Acute Worsening Research Articles

Imaging Intertrochanteric Extension of Greater Trochanteric Fracture in a 59-year-old Man: A Case Report

Intertrochanteric fractures occur in the region between the greater and the lesser trochanters along the junction of the femoral neck and the shaft. Isolated greater trochanteric fractures seen on initial radiographs may be shown to have intertrochanteric extension on additional imaging modalities, including magnetic resonance imaging (MRI), computed tomography, and bone scintigraphy. We report a case of intertrochanteric extension of greater trochanteric fracture in a 59-year-old man who presented with acute worsening of chronic left hip pain after a minor fall. Radiographs of the hips revealed a left greater trochanteric fracture with suspected intertrochanteric extension. Computed tomography of the left hip, one day later, showed a minimally displaced fracture of the left greater trochanter without intertrochanteric extension. The same-day MRI of the hip showed an acute nondisplaced intertrochanteric extension of a minimally displaced greater trochanteric fracture. While the greater trochanteric fracture was seen on all three imaging modalities, the intertrochanteric extension was distinctly visualized only on MRI.

Guillain-Barré-Like Syndrome From Esophageal Squamous Cell Carcinoma

Guillain-Barré-like syndrome (GBS) has been noted in solid tumors such as hepatocellular carcinoma, gastric, breast, and colon cancer and is characterized by an ascending weakness generally with mild paresthesias; however, it has not been noted in esophageal squamous cell carcinoma. A 64-year-old woman with moderately differentiated squamous cell carcinoma of the upper esophagus receiving 5-fluorouracil and cisplatin chemotherapy concurrently with radiation therapy presented for two weeks of progressive lower extremity weakness and numbness. She experienced acute worsening of symptoms after her cisplatin infusion. She underwent a lumbar puncture that revealed findings consistent with GBS and she began treatment with intravenous immunoglobin. She had gradual improvement in her weakness and paresthesias and was discharged to an inpatient rehabilitation facility. This case documents the first noted association between GBS and esophageal squamous cell carcinoma.

A machine-learning-based prediction method for easy COPD classification based on pulse oximetry clinical use

Chronic Obstructive Pulmonary Disease (COPD) is a progressive, obstructive lung disease that restricts airflow from the lungs. COPD patients are at risk of sudden and acute worsening of symptoms called exacerbations. Early identification and classification of COPD exacerbation can reduce COPD risks and improve patient’s healthcare and management. Pulse oximetry is a non-invasive technique used to assess patients with acutely worsening symptoms. As part of manual diagnosis based on pulse oximetry, clinicians examine three warning signs to classify COPD patients. This may lack high sensitivity and specificity which requires a blood test. However, laboratory tests require time, further delayed treatment and additional costs. This research proposes a prediction method for COPD patients’ classification based on pulse oximetry three manual warning signs and the resulting derived few key features that can be obtained in a short time. The model was developed on a robust physician labeled dataset with clinically diverse patient cases. Five classification algorithms were applied on the mentioned dataset and the results showed that the best algorithm is XGBoost with the accuracy of 91.04%, precision of 99.86%, recall of 82.19%, F1 measure value of 90.05% with an AUC value of 95.8%. Age, current and baseline heart rate, current and baseline pulse ox. (SPO2) were found the top most important predictors. These findings suggest the strength of XGBoost model together with the availability and the simplicity of input variables in classifying COPD daily living using a (wearable) pulse oximeter.

Hyponatremia from oxcarbazepine: A case report

IntroductionOxcarbazepine (OXC) is an antiepileptic drug used as a mood stabilizer in patients diagnosed with bipolar disorder (BD). OXC has been reported as a source of hyponatremia in its use in both epilepsy and BD.ObjectivesWe present the case of a 53 year-old male patient diagnosed with Schizoaffective disorder, bipolar type who developed hyponatremia during his treatment with OXC.MethodsThe patient’s treatment was desvelafaxine 100 mg, Paliperidone depot 150 mg, Oxcarbazepine 600 mg which he had maintained for at least one year. He began to manifest headache, asthenia and mild confusion gradually, with morning predominance, without being clearly suggestive of an acute worsening.ResultsIn control analysis, the existence of sodium leveles of 127 and low osmolarity was observed. Therefore it was decided to suspend furosemide, close monitoring of water intake in order to rule out primary polydipsia and extra salt was introduced into the diet. Given the persistence of the symptoms, laboratory abnormalities and ruled out the existence of primary polydipsia, it was decided to suspend treatment with oxcarbazepine. After the discontinuation of the aforementioned drug the analytical findings went back to normal ranges and the symptoms disappeared.ConclusionsCarrying out control tests in patients with psychiatric pathology and multiple psychiatric treatments is essential to be able to rule out analytical alterations which could be asymptomatic or with nonspecific symptoms that could be attributed to the underlying pathology. The easy reversal of symptoms encourages us to emphasize the study and differential diagnosis of each case.DisclosureNo significant relationships.

AB1289 STUDY DESIGN OF A PHASE 2/3 RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY TO ASSESS THE EFFICACY AND SAFETY OF NIPOCALIMAB, AN FcRn ANTAGONIST, IN WARM AUTOIMMUNE HEMOLYTIC ANEMIA (wAIHA)

BackgroundWarm autoimmune hemolytic anemia (wAIHA) is characterized by the destruction of red blood cells (RBCs) by pathogenic autoantibodies which bind to RBCs and lead to their clearance in the spleen and liver. Patients with wAIHA can experience acute worsening of anemia, which can be a medical emergency, and have an increased risk of thromboembolic events and premature death. Nipocalimab is a fully human, aglycosylated, effectorless IgG1 monoclonal antibody that targets the IgG binding site on the neonatal Fc receptor (FcRn) with high affinity. FcRn, which is expressed in endothelial cells, is responsible for recycling IgG into the circulation and for the relatively long half-life of IgG antibodies compared to other Igs. It is expected that nipocalimab, by inhibiting IgG binding to FcRn, will prevent IgG recycling and lower pathogenic IgG autoantibodies that cause many autoimmune diseases including warm autoimmune hemolytic anemia (wAIHA).Nipocalimab has been studied in multiple phase 1 studies in healthy subjects and in a recently completed phase 2 study in subjects with Generalized Myasthenia Gravis (gMG). In the gMG phase 2 study, nipocalimab was well tolerated at doses from 5 mg/kg every 4 weeks to 60 mg/kg every 2 weeks. Treatment with nipocalimab was associated with rapid and durable total serum IgG and pathogenic IgG autoantibody reduction and meaningful clinical response. A statistically significant relationship between IgG autoantibody reduction and clinical benefit was observed. This study provided proof-of-concept evidence that lowering pathogenic IgG autoantibodies can ameliorate the autoimmune condition these antibodies cause.ObjectivesTo share the rationale and study design for an adaptive, phase 2/3 multicenter, randomized, double-blind, placebo-controlled study in patients with wAIHA whose aim is to evaluate the efficacy, safety, tolerability, PK, and PD of nipocalimab compared with placebo1.MethodsMale or female patients ≥18 years of age who have been diagnosed with primary or secondary wAIHA and have not experienced a sufficient response or have not tolerated currently available treatments will be included in the study. Patients with cold antibody AIHA, cold agglutinin syndrome, mixed type (i.e., warm and cold) AIHA, or paroxysmal cold hemoglobinuria will be excluded. Patients will be randomized 1:1:1 to receive nipocalimab at two different dose schedules or placebo. Following completion of 24 weeks of double-blind treatment, patients may enter an open-label extension period to receive nipocalimab.ResultsThe following endpoints will be analyzed:Primary endpoint:Percentage of participants achieving durable response of improvement in hemoglobin (Hgb).Main secondary endpoints:Change from baseline in the total score from the Functional Assessment of Chronic Illness Therapy-Fatigue Scale at the end of the double-blind period.Number of participants who attain normal lactate dehydrogenase, normal haptoglobin, and normal indirect bilirubin levels at a minimum of 3 consecutive visits after baseline.ConclusionA phase 2 study investigating nipocalimab in patients with gMG provided proof of concept for a phase 2/3 interventional study with nipocalimab in patients with wAIHA. This phase 2/3 study is currently enrolling in the USA and Europe.

Personalized Care in Late-Stage Parkinson's Disease: Challenges and Opportunities.

Late-stage Parkinson’s disease (LSPD) patients are highly dependent on activities of daily living and require significant medical needs. In LSPD, there is a significant caregiver burden and greater health economic impact compared to earlier PD stages. The clinical presentation in LSPD is dominated by motor and non-motor symptoms (NMS) that most of the time have a sub-optimal to no response to dopaminergic treatment, especially when dementia is present. Non-pharmacological interventions, including physiotherapy, cognitive stimulation, speech, occupational therapy, and a specialized PD nurse, assume a key role in LSPD to mitigate the impact of disease milestones or prevent acute clinical worsening and optimize the management of troublesome NMS. However, the feasibility of these approaches is limited by patients’ cognitive impairment and the difficulty in delivering care at home. The present care challenge for LSPD is the ability to offer a person-centered, home-delivered palliative care model based on Advanced Care Planning. An ongoing European multicentric project, PD_Pal, aims to address this challenge.

Pain Trajectories After Valve Surgeries Performed via Midline Sternotomy Versus Mini-Thoracotomy

Controlling moderate-to-severe pain remains a major challenge after cardiothoracic surgery. Several outcomes have been compared extensively after valve surgery performed via midline sternotomy versus mini-thoracotomy, but postoperative pain (POP) was not adequately examined. Therefore, the authors tested the hypothesis that there is no difference in POP trajectories in patients undergoing valve surgery via midline sternotomy versus mini-thoracotomy. An Institutional Review Board-approved retrospective study. At a single, large academic medical center. Adult patients who underwent mitral or aortic valve surgeries over a 5-year period. The authors compared the characteristics of pain between valve surgery patients receiving either midline sternotomy or mini-thoracotomy. To identify pain score trajectories, the authors employed latent class linear mixed models and then used multinomial regression models to study the association between incision type and pain trajectory class. The authors' cohort consisted of 1,660 surgical patients-544 (33%) received a midline sternotomy, and 1,116 (66%) received a mini-thoracotomy. The authors identified the following 4 pain trajectory classes: stationary, rapidly improving, slowly improving, and acute worsening pain. Compared to the rapidly improving class, the odds of belonging to the stationary (adjusted odds ratio [aOR] [95% CI] 1.45 [1.01- 2.08]; p=0.04) or the acute worsening class (aOR [95% CI] 1.71 [1.10-2.67] p=0.02) were significantly higher for sternotomy patients compared to mini-thoracotomy. Midline sternotomies are associated with higher odds of having an acute worsening or stationary versus a rapidly improving pain trajectory compared to mini-thoracotomies. Therefore, the choice of incision may play an important role in determining POP trajectory after valve surgery.

Acute Worsening of Glycaemic Control in a Patient with Latent Autoimmune Diabetes of Adulthood After Receiving the COVID-19 Vaccine

Patients with diabetes who are infected with severe acute respiratory syndrome coronavirus 2 experience a worsening of glycaemic control and are at increased risk for severe outcomes. Little is known regarding the impact of COVID-19 vaccinations on glycaemic control. This case report explores a patient with diabetes who experienced an acute worsening of glucose control in the week following the second dose of the Pfizer-BioNTech COVID-19 vaccine.

Reply.

Some people create their own storms and then get upset when it rains. —Anonymous We welcome the opinions of Balkrishna et al. on our multicenter study, which demonstrated a strong association of Tinospora cordifolia (Giloy) and autoimmune-like hepatitis.[1] The authors’ arguments supporting the “safety” of Giloy come from multiple preclinical sources; these unpublished, non-peer-reviewed work have misinterpreted published data on Giloy, or the lack of it, to suit their narrative. They claim that 40 ml/day of Giloy was akin to an “overdose” and provide a misleading citation. In fact, their own product page and that of the Ministry of Ayush Guidelines on coronavirus disease 2019 mention a maximum daily dose of 60–80 ml/day.[2, 3] Nonetheless, the authors’ claims are fictitious, as the efficacy and safety Giloy for the prevention or mitigation of any disease condition in humans is not yet identified through robust clinical trials. Contrary to what Balkrishna et al. argue, our patients consumed properly identified Giloy and authentically marketed Giloy-based products, which were advertised and recommended via public and private Ayush promotions. The presence of a pre-existing liver condition does not exclude Giloy liver injury, but enforces the importance of diagnosing herb-induced acute worsening of chronic liver disease, which is known to be associated with high mortality.[4] The type, concentration, effective dose, safety limits, and toxicity of bio-active phytocompounds in Giloy products should ideally be disclosed by the manufacturer. The authors lay out irrational arguments leveraged on their confirmation biases, in support of the safety of Giloy, using various preclinical rat models. However, it is well known that animal models have sizeable limitations for predicting toxicity in human clinical trials.[5] Balkrishna et al. appeal to ignorance regarding liver-toxic furano-diterpenoids, based on inaccurate citations that do not support their claims that these hepatotoxic compounds are lost during purification. The preparatory process for various Giloy-based formulations is not standardized. Nonetheless, they have missed the fact that Ayush Ministry guidelines explicitly state the use of aqueous-base extracted Giloy and not alcohol or chloroform processed decoctions.[3] The authors have misinterpreted our study, taken to strawman arguments and red-herring fallacies on cherry-picked aspects of chemical analysis, all the while trying to find closure for their labyrinthine, but flawed narrative on the safety of Giloy.[6] Giloy liver injury is a clinical diagnosis of exclusion, based on causality assessment and temporal association which we have succinctly proven. Finally, Balkrishna et al. willfully ignore the editorial on Giloy liver injury by experts from the US Drug-Induced Liver Injury Network, which re-assessed that Giloy can lead to liver injury with autoimmune features as well as worsen silent autoimmune hepatitis, which was also confirmed in our study.[7] Therefore, the evidence presented in our study strongly associates Giloy with observed hepatotoxicity and restates that non-evidence-based, poorly regulated traditional herbal products must be curbed. A “supervised” prescription is not the solution here, but awareness of the potential toxicity of Giloy, which has no proven clinical benefits. Our study demonstrates that preventing a modifiable disease is far more important than treating inadvertent complications. Nothing to report.

MP14-02 THE SOCIAL IMPACT OF SURGERY FOR NEPHROLITHIASIS: RESULTS FROM THE ENDOUROLOGIC SOCIETY TOWER RESEARCH COLLABORATIVE

You have accessJournal of UrologyCME1 May 2022MP14-02 THE SOCIAL IMPACT OF SURGERY FOR NEPHROLITHIASIS: RESULTS FROM THE ENDOUROLOGIC SOCIETY TOWER RESEARCH COLLABORATIVE Amanda Jones, Christian Rodriguez, George Lin, Hanna Stambakio, Ben Chew, Joshua Stern, and Justin Ziemba Amanda JonesAmanda Jones More articles by this author , Christian RodriguezChristian Rodriguez More articles by this author , George LinGeorge Lin More articles by this author , Hanna StambakioHanna Stambakio More articles by this author , Ben ChewBen Chew More articles by this author , Joshua SternJoshua Stern More articles by this author , and Justin ZiembaJustin Ziemba More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002543.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephrolithiasis is among the most common urological conditions. However, the social impact of the disease remains significantly understudied, particularly following surgical intervention. We prospectively captured patient-reported ability to participate in social roles and activities in patients following ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) for nephrolithiasis. METHODS: Adults undergoing URS or PCNL for renal/ureteral stones were eligible for inclusion (10/2020-10/2021). Patients prospectively completed PROMIS-Ability to Participate in Social Roles and Activities instrument pre-operatively (POD 0) and via email on POD 1, 7, and 14. Scores are reported as T-scores (normalized to US pop., mean=50) with a change of 5 (0.5 SD) considered clinically significant. All post-operative ureteral stents and/or nephrostomy tubes were removed by POD 7. RESULTS: A total of 145 patients completed enrollment, 102 of which underwent URS and 43 of which underwent PCNL. For URS, there was an acute worsening of social participation between POD 0 and 1, but this recovered and even improved to above the baseline between POD 7 and 14 (repeated measures ANOVA; p <0.001) (Figure 1). For PCNL, there was a similar acute worsening of social participation between POD 0 and 1, but this did not recover and remained below the baseline even at POD 14 (repeated measures ANOVA; p<0.001) (Figure 2). CONCLUSIONS: Ability to participate in social roles and activities declines immediately post-operatively for both patients undergoing URS and PCNL. However, there appears to be a relatively rapid recovery for patients undergoing URS between POD 7 and 14, but patients undergoing PCNL experience a greater impact with recovery beyond POD 14. Results offer meaningful insights to assist in counseling patients prior to the surgical treatment of nephrolithiasis. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e231 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Jones More articles by this author Christian Rodriguez More articles by this author George Lin More articles by this author Hanna Stambakio More articles by this author Ben Chew More articles by this author Joshua Stern More articles by this author Justin Ziemba More articles by this author Expand All Advertisement PDF DownloadLoading ...

COVID 19 AND SPONTANEOUS PNEUMOTHORAX, RETROSPECTIVE CASE SERIES

COVID-19 Sars Co V2 or Corona Virus disease is a highly infectious multisystem disease with severe acute lung injury leading to ARDS and respiratory failure as its main complication. Spontaneous pneumothorax is a complication which is though uncommon but could be life threatening and hence carries poor prognosis. We hereby describe a series of six cases of spontaneous pneumothorax which were seen in Bahria International Hospital COVID management unit during last 3 months of COVID-19 surge in Lahore These cases indicate that multiple factors are associated with development of spontaneous pneumothorax in COVID-19 pneumonia patients but main role is played by the increased inflammatory response and can be regarded as a potential underlying mechanism of pneumothorax in such patients, leading to acute decompensation and worsening of respiratory failure and poor outcome.

Silent Myocardial Infarction in Hypereosinophilic Syndrome Overlapped with JAK2-Mediated Essential Thrombocytosis: A Case Report

A 61-year-old male with chronic cough, paraesthesia of the extremities, and sinusitis presented for acute worsening of symptoms despite initial treatment with antibiotics and prednisone. Emergency department evaluation revealed mild elevated troponin without ECG changes in absence of coronary symptoms, but markedly elevated eosinophil count and an abnormal chest CT. A nuclear stress test revealed basal and inferoseptal dyskinesis with fixed apical defect. Left heart catheterisation revealed multiple coronary stenosis requiring intervention. Further extensive work-up confirmed a diagnosis of hypereosinophilic syndrome complicated with respiratory, cardiac, gastroenterological, and neurological involvement. The patient was initially treated with a high dose of intravenous steroid and hydroxyurea. Flow cytometry revealed negative FIP1L1-PDGFRA gene rearrangement, but was positive for JAK2 V617F mutation and perinuclear antineutrophil cytoplasmic antibodies/cytoplasmic antineutrophil cytoplasmic antibodies, indicating possible overlap of eosinophilic granulomatosis with polyangiitis.

Wearables in Schizophrenia: Update on Current and Future Clinical Applications

Schizophrenia affects 1% of the world population and is associated with a reduction in life expectancy of 20 years. The increasing prevalence of both consumer technology and clinical-grade wearable technology offers new metrics to guide clinical decision-making remotely and in real time. Herein, recent literature is reviewed to determine the potential utility of wearables in schizophrenia, including their utility in diagnosis, first-episode psychosis, and relapse prevention and their acceptability to patients. Several studies have further confirmed the validity of various devices in their ability to track sleep—an especially useful metric in schizophrenia, as sleep disturbances may be predictive of disease onset or the acute worsening of psychotic symptoms. Through machine learning, wearable-obtained heart rate and motor activity were used to differentiate between controls and patients with schizophrenia. Wearables can capture the autonomic dysregulation that has been detected when patients are actively experiencing paranoia, hallucinations, or delusions. Multiple platforms are currently being researched, such as Health Outcomes Through Positive Engagement and Self-Empowerment, Mobile Therapeutic Attention for Treatment-Resistant Schizophrenia, and Sleepsight, that may ultimately link patient data to clinicians. The future is bright for wearables in schizophrenia, as the recent literature exemplifies their potential to offer real-time insights to guide diagnosis and management.

Defining Physiological Decompensation: An Expert Consensus and Retrospective Outcome Validation.

OBJECTIVES:Physiological decompensation of hospitalized patients is common and is associated with substantial morbidity and mortality. Research surrounding patient decompensation has been hampered by the absence of a robust definition of decompensation and lack of standardized clinical criteria with which to identify patients who have decompensated. We aimed to: 1) develop a consensus definition of physiological decompensation and 2) to develop clinical criteria to identify patients who have decompensated.DESIGN:We utilized a three-phase, modified electronic Delphi (eDelphi) process, followed by a discussion round to generate consensus on the definition of physiological decompensation and on criteria to identify decompensation. We then validated the criteria using a retrospective cohort study of adult patients admitted to the Hospital of the University of Pennsylvania.SETTING:Quaternary academic medical center.PATIENTS:Adult patients admitted to the Hospital of the University of Pennsylvania who had triggered a rapid response team (RRT) response between January 1, 2019, and December 31, 2020.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Sixty-nine experts participated in the eDelphi. Participation was high across the three survey rounds (first round: 93%, second round: 94%, and third round: 98%). The expert panel arrived at a consensus definition of physiological decompensation, “An acute worsening of a patient’s clinical status that poses a substantial increase to an individual’s short-term risk of death or serious harm.” Consensus was also reached on criteria for physiological decompensation. Invasive mechanical ventilation, severe hypoxemia, and use of vasopressor or inotrope medication were bundled as criteria for our novel decompensation metric: the adult inpatient decompensation event (AIDE). Patients who met greater than one AIDE criteria within 24 hours of an RRT call had increased adjusted odds of 7-day mortality (adjusted odds ratio [aOR], 4.1 [95% CI, 2.5–6.7]) and intensive care unit transfer (aOR, 20.6 [95% CI, 14.2–30.0]).CONCLUSIONS:Through the eDelphi process, we have reached a consensus definition of physiological decompensation and proposed clinical criteria with which to identify patients who have decompensated using data easily available from the electronic medical record, the AIDE criteria.

Development and Internal Validation of a Recursive Partitioning Analysis–Based Model Predictive of Pain Flare Incidence After Spine Stereotactic Body Radiation Therapy

PurposePain flares are a common acute toxic effect after stereotactic body radiation therapy (SBRT) for spine metastasis. We aimed to identify a subset of patients with the highest rate of pain flare after spine SBRT to optimize prophylactic corticosteroid administration. Methods and MaterialsThe data set included 428 patients with 610 treatments. We defined pain flare as acute worsening of pain at the treatment site requiring new or higher dose therapy with corticosteroids, opiates, and/or hospitalization. Data were split into 70% training and 30% validation sets using a random number generator. After feature importance testing and generation of a correlation heatmap, feature extraction was performed via recursive partitioning analysis. ResultsWe identified 125 total pain flares (20%). Five variables met significance (P < .02) for model inclusion: renal primary, soft tissue involvement, Bilsky >0, spinal instability neoplastic score >6, and gross tumor volume >8 cc. One point was assigned for each variable. The low-risk group (score = 0, n = 159) had pain flare rates of 7.0% and 13.6% in the training and validation sets; the intermediate-risk group (score = 1, n = 150) had rates of 14.0% and 16.3%; and the high-risk group (score >1, n = 301) had rates of 28.8% and 31.3%. Patients in the high-risk group had higher rates of flare (odds ratio, 3.50; 95% confidence interval, 2.06-5.92) and accumulated health care costs 3 and 6 months post-SBRT, relative to intermediate- and low-risk patients (P < .001). ConclusionsOur internally validated model identifies a high-risk group of patients more likely to develop a pain flare after spine SBRT, for whom prophylactic steroids may be considered. Evaluation in a clinical trial is warranted.

Tinospora Cordifolia (Giloy)-Induced Liver Injury During the COVID-19 Pandemic-Multicenter Nationwide Study From India.

Tinospora cordifolia (Giloy) is an herbal supplement commonly used in the Indian alternative medicine system Ayurveda. This herb has been promoted to the public in India as an immune booster to prevent novel coronavirus disease 2019. However, small reports have recently shown an association between Giloy use and the development of herb‐induced liver injury (HILI) with autoimmune features in some patients. This large retrospective Indian multicenter study spanning 13 centers at nine locations was designed to identify features and outcomes of HILI temporally associated with Giloy use. Chemical and toxicological analyses of retrieved Giloy samples using state‐of‐the‐art methods were also performed. We report 43 patients, of whom more than half were female, with a median time from initial Giloy consumption to symptom onset of 46 days. Patients presented with acute hepatitis, acute worsening of chronic liver disease (CLD, the most common clinical presentation), or acute liver failure. Causality assessment revealed probable liver injury in 67.4%. The most common autoantibody detected was anti‐nuclear antibody. Liver biopsy in a subset revealed HILI associated with autoimmune features and hepatocyte and canalicular cholestasis and neutrophilic and eosinophilic infiltration. Conclusion: Giloy is associated with acute hepatitis with autoimmune features and can unmask autoimmune hepatitis (AIH) in people with silent AIH‐related CLD. Further studies on the safety (and efficacy) of untested but heavily promoted herbals in alternative systems of medicine are an unmet need in the interests of public health and are especially important during this global health emergency.

Pulmonary Exacerbations in Pediatric Patients: Retrospective Study in a Portuguese Cystic Fibrosis Center.

(1) Background: Cystic fibrosis (CF) is a multisystemic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Lung disease, the leading cause of morbimortality, is marked by acute worsening of symptoms—such as pulmonary exacerbations (PEx). The objectives of this study were: Identifying the frequency of PEx in pediatric CF patients; Characterizing each PEx; Finding association between the frequency and characteristics of the PEx and patients’ features. (2) Methods: Retrospective analysis of all PEx from a period of January 2015 to December 2019 in a group of pediatric patients from a single CF center. Data were collected from medical records. Descriptive statistics and chi-square/Fisher’s test were used. (3) Results: Thirty-four pediatric patients contributed to the total sample used in this study and 198 PEx were identified, median of 1.0 PEx/patient/year. Most frequent PEx symptoms were increased cough (93.9%) and change in secretions (88.4%), most common pathogens were Staphylococcus aureus (54.9%) and Pseudomonas aeruginosa (24.9%). The majority were treated as outpatient (85.9%). Most common antibiotics included amoxicillin/clavulanate (35.9%) and ciprofloxacin (22.7%). Outcome was favorable in all PEx. (4) Conclusion: Results were consistent with what has been described in literature. More studies are necessary for a better characterization of CF PEx, in order to develop standardized protocols for their management.

Acute Respiratory Deterioration in Rheumatoid Arthritis-Associated Interstitial Lung Disease: A Single-Center Study

Interstitial lung disease (ILD) is associated with increased morbidity and mortality in rheumatoid arthritis (RA). Moreover, acute exacerbation (AE) is a devastating complication of RA plus ILD. However, few data on AE in RA-associated ILD are available. What are the incidence, risk factors, and outcomes of AE in patients with RA-associated ILD? The clinical data of 310 patients with RA-associated ILD were analyzed retrospectively. AE was defined as the acute worsening of dyspnea typically within 30days with new bilateral lung infiltration, which was based on a 2016 report by an international working group. The mean age of the participants was 61.9 years, and 56.2%of them were women. During follow-up (median, 47.7months), AE occurred in 87 patients (28.1%). The 1-year, 3-year, and 5-year cumulative incidence rates of AE in patients with RA-associated ILD were 9.2%, 19.8%, and 29.4%, respectively. Ever smoker status, lower FVC, and shorter 6-min walk distance were significant risk factors for the occurrence of AE. In the multivariate Cox analysis adjusted by age, sex, smoking status, lung function, exercise capacity, and high-resolution CT scan pattern, AE was a significant prognostic factor for overall survival (hazard ratio, 2.423; 95%CI, 1.605-3.660; P< .001) in patients with RA-associated ILD. The 30-day and 90-day mortalities after AE were 12.6%and 29.9%, respectively. Our findings suggest that approximately one-third of patients with RA-associated ILD experience AE and that ever smoker status, and lower lung function and exercise capacity predispose patients to AE. AE significantly affects the overall survival of patients with RA-associated ILD.

Acute worsening of native lung fibrosis after single lung transplantation for pulmonary fibrosis: two case reports

BackgroundIn patients receiving single lung transplantation for idiopathic pulmonary fibrosis, worsening of fibrosis of the native lung is usually progressive over time, with no significant effects on gas exchange.Case presentationHere, we describe the cases of two Caucasian male recipients of single lung transplants for idiopathic pulmonary fibrosis, 65 and 62 years of age, who exhibited acute worsening of lung fibrosis after an episode of serious viral infection (cytomegalovirus primo-infection in one case and COVID-19 in the other). In both cases, along with opacification of the native lung over several days, the patients presented acute respiratory failure that required the use of high-flow nasal oxygen therapy. Eventually, hypoxemic respiratory failure resolved, but with rapid progression of fibrosis of the native lung.ConclusionWe conclude that acute worsening of fibrosis on the native lung secondary to a severe viral infection should be added to the list of potential complications developing on the native lung after single lung transplantation for idiopathic pulmonary fibrosis.

Time to adequately heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

All healthcare stressors converge in the emergency department (ED), which sees an annual increase of 6-7% with more than 25 million patient visits in the UK. This translates to 44,435 attendances per 100,000 population in the period 2019-2020 [1]. Acute pain is the primary reason patients seek emergency medical care. Consequently, substandard acute pain treatment is one of the most frequently heard complaints and has been labelled as a public health problem [2]. Pain remains under-acknowledged, -assessed and -treated, mainly in case of overcrowding in the ED and especially in the more vulnerable groups, including the elderly and children. Many patients express an initial pain score of 10 out of 10 on the visual analogue scale (VAS) in the ED. Generally, initial pain treatment combines oral acetaminophen, NSAID and/or (IV) opioids. Nevertheless, despite these pain killers, most patients continue to suffer and score their pain at 8/10 or higher. Untreated pain can have both short- and long-term effects, including sensitisation to pain episodes in later life [3]. Most visits to the emergency department involve patients with conditions that include: a) injuries and trauma from (motor vehicle) accidents, physical assaults or falls, with or without circulatory shock; b) cardiovascular and cerebral attacks or loss of consciousness; c) severe pain of diverse causes, both acute and chronic origin; d) acute worsening of a serious illness or disease, including problems with breathing and bleeding; e) mental illness; f) burns; g) anaphylactic and allergic reactions; g) drug overdoses and poisoning; and h) pregnancy-related complications. In most of these cases, patients present with pain as a substantial factor. Keywords: Emergency department, Hip fracture, Pain, Regional anaesthesia, Nerve blocks, Ultrasonography