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Objective: Novel oral anticoagulants (NOACs) are increasingly being preferred by clinicians (and patients) because they have a wide therapeutic window and therefore do not require monitoring of anticoagulant effect. Herein, we describe the unfortunate case of a patient who had fatal consequences as a result of switching from warfarin to rivaroxaban. Case Summary: A 90-year-old Caucasian woman, with atrial fibrillation on chronic anticoagulation with warfarin, was admitted to the hospital for pneumonia. She was treated with levofloxacin. In the same admission, her warfarin was switched to rivaroxaban. On Day 3 after the switch, her INR was found to be 6, and she developed a cervical epidural hematoma from C2 to C7. She ultimately developed respiratory arrest, was put on comfort care and died. Discussion: Rivaroxaban and warfarin are known to have a synergistic anticoagulant effect, usually seen shortly after switching. Antibiotics also increase the effects of warfarin by the inhibition of metabolizing isoenzymes. It is hypothesized that these two effects led to the fatal cervical spinal hematoma. Conclusion: The convenience of a wide therapeutic window and no requirement of laboratory monitoring makes the NOACs a desirable option for anticoagulation. However, there is lack of data and recommendations on how to transition patients from Warfarin to NOACs or even how to transition from one NOAC to another. Care should be taken to ensure continuous monitoring of anticoagulation when stopping, interrupting or switching between NOACS to avoid the possibility of fatal bleeding and strokes.

Background: A portion of patients with influenza develop a severe, life t-threatening illness requiring intensive care. We observed a significant number of critically ill influenza patients with eosinophilia during the 2015 influenza season in New Mexico. Methods: Patients were identified sequentially by reviewing disposition records of all patients admitted to the University of New Mexico Hospital medical intensive care unit between October 2015 and May 2016 for a diagnosis of influenza. Results: Eleven patients were identified who developed respiratory failure from influenza. Average age was 43.7 + 11.3 (SD) with an average SAPS-2 score of 52.0 + 13.9 (SD) on admission. All 11 were found to have H1N1 influenza. All 11 required mechanical ventilation vasopressor support. Ten patients survived. Notably, 6 (54.5%) developed peripheral eosinophilia (>300/μL) during their hospitalization and all but one of these did not have peripheral eosinophilia at the time of admission. Bronchoalveolar lavage was performed in 5 patients (45.5%) and none were consistent with eosinophilic pneumonia. Further data analysis revealed exploration revealed no significant differences in multiple parameters and no clear cut cause of drug-induced eosinophilia was identified. Conclusion: During the 2015 influenza season in New Mexico, a disproportionate number of patients with H1N1 influenza and respiratory failure developed peripheral eosinophilia. Type 2 errors could have occurred due to low sample size. Given the unusual frequency of peripheral eosinophilia further studies regarding the association of influenza A and peripheral eosinophilia is warranted.

No abstract available. Article truncated after 150 words. A 53-year-old woman presented to the emergency department after a sudden cardiac arrest at home. The patient had a history of asthma and tracheal stenosis and had progressive shortness of breath over the previous days. The patient’s family noticed a “thump” sound from the patient’s room, and found her apneic. They called 911 and began cardiopulmonary resuscitation. Paramedics arrived on the scene, found an initial rhythm of pulseless electrical activity. The patient eventually achieved return of spontaneous circulation and was transported to the hospital. On arrival the patient was in normal sinus rhythm, with a heart rate of 110 beats per minute. Blood pressure was 80/45 mmHg, on an epinephrine infusion. The patient was afebrile, endotracheally intubated, unresponsive and ventilated at 30 breaths per minute. An initial chest radiograph was compatible with aspiration pneumonitis and a small pneumothorax. Initial electrocardiogram on arrival had 1mm ST-segment depressions in leads V4 to …

No abstract available. Article truncated at 150 words. A 73-year-old man presented with a three-day history of diffuse abdominal pain, decreased urine output, nausea and vomiting. His past medical history included diabetes, coronary artery disease, hypertension and chronic back pain. The patient reported being started on hydrochlorothiazide, furosemide, pregabalin and diclofenac within the last week in addition to his long-standing metformin prescription. Initial vitals were significant for tachypnea, tachycardia to 120 bpm, hypothermia to 35ºC and hypotension with a blood pressure of 70/40 mm Hg. Physical exam was remarkable for bilateral lung wheezing and significant respiratory distress. Laboratory examination was concerning for a pH of 6.85, pCO2 of < 5mmHg, serum lactate of 27mmol/l, WBC of 15.6 x106 cells/cc and a serum creatinine of 8.36 mg/dl. A chest X-ray showed evidence of mild pulmonary edema and a CT of the abdomen did not show any acute pathology. What is the most likely etiology of the patient’s severe acidosis? …

No abstract available. Article truncated after first page. History of Present Illness: A 54-year-old Hispanic male who was incarcerated 3 days prior to hospital admission was brought into the emergency room from prison for alcohol related withdrawal seizures. Physical Examination: Upon arrival to the ER, the patient was noted to be hypoxic with copious thick secretions in his mouth. He was intubated for airway protection, started on propofol and fentanyl drips as well as intravenous thiamine and folic acid. Radiography: A chest radiograph was performed (Figure 1). Which of the following are true regarding management of this patient? 1. Phenytoin should be administered for prevention of seizures; 2. Prophylactic antibiotics for aspiration pneumonia should be administered; 3. Thiamine and folic acid should be administered; 4. 1 and 3; 5. All of the above. …

No abstract available. Article truncated after first page. A 46-year-old man presented after a motor vehicle collision. He suffered abdominal injuries (liver laceration, avulsed gall bladder) which were successfully managed non-operatively. The patient remained intubated on mechanical ventilation and remained hypotensive after the injuries resolved. The patient required norepinephrine at low doses to maintain a normal blood pressure. It was noted the patient had a history of remote tricuspid valve replacement. A bedside echocardiogram was then performed to determine the etiology of the patient’s persistent hypotension after hypovolemia had been excluded. What tricuspid pathology do the following videos and images demonstrate? 1. Mobile vegetation; 2. Tricuspid Regurgitation; 3. Tricuspid Stenosis; 4. All of the above.

No abstract available. Article truncated after 150 words. Multiple thrombi can be seen in transit through the right atrium. A second thrombus is seen near the subvalvular apparatus. Multiple other small thrombi are also visualized. Aside from obvious clot caught in transit, the ultrasound displays other classical signs that can be associated with pulmonary embolism. When compared to the TEE performed 2 days prior (video 1), the right ventricle was now noted to be moderately to severely dilated with an RV/LV ratio of approximately 1.2/1 (1). The right ventricular function was also now moderately reduced with hypokinesis of the base and relative sparing of the apex (McConnell’s sign) (2). This sign is associated with acute pulmonary embolism and also acute right ventricular infarction. The image below shows video 2, with an “M” placed just below the point where the sparing of the apical motion meets the hypokinesis of the free wall (hinge point) (video 3). Also noted is …

No abstract available. Article truncated after 150 words. A 43 year old previously healthy woman was transferred to our hospital with refractory hypoxemia secondary to acute respiratory distress syndrome (ARDS) due to H1N1 influenza. She had presented to the outside hospital one week prior with cough and fevers. Chest radiography and computerized tomography of the chest revealed bilateral airspace opacities due to dependent consolidation and bilateral ground glass opacities. A transthoracic echocardiogram at the time of the patient’s admission was reported as not revealing any significant abnormalities. At the outside hospital she was placed on mechanical ventilation with low tidal volume, high Positive end-expiratory pressure (20 cm H20), and a Fraction of inspired Oxygen (FiO2) of 1.0. Paralysis was later employed without significant improvement. Upon arrival to our hospital, patient was severely hypoxemic with partial pressure of oxygen / FiO2 (P/F) ratio of 43. She was paralyzed with cis-atracurium and placed on airway pressure release ventilation (APRV) with ...

No abstract available. Article truncated at 150 words. A 40 year old man with a past medical history of intravenous drug abuse presented to the emergency department with difficulty walking and lower extremity weakness. He did admit to recent heroin use. He became somnolent in the ED and was given naloxone. However, he did not improve his level of consciousness sufficiently and was intubated for hypercarbia. The patient was transferred to the MICU and was evaluated for respiratory failure. He later that day passed a spontaneous breathing trial after he awoke and was extubated. However, he was soon thereafter was re-intubated for poor respiratory efforts and a weak cough. With an unexplained etiology for the respiratory failure, CT of the head, MRI of the brain and lab evaluation were pursued but were negative. At that point, a bedside ultrasound of the right hemi-diaphragm in the zone of apposition was obtained and is shown below: Figure 1. Ultrasound of ...

No abstract available. Article truncated after first page. A 59 year old woman with a past medical history significant for stage IV MALT lymphoma (after chemotherapy and in remission) presented from a long term care facility for respiratory distress and altered mental status. The patient was in hypercarbic respiratory failure with a severe lactic acidosis. Her blood pressure deteriorated, she was begun on vasopressors and intubated. Pertinent labs demonstrated a white blood cell count of 0.9 X106 /ml, a hemoglobin of 7.1 g/dl, and a platelet count 66 X106 /ml. The patient was started on Cefepime and Linezolid presumptively for septic shock. Ultrasounds of her thorax were performed (Videos 1 & 2). What is the best explanation for the ultrasound findings shown above?1. Large pleural effusion; 2. Pneumothorax; 3. Consolidation due to pneumonia; 4. Ruptured diaphragm; 5. Lung abscess

No abstract available. Article truncated after first page. A 49-year-old man with type 2 diabetes, intravenous drug abuse and heart failure presented to the emergency room with 2 weeks of progressively worsening chest pain, lower extremity swelling and shortness of breath. The patient was found to have an elevated troponin as well as brain natriuretic peptide and the absence of ischemic electrocardiogram findings. The patient was admitted to the medical ICU for hypoxic respiratory failure and shock of uncertain etiology. Clinically he seemed to be in decompensated heart failure and a bedside echocardiogram was performed (Figures 1 and 2). What is the best explanation for the echocardiographic findings shown above? 1. Atrial myxoma; 2. Cardiac amyloidosis; 3. Cardiac lymphoma; 4. Takotsubo cardiomyopathy; 5. Tricuspid valve endocarditis ...

No abstract available. Article truncated after first page. An 82-year-old woman with prior medical history of stage IV colon cancer and chronic obstructive pulmonary disease presented to the medical intensive care unit with newly diagnosed community acquired pneumonia and acute kidney injury. The patient presented with acute onset of shortness of breath, nausea, generalized weakness, bilateral lower extremity swelling and decreased urine output. She was transferred for short term dialysis in the setting of multiple electrolyte abnormalities, including hyperkalemia of 6.4 mmol/l, as well as a creatinine of 6.5 mg/dl. The following imaging of the right internal jugular vein was performed with ultrasound during preparation for placement of a temporary triple lumen hemodialysis catheter. Based on the above imaging what would be the best location to place the dialysis catheter? 1. Left internal jugular vein; 2. Right femoral vein; 3. Right internal jugular vein; 4. Right subclavian vein. ...

No abstract available. Article truncated after 150 words. A 46 year old woman presented with progressive severe hypoxemia and a chronic appearing pulmonary embolus on chest CT angiogram to the intensive care unit. The patient was hemodynamically stable, but had an oxygen saturation of 86% on a high-flow 100% oxygen mask. The patient had been previously investigated for interstitial lung disease over the past 2 year, this was felt to be due to non-specific interstitial pneumonitis. Her echocardiogram findings are as presented below (Figures 1 and 2). The patient had refractory hypoxemia despite trials of high flow oxygen and non-invasive positive pressure ventilation. She had mild symptoms at rest but experienced severe activity intolerance secondary to exertional dyspnea. Vitals including blood pressure remained stable and normal during admission and the patient had a pulsus paradoxus measurement of < 10 mmHg. She had previously had an echocardiogram 6 months before that revealed significant pulmonary hypertension. What would be the ...

No abstract available. Article truncated after first page. A 63 year old female with a history of acute myelogenous leukemia presents with shortness of breath, fever and hypotension to the ICU. She is in septic shock on norepinephrine, and has been treated on the oncology unit with vancomycin, cefepime, acyclovir and voriconazole. She has been neutropenic for 1 month. The patient develops a progressive right lower chest opacity. This opacity has progressed in spite of antibiotics and antifungals. The portable AP chest radiograph is presented below (Figure 1). An ultrasound of the right chest was performed for further evaluation of the opacity (figure 2). Question: What pathology does the ultrasound reveal in the right hemithorax? 1. Air filled cavity; 2. Chest wall abscess; 3. Fractured ribs; 4. Pleural effusion and suspected empyema; 5. Simple consolidation ...

No abstract available. Article truncated at 150 words. A 34-year-old woman presented to the Emergency department with abdominal pain after ingestion of an unknown liquid that family felt might be poisonous. The patient had a past history of prior suicide attempts, as well as a history of polysubstance and alcohol abuse. The patient was confused, tangential and a difficult historian. The patient had a heart rate of 72, was normotensive, and had an oxygen saturation of 100% on room air. She was confused and answered questions intermittently. The remainder of her physical examination including her neurological exam was normal. The initial serum chemistry, anion gap, lactate, liver function tests were normal. Urine drug screen was positive for benzodiazepines, for which the patient was prescribed. An abdominal x-ray was performed showing a radiopaque substance in the abdomen (Figure 1A). It was eventually determined she ingested elemental mercury. Blood levels were elevated, and she did eventually have hematochezia. Colonoscopy was …

No abstract available. Article truncated after first page. A 54 year old male with a past medical history significant for granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis) and chronic kidney disease presented with hemoptysis and chest pain. On presentation, he was found to have a 10 cm right middle lobe cavitary lesion and was subsequently treated with high dose steroids, antibiotics and antifungals based on bronchoalveolar lavage results. On day 9 of his hospital stay the patient was found to have bilateral lower extremity deep venous thromboses that were treated with intravenous heparin. On day 11 of his stay, the patient started experiencing lower abdominal pain and hypotension. The patient was resuscitated with saline. Bedside ultrasonography was performed. What does the transverse view of the lower abdomen (just above the symphysis pubis) demonstrate? 1. Abdominal wall hematoma; 2. Distended bladder; 3. Horseshoe kidney; 4. Psoas hematoma.

A case-control design determined whether konzo, an upper motoneuron disease linked to food (cassava) toxicity was associated with protein carbamoylation and genetic variations. Exon sequences of thiosulfate sulfurtransferase (TST) or mercaptopyruvate sulfurtransferase (MPST), plasma cyanide detoxification rates, and 2D-LC-MS/MS albumin carbamoylation were assessed in 40 children [21 konzo-affected and 19 putatively healthy controls, mean (SD) age: 9.2 (3.0) years] subjected to cognition and motor testing using the Kaufman Assessment Battery and the Bruininks/Oseretsky Test, respectively. Konzo was significantly associated with higher levels of carbamoylated peptides 206-219 (LDELRDEGKASSAK, pep1) after adjusting for age, gender, albumin concentrations and BUN [regression coefficient: 0.03 (95%CI:0.02-0.05), p = 0.01]. Levels of pep1 negatively correlated with performance scores at all modalities of motor proficiency (r = 0.38 to 0.61; all p

Oculopharyngodistal myopathy (OPDM, OMIM #164310) and oculopharyngeal myopathy with leukoencephalopathy (OPML, OMIM #618637) are rare autosomal dominant diseases characterized by adult-onset weakness and atrophy of skeletal muscles of the face, the pharynx, the eyelid and the distal limbs. At the histopathological level, OPDM and OPML muscle fibers are characterized by the presence of cytoplasmic rimmed vacuoles and intranuclear inclusions, which are both ubiquitin- and p62-positive but of unknown origin. Recently, the genetic cause of OPML was identified as an expansion of GGC repeats, however located in a long non-coding RNA, LOC642361. Of interest, several genetic causes of OPDM were also identified very recently as identical expansions of 50 to 200 GGC repeats, however located within genetic regions annotated as "non-coding" in at least 5 different genes: LRP12, GIPC1, NOTCH2NLC, RILPL1 and ABCD3. As a result, OPDM is now sub-divided in 5 sub-groups, OPDM type 1 to 5, according to the genetic localization of its causal expanded GGC microsatellite mutation. Here, we found that the GGC repeat expansions located either in LOC642361 and that causes OPML, within GIPC1 or NOTCH2NLC 5'UTRs responsible respectively of OPDM2 and 3, or within RILPL1 antisense transcript, which cause OPDM4, are all embedded in small, previously unrecognized ORFs. Consequently, all these different GGC repeat expansions are translated in novel polyGlycine-containing proteins. Importantly, antibodies developed against these various proteins stain the rimmed vacuoles and intranuclear inclusions typical of OPDM, confirming translation of these GGC repeat expansions into novel proteins in patients. Moreover, we developed cell models for OPML, OPDM2, OPDM3 and OPDM4 and found that these polyGlycine proteins form cytoplasmic and intranuclear inclusions and are toxic for muscle cells. We are now in the process to develop mouse models of OPDM and OPML and first data will be presented. Finally, we found a pharmaceutical compound that solubilizes polyGlycine aggregates and rescues viability of muscle cell cultures, thus bringing hope to develop therapeutical options for these neuromuscular diseases. To conclude, these data suggest a common mechanism of toxicity to the multiple GGC repeat expansions in OPDM and OPML: their translation into novel and toxic polyGlycine-containing proteins. [ABSTRACT FROM AUTHOR]