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Background: Inhaler education for patients with asthma and patients with COPD is typically provided by non-pulmonologists. We studied inhaler education by pulmonologists to determine changes in clinical outcomes and inhaler use., Methods: This was a retrospective study of 296 subjects diagnosed with asthma, COPD, or both that evaluated use of inhaler technique education and its impact on (1) inhaler/dosage change consisting of dosage change in the same class of inhaler and/or change in number of inhalers, (2) forced expiratory volume in one second/forced vital capacity (FEV 1 /FVC%), (3) disease symptom control, (4) out-patient visits, (5) urgent care visits (6) emergency department visits, and (7) hospital admissions. One group received inhaler technique education by a pulmonologist while the other group did not., Results: The pulmonologist inhaler technique-educated group had significantly decreased relative risk for inhaler/dosage increase (relative risk 0.57 [95% CI 0.34-0.96], P = .03) and significantly increased odds for symptom control (odds ratio 2.15 [95% CI 1.24-3.74], P = .01) at 1-y follow-up as compared to the no education group. No differences occurred for FEV 1 /FVC%, out-patient visits, urgent care visits, emergency department visits, and hospital admissions., Conclusions: Pulmonologist education of inhaler technique for patients with asthma and patients with COPD was associated with decreased relative risk for inhaler/dosage increase and increased odds for symptom control. We recommend pulmonologists provide education of inhaler technique to patients with asthma and patients with COPD and not rely on non-pulmonologist education alone. Prospective research is needed to confirm the importance of proper inhaler techniques., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Background: Pulmonary hypertension (PH) is a known complication of HIV infection. Outcomes of HIV-infected patients with PH (HIV-PH) have not been well established. We aim to assess various in-hospital outcomes such as mortality, resource utilization, and health care burden associated with HIV patients with concurrent PH., Materials and Methods: We used National Inpatient Sample (NIS) 2015 Quarter 4 through 2019 for this study. We identified patients using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnostic codes with both HIV and pulmonary hypertension. Cohorts were weighted by NIS-provided algorithm which allows for national estimates. Univariate and multivariate regression analyses were used to determine odds ratios., Results: A total of 910,120 patients were identified with HIV, among which 28,175 (3.19%) were identified to have concurrent PH. When compared to HIV alone, HIV-PH patients were older (54.53(±11.61) vs. 49.44(±13.11), predominantly black (64.45% vs. 51.8%%), more often male (57.2%), all p < 0.001. HIV-PH cohort had higher comorbidities with higher Charlson Comorbidity Index (CCI) (7.07(±3.53) vs. 5.17(±3.65), had slightly longer LOS [adjusted mean difference (aMD) 0.79], higher healthcare burden corrected for inflation (aMD $17,065); all p < 0.001. In univariate regression analysis, patients with HIV-PH had significantly higher rates of developing heart failure (aOR 10.44), cardiogenic shock (aOR 5.67), cardiomyopathy (aOR 4.97), in-hospital cardiac arrest (aOR 1.94), respiratory failure (aOR 3.29), invasive mechanical ventilation (aOR 1.71), aspiration pneumonia (aOR 1.29), acute kidney injury (aOR 2.14). Lastly, patients with HIV-PH had higher in-hospital mortality within 30 days of admission (aOR 1.28) & overall in-hospital mortality (aOR 1.23); p < 0.005)., Conclusion: In patients with concomitant HIV and PH, there is a higher burden of comorbidities, and is associated with worse outcomes including mortality. Through this study, we highlight outcomes that will better risk stratifying patients with concurrent HIV and PH., Competing Interests: Declaration of competing interest We declare no conflict of interest that could be perceived as prejudicing the impartiality of this research. There are no financial or personal relationships with other people or organizations that could inappropriately influence or bias our work., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Non-Hodgkin's lymphoma (NHL) involving skeletal muscle is generally found to be a secondary metastasis and extremely rarely as a primary site of malignancy. Furthermore, in HIV patients, an increased incidence of lymphomas may be identified within the first six months of highly active antiretroviral therapy (HAART) initiation unmasked by immune reconstitution inflammatory syndrome (IRIS). We illustrate an extremely rare instance of NHL of the skeletal muscle in a young immunocompromised male with HIV/AIDS presenting as necrotizing myofasciitis complicated by compartment syndrome and hemodialysis-refractory type B lactic acidosis. A young Hispanic male with AIDS was admitted for acute left thigh pain and was soon found to have abscess formation with compartment syndrome requiring thigh fasciotomy. During the course of the ICU stay, the patient's clinical status acutely worsened with sepsis-induced multiorgan failure, including acute renal and acute liver failure requiring N-acetylcysteine and severe refractory metabolic acidosis requiring renal replacement therapy. Repeat imaging demonstrated diffuse myonecrosis. Left thigh muscle biopsy confirmed aggressive NHL of skeletal muscle. Despite months of arduous medical management in ICU, doxorubicin, vincristine, cyclophosphamide chemotherapy with concurrent high-dose prednisone for the vented patient, and intermittent curves of improvement, our patient succumbed to the nature of the disease and subsequently died from severe sepsis from the immunocompromised state. Interestingly, our patient's initial CD4 count was 1, which improved to 96 after five months of HAART, raising concerns for IRIS lymphoma. Given such rapid improvement with chemotherapy, the possibility of IRIS-related lymphoma, and the surprising dearth of data for chemotherapy use in critically ill patients on mechanical ventilation, more research is needed in these topics to better approach such complicated patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Mehta et al.)

Myopericarditis is a rare consequence of COVID-19 infection. Although extremely rare, COVID-19 can present without pulmonary involvement, and there have been reports of isolated cardiac involvement in one prior case We report a case of a young African American man presenting with myopericarditis following a recently recovered COVID-19 infection. Complicated by ICU admission requiring vasopressors; with eventual resolution following initiation of aspirin and colchicine for myopericarditis. Life threatening myopericarditis can occur following resolution of COVID-19 disease. The degree of cardiac involvement correlates poorly to the severity of pulmonary involvement., (Published by Elsevier Inc.)

Objective: In early 2019, a new coronavirus called SARS-CoV-2 emerged and changed the course of civilization. Our study aims to analyze the association between acute liver failure (ALF) and mortality in patients infected with COVID-19. A retrospective analysis of 864 COVID-19-infected patients admitted to Nassau University Medical Center in New York was performed., Design: ALF is identified by acute liver injury (elevations in liver enzymes), hepatic encephalopathy and an international normalised ratio greater than or equal to 1.5. These parameters were analysed via daily blood work and clinical assessment. Multivariate logistic regression model predicting mortality and controlling for confounders such as age, coronary artery disease, intubation, hypertension, diabetes mellitus and acute kidney injury were used to determine the association of ALF with mortality., Results: A total of 624 patients, out of the initial 864, met the inclusion criteria-having acute hepatitis and COVID-19 infection. Of those 624, 43 (6.9%) patients developed ALF during the course of their hospitalisation and their mortality rate was 74.4%. The majority of patients with ALF were male (60.6%). The logistic model predicting death and controlling for confounders shows COVID-19 patients with ALF had a nearly four-fold higher odds of death in comparison to those without ALF (p=0.0063)., Conclusions: Findings from this study suggest that there is a significant association between mortality and the presence of ALF in patients infected with COVID-19. Further investigation into patients with COVID-19 and ALF can lead to enhanced treatment regimens and risk stratification tools, which can ultimately improve mortality rates during these arduous times., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Valproic acid (VPA) is commonly used medication to treat seizure disorder and as prophylaxis for bipolar disorder. Acute VPA toxicity can cause varied symptoms ranging from mild drowsiness to severe cerebral oedema and coma. The therapeutic level of VPA is around 50-100 µg/mL and most of it is protein bound. It is mainly metabolised by liver and is eliminated via bile. The metabolites of VPA interfere with urea cycle and cause deficiency in carnitine leading to increase in ammonia levels. The use of carnitine to treat VPA toxicity is well known but it is still unclear if it lowers VPA levels. We report a case of VPA toxicity that did not respond to use of carnitine at 6000 mg orally but was successfully treated using meropenem leading to lowering of VPA levels and also clinical improvement of patient., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Cytomegalovirus (CMV) is a common double-stranded DNA (dsDNA) virus affecting a large majority of the world's population. In immunocompetent patients, CMV infection can range anywhere from an asymptomatic course to mononucleosis. However, in the immunocompromised patient, prognosis can be deadly as CMV can disseminate to the retina, liver, lungs, heart, and GI tract. We present a case of CMV pancreatitis afflicting an immunocompromised patient. Case Summary . A 45-year-old Hispanic female with no past medical history presented to the emergency department (ED) for three days of abdominal pain associated with nausea, vomiting, and diarrhea. ED vitals showed a sepsis picture with fever, tachycardia, low white blood cell (WBC) count with bandemia, and CT scan showing acute pancreatitis, cholelithiasis, gastritis, and colitis. The patient denied alcohol use and MRCP showed no stone impaction. Sepsis protocolled was initiated for biliary pancreatitis, and the patient was admitted to the medicine floors with appropriate consulting services. Over the course of admission, the patient responded poorly to treatment and had a steady decline in respiratory status. She tested positive for HIV with a severely depressed CD4 count (42 cells/McL) and high viral load (1,492,761 copies/ml) and started on appropriate prophylactic antibiotics and HAART therapy. The patient was moved to the Medical Intensive Care Unit (MICU) after acute respiratory failure secondary to ARDS requiring mechanical ventilation with initiation of ARDS protocol. The patient was hemodynamically unstable and required vasopressor support. Hospital course was complicated by melena which prompted an esophagogastroduodenostomy (EGD) with biopsy yielding CMV gastritis. Serum CMV viral load was also found to be positive along with an elevated lipase level, indicative of pancreatitis. Despite initiation of ganciclovir, the patient continued to have refractory hypoxia despite full ventilatory support and proning. Unfortunately, the patient was deemed too unstable for transfer to an ECMO facility. She eventually succumbed to respiratory failure. Discussion . CMV is a Herpesviridae virus that is prevalent among more than half of the world's population. Its effects range from no presenting symptoms to respiratory failure depending on immune status. CMV more commonly affects the retina, lungs, liver, and GI tract; however, in rare cases, it is known to affect the pancreas as well. Other more common causes of pancreatitis were ruled out during the progression of this patient, and an elevated lipase with high CMV viral load points towards CMV pancreatitis., Conclusion: This is one of only a few reported cases of CMV pancreatitis and warrants further study due to the massive prevalence of CMV in the entire world's population. Our case demonstrates the extent of dissemination of CMV in a severely immunocompromised patient by showing clear cut pancreatitis secondary to said viral infection with exclusion of other possible causes. Our hope is that clinicians will change their practice to include a more scrutinized study into causes of pancreatitis especially in their immunocompromised patients., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Jaffer Ahmad et al.)

Case Presentation: A 48-year-old man presented with a chief report of worsening dysphagia for 5 days. Initially, he had difficulty swallowing solids, but it has progressed to difficulty with liquids. There was associated sialorrhea, hypophonia, slurring of speech, hoarseness of voice, cough, and prominent upper extremity weakness. Of note, 2 weeks ago, the patient had an upper respiratory tract infection (including otitis media) that was treated with amoxicillin-clavulanate. His wife and son were also recently sick with an upper respiratory tract infection. His medical history included hypertension managed with amlodipine; he denied any history of TB, recent travel, or canned food ingestion. He denied fevers, stridor, dyspnea, rash, odynophagia, nausea, vomiting, or diarrhea., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: Klebsiella pneumoniae meningitis is most commonly seen as a nosocomial infection and in post-neurosurgical patients. Reports of community acquired Klebsiella pneumoniae meningitis cases are rare in the United States. The objective of this case report is to discuss an uncommon pathogen causing meningitis, Klebsiella pneumoniae , its risk and prognostic factors and to emphasize the importance of early recognition and appropriate antibiotic treatment., Case Report: We report a clinical case of adult community acquired Klebsiella pneumoniae meningitis with recovery. A 54-year-old diabetic male presented with two-week history of intermittent fevers, acute bilateral ear pain, headache and unsteady gait. Broad spectrum antibiotics were initiated. Klebsiella pneumoniae was isolated in the cerebrospinal fluid cultures. The patient recovered with only mild hearing loss in his left ear., Conclusion: Our case highlights the importance of suspecting Klebsiella pneumoniae in community acquired meningitis., Competing Interests: Conflicts of interest: All authors – none to declare.

Goodpasture's disease is an uncommon composite of features including renal failure with pulmonary hemorrhage secondary to an autoimmune response that specifically targets these organ systems. We present a case of particular interest in regards to atypical presentation, and the uncommon treatment that the patient underwent. A 65-year-old Afghani female arrived with complaints of nausea, vomiting, loss of appetite, malaise, decreased urine output, exertional dyspnea, and cough. The patient presented initially with renal failure and unexpectedly developed respiratory failure after hemodialysis. Initial CT of thorax revealed diffuse bilateral pulmonary edema. Subsequently, the patient received a bronchoscopy demonstrating alveolar hemorrhage, which highlights a clinician's need to maintain a differential and reassess patients. Anti-GBM antibody in the serum was detected and the renal biopsy revealed evidence of the antibody on immunofluorescence. In regards to management, the patient could only be treated with plasmapheresis as she had contraindication to initiation of immunosuppression, after which she showed significant clinical improvement. We would like to highlight the benefit of plasmapheresis without concomitant immunosuppression and recommend such an approach to be considered in similar clinical scenarios, where contraindication for immunosuppressant therapy exists.

Emphysematous gastritis with portal venous air is a rare condition usually caused by gas forming organisms. This may be secondary to local spread of an infection through the mucosa or rarely hematogenous dissemination from a distant focus. We present a young diabetic woman with uncontrolled diabetes mellitus who was admitted with sepsis and severe abdominal symptoms. Investigation revealed emphysematous pyelonephritis due to E. coli infection associated with emphysematous gastritis and air in the portal tract. She improved with broad spectrum antibiotics, fluid resuscitation and electrolyte and diabetic management. To our knowledge this is the first report showing the association between emphysematous pyelonephritis and gastritis with air in the portal system.

Aims: Reference values exist for endocardial but not for epicardial (EPI) substrate mapping in cases of cardiomyopathy-associated ventricular tachycardia. We sought to establish such values for EPI electrogram voltage, including areas with overlying fat., Methods and Results: Ten patients (six males) undergoing cardiac surgery were studied. After opening the pericardium, the distal bipole of an electrophysiology catheter was placed tangential to the EPI surface to obtain an electrogram recording. The bipole was tangentially rotated 90 degrees and the higher of the two amplitudes (mV) was taken as the local amplitude. Recordings were taken from normal left and right ventricular myocardium (n = 26 data points each), over thick (> or = 0.5 cm) fat at both ventricular bases (n = 16) and thin (<0.5 cm) fat at the mid-ventricular level (n = 32). A total of 100 recordings (mean 10/patient) were analysed. Four patients underwent valvular surgery, three bypass surgery, and three combined procedures. Mean age was 61.7 +/- 10.4 years and mean left ventricular ejection fraction was 46 +/- 12%. Electrogram amplitude was inversely related to EPI fat thickness. Over thick fat, 31% of recordings were <0.5 mV., Conclusion: Human EPI electrogram amplitude varies by ventricular chamber and significantly by EPI fat thickness. A cut-off of 0.5 mV to define 'scar' will include normal areas with thick overlying fat. EPI substrate maps should include data on EPI fat thickness for higher specificity.

Purpose: The aims of our study were to examine the role of colonoscopy as further workup for bowel wall thickening reported on computed tomography (CT) scans and to investigate whether there were significant differences in pathology found among the racial groups in our study population., Methods: This is a retrospective study from March 2005 and January 2007 of all patients who have undergone colonoscopy for bowel wall thickening found on CT scans of the abdomen., Results: Of 94 patients with bowel wall thickening on CT scans, 7 (8%) had adenocarcinoma, 5 (5%) had large adenomas, 3 (3%) had infectious colitis, 2 (2%) ischemic colitis, 1 (1%) had inflammatory bowel disease, and 1 (1%) had a benign stricture. Bowel wall thickening on CT scan predicted clinical pathology in 34% of African Americans, as compared to 14% of Hispanics. Patients with significant pathology were more likely to have anemia and lower albumin levels., Conclusion: Patients with bowel wall thickening found on CT scans should be referred for colonoscopy, given that significant pathology is found in 20% of the cases. African Americans were 2.5 times more likely to have clinically significant pathology as compared to Hispanics.

Single-wall carbon nanotube samples were studied under high pressures to 62 GPa using designer diamond anvils with buried electrical microprobes that allowed for monitoring of the four-probe electrical resistance at elevated pressure. After initial densification, the electrical resistance shows a steady increase from 3 to 42 GPa, followed by a sharp rise above 42 GPa. This sharp rise in electrical resistance at high pressures is attributed to opening of an energy band gap with compression. Nanoindentation hardness measurements on the pressure-treated carbon nanotube samples gave a hardness value of 0.50 +/- 0.03 GPa. This hardness value is approximately 2 orders of magnitude lower than the amorphous carbon phase produced in fullerenes under similar conditions. Therefore, the pressure treatment of single-wall carbon nanotubes to 62 GPa did not produce a superhard carbon phase.

We compare electrical and mechanical properties of C70 fullerene with high purity graphite to 48 GPa at room temperature using designer diamond anvils with embedded electrical microprobes. The electrical resistance of C70 shows a minimum at 20 GPa with transformation to an amorphous insulating phase complete above 35 GPa, while graphite remains conducting. Nanoindentation shows hardness values 220 times larger for the pressure quenched amorphous phase than for similarly treated graphite. Our studies establish that the amorphous carbon phase produced from C70 has unique properties not attainable from graphite.

Hypertensive diabetic rats develop a cardiomyopathy characterized by systolic and diastolic ventricular dysfunction, myocardial hypertrophy and fibrosis, pulmonary congestion and a very high mortality rate. Alterations in contractile proteins and sarcoplasmic reticular calcium (Ca2+) transport in diabetic myocardium and their partial reversal with verapamil suggest that calcium channel blockade may prevent death from congestive heart failure in hypertensive diabetic rats. A large group of rats with renovascular hypertension and streptozotocin diabetes were divided into four groups: untreated animals (Group 1) and animals treated with 100 (Group 2), 300 (Group 3) or 600 (Group 4) mg/kg per day of sustained release diltiazem mixed in their food. Treatment was begun shortly after the onset of hypertension and diabetes. Mortality rates after 4 months were 59% (19 of 32), 53% (17 of 32), 27% (7 of 26) and 35% (12 of 34) in Groups 1, 2, 3 and 4, respectively; the mortality rate in age-matched control rats was 5% (1 of 19). The reductions in mortality rates in Groups 3 and 4 were statistically significant. Diltiazem did not change systolic blood pressure, serum glucose concentration, heart rate or left ventricular mass. There was a trend to decreased left ventricular interstitial fibrosis and perivascular fibrosis in diltiazem-treated animals. Ventricular collagen concentration was similar in untreated hypertensive diabetic and control rats; levels were higher in hypertensive diabetic rats that died than in those that survived. There was a trend to decreased collagen concentration as diltiazem dose increased. Myosin isoenzyme distribution was not changed in Groups 3 and 4 (in comparison with Group 1). In all hypertensive diabetic groups, rats that died had a higher blood pressure, heart rate, relative left ventricular mass, lung weight and lung water than did survivors. The mortality rate was two to three times higher among rats with an initial blood pressure greater than or equal to 180 mm Hg. The beneficial effects of diltiazem on survival were most significant among rats with severe hypertension.