 109) with worsening symptoms and a positive respiratory viral test were randomised 1:1 to SNG001 or placebo once-daily for 14 days in two Groups: A (no moderate exacerbation); B (moderate COPD exacerbation [i.e., acute worsening of respiratory symptoms treated with antibiotics and/or oral corticosteroids]).ResultsIn Part 1, SNG001 upregulated sputum interferon gene expression. In Part 2, there were minimal SNG001–placebo differences in the efficacy endpoints; however, whereas gene expression was initially upregulated by viral infection, then declined on placebo, levels were maintained with SNG001. Furthermore, the proportion of patients with detectable rhinovirus (the most common virus) on Day 7 was lower with SNG001. In Group B, serum C-reactive protein and the proportion of patients with purulent sputum increased with placebo (suggesting bacterial infection), but not with SNG001. The overall adverse event incidence was similar with both treatments.ConclusionsOverall, SNG001 was well-tolerated in patients with COPD, and upregulated lung antiviral defences to accelerate viral clearance. These findings warrant further investigation in a larger study.Trial registrationEU clinical trials register (2017-003679-75), 6 October 2017.

#234 Clinical spectrum and genetic variants of Alport syndrome and thin basement membrane nephropathy—single center experience

Abstract Background and aims Alport syndrome (AS) and thin basement membrane nephropathy (TBMN) are genetically heterogeneous kidney diseases that manifest with kidney involvement, AS also with hearing and visual impairment. Electron microscopic examination shows characteristic ultrastructural changes in the glomerular basement membrane (GBM) in AS and TBMN, but cannot reliably distinguish between the two entities. Therefore, molecular genetic studies and the identification of individual pathogenic variants in the target genes are crucial to confirm the diagnosis. The aim of our study is to determine the significance of the genetic variants associated with the ultrastructural changes of GBM found in the renal biopsy. Method We retrospectively analyzed records of patients from the University Medical Centre Ljubljana in which ultrastructural GBM changes characteristic for AS and TBMN were found in the renal biopsy, including their clinical, laboratory and histological features. Molecular genetic investigations were made using the new generation sequencing method (NGS) to determine germline pathogenic variants in genes directly related to AS and TBMN (COL4A3, COL4A4 and COL4A5) and in genes that are important in syndromes with a related clinical picture (COL4A6, CD151, LMX1B, MYH9, FN1 and MYO1E). The pathogenicity of variants was determined according to the Clinical Molecular Genetic Society best practice guidelines. Results The study included 73 patients with ultrastructurally confirmed thin GBM. Indications for kidney biopsy were chronic nephritis syndrome in 33 patients (45%), acute worsening of renal function in 16 (22%), nephrotic syndrome in 9 (12%), nephrotic proteinuria and chronic kidney disease in 6 (8%), isolated proteinuria in 5 (7%) and suspected vasculitis in 4 patients (6%). At the time of kidney biopsy average age was 50 ± 16 years, average creatinine 112 ± 70 µmol/L and average estimated glomerular filtration rate (eGFR) 65 ± 24 ml/min/1.73 m2, 7 patients had eGFR below 30 ml/min/1.73 m2. Average daily proteinuria was 2.4 ± 3.3 gr and 88% of patients had hematuria. 38% of them have hearing impairment and 43% had positive familiar history of kidney disease. We recorded 33 patients (45%) with genetic variants associated with AS or TBMN: 22 patients (67%) with pathogenic variants, 2 patients (6%) with likely pathogenic and 9 patients (27%) with variants of uncertain significance. The presence of a positive genetic analysis was associated with a higher level of hematuria (p = 0.003), a lower level of proteinuria (p = 0.004) and a positive family history of kidney disease (p &amp;lt; 0.001). It was also associated with hearing loss, but the association was not statistically significant (p = 0.099). Patients with genetic variants had similar eGFR to those with negative genetics (63.9 ml/min/1.73 m2 (58.3-69.4) vs 66.2 ml/min/1.73 m2 (60.0-72.3)), p = 0.698. We also found no differences in GBM thickness in patients without compared to those with identified gene variants (213 nm (160-315) vs. 209 nm (140-410)), p = 0.761. 32 patients (44%) had only focal chronic changes and ultrastructural changes of thin GBM present on kidney biopsy and 41 patients (56%) had also been diagnosed with other renal pathology. When comparing these two groups, patients without associated pathology had lower daily proteinuria (p = 0.048), higher level of hematuria (p = 0.021), frequent hearing impairment (p = 0.008) and also positive genetics analysis (p = 0.016). Conclusion We have shown that in patients with proven ultrastructural alterations in GBM, the presence of so far recognized genetic variants associated with AS and TBMN is 45%, and corresponds to the frequency of other phenotypic characteristics of AS, including hearing impairment and positive family history. In the future, additional clinical tools will be required to accurately determine the role of coexistent thin GBM on the prognosis of patients with other relevant kidney pathology and other genetic tools beyond NGS should be employed to explore other pathologic genetic variants associated with the AS spectrum.

Tolosa Hunt Syndrome: An Atypical Presentation of a Rare Condition

Abstract Purpose: Tolosa-Hunt Syndrome (THS) is a rare disorder with signs and symptoms that mimic various other diseases. Diagnosis of THS, especially in atypical cases, can be challenging due to the need to exclude other diseases. Observations: A 59-year-old-male presented with acute vision loss of his left eye preceded by acute worsening of chronic headaches. Additionally, he had near complete ophthalmoplegia of this eye. He underwent extensive workup including numerous hematologic studies, cerebrospinal fluid studies, and neuro-radiological imaging studies. All tests had normal results except for an elevated ESR of 92 mm/hour and an abnormal MRI of the brain and orbits. The MRI revealed the left orbit as abnormal with proptosis and intraconal inflammatory change. It also showed abnormal enhancement of the left orbital apex and adjacent lateral aspect of the left sphenoid sinus. He was diagnosed with THS and rapidly responded to corticosteroid treatment. Conclusions and Importance: THS can be challenging to diagnose because it is a diagnosis of exclusion. An added difficulty with THS is the need to quickly recognize and diagnose it since early treatment with corticosteroids can produce a rapid treatment response and decreases the chance of severe residual symptoms. THS does not usually affect the optic nerve, but optic nerve damage can occur and involvement of the optic nerve further increases the urgency of diagnosing it and promptly initiating treatment.

Perioperative Management of Spinal Arteriovenous Malformation Embolization: Delayed Venous Thrombosis and Implications for Severe Back Pain.

The prognosis of untreated spinal arteriovenous malformations (SAVMs) is poor. Embolization plays an important role in the management of intramedullary SAVMs. Delayed aggravation due to spinal venous thrombosis following successful embolization has been reported; however, perioperative management strategies to prevent thrombosis have not been explored. We present our single-center experience of SAVM embolization and perioperative management, including anticoagulation. We retrospectively evaluated 18patients with SAVMs who underwent transarterial embolization. Perioperative anticoagulation therapy was administered to selected patients. We compared the characteristics of the patients, including perioperative management procedures, between those with and without postoperative worsening following embolization. Acute postoperative worsening within 1week occurred in 4 (22.2%) patients. Of these, immediate worsening was observed in one patient as aprocedure-related complication. Delayed worsening after 24 h was observed in 3 patients, caused by delayed venous thrombosis with severe back pain. Rescue anticoagulation for delayed worsening improved symptoms in two patients. Acomparison between patients with and without acute postoperative worsening revealed significant differences in age (median 46.5 vs. 26.5 years, p = 0.009) and the presence of postoperative back pain (75.0% vs. 0%, p = 0.005); however, there was no significant difference in use of selective anticoagulation (p = 0.274). The results of this study suggest that SAVM embolization can cause acute worsening due to postoperative venous thrombosis with severe back pain, which may be reversed by anticoagulation therapy. Back pain is an important finding that suggests venous thrombosis, and anticoagulation should be urgently administered.

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

BackgroundBuprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients.MethodsWe conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics.ResultsThere were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation.ConclusionsWithdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients’ withdrawal experiences.

Bedside clinical assessment of patients with common upper limb tremor and algorithmic approach.

The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the evaluation of tremor is to identify the tremulous movement and exclude the tremor mimics. The second step is to classify the tremor syndrome based on the characteristics of tremor from historical clues and focused examination (Axis 1). Comprehensive tremor examinations involve the assessment of tremor in different conditions (rest, action or mixed, position or task-specific), distribution of tremor (upper limb, lower limb, head, jaw), positive signs for functional tremor (FT) if suspected (distractibility, entrainment, co-contraction), and associated neurological signs including parkinsonism, dystonic posture, cerebellar/brainstem signs, neuropathy, and cognitive impairment. A pivotal feature in this step is to determine any distinct feature of a specific isolated or combined tremor syndrome. In this review, we propose an algorithm to assess upper limb tremors. Ancillary testing should be performed if clinical evaluation is unclear. The choice of investigation depends on the types of tremors considered to narrow down the spectrum of etiology (Axis 2). Laboratory blood tests are considered for acute onset and acute worsening of tremors, while structural neuroimaging is indicated in unilateral tremors with acute onset, nonclassical presentations, and a combination of neurological symptoms. Neurophysiological study is an important tool that aids in distinguishing between tremor and myoclonus, etiology of tremor and document specific signs of FT. Treatment is mainly symptomatic based depending on the etiology of the tremor and the patient's disabilities.

Infective Endocarditis due to Unusual Pathogens Complicated with Pulmonary Thromboembolism: A Rare Occurrence in a Premature Infant

Background: Survival of low birth weight preterm neonates has increased with the availability of better neonatal care, however, the use of central lines for longer duration increases the risk of bacterial and fungal sepsis. Neonatal infective endocarditis (IE) is a rare presentation of neonatal sepsis and is often associated with complications and high mortality. Clinical Description: A 36 weeker, premature baby, hospitalized for early onset sepsis, was transferred to our hospital on day 15 of life, with an umbilical catheter in situ, with fever, respiratory distress, and persistent thrombocytopenia. Clinical examination revealed decreased oxygen saturation, crepitations in the right lung field, systolic murmur, and hepatomegaly. Management and Outcome: Baseline investigations revealed positive septic screen with thrombocytopenia with meningitis, neonatal cholestasis, and right sided consolidation on chest X ray. A two dimensional echocardiography (ECHO) revealed vegetation on the tricuspid valve, and blood culture from two sites revealed growth of Candida tropicalis and Serratia marcescens. Colistin, tigecycline, and amphotericin B therapy were initiated as per sensitivity along with low molecular weight heparin for prevention of embolization. The baby developed acute worsening in respiratory distress after 4 weeks of therapy. Repeat ECHO revealed increased size of cardiac vegetation and computed tomography of thorax with pulmonary angiography revealed pulmonary thromboembolism. Unfortunately, the baby succumbed to complications of IE. Conclusion: Invasive instrumentations such as umbilical catheterization and prolonged hospitalizations of premature newborns predispose them to develop IE, especially with unusual organisms. Such infections have a complicated course and may be fatal.

Blood eosinophil variability in patients presenting with acute exacerbations of COPD within the past year and its correlation with treatment plan

BackgroundChronic obstructive pulmonary disease (COPD) is an acknowledged contributor to universal fatality and morbidity. Using biomarkers to pinpoint its phenotypes is crucial, enabling individualized treatment and enhancing prognosis.ObjectiveStudying the steadiness of blood eosinophi1s in cases who experienced repeated hospital admissions for acute worsening of COPD during a year and its correlation to the treatment plan.MethodsA retrospective cohort study includes 270 COPD male patients with acute exacerbations. The patients were divided into three groups: fluctuating (ranges between ≥ 150 cells/ul and < 150 cells/ul), non-EOS (< 150 cells/ul), and Eosinophil (EOS) (≥ 150 cells/ul).ResultsMost patients were in the fluctuating blood EOS group (53.3%). The median length of hospital stay was longer in the fluctuating group (5 days). There was a significant positive correlation between the number of exacerbations and both EOS count and EOS/WBCs. A higher eosinophilic count was associated with an increased risk of eosinophilic exacerbations. Most patients used steroids (higher in the EOS group, 61.6%).ConclusionBlood eosinophilic count is promising for investigating acute COPD exacerbations. Peripheral blood eosinophilia is a relevant biomarker for directing the management of COPD exacerbations, including steroids.