Acute Onset Of Symptoms Research Articles

Direct cost analysis of rapid MRI in the emergency department evaluation of patients suspected of having acute ischemic stroke*.

Abbreviated "rapid MRI" protocols have become more common for the evaluation of acute ischemic stroke (AIS). Prior research has not evaluated the effect of rapid MRIs on cost or hospital length of stay in AIS patients. We retrospectively identified AIS patients who presented within 6h of acute neurologic symptom onset to an emergency department (ED) and activated a "brain attack" code. We included sequential patients from January 2012 to September 2015, before rapid MRI was available, who had CT perfusion (CTP) and compared them to patients from October 2015 to May 2018 who had a rapid MRI. We used inverse-probability-weighting (IPW) to balance the cohorts. The primary outcomes were direct cost to our healthcare system and total hospital length of stay (LOS). We included 408 brain attack activations (mean ± SD age 62.1 ± 17.6years, 47.8% male): 257 in the CTP cohort and 151 in the MRI cohort. Discharge diagnosis was ischemic stroke in 193/408 (47.3%). After patient matching, we found significant reductions for the MRI cohort in total cost (-18.7%, 95% CI -35.0, -2.4, p = 0.02) and hospital LOS (-17.0%, 95% CI -31.2, -2.8, p = 0.02), with no difference in ED LOS (p = 0.74) as compared to the CTP cohort. Although these results are preliminary and hypothesis-generating, we found that the use of a rapid MRI protocol in emergency department brain attacks was associated with a 18.7% reduction in total direct cost and 17% reduction in hospital length of stay.

165-LB: The Impact of COVID-19 Vaccination on Development of Hyperglycemic Crisis

Hyperglycemic crisis (HC) has been reported in patients with COVID-19 infection, but there is little data about HC following COVID-19 vaccination, with 10 patients described to date. We performed a retrospective observational study examining the correlation between COVID-19 vaccination and HC in adult patients admitted from 1/1/21-7/1/21 at our institution. There were 91 admissions for HC during the study period. Forty-one were admissions for diabetic ketoacidosis (DKA) in patients with type 1 diabetes (T1D) , 2 of which also had hyperglycemic hyperosmolar state (HHS) . In patients with type 2 diabetes (T2D) , there were 49 admissions for DKA, 6 of which also had HHS, and 1 admission for HHS alone. In patients with T1D, 17 admissions occurred following COVID-19 vaccination, ranging from <24 hours to more than 3 months after, including 1 new diagnosis of T1D. All cases had a trigger of insulin omission or other medical illness, including 7 with admission for COVID-19 infection. In patients with T2D, 20 DKA or overlap admissions and 1 HHS admission occurred following COVID-19 vaccination, ranging from 1 to 40 days after. Six of these patients had no clear trigger of medical illness or insulin omission, 3 of which were new diagnoses of T2D. Two were following the first vaccination and 4 following the second vaccination. Hemoglobin A1c at admission was >11% in all 6 of these patients. Among patients with T1D, there were no cases of HC that appeared to be attributable to COVID-19 vaccination. In patients with T2D, while there were six cases following vaccination with no other clear trigger, the degree of hemoglobin A1C elevation at the time of admission was suggestive of longer duration of poor glycemic control. Three of these cases did have acute symptom onset following vaccination within one week of presentation, so it is possible that HC was provoked by vaccination in these patients. While it is not clear that COVID vaccination leads to HC in T1D, it may be an acute trigger for HC in patients with T2D who have poor underlying glycemic control. Large scale population studies are needed to better assess rates of HC following COVID-19 vaccination. Disclosure K. L. Modzelewski: None. S. Alexanian: None.

The Various Faces of Creutzfeldt-Jakob Disease (CJD); a Case of CJD Presenting as Psychosis in a Middle-Aged Woman

AimsCreutzfeldt-Jakob disease (CJD) is a rare, progressive, fatal neurodegenerative disorder caused by an abnormal glycoprotein known as the prion protein. The core features include progressive cognitive decline, cerebellar dysfunction, personality changes, and visual disturbances. Although psychiatric symptoms are rare, they can be the primary symptom of CJD, and such presentations can pose diagnostic difficulties. In this paper, we describe the case of Ms. R, who manifested psychotic symptoms as the first signs of CJD.MethodsMs. R, was a 49-year-old white British female not previously known to psychiatric services, who presented with acute onset of florid psychotic symptoms. Her symptoms included auditory hallucinations, paranoia, and thought disorder. She was treated with antipsychotics for over four weeks, following her admission, but no improvement was seen. Instead, her psychosis worsened with cognitive decline, mutism, and the appearance of neurological symptoms such as jerky body movement, ataxia, and falls. All screening blood tests, chest X-ray, and CT abdomen were normal. The MRI, however revealed few patches of high T2/FLAIR signal in the deep white matter. Cerebrospinal fluid showed increased protein. Neurologist reviews suggested the possibility of sporadic CJD (sCJD) as a probable diagnosis. As her condition deteriorated, she became comatose and died four months after the appearance of the first psychiatric symptoms.ResultsIt can be challenging to diagnose CJD since the clinical picture overlaps with other neuropsychiatric and neurodegenerative conditions. It requires the presence of relevant clinical findings along with positive CSF, EEG, or MRI findings to make a probable diagnosis. Regarding our case, some noteworthy observations were psychosis as the initial symptom, relatively delayed onset of neurological signs, rapid deterioration with brief duration of illness. The MRI findings were typical of those seen in sCJD, although the EEG did not suggest sCJD. A differential of variant CJD was considered because of her age, prominent psychiatric symptoms, and delayed neurological signs.ConclusionCreutzfeldt-Jakob disease course is rapidly progressive, and majority of patients die within one year. Therefore, awareness of early clinical features is of great significance. Among other things, this would enable patients and their families time to understand the nature of CJD, prognosis and prepare advanced directives. This case adds to the growing number of atypical presentation of CJD as well as pointing to an expanding spectrum of the disease. Therefore, clinicians should consider CJD in the differential diagnosis of new-onset psychosis, particularly if symptoms persist and worsen despite standard psychiatric treatment.

Evaluation of the prevalence and clinical and laboratory features of acute viral myositis in children with influenza referred to the emergency department of Ali Asghar Tehran Hospital in 2019 and 2020.

ABSTRACTIntroduction:Influenza-related viral myositis is observed mostly in children with influenza, and the disease is more common in influenza type B. The aim of the present study was to evaluate the prevalence, and clinical and laboratory features of acute viral myositis in children with influenza in 2019 and 2020.Methods:This retrospective cross-sectional study was performed in Ali Asghar Hospital, from December 2019 to February 2020. Children aged 2–14 years with symptoms of acute onset of fever, along with the symptoms of influenza with or without muscle pain who referred to the emergency department of Hazrat Ali Asghar Children’s Hospital, were included in the study. The data were collected and analyzed by Statistical Package for the Social Sciences (SPSS) version 22.Results:Out of the 105 participants in this study, 62 (59%) were male and the rest were female. The average age of the patients was 5.34 years (SD = 2.63). Clinical signs of lower limb pain, myalgia, lameness, weakness, and lethargy were significantly more common in patients with myositis (P-value < 0.05). In-vitro examination demonstrated that creatine phosphokinase (CPK), aspartate aminotransferase (AST), and aAlanine aminotransferease (ALT) levels were significantly higher in patients with myositis.Conclusion:Based on the present results, the clinical symptoms in patients are quite clear, and based on the symptoms, it is possible to diagnose and treat myositis without relying on laboratory findings; due to the self-limitation of this complication and lack of the need for complex treatments in case of early diagnosis, physicians can diagnose and treat many cases, depending on the clinical symptoms and the accuracy of the examination.

Case Report: Buprenorphine-precipitated fentanyl withdrawal treated with high-dose buprenorphine

Background: Buprenorphine, a partial agonist of the mu-opioid receptor, is an increasingly prescribed medication for maintenance treatment of opioid use disorder. When this medication is taken in the context of active opioid use, precipitated withdrawal can occur, leading to acute onset of opioid withdrawal symptoms. Fentanyl complicates use of buprenorphine, as it slowly releases from body stores and can lead to higher risk of precipitated withdrawal. Objectives: Describe the successful management of buprenorphine precipitated opioid withdrawal from fentanyl with high doses of buprenorphine. We seek to highlight how no adverse effects occurred in this patient and illustrate his stable transition to outpatient treatment. Case report: We present the case of a patient with severe opioid use disorder who presented in moderately severe opioid withdrawal after taking non-prescribed buprenorphine-naloxone which precipitated opioid withdrawal from daily fentanyl use. He was treated with high doses of buprenorphine, 148 mg over the first 48 hours, averaging 63 mg per day over four days. The patient reported rapid improvement in withdrawal symptoms without noted side effects and was able to successfully taper to 16 mg twice daily by discharge. Conclusions: This case demonstrates the safety and effectiveness of buprenorphine at high doses for treatment of precipitated withdrawal. While other options include symptomatic withdrawal management, initiating methadone or less researched options like ketamine, utilizing buprenorphine can preserve or re-establish confidence in this life-saving medication. This case also increases the previously documented upper boundary on buprenorphine dosing for withdrawal and should provide additional confidence in its use.

When Agitation, Hallucination, and Paranoia Mean More Than Psychosis.

When Agitation, Hallucination, and Paranoia Mean More Than Psychosis.

Breathing exercise and chest physiotherapy in post-acute COVID-19 patient: a case report

Background: Severe acute respiratory syndrome (SARS CoV2) and coronavirus disease 2019 causes vary from mild to severe clinical manifestation. Complications from COVID-19 can show several manifestations such as pulmonary, cardiovascular, neuromuscular, and renal systems, which could lead to multi-organ failure. Lung fibrosis and recurrent pneumonia are some of some sequelae of survivors, and some need readmission to hospital, although the PCR swab test remains negative. Post-acute COVID-19 is a syndrome characterized by persistent clinical symptoms beyond four weeks from the onset of acute symptoms. Case: In this writing, a 57-year-old male presented with chief complaints of shortness of breath and cough 2 days after being discharged from the hospital because of a COVID-19 infection. His PCR swab test result remains negative when readmission. The patient was on non-invasive ventilation, medical therapy and physical therapies such as breathing exercises and chest physiotherapy. The physical therapy was done twice daily. On the seventh day of exercise, the shortness of breath was improved, and NIV was tapered down. The patient was discharged after 27 days of hospitalization. Conclusion: This case shows the benefit of breathing exercises and chest physiotherapy for the Post-acute COVID-19 patient. This helps improve respiratory muscle strength and chest expansion in order to improve oxygen perfusion.

Coronavirus disease 2019 presenting as psychosis: a case report

BackgroundThe coronavirus disease 2019 syndrome typically consists of respiratory symptoms and other general nonspecific symptoms. Psychotic manifestations of coronavirus disease 2019 attributable to severe acute respiratory syndrome coronavirus 2 infection are seldom reported. We report a case of coronavirus disease 2019 in a young West African male who had no known risk factors of psychiatric illness or past history of psychiatric disease presenting with acute psychosis.Case presentationOur patient, who was a young West African male, presented without the typical respiratory symptoms of coronavirus disease 2019 and also without a background history of psychiatric illness or any other significant stressors in his past or present social history. He had acute onset of psychotic symptoms consisting of visual and auditory hallucinations, delusions of persecution, and lack of insight. He was admitted and managed with antipsychotic medication and mood stabilizer. His laboratory workup was normal except for positive coronavirus disease 2019 polymerase chain reaction and his liver enzymes, which showed elevated gamma glutamyl transferase, a finding consistent with coronavirus disease 2019. His head computed tomography scan was also normal. The patient made a gradual recovery from his psychotic symptoms, with gain of insight 7 weeks after onset of symptoms, at which time his coronavirus disease 2019 test came back negative along with other laboratory parameters. He returned to work 12 weeks after his presentation and has been performing well.ConclusionPsychosis can be a primary presenting symptom in patients with coronavirus disease 2019, including those without respiratory symptoms.

Muscle dysfunction in the long coronavirus disease 2019 syndrome: Pathogenesis and clinical approach.

In long coronavirus disease 2019 (long COVID‐19), involvement of the musculoskeletal system is characterised by the persistence or appearance of symptoms such as fatigue, muscle weakness, myalgia, and decline in physical and functional performance, even at 4 weeks after the onset of acute symptoms of COVID‐19. Muscle injury biomarkers are altered during the acute phase of the disease. The cellular damage and hyperinflammatory state induced by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection may contribute to the persistence of symptoms, hypoxaemia, mitochondrial damage, and dysregulation of the renin‐angiotensin system. In addition, the occurrence of cerebrovascular diseases, involvement of the peripheral nervous system, and harmful effects of hospitalisation, such as the use of drugs, immobility, and weakness acquired in the intensive care unit, all aggravate muscle damage. Here, we review the multifactorial mechanisms of muscle tissue injury, aggravating conditions, and associated sequelae in long COVID‐19.

PRES and RCVS: Two Distinct Entities or a Spectrum of the Same Disease?

ObjectivesTo report a case of a patient with overlapping posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS), and review the existing literature emphasizing the pathophysiological overlap of these two entities. Materials and MethodsWe conducted a literature search in electronic database PubMed identifying studies reporting the overlap of PRES and RCVS. ResultsPRES and RCVS are two increasingly recognized entities that share similar clinical and imaging features. PRES is characterized by vasogenic edema predominantly in the parieto-occipital regions, associated with acute onset of neurological symptoms including encephalopathy, seizures, headaches, and visual disturbances. RCVS is characterized by reversible segmental and multifocal vasoconstriction of the cerebral arteries and classically presents with thunderclap headache, with or without associated focal neurological deficits and seizures. PRES is frequently associated with uncontrolled hypertension but can also be seen in the setting of renal failure, exposure to cytotoxic agents, or pre-eclampsia. RCVS is often triggered by exposure to vasoactive agents, postpartum state, or immunosuppression. We report a case of a patient presenting with vision changes and hemiparesis, and found to have extensive cytotoxic and vasogenic edema involving the cortex and subcortical white matter on brain imaging. These changes were primarily noted in the parieto-occipital and brainstem regions, along with features of reversible vasculopathy on vascular imaging suggestive of coexisting PRES and RCVS. ConclusionsPRES and RCVS share precipitating factors, clinical and radiological features, and frequently co-exist, suggesting a common pathophysiological mechanism related to reversible dysregulation of cerebral vasculature, endothelial dysfunction, and breakdown of the blood-brain barrier.

Long COVID-19 Syndrome: Multiorgan Damage and Recommendations for Follow-Up and Rehabilitation

Abstract The majority of the SARS-CoV-2 infected patients fully recover within a few weeks. However, a significant proportion of them, independently of their age, still have multi-organ damage, similar to that during the acute phase of infection, or symptoms for a longer term afte r recovery. “Postacute-COVID-19 (Long COVID-19 Syndrome)” is a term used for COVID-19 patients who are still symptomatic 4 and 12 weeks after the onset of acute symptoms and “Post-COVID-19-syndrome” ‒ for those with symptoms for longer than 12 weeks after the onset of acute symptoms. The severity of the initial infection does not correlate with the probability for and with the severity of long-term symptoms. This review comments on the multiorgan effects of Long COVID-19 Syndrome: respiratory, cardiovascular, hematological, renal, gastrointestinal, neurological, and metabolic ones. Recommendations for follow-up and rehabilitation for the recovery of Long COVID-19 Syndrome patients are discussed in detail.

Hyper-reflective track as an imaging biomarker for clinical improvement in photic retinopathy

Photic damage occurs due to varied etiologies. In two cases presenting with acute onset symptoms, fundus exam in Case 1 (Welder's arc) showed foveal yellow spot in the left eye. In Case 2 (Solar eclipse), foveal yellow spot was noted bilaterally. Spectral domain Optical coherence tomography revealed disruption of ellipsoid zone and a hyperreflective track extending from outer to inner retina. This hyperreflective track resolved on follow-up and correlated with symptomatic improvement. The hyperreflective track possibly indicates acute photic damage to retina and can serve as a prognostic marker for clinical improvement.

Utilization of Emergent Magnetic Resonance Imaging in the Diagnosis of Acute Ischemic Stroke

Utilizing an emergent magnetic resonance imaging (MRI) pathway for emergency department patients with acute onset of stroke-like symptoms allows for optimization of acute ischemic stroke treatment. Emergent MRI increases the percentage of patients administered intravenous tissue plasminogen activator (IV tPA) and minimizes stroke-related long-term disabilities. MRI also reduces the overall cost of stroke-related care by (1) preventing unnecessary IV tPA administration and its associated hospital costs and (2) facilitating faster stroke etiology work-up and treatment plan initiation to reduce hospital length of stay. The primary purpose of this article is to summarize two hospitals’ experience utilizing an evidence-based emergent MRI pathway for patients presenting to the emergency department with stroke-like symptoms who may be IV tPA eligible. Secondary purposes are to describe (1) emergent MRI pathway challenges with implemented mitigation strategies and (2) case examples (wake-up stroke; mild stroke-like symptoms with acute ischemic stroke confirmed by MRI).

Cardiac MRI in Suspected Acute Myocarditis After COVID-19 mRNA Vaccination.

To evaluate cardiac MRI characteristics in patients with suspected hypersensitivity myocarditis following mRNA COVID-19 vaccination. Patients clinically suspected of acute myocarditis after COVID-19 vaccination were retrospectively analyzed and compared against a healthy control group. Cardiac MRI protocol included parameters such as T1 and T2 relaxation times, extracellular volume (ECV), T2 signal intensity ratio, and late gadolinium enhancement (LGE). Lymph node size was assessed in the patient group on the injection side. Student t-test, analyses of variance (ANOVA) with Tukey post-hoc test, and χ2 test were used for statistical analysis. 20 patients with clinically suspected post-vaccine myocarditis (28 ± 12 years; 12 men) and 40 controls (31 ± 11years; 25 men) were evaluated. According to the 2018 Lake Louise criteria (LLC), patients with clinically suspected myocarditis were further subdivided into an LLC-positive group (n = 9) and an LLC-negative group (n = 11). The mean time of symptom onset after vaccination was 1.1 ± 1.2 days (LLC-positive) and 6.5 ± 9.2 days (LLC-negative). Group differences in inflammatory variables between myocarditis patients and control subjects were more pronounced in the LLC-positive group (e. g., T1 relaxation time: 1041 ± 61 ms [LLC positive] vs. 1008 ± 79 ms [LLC-negative] vs. 970 ± 25 ms [control]; p <.001; or T2 signal intensity ratio 2.0 ± 0.3 vs. 1.6 ± 0.3 [LLC-negative] and vs. 1.6 ± 0.3 [control], p = .012). LLC-positive patients were significantly faster in receiving an MRI after initial symptom onset (8.8 ± 6.1 days vs. 52.7 ± 33.4 days; p = .001) and had higher troponin T levels (3938 ± 5850 ng/l vs. 9 ± 11 ng/l; p <.001). LGE lesions were predominantly located at the subepicardium of the lateral wall. Axillary lymphadenopathy was more frequent in the LLC-positive group compared to the LLC-negative group (8/9 [89 %] vs. 0/11 [0 %], p < 0.001). Vaccine-induced myocarditis should be considered in patients with acute symptom onset after mRNA vaccination, especially if elevated serum troponin T is observed. Imaging findings of vaccine-induced myocarditis are similar to virus-induced myocarditis, allowing for the use of the Lake Louise Criteria for diagnostic purposes. · Vaccine-induced hypersensitivity myocarditis can be confirmed with cardiac MRI. · Especially patients with sudden onset of symptoms and elevated serum troponin T had positive cardiac MRI findings. · Cardiac MRI characteristics of vaccine-induced myocarditis are similar to those in virus-induced myocarditis. · Kravchenko D, Isaak A, Mesropyan N et al. Cardiac MRI in Suspected Acute Myocarditis After COVID-19 mRNA Vaccination. Fortschr Röntgenstr 2022; 194: 1003 - 1011.

Identification of Distinct Long COVID Clinical Phenotypes Through Cluster Analysis of Self-Reported Symptoms.

BackgroundWe aimed to describe the clinical presentation of individuals presenting with prolonged recovery from coronavirus disease 2019 (COVID-19), known as long COVID.MethodsThis was an analysis within a multicenter, prospective cohort study of individuals with a confirmed diagnosis of COVID-19 and persistent symptoms >4 weeks from onset of acute symptoms. We performed a multiple correspondence analysis (MCA) on the most common self-reported symptoms and hierarchical clustering on the results of the MCA to identify symptom clusters.ResultsTwo hundred thirty-three individuals were included in the analysis; the median age of the cohort was 43 (interquartile range [IQR], 36–54) years, 74% were women, and 77.3% reported a mild initial illness. MCA and hierarchical clustering revealed 3 clusters. Cluster 1 had predominantly pain symptoms with a higher proportion of joint pain, myalgia, and headache; cluster 2 had a preponderance of cardiovascular symptoms with prominent chest pain, shortness of breath, and palpitations; and cluster 3 had significantly fewer symptoms than the other clusters (2 [IQR, 2–3] symptoms per individual in cluster 3 vs 6 [IQR, 5–7] and 4 [IQR, 3–5] in clusters 1 and 2, respectively; P < .001). Clusters 1 and 2 had greater functional impairment, demonstrated by significantly longer work absence, higher dyspnea scores, and lower scores in SF-36 domains of general health, physical functioning, and role limitation due to physical functioning and social functioning.ConclusionsClusters of symptoms are evident in long COVID patients that are associated with functional impairments and may point to distinct underlying pathophysiologic mechanisms of disease.

Stroke events after transcatheter aortic valve implantation: Temporal relationships and affected brain regions

BackgroundDespite continuous improvements in transcatheter aortic valve implantation (TAVI), periprocedural strokes remain a devastating complication. Randomized controlled trials failed to demonstrate a reduction in clinically apparent strokes or mortality after TAVI due to cerebral embolic protection (CEP). To identify potential targets of CEP strategies during TAVI, we evaluated affected brain regions, and temporal patterns of stroke onset in a routine clinical sample. Methods and resultsA total of 3,164 consecutive patients treated with TAVI from 2008 to 2019 at a single center were screened for cerebrovascular events. Affected cerebral regions were determined according to clinical symptoms and brain imaging. Rates of disabling stroke and non–disabling stroke at 30 days were 2.2% and 1.4%, respectively. The frequency of all strokes decreased from 5.0% to 3.0% over time (P = .012). Patients with impaired left-ventricular function (OR 2.19), increased CHA2DS2-VASc (OR 1.39) and moderate/severe spontaneous echo contrast (OR 3.60) had a higher stroke risk. Acute symptom onset occurred during TAVI (19.4%), within 24 hours (40.3%) or later (25.0%); 98.3% of strokes were of ischemic origin. In intraprocedural strokes, 53.2% of lesions were found in locations considered protected by current CEP devices, and 37.5% of patients with intraprocedural strokes were exclusively affected in these areas. Baseline or procedural parameters were not associated with embolic distribution patterns. ConclusionsMost strokes occurred early after TAVI – but not necessarily during the procedure – and affected multiple brain regions only partially protected by current CEP devices. Efficient prevention of cerebrovascular events may require strategies beyond the TAVI procedure to minimize stroke risk and additional randomized controlled trials will be required to clarify the role of CEP in efficient stroke prevention during TAVI.

Prolonged migraine aura resembling ischemic stroke following CoronaVac vaccination: an extended case series

BackgroundAfter the initiation of the COVID-19 vaccination program in Thailand, thousands of patients have experienced unusual focal neurological symptoms. We report 8 patients with focal neurological symptoms after receiving inactivated virus vaccine, CoronaVac.Case seriesPatients were aged 24–48 years and 75% were female. Acute onset of focal neurological symptoms occurred within the first 24 h after vaccination in 75% and between 1-7d in 25%. All presented with lateralized sensory deficits, motor deficits, or both, of 2–14 day duration. Migraine headache occurred in half of the patients. Magnetic resonance imaging of the brain during and after the attacks did not demonstrate any abnormalities suggesting ischemic stroke. All patients showed moderately large regions of hypoperfusion and concurrent smaller regions of hyperperfusion on SPECT imaging while symptomatic. None developed permanent deficits or structural brain injury.DiscussionsHere, we present a case series of transient focal neurological syndrome following Coronavac vaccination. The characteristic sensory symptoms, history of migraine, female predominant, and abnormal functional brain imaging without structural changes suggest migraine aura as pathophysiology. We propose that pain related to vaccine injection, component of vaccine, such as aluminum, or inflammation related to vaccination might trigger migraine aura in susceptible patients.

Multi‐disciplinary collaborative consensus guidance statement on the assessment and treatment of breathing discomfort and respiratory sequelae in patients with post‐acute sequelae of SARS‐CoV‐2 infection (PASC)

<scp>Multi‐disciplinary</scp> collaborative consensus guidance statement on the assessment and treatment of breathing discomfort and respiratory sequelae in patients with <scp>post‐acute</scp> sequelae of <scp>SARS‐CoV</scp>‐2 infection (<scp>PASC</scp>)

Outcomes in patients with inflammatory bowel disease and acute gastrointestinal symptoms who test indeterminate for Clostridioides difficile.

BackgroundInflammatory bowel disease (IBD) and Clostridioides difficile infection (CDI) can present with similar symptoms. The current preferred method for diagnosing CDI is the nucleic acid amplification test (NAAT) for C. difficile in stool, followed by reflex toxin enzyme immunoassay (EIA) when NAAT is positive. The clinical significance of NAAT(+)/EIA(-) in the IBD population is uncertain.MethodsThis retrospective cohort included IBD patients who presented with acute onset of gastrointestinal symptoms and a C. difficile NAAT(+) test. The primary outcome was C. difficile recurrence within 12 months. Other outcomes examined included hospital admissions within 30 days of CDI, change of IBD maintenance therapy within 90 days of CDI, and complications such as bowel resection or death.ResultsA total of 71 patients were included. Eighty-four percent of the tests were EIA(-) and among the EIA(-) 88% were treated with antibiotics. Outcomes between EIA(+) and EIA(-) were not significantly different in terms of recurrences, admissions, changes to IBD medications or complications. Outcomes were also similar when comparing those who received antibiotic therapy to those who did not.ConclusionsOur cohort did not demonstrate a significant difference in outcomes between EIA(+) and EIA(-) C. difficile patients. Treatment for EIA(-) patients did not improve outcomes. Even though there may be a role for antibiotic therapy in IBD patients who test NAAT(+)/EIA(-) for C. difficile, further studies will be needed to identify that subpopulation.

Analysis of the clinical characteristics of olanzapine-induced acute pancreatitis.

Numerous case reports of acute pancreatitis (AP) induced by olanzapine have been published. Little is, however, known about the clinical features of olanzapine-induced AP. The aim of the study was to explore the clinical characteristics of olanzapine-induced AP. We collected literature on AP cases induced by olanzapine from 1996 to April 2021 for retrospective analysis in Chinese and English. The median time to onset of olanzapine-induced acute pancreatic symptoms was 12 (range = 0.86–216) weeks in 25 patients. The clinical features of AP range from asymptomatic elevation of blood amylase/lipase levels to digestive system symptoms (abdominal pain, vomiting, and nausea) and even death in a small number of patients. Laboratory tests showed varying degrees of elevated serum amylase and lipase levels, along with high blood sugar and high triglyceride levels in some patients. Computed tomography showed acute edematous pancreatitis, acute hemorrhagic pancreatitis, and acute necrotizing pancreatitis in the patients. The patients’ symptoms were completely relieved and high triglyceride levels gradually returned to normal levels after olanzapine was stopped. Some patients with hyperglycemia still needed hypoglycemic therapy. AP is a rare adverse effect of olanzapine. Clinicians should be aware of such complications and monitor pancreatin.