3,296,130 results on '"medicine.drug"'
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2. Sodium-glucose co-transporter 2 inhibitors: game changers when handled with care?
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Zay Htet and Mahzuz Karim
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medicine.medical_specialty ,030209 endocrinology & metabolism ,Disease ,030204 cardiovascular system & hematology ,Diabetes Complications ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Diabetes mellitus ,medicine ,Empagliflozin ,Humans ,In patient ,Dapagliflozin ,Intensive care medicine ,Sodium-Glucose Transporter 2 Inhibitors ,Canagliflozin ,business.industry ,General Medicine ,medicine.disease ,chemistry ,Diabetes Mellitus, Type 2 ,Novel agents ,Cardiovascular Diseases ,Relative risk ,business ,medicine.drug - Abstract
Recent years have seen a paradigm shift in the management of patients with diabetes mellitus. Rather than good glycaemic control being the sole primary aim, the therapeutic focus has broadened to consider potential additional cardiovascular and renal benefits. Sodium-glucose co-transporter 2 inhibitors, such as empagliflozin, canagliflozin and dapagliflozin, have gained increasing prominence, with evidence suggesting significant improvement in outcomes in patients with established cardiovascular and renal disease. Here, we discuss the benefits and relative risks of these novel agents and highlight important clinical issues of relevance to general physicians.
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- 2024
3. Ivabradine for Uncontrolled Sinus Tachycardia in Thyrotoxic Cardiomyopathy - Case Report
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Natan Arotsker, Moti Klein, Yoav Bichovsky, Limor Besser, Amit Frenkel, Merav Fraenkel, Ben-Zion Joshua, and Doron Zahger
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Tachycardia ,medicine.medical_specialty ,Thyrotoxic cardiomyopathy ,business.industry ,Sinus tachycardia ,Endocrinology, Diabetes and Metabolism ,Propranolol ,medicine.disease ,Internal medicine ,Heart failure ,Heart rate ,medicine ,Cardiology ,Thyroid storm ,Immunology and Allergy ,medicine.symptom ,business ,Ivabradine ,medicine.drug - Abstract
Background: Beta blockers, mainly propranalol, are usually administered to control heart rate in patients with thyrotoxicosis, especially when congestive heart failure presents. However, when thyrotoxicosis is not controlled, heart rate may be difficult to control even with maximal doses of propranolol. This presentation alerts physicians to the possibility of using ivabradine, a selective inhibitor of the sinoatrial pacemaker, for the control of heart rate. Case presentation: We present a 37-year-old woman with thyrotoxicosis and congestive heart failure whose heart rate was not controlled with a maximal dose of beta blockers during a thyroid storm. The addition of ivabradine, a selective inhibitor of the sinoatrial pacemaker, controlled her heart rate within 48 hours. Conclusion: Ivabradine should be considered in patients with thyrotoxicosis, including those with heart failure, in whom beta blockers are insufficient to control heart rate
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- 2023
4. Distinct Patterns of Abnormal Lateral Orbitofrontal Cortex Activity During Compulsive Grooming and Reversal Learning Normalize After Fluoxetine
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Sean C. Piantadosi, Matthew Geramita, Elizabeth E. Manning, Jamie L. Pierson, and Susanne E. Ahmari
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Fluoxetine ,Neural activity ,Calcium imaging ,Lateral Orbitofrontal Cortex ,Neural substrate ,medicine ,Psychology ,Neuroscience ,Biological Psychiatry ,medicine.drug - Abstract
Background Patients with obsessive-compulsive disorder (OCD) display disrupted performance and abnormal lateral orbitofrontal cortex (LOFC) activity during reversal learning tasks, yet it is unknown whether compulsions and reversal learning deficits share a common neural substrate. To answer this question, we measured neural activity with in vivo calcium imaging in LOFC during compulsive grooming and reversal learning before and after fluoxetine treatment. Methods Sapap3-knockout (KO) mice were used as a model for OCD-relevant behaviors. Sapap3-KOs and control littermates were injected with virus encoding GCaMP6f and implanted with gradient-index lenses to visualize LOFC activity using miniature microscopes. Grooming, reversal learning, and neural activity were measured pre- and post-fluoxetine treatment (18mg/kg, 4 weeks). Results Baseline compulsive grooming and reversal learning impairments in KOs improved after fluoxetine treatment. Additionally, KOs display distinct patterns of abnormal LOFC activity during grooming and reversal learning, both of which normalize after fluoxetine. Finally, reversal learning-associated neurons are distributed randomly amongst grooming-associated neurons (i.e. overlap is what would be expected by chance). Conclusions In OCD, the LOFC is disrupted during both compulsive behaviors and reversal learning, yet whether these behaviors share common neural underpinnings is unknown. We find that the LOFC plays distinct roles in compulsive grooming and impaired reversal learning and their improvement with fluoxetine. These findings suggest that LOFC plays separate roles in pathophysiology and treatment of different perseverative behaviors in OCD.
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- 2023
5. Neutrophilic dermatosis of the dorsal hands: A review of 123 cases
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David Pisani, Daniel Micallef, M. J. Boffa, and Maria Bonnici
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medicine.medical_specialty ,business.industry ,Sweet Syndrome ,Neutrophilic dermatosis of the dorsal hands ,Dermatology ,Dapsone ,medicine.disease ,Inflammatory bowel disease ,030207 dermatology & venereal diseases ,03 medical and health sciences ,0302 clinical medicine ,Patient age ,Female preponderance ,030220 oncology & carcinogenesis ,Erythematous plaque ,medicine ,Proper treatment ,business ,medicine.drug - Abstract
Background Neutrophilic dermatosis of the dorsal hands is an uncommon localised variant of Sweet syndrome first described in 1995. It is characterised by tender erythematous plaques, pustules and bullae on the dorsa of the hands. Literature Review A total of 123 cases of NDDH are included in this review. The mean patient age was 62.1 years and there was a slight female preponderance. 78.0% of cases had reported bilateral involvement and other sites were affected in almost a third of cases. Underlying disease was found in around 40% of patients, with the most common associations being haematological disorders (gammopathies, myelodysplasias or malignancies), recent infection, solid organ tumours and inflammatory bowel disease. Systemic and/or topical corticosteroids were employed in the treatment of 88.1% of cases while dapsone, colchicine and tetracyclines were the commonest steroid-sparing agents used. Improvement was often rapid and complete resolution the norm. Conclusions Whilst being uncommon, NDDH is frequently misdiagnosed and thus, its exact prevalence is probably underestimated. This may have significant implications including treatment delays or incorrect management. Moreover, recognition of NDDH is important since a correct diagnosis should trigger a search for underlying diseases and proper treatment with corticosteroids and/or steroid-sparing agents which is almost invariably curative.
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- 2023
6. Accumbal Histamine Signaling Engages Discrete Interneuron Microcircuits
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Erin S. Calipari, Lillian J. Brady, Kevin M. Manz, and Brad A. Grueter
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Interneuron ,biology ,Nucleus accumbens ,Optogenetics ,Article ,Synapse ,medicine.anatomical_structure ,Dopamine ,Synaptic plasticity ,medicine ,biology.protein ,Prefrontal cortex ,Neuroscience ,Biological Psychiatry ,Parvalbumin ,medicine.drug - Abstract
BACKGROUND: Central histamine (HA) signaling modulates diverse cortical and subcortical circuits throughout the brain, including the nucleus accumbens (NAc). The NAc, a key striatal subregion directing reward-related behavior, expresses diverse HA receptor subtypes that elicit cellular and synaptic plasticity. However, the neuromodulatory capacity of HA within interneuron microcircuits in the NAc remains unknown. METHODS: We combined electrophysiology, pharmacology, voltammetry, and optogenetics in male transgenic reporter mice to determine how HA influences microcircuit motifs controlled by parvalbumin-expressing fast-spiking interneurons (PV-INs) and tonically active cholinergic interneurons (CINs) in the NAc shell. RESULTS: HA enhanced CIN output through an H(2) receptor (H(2)R)-dependent effector pathway requiring Ca(2+)-activated small-conductance K(1) channels, with a small but discernible contribution from H(1)Rs and synaptic H(3)Rs. While PV-IN excitability was unaffected by HA, presynaptic H(3)Rs decreased feedforward drive onto PV-INs via AC-cAMP-PKA (adenylyl cyclase-cyclic adenosine monophosphate-protein kinase A) signaling. H(3)R-dependent plasticity was differentially expressed at mediodorsal thalamus and prefrontal cortex synapses onto PV-INs, with mediodorsal thalamus synapses undergoing HA-induced long-term depression. These effects triggered downstream shifts in PV-IN- and CIN-controlled microcircuits, including near-complete collapse of mediodorsal thalamus-evoked feedforward inhibition and increased mesoaccumbens dopamine release. CONCLUSIONS: HA targets H-|R, H(2)R, and H(3)Rs in the NAc shell to engage synapse- and cell type-specific mechanisms that bidirectionally regulate PV-IN and CIN microcircuit activity. These findings extend the current conceptual framework of HA signaling and offer critical insight into the modulatory potential of HA in the brain.
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- 2023
7. Quantitative Assessment of the in vivo Dissolution Rate to Establish a Modified IVIVC for Isosorbide Mononitrate Tablets
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Li Zhang, Zeneng Cheng, Lei Wang, Guoqing Zhang, and Yuexiang Tan
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IVIVC ,Chromatography ,Pharmacokinetics ,In vivo ,In vitro dissolution ,Chemistry ,Isosorbide mononitrate ,medicine ,Quantitative assessment ,Pharmaceutical Science ,Dissolution ,Dosage form ,medicine.drug - Abstract
A modified in vitro-in vivo correlation (IVIVC) of the oral solid dosage forms has been proposed as a linear correlation between in vitro and in vivo dissolution. Nevertheless, the analysis of in vivo dissolution is limited by the lack of available methods. In this proof-of-concept study, a novel pharmacokinetic (PK) model containing the in vivo dissolution process and its quantification was presented to directly estimate the in vivo dissolution rate constant (kd). The new model was validated with a hypothetical oral solution (kd → +∞). The accuracy of the new method was clarified by comparing with the relatively true value of kd from the literature. Isosorbide mononitrate (ISMN) was used as a model drug to explore the practicability of the novel method. The dissolution capacities of ISMN reference and test tablets were discriminated by an improved in vitro dissolution method. Following the human PK studies, the kd values and corresponding in vivo dissolution profiles of two formulations were obtained using the novel method. Finally, a modified level A IVIVC between in vitro and in vivo dissolution of ISMN tablets was established, which is expected to guide the optimization of the tablet formulation containing ISMN.
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- 2023
8. Nephrogenic Syndrome of Inappropriate Antidiuresis Mimicking Hyporeninemic Hypoaldosteronism: Case Report of Two Infants
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Cengiz Kara, Elif İzci Güllü, Jamala Mammadova, Murat Aydin, Eda Çelebi Bitkin, İstinye Üniversitesi, Tıp Fakültesi, Dahili Tıp Bilimleri Bölümü, and Kara, Cengiz
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Inappropriate Antidiuretic Hormone Secretion ,medicine.medical_specialty ,Vasopressin ,business.industry ,Endocrinology, Diabetes and Metabolism ,Fludrocortisone ,Hyporeninemic hypoaldosteronism ,medicine.disease ,Gastroenterology ,Plasma osmolality ,AVPR2 Gene ,Endocrinology ,Arginine vasopressin receptor 2 ,Internal medicine ,Pediatrics, Perinatology and Child Health ,Syndrome of inappropriate antidiuretic hormone secretion ,medicine ,Urine osmolality ,Hyponatremia ,business ,medicine.drug - Abstract
Nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is an X-linked disease caused by activating mutations in the arginine vasopressin (AVP) receptor-2 (AVPR2) gene. Affected patients excrete concentrated urine despite very low levels of AVP, and consequently develop euvolemic hyponatremia. Due to its low frequency, patients may be misdiagnosed and treated incorrectly. We report two related male infants with NSIAD that was initially confused with hyporeninemic hypoaldosteronism (HH). First, a 2-month-old male presented with hyponatremia, low plasma osmolality, relatively high urine osmolality, and low plasma renin-aldosterone levels. These clinical and laboratory findings were compatible with syndrome of inappropriate antidiuretic hormone secretion without apparent cause. Consequently,fludrocortisone was initiated with a presumptive diagnosis of HH While correction of hyponatremia, fludrocortisone treatment led to hypertension and discontinued in a short time. The second patient at age of 1 year was admitted with a history of oligohydramnios, four times hospitalizations due to hyponatremia since birth, and a diagnosis of epilepsy. Similarly, the second infant had clinical and laboratory findings compatible with syndrome of inappropriate antidiuretic hormone secretion with no apparent cause. Fluid restriction normalized his serum sodium despite plasma AVP level was undetectable. In both infants, AVPR2 gene analysis revealed a known mutation (c.409C>T; p.R137C) and confirmed the diagnosis of NSIAD. In conclusion, NSIAD should be considered in all patients with unexplained euvolemic hyponatremia despite high urine osmolality. In case of unawareness from NSIAD, plasma renin-aldosterone profile can be confused with HH, especially in the infants. 34645113
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- 2023
9. Liraglutide Treatment in a Morbidly Obese Adolescent with a MC4R Gene Variant: Side Effects Reduce Success
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İbrahim Tekedereli, Ayşehan Akıncı, Emine Çamtosun, Nurdan Çiftçi, and Leman Kayaş
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medicine.medical_specialty ,Liraglutide ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine.disease ,Obesity ,Orlistat ,Endocrinology ,Insulin resistance ,Weight loss ,Internal medicine ,Pediatrics, Perinatology and Child Health ,medicine ,medicine.symptom ,business ,Body mass index ,Weight gain ,Acanthosis nigricans ,medicine.drug - Abstract
Variants of the melanocortin-4 receptor (MC4R) gene are the most common cause of monogenic obesity. In this situation; while obesity cannot be controlled with diet and exercise, it was shown that Glucagon-like-peptide-1 receptor agonists (GLP-1 RA) provide weight loss in short term. In this paper, we present our experience with Liraglutide treatment in an adolescent patient carrying MC4R gene variant. A female patient had admitted first at the age of 12.5 years with a complaint of progressive weight gain. She had a marked excess of appetite since infancy. In the physical examination of the pubertal female patient with a body mass index (BMI) of 36.1kg/m2 (3.48 SDS), there was no pathological finding except diffuse acanthosis nigricans. Laboratory examinations revealed only insulin resistance. Weight loss couldn't be achieved with lifestyle changes, metformin and orlistat treatments In genetic examination, a sporadic heterozygous c.206T>G(p.I69R) variant (reported previously) was found in the MC4R gene. GLP-1 RA Liraglutide treatment was initiated and a loss of 19.2% reduction was achieved in the patient's body weight and BMI at the end of 32 weeks. However, the patient, whose treatment compliance was disrupted due to significant gastrointestinal complaints, returned to her former weight within a few months after treatment was stopped. In our case carrying a pathogenic variant in the MC4R gene, decrease of appetite and weight loss were achieved with Liraglutide treatment, but this situation could not be maintained. In such cases, there is a need for effective and tolerable treatment options.
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- 2023
10. Prolyl Endopeptidase-like Deficiency Associated with Growth Hormone Deficiency
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Diego Yeste, Maria Irene Valenzuela, Rosangela Tomasini, Maria Grazia Clemente, Paula Fernández-Alvarez, and Laura Sayol-Torres
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medicine.medical_specialty ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine.disease ,Phenotype ,Growth hormone deficiency ,Endocrinology ,Hypergonadotropic hypogonadism ,Neonatal hypotonia ,Prolyl endopeptidase ,Internal medicine ,Pediatrics, Perinatology and Child Health ,Genotype ,medicine ,Allele ,business ,medicine.drug ,Congenital disorder - Abstract
Prolyl endopeptidase-like (PREPL) deficiency (MIM#616224) is a rare congenital disorder characterised by neonatal hypotonia and feeding difficulties, growth hormone (GH) deficiency and hypergonadotropic hypogonadism. This syndrome is an autosomal recessive disease resulting from mutations in the PREPL gene (MIM#609557). Herein we report a 7-year-old female patient with biallelic mutations in PREPL (c.1528C>T in one allele and a whole gene deletion in the other) with early growth impairment in infancy. Growth hormone deficiency was confirmed at 20 months of life. Recombinant growth hormone treatment was introduced with a good response. Her clinical features were similar to those of previously reported cases. The description of new patients with PREPL deficiency syndrome is essential to better delineate the phenotypic and genotypic spectrum of the disease.
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- 2023
11. Phase III Study Comparing Cisplatin Plus Gemcitabine With Cisplatin Plus Pemetrexed in Chemotherapy-Naive Patients With Advanced-Stage Non–Small-Cell Lung Cancer
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Lorinda Simms, Shehkar Patil, David R. Gandara, Anders Mellemgaard, Raghunadharao Digumarti, Bonne Biesma, Johan Vansteenkiste, Mauro Zukin, Joachim von Pawel, Katherine P. Sugarman, Keunchil Park, Christian Manegold, Filippo de Marinis, Tuncay Göksel, Janusz Rolski, Piotr Serwatowski, Jin S. Lee, Giorgio V. Scagliotti, Ulrich Gatzemeier, and Purvish M. Parikh
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Male ,Oncology ,medicine.medical_specialty ,Cancer Research ,Guanine ,Lung Neoplasms ,medicine.medical_treatment ,Kaplan-Meier Estimate ,Pemetrexed ,Deoxycytidine ,chemistry.chemical_compound ,Glutamates ,Carcinoma, Non-Small-Cell Lung ,Internal medicine ,Antineoplastic Combined Chemotherapy Protocols ,medicine ,Humans ,Lung cancer ,Aged ,Cisplatin ,Chemotherapy ,business.industry ,Middle Aged ,medicine.disease ,Gemcitabine ,Surgery ,Regimen ,chemistry ,Female ,business ,medicine.drug ,Necitumumab - Abstract
PURPOSE Cisplatin plus gemcitabine is a standard regimen for first-line treatment of advanced non–small-cell lung cancer (NSCLC). Phase II studies of pemetrexed plus platinum compounds have also shown activity in this setting. PATIENTS AND METHODS This noninferiority, phase III, randomized study compared the overall survival between treatment arms using a fixed margin method (hazard ratio [HR] < 1.176) in 1,725 chemotherapy-naive patients with stage IIIB or IV NSCLC and an Eastern Cooperative Oncology Group performance status of 0 to 1. Patients received cisplatin 75 mg/m2 on day 1 and gemcitabine 1,250 mg/m2 on days 1 and 8 (n = 863) or cisplatin 75 mg/m2 and pemetrexed 500 mg/m2 on day 1 (n = 862) every 3 weeks for up to six cycles. RESULTS Overall survival for cisplatin/pemetrexed was noninferior to cisplatin/gemcitabine (median survival, 10.3 v 10.3 months, respectively; HR = 0.94; 95% CI, 0.84 to 1.05). Overall survival was statistically superior for cisplatin/pemetrexed versus cisplatin/gemcitabine in patients with adenocarcinoma (n = 847; 12.6 v 10.9 months, respectively) and large-cell carcinoma histology (n = 153; 10.4 v 6.7 months, respectively). In contrast, in patients with squamous cell histology, there was a significant improvement in survival with cisplatin/gemcitabine versus cisplatin/pemetrexed (n = 473; 10.8 v 9.4 months, respectively). For cisplatin/pemetrexed, rates of grade 3 or 4 neutropenia, anemia, and thrombocytopenia ( P ≤ .001); febrile neutropenia ( P = .002); and alopecia ( P < .001) were significantly lower, whereas grade 3 or 4 nausea ( P = .004) was more common. CONCLUSION In advanced NSCLC, cisplatin/pemetrexed provides similar efficacy with better tolerability and more convenient administration than cisplatin/gemcitabine. This is the first prospective phase III study in NSCLC to show survival differences based on histologic type.
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- 2023
12. Descripción de una serie de pacientes con miastenia gravis refractaria
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Tomás Segura, A. Martínez-Martín, J.M. Pardal-Fernández, I. Díaz-Maroto, and Jorge García-García
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medicine.medical_specialty ,business.industry ,Eculizumab ,medicine.disease ,Gastroenterology ,Myasthenia gravis ,03 medical and health sciences ,0302 clinical medicine ,Refractory ,Disease severity ,Quality of life ,Prednisone ,Internal medicine ,Cohort ,medicine ,Rituximab ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
INTRODUCTION Advances in the treatment of myasthenia gravis (MG) have improved quality of life and prognosis for the majority of patients. However, 10%-20% of patients present refractory MG, with frequent relapses and significant functional limitations. PATIENTS AND METHODS Patients with refractory MG were selected from a cohort of patients diagnosed with MG between January 2008 and June 2019. Refractory MG was defined as lack of response to treatment with prednisone and at least 2 immunosuppressants, inability to withdraw treatment without relapse in the last 12 months, or intolerance to treatment with severe adverse reactions. RESULTS We identified 84 patients with MG, 11 of whom (13%) met criteria for refractory MG. Mean (standard deviation) age was 47 (18) years; 64% of patients with refractory MG had early-onset generalised myasthenia (as compared to 22% in the group of patients with MG; P
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- 2023
13. Randomized Phase II Trial Comparing Bevacizumab Plus Carboplatin and Paclitaxel With Carboplatin and Paclitaxel Alone in Previously Untreated Locally Advanced or Metastatic Non-Small-Cell Lung Cancer
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David H. Johnson, Roy S. Herbst, Corey J. Langer, Louis Fehrenbacher, William Novotny, Eric Holmgren, Jacques Gaudreault, John Nemunaitis, David M. Jablons, Fairooz F. Kabbinavar, Russell F. DeVore, and Lisa A. Damico
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Male ,medicine.medical_specialty ,Cancer Research ,Lung Neoplasms ,Bevacizumab ,Paclitaxel ,Urology ,Antibodies, Monoclonal, Humanized ,Carboplatin ,chemistry.chemical_compound ,Carcinoma, Non-Small-Cell Lung ,Antineoplastic Combined Chemotherapy Protocols ,medicine ,Carcinoma ,Motesanib ,Humans ,Lung cancer ,Proportional Hazards Models ,Dose-Response Relationship, Drug ,business.industry ,Area under the curve ,Antibodies, Monoclonal ,medicine.disease ,Survival Analysis ,Surgery ,chemistry ,Oncology ,Female ,business ,medicine.drug ,Necitumumab - Abstract
Purpose To investigate the efficacy and safety of bevacizumab plus carboplatin and paclitaxel in patients with advanced or recurrent non-small-cell lung cancer. Patients and Methods In a phase II trial, 99 patients were randomly assigned to bevacizumab 7.5 (n = 32) or 15 mg/kg (n = 35) plus carboplatin (area under the curve = 6) and paclitaxel (200 mg/m2) every 3 weeks or carboplatin and paclitaxel alone (n = 32). Primary efficacy end points were time to disease progression and best confirmed response rate. On disease progression, patients in the control arm had the option to receive single-agent bevacizumab 15 mg/kg every 3 weeks. Results Compared with the control arm, treatment with carboplatin and paclitaxel plus bevacizumab (15 mg/kg) resulted in a higher response rate (31.5% v 18.8%), longer median time to progression (7.4 v 4.2 months) and a modest increase in survival (17.7 v 14.9 months). Of the 19 control patients that crossed over to single-agent bevacizumab, five experienced stable disease, and 1-year survival was 47%. Bleeding was the most prominent adverse event and was manifested in two distinct clinical patterns; minor mucocutaneous hemorrhage and major hemoptysis. Major hemoptysis was associated with squamous cell histology, tumor necrosis and cavitation, and disease location close to major blood vessels. Conclusion Bevacizumab in combination with carboplatin and paclitaxel improved overall response and time to progression in patients with advanced or recurrent non-small-cell lung cancer. Patients with nonsquamous cell histology appear to be a subpopulation with improved outcome and acceptable safety risks.
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- 2023
14. DRESS, the maverick among SCARS: A case series-based review of literature
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Pankaj Das, Anwita Sinha, Preema Sinha, Prerna Shankar, Prateek Kinra, Aradhana Sood, and Vikas Pathania
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Phenytoin ,medicine.medical_specialty ,business.industry ,Hypersensitivity syndrome ,Scars ,General Medicine ,Disease ,Tertiary care hospital ,Multiorgan failure ,Dermatology ,medicine ,medicine.symptom ,Presentation (obstetrics) ,Adverse effect ,business ,medicine.drug - Abstract
DRESS is a potentially life-threatening severe cutaneous adverse reaction (SCAR). Historically, it was most frequently linked with phenytoin and was initially described as phenytoin hypersensitivity syndrome; however, it was later found to be caused by various other medications, with the commonest been aromatic anticonvulsants, allopurinol and sulfonamides. The severity of this entity is related to systemic involvement, which can result in multiorgan failure and death. The diagnosis of DRESS, especially in the early stages, remains challenging and elusive due to its heterogeneous clinical presentation and the complex course of the disease with different patterns depending on the causal drug. The most important step in the management of DRESS is early diagnosis and immediate cessation of the suspected offending drug along with oral steroids or immunosuppressants to control the disease. We describe the varying presentation and management of six adults with DRESS from a tertiary care hospital, observed over a two-year period with a brief review of the literature.
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- 2023
15. Oxcarbazepine-induced toxic epidermal necrolysis in lupus erythematosus: Turning into a 'frequent' rarity but is it diagnosing that matters?
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Rohit Kothari, Arun Hegde, Prateek Kinra, and Adwait Sodani
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Drug ,medicine.medical_specialty ,Lupus erythematosus ,business.industry ,media_common.quotation_subject ,Lupus nephritis ,General Medicine ,medicine.disease ,Dermatology ,Rash ,Toxic epidermal necrolysis ,Pulse methylprednisolone ,medicine ,medicine.symptom ,Vasculitis ,Oxcarbazepine ,business ,media_common ,medicine.drug - Abstract
Classic Toxic Epidermal Necrolysis (TEN) in Lupus Erythematosus (LE) is rare and that caused by oxcarbazepine is even rarer. It can be triggered/induced by various insults, the most prominent being drugs. Herein, we describe a young female, a diagnosed case of LE with lupus nephritis, with recent-onset central nervous system vasculitis (incidentally detected on neuroimaging while she was being evaluated for a recent-onset behavioural change), who within a month of exposure to the drug developed an extensive exfoliating skin rash with mucosal lesions, which on histopathological evaluation showed TEN in LE, triggered by Oxcarbazepine, which was commenced for seizure prophylaxis. She was managed with pulse methylprednisolone, followed by intravenous immunoglobulin (IVIg), after which she made a satisfactory recovery. It is highlighted that TEN in LE patterns must be recognized in an emergency and Acute Syndrome of Apoptotic Panepidermolysis (ASAP) concept applied promptly without awaiting diagnoses. Further, many common drugs possibly trigger this pathology making the rara-avis not rare anymore!
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- 2023
16. Hydration State and Hyaluronidase Treatment Significantly Affect Porcine Vocal Fold Biomechanics
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Julian M. Jimenez, Chenwei Duan, Craig J. Goergen, Abigail Cox, Preeti M. Sivasankar, and Sarah Calve
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Fold (higher-order function) ,LPN and LVN ,medicine.disease ,Article ,Extracellular matrix ,030507 speech-language pathology & audiology ,03 medical and health sciences ,Speech and Hearing ,chemistry.chemical_compound ,0302 clinical medicine ,medicine.anatomical_structure ,Otorhinolaryngology ,chemistry ,Hyaluronidase ,Vocal folds ,Hyaluronic acid ,otorhinolaryngologic diseases ,medicine ,Biophysics ,Tonicity ,Dehydration ,030223 otorhinolaryngology ,0305 other medical science ,Ex vivo ,medicine.drug - Abstract
Summary Objectives The understanding of vocal fold hydration state, including dehydrated, euhydrated, rehydrated tissue, and how hydration affects vocal fold biomechanical properties is still evolving. Although clinical observations support the benefits of increasing vocal fold hydration after dehydrating events, more mechanistic information on the effects of vocal fold dehydration and the beneficial effects of rehydration are needed. Alterations to hyaluronic acid (HA), an important component of the vocal fold extracellular matrix, are likely to influence the biomechanical properties of vocal folds. In this study, we investigated the influence of hydration state and HA on vocal fold tissue stiffness via biomechanical testing. Study design Prospective, ex vivo study design. Methods Fresh porcine vocal folds (N = 18) were examined following sequential immersion in hypertonic (dehydration) and isotonic solutions (rehydration). In a separate experiment, vocal folds were incubated in hyaluronidase (Hyal) to remove HA. Control tissues were not exposed to any challenges. A custom micromechanical system with a microforce sensing probe was used to measure the force-displacement response. Optical strain was calculated, and ultrasound imaging was used to measure tissue cross-sectional area to obtain stress-strain curves. Results Significant increases (P ≤ 0.05) were found in tangent moduli between dehydrated and rehydrated vocal folds at strains of e = 0.15. The tangent moduli of Hyal-digested tissues significantly increased at both e = 0.15 and 0.3 (P ≤ 0.05). Conclusion Vocal fold dehydration increased tissue stiffness and rehydration reduced the stiffness. Loss of HA increased vocal fold stiffness, suggesting a potential mechanical role for HA in euhydrated vocal folds.
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- 2023
17. Ultrasound-guided continuous costoclavicular block through retrograde stimulating catheter technique for postoperative analgesia in shoulder surgery: a case series
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Sandeep Diwan, Abhijit S Nair, Parag Sancheti, and Divya Sethi
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medicine.medical_specialty ,Proximal humerus ,Shoulder surgery ,business.industry ,medicine.medical_treatment ,Postoperative pain ,Analgesic ,General Medicine ,Ultrasound guided ,Surgery ,03 medical and health sciences ,Catheter ,0302 clinical medicine ,030202 anesthesiology ,medicine ,Tramadol ,business ,Brachial plexus ,medicine.drug - Abstract
In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.
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- 2023
18. Antivirals Targeting the Neuraminidase
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Teena Mohan and Larisa V. Gubareva
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0301 basic medicine ,Oseltamivir ,medicine.drug_class ,Neuraminidase ,Monoclonal antibody ,Antiviral Agents ,General Biochemistry, Genetics and Molecular Biology ,Epitope ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Zanamivir ,Drug Resistance, Viral ,Influenza, Human ,medicine ,Humans ,Enzyme Inhibitors ,biology ,Chemistry ,Antibodies, Monoclonal ,Virology ,Laninamivir ,030104 developmental biology ,Viral replication ,030220 oncology & carcinogenesis ,biology.protein ,Peramivir ,medicine.drug - Abstract
The neuraminidase (NA) of influenza A and B viruses plays a distinct role in viral replication and has a highly conserved catalytic site. Numerous sialic (neuraminic) acid analogs that competitively bind to the NA active site and potently inhibit enzyme activity have been synthesized and tested. Four NA inhibitors are now licensed in various parts of the world (zanamivir, oseltamivir, peramivir, and laninamivir) to treat influenza A and B infections. NA changes, naturally occurring or acquired under selective pressure, have been shown to reduce drug binding, thereby affecting the effectiveness of NA inhibitors. Drug resistance and other drawbacks have prompted the search for the next-generation NA-targeting therapeutics. One of the promising approaches is the identification of monoclonal antibodies (mAbs) targeting the conserved NA epitopes. Anti-NA mAbs demonstrate Fab-based antiviral activity supplemented with Fc-mediated immune effector functions. Antiviral Fc-conjugates offer another cutting-edge strategy that is based on a multimodal mechanism of action. These novel antiviral agents are composed of a small-molecule NA inhibitor and an Fc-region that simultaneously engages the immune system. The significant advancements made in recent years further support the value of NA as an attractive target for the antiviral development.
- Published
- 2024
19. Isolation and characterization of bacteria associated with silkworm gut under antibiotic-treated larval feeding
- Author
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A. Javaid, M. Hussain, K. Aftab, M. F. Malik, M. Umar, and T. Iqbal
- Subjects
QH301-705.5 ,medicine.drug_class ,Tetracycline ,Science ,sericulture ,Antibiotics ,B. mori ,Microbial Sensitivity Tests ,Biology ,silkworm gut ,Serratia ,Microbiology ,Agar plate ,RNA, Ribosomal, 16S ,Ampicillin ,bacterial pathogens ,medicine ,Animals ,Biology (General) ,Phylogeny ,Bacteria ,Pseudomonas ,fungi ,Botany ,chinese race ,Bombyx ,biology.organism_classification ,Anti-Bacterial Agents ,Penicillin ,QL1-991 ,Larva ,QK1-989 ,General Agricultural and Biological Sciences ,Zoology ,medicine.drug - Abstract
The impact of antibiotics on growth, cocoon production was assessed in addition to isolation and characterization of bacteria associated with silkworm gut of infected larvae. Larval rearing was maintained at recommended conditions of temperature and humidity. Silkworm larvae showing abnormal symptoms were collected from the control group and dissected for gut collection. Bacteria were isolated from the gut content by spreading on agar plates and incubated at 37 °C for 48 hrs. Bacterial identification and phylogenetic analysis were carried out by 16S rRNA gene sequencing. The isolated bacteria were subjected to antimicrobial susceptibility test (disc diffusion methods) by using Penicillin (10 µg/mL), Tetracycline (30 µg/mL), Amoxicillin (25 µg/mL), Ampicillin (10 µg/mL), and Erythromycin (15 µg/mL). All isolated strains showed positive results for the catalase test. We isolated and identified bacterial strains (n = 06) from the gut of healthy and diseased silkworm larvae. Based on the 16S rRNA gene sequence, isolated bacteria showed close relation with Serratia, Bacillus, and Pseudomonas spp. Notably, 83.3% of strains were resistant to Penicillin, Tetracycline, Amoxicillin, Ampicillin, and Erythromycin but 16.6% showed antibiotic susceptibility to the above-mentioned commonly used antibiotics. Silkworm larvae fed on penicillin-treated leaves showed significant improvement in larval weight, larval length, and cocoon production. Significantly higher larval weight (6.88g), larval length (5.84cm), and cocoon weight (1.33g) were recorded for larvae fed on leaves treated with penicillin as compared to other antibiotics. Isolated bacterial strains showed close relation with Serratia spp., Bacillus spp. and Pseudomonas spp.
- Published
- 2024
20. Disorders of the Adrenal Gland
- Author
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Patricia Y. Fechner
- Subjects
medicine.medical_specialty ,Adrenal gland ,business.industry ,medicine.drug_class ,Adrenal crisis ,Gestational age ,medicine.disease ,medicine.anatomical_structure ,Endocrinology ,Mineralocorticoid ,Internal medicine ,medicine ,High doses ,Adrenal insufficiency ,Congenital adrenal hyperplasia ,medicine.symptom ,business ,Hydrocortisone ,medicine.drug - Abstract
• Infants born with ambiguous genitalia or nonpalpable testes need to be evaluated for congenital adrenal hyperplasia as it can be life threatening. • Adrenal steroid levels vary with gestational age. • Adrenal insufficiency should be treated with hydrocortisone to avoid adrenal crisis. High doses of hydrocortisone contain mineralocorticoid activity.
- Published
- 2024
21. Post-thymectomy myasthenia gravis: a case report and systematic review of literature
- Author
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Adam Maxwell, Gabriel Yiin, Alexandra Rice, and Louise Gurowich
- Subjects
Weakness ,Pediatrics ,medicine.medical_specialty ,Neuromuscular disease ,Thymoma ,medicine.medical_treatment ,Ptosis ,Myasthenia Gravis ,medicine ,Humans ,Receptors, Cholinergic ,Autoantibodies ,Aged, 80 and over ,business.industry ,Correction ,General Medicine ,Thymus Neoplasms ,medicine.disease ,Thymectomy ,Myasthenia gravis ,Pyridostigmine ,Prednisolone ,Female ,medicine.symptom ,business ,medicine.drug - Abstract
Myasthenia gravis (MG) is an autoimmune condition affecting the neuromuscular junction characterised by weakness and fatiguability, carrying a high morbidity if treatment is delayed. A clear association with thymoma has led to management with thymectomy as a common practice, but MG presenting post-thymectomy has rarely been reported. We present a case of an 82- year-old woman developing fatigue, ptosis and dysarthria 3 months after thymectomy. After a clinical diagnosis of MG was made, she responded well to prompt treatment with prednisolone and pyridostigmine. Her anti-acetylcholine receptor antibody (anti-AChR) subsequently came back positive. Our systematic review reveals that post-thymectomy MG can be categorised as early-onset or late-onset form with differing aetiology, and demonstrated correlation between preoperative anti-AChR titres and post-thymectomy MG. The postulated mechanisms for post-thymectomy MG centre around long-lasting peripheral autoantibodies. Clinicians should actively look for MG symptoms in thymoma patients and measure anti-AChR preoperatively to aid prognostication.
- Published
- 2023
22. Effects of plant-based versus marine-based omega-3 fatty acids and sucrose on brain and liver fatty acids in a mouse model of chemotherapy
- Author
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Tonya Orchard, Tial TinKai, Rachel M. Cole, A. Courtney DeVries, Rebecca Andridge, Kate Ormiston, Maryam B. Lustberg, Julie Fitzgerald, and Monica M. Gaudier-Diaz
- Subjects
medicine.medical_specialty ,Sucrose ,Docosahexaenoic Acids ,Linoleic acid ,Medicine (miscellaneous) ,Lipid peroxidation ,chemistry.chemical_compound ,Mice ,Internal medicine ,Fatty Acids, Omega-3 ,medicine ,Animals ,Doxorubicin ,chemistry.chemical_classification ,Nutrition and Dietetics ,alpha-Linolenic acid ,General Neuroscience ,Brain-Derived Neurotrophic Factor ,Fatty Acids ,food and beverages ,Brain ,General Medicine ,Eicosapentaenoic acid ,Mice, Inbred C57BL ,Disease Models, Animal ,Endocrinology ,chemistry ,Eicosapentaenoic Acid ,Liver ,Docosahexaenoic acid ,lipids (amino acids, peptides, and proteins) ,Biomarkers ,Polyunsaturated fatty acid ,medicine.drug - Abstract
Chemotherapy can result in toxic side effects in the brain. Intake of marine-based omega-3 polyunsaturated fatty acids (n-3 PUFAs), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), alter brain fatty acids, potentially improving brain function. However, it is unclear if alpha-linolenic acid (ALA), the plant-based n-3, affects brain PUFAs during chemotherapy. The objective of this study was to examine the effects of dietary ALA, EPA and DHA, with high or low sucrose, on brain PUFAs in a mouse model of chemotherapy. Secondarily, the use of liver PUFAs as surrogate measures of brain PUFAs was examined. Lipid peroxidation (4-HNE) and neurotrophic markers (BDNF) were assessed. Female C57Bl/6 mice (n = 90) were randomized to 1 of 5 diets (high EPA + DHA/high or low sucrose, high ALA/high or low sucrose, or control with no EPA + DHA/low ALA/low sucrose) and injected with doxorubicin-based chemotherapy or saline. Brain EPA and DHA were greater (p < 0.0001) with high EPA + DHA diets, regardless of sucrose; there were no significant differences in brain PUFAs between high ALA diets and control. Chemotherapy-treated mice had higher brain and liver DHA (p < 0.05) and lower brain and liver linoleic acid (p < 0.0001). Brain n-3 and n-6 PUFAs were strongly correlated with liver n-3 (r = 0.8214, p < 0.0001) and n-6 PUFAs (r = 0.7568, p < 0.0001). BDNF was correlated with brain total PUFAs (r = 0.36; p < 0.05). In conclusion, dietary ALA in proportions approximately two times greater than consumed by humans did not appreciably increase brain n-3 PUFAs compared to low ALA intake. Liver PUFAs may be a useful surrogate marker of brain PUFAs in this mouse model.
- Published
- 2023
23. The Association of Postoperative Opioid Prescriptions with Patient Outcomes
- Author
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Vidhya Gunaseelan, Michael J. Englesbe, Mark C. Bicket, Craig S. Brown, Kao-Ping Chua, Jennifer F. Waljee, Chad M. Brummett, Yen-Ling Lai, and Ryan Howard
- Subjects
Adult ,Male ,medicine.medical_specialty ,Quality of life ,Internal medicine ,medicine ,Humans ,Practice Patterns, Physicians' ,Adverse effect ,Retrospective Studies ,Pain, Postoperative ,business.industry ,Incidence (epidemiology) ,Retrospective cohort study ,Emergency department ,Middle Aged ,Confidence interval ,Analgesics, Opioid ,Prescriptions ,Opioid ,Cohort ,Quality of Life ,Surgery ,Female ,business ,medicine.drug - Abstract
Objective To compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids. Summary of background data Postoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks. Methods We performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups. Results In a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids (P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%-13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%-85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)]. Conclusions Patients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.
- Published
- 2023
24. Vasopressor Discontinuation Order in Septic Shock With Reduced Left Ventricular Function
- Author
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Hannah Dykes, Andrea Sikora Newsome, Timothy W Jones, Susan E. Smith, Christy Forehand, and Ashley Taylor
- Subjects
Adult ,Vasopressin ,medicine.medical_specialty ,Vasopressins ,030204 cardiovascular system & hematology ,Ventricular Function, Left ,Article ,Norepinephrine (medication) ,03 medical and health sciences ,Norepinephrine ,0302 clinical medicine ,Internal medicine ,medicine ,Humans ,Vasoconstrictor Agents ,Pharmacology (medical) ,030212 general & internal medicine ,Retrospective Studies ,Ventricular function ,business.industry ,Septic shock ,medicine.disease ,Shock, Septic ,Discontinuation ,Heart failure ,Cardiology ,Hypotension ,business ,medicine.drug - Abstract
Background: The optimal vasopressor management for septic patients with left ventricular (LV) dysfunction has not been well established, and current evidence is conflicting regarding the optimal vasopressor discontinuation order. Objective: The objective was to evaluate the impact of LV dysfunction on the hemodynamic management of septic shock by assessing the incidence of clinically significant hypotension after vasopressor discontinuation. Methods: In this single-center, retrospective cohort study, adult patients were included if they met the Sepsis-3 definition of septic shock, had LV dysfunction (defined as an ejection fraction ≤40%), and received norepinephrine and vasopressin as the last vasopressors discontinued. The primary outcome was the incidence of clinically significant hypotension following discontinuation of vasopressin or norepinephrine. Clinically significant hypotension was defined as a MAP less than 60 mmHg and the need for either: 1) the reinstitution of the previously discontinued agent at any dosage, 2) the receipt of at least 500 mL of a crystalloid at a rate of at least 500 mL/hour, 3) or the receipt of at least 25 grams of albumin 5% at a rate of at least 25 gram/hour. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and ICU and hospital mortality. Results: A total of 78 patients met inclusion criteria, with 37 patients having vasopressin discontinued first and 41 having norepinephrine discontinued first. Clinically significant hypotension occurred in 28 patients (76%) following the discontinuation of vasopressin, compared to 28 patients (81%) following the discontinuation of norepinephrine (p = 0.61). ICU length of stay was 9 days in the vasopressin discontinued first cohort, compared to 15 days in the norepinephrine discontinued first cohort (p = 0.01). There was no statistically significant difference in mortality observed. Conclusion: The discontinuation order of norepinephrine and vasopressin did not impact the incidence of clinically significant hypotension in patients with septic shock and LV dysfunction, but may influence ICU length of stay, although other factors may have impacted this finding.
- Published
- 2023
25. Spontaneous heparin-induced thrombocytopaenia with adrenal haemorrhage following orthopaedic surgery: a case report and literature review
- Author
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Yingyong Chinthammitr, Nonglak Kanitsap, and Supawee Saengboon
- Subjects
medicine.medical_specialty ,Adrenal disorder ,business.industry ,Heparin ,Adrenal Gland Diseases ,Anticoagulants ,Hemorrhage ,General Medicine ,medicine.disease ,Fondaparinux ,Thrombosis ,Arterial occlusion ,Thrombocytopenia ,Surgery ,medicine ,Humans ,Apixaban ,Female ,Platelet activation ,Thrombus ,business ,Arthroplasty, Replacement, Knee ,medicine.drug ,Aged - Abstract
A 68-year-old woman was admitted to the hospital for elective total knee arthroplasty in both knees without preceding heparin exposure. She developed adrenal haemorrhage and thrombocytopaenia on postoperative day 12, followed by right leg arterial occlusion and multiple venous intra-abdominal sites thrombosis. After given unfractionated heparin to treat arterial occlusion, platelet count was gradually declined. Spontaneous heparin-induced thrombocytopaenia was diagnosed by heparin-induced platelet activation test with light transmission aggregometry. The patient was successfully treated with fondaparinux and intravenous immunoglobulin. Apixaban was given after recovery of platelet count. Resolution of both thrombus along aorta and adrenal haemorrhage were shown by CT of whole abdomen after 2 months of treatment. Our case demonstrates that this serious complication is important but seldom recognised early.
- Published
- 2023
26. Terlipressin-induced skin necrosis
- Author
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Pooja Chandran, Itish Patnaik, Nupur B Patel, and Gaurav Jain
- Subjects
Liver Cirrhosis ,medicine.medical_specialty ,Alcoholic liver disease ,Necrosis ,business.industry ,General Medicine ,Gastrointestinal system ,medicine.disease ,Gastroenterology ,Internal medicine ,medicine ,Skin Abnormalities ,Humans ,Vasoconstrictor Agents ,medicine.symptom ,Terlipressin ,business ,medicine.drug - Published
- 2023
27. Takotsubo cardiomyopathy associated with dydrogesterone use
- Author
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Adam Ioannou
- Subjects
medicine.medical_specialty ,Postmenopausal women ,Apical ballooning ,business.industry ,Cardiomyopathy ,General Medicine ,Dydrogesterone ,medicine.disease ,Coronary artery disease ,Pathogenesis ,chemistry.chemical_compound ,Treatment Outcome ,chemistry ,Echocardiography ,Takotsubo Cardiomyopathy ,Heart failure ,Internal medicine ,medicine ,Cardiology ,Humans ,Female ,business ,Retroprogesterone ,medicine.drug - Abstract
Takotsubo cardiomyopathy is characterised by left ventricular apical ballooning, in the absence of coronary artery disease, and classically occurs at times of intense stress. Due to the striking preponderance of Takotsubo cardiomyopathy occurring in postmenopausal women, it has been postulated that female sex hormones may also be implicated in its pathogenesis. This case report describes the first case of Takotsubo cardiomyopathy associated with the initiation of dydrogesterone (a synthetic retroprogesterone) in a premenopausal woman.
- Published
- 2023
28. Giant cell arteritis associated with PD-1 inhibition
- Author
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Jisna Paul and Nina Couette
- Subjects
medicine.medical_specialty ,Giant Cell Arteritis ,Programmed Cell Death 1 Receptor ,Adenocarcinoma of Lung ,Pembrolizumab ,Antibodies, Monoclonal, Humanized ,Gastroenterology ,Internal medicine ,Synovitis ,medicine ,Humans ,Ultrasonography ,business.industry ,Antagonist ,Headache ,General Medicine ,Middle Aged ,medicine.disease ,Rheumatology ,Temporal Arteries ,Giant cell arteritis ,Methotrexate ,Female ,Vasculitis ,business ,Metastatic Lung Adenocarcinoma ,medicine.drug - Abstract
A 50-year-old woman was referred to rheumatology for new onset polyarthralgia and headache. She had a history of metastatic lung adenocarcinoma and was started on treatment with the programmed death 1 receptor (PD-1) antagonist pembrolizumab 2 months prior. Examination revealed left temporal artery tenderness and hand synovitis. Investigations revealed enlarged temporal artery on ultrasound imaging. On steroid treatment, she had resolution of symptoms, but due to significant steroid side effects required methotrexate and her PD-1 antagonist therapy was continued in consultation with her oncologist. Her malignant disease has remained stable, and she has improved functional status.
- Published
- 2023
29. Anti-NMDAR encephalitis presenting after immature teratoma resection
- Author
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Merry Markham, Deandra Kimberly Chetram, Aisha Elfasi, and Kelsey Pan
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Bleomycin ,Gastroenterology ,Methylprednisolone ,Receptors, N-Methyl-D-Aspartate ,chemistry.chemical_compound ,Internal medicine ,medicine ,Humans ,Etoposide ,Cisplatin ,Anti-N-Methyl-D-Aspartate Receptor Encephalitis ,Ovarian Neoplasms ,Chemotherapy ,biology ,business.industry ,Teratoma ,Cancer ,General Medicine ,medicine.disease ,chemistry ,biology.protein ,Immature teratoma ,Female ,Antibody ,business ,Encephalitis ,medicine.drug - Abstract
This is a case of a young woman who developed neurological and psychiatric symptoms 3 days after resection of an immature teratoma. She was diagnosed with anti-NMDA receptor encephalitis via positive serum antibody titres, which was later confirmed with cerebrospinal fluid antibody titres. Given her cancer diagnosis, she underwent treatment with bleomycin, etoposide and cisplatin chemotherapy in addition to 5 days of high-dose steroids (1 g of intravenous methylprednisolone) for the encephalitis. This treatment regimen led to significant clinical improvement 3 weeks after completion of one cycle of chemotherapy.
- Published
- 2023
30. Prurigo excoriée treated with low dose naltrexone
- Author
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Christopher B Bunker and Leonard Timoney
- Subjects
medicine.medical_specialty ,medicine.drug_class ,Antibiotics ,Refractory ,Quality of life ,Prurigo ,medicine ,Humans ,skin and connective tissue diseases ,Isotretinoin ,Acne ,business.industry ,Pruritus ,General Medicine ,Middle Aged ,medicine.disease ,Dermatology ,Naltrexone ,Quality of Life ,Female ,Low-dose naltrexone ,business ,Anxiolytic agents ,medicine.drug - Abstract
A 53-year-old woman presented with a 25-year history of acne excoriée and prurigo excoriée. Her symptoms began in 1988 coinciding with her husband’s death from a brain tumour when she was 27. The pruritus affected her quality of life and disturbed her sleep. She had scarring on her face and body resulting from persistent scratching. The pruritus proved refractory to treatment despite a multi-modal treatment approach including multiple topicals, phototherapy and systemic agents such as isotretinoin, antibiotics, anxiolytic agents and neuromodulators. She was extremely frustrated that various treatments had been ineffective at controlling the itch-scratch cycle. She was commenced on low dose naltrexone (LDN), 3 mg nocte, and she became itch free within a few weeks. She reports that the LDN has had a beneficial impact on her quality of life.
- Published
- 2023
31. Minocycline-induced blue sclera and skin hyperpigmentation
- Author
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Stacey Law
- Subjects
Male ,medicine.medical_specialty ,integumentary system ,Side effect ,business.industry ,Minocycline ,General Medicine ,SKIN DISCOLOURATION ,Amiodarone ,Dermatology ,Sclera ,Anti-Bacterial Agents ,Lethargy ,medicine.anatomical_structure ,Hyperpigmentation ,Skin hyperpigmentation ,medicine ,Humans ,business ,Adverse effect ,medicine.drug ,Aged ,Skin - Abstract
A 73-year-old man presented to the emergency department with lethargy and influenza-like symptoms. Incidentally, prominent blue sclera and blue-grey skin discolouration to the periorbital skin, pinnae, neck, upper and lower limbs, hands, feet, fingernails and toenails were noted. His general practitioner (GP) had previously ceased amiodarone, believing it to be the causative agent. A literature search confirms the side effects were likely due to minocycline, which the patient had been taking for 10 years. Long-term minocycline use is associated with scleral and skin hyperpigmentation, with no apparent adverse effect on ocular structure or function. The pigmentation may reverse with cessation of minocycline, or it may be permanent. Amiodarone may also cause skin hyperpigmentation, but scleral pigmentation is not a known association. This case report explores the side effect profiles of these two drugs, and highlights the potential for confusion regarding causative agents when used concurrently.
- Published
- 2023
32. Resolution of possible acquired protein S deficiency after viral suppression in HIV infection
- Author
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Leigh Cervino, Patricia Pecora Fulco, and Jillian E. Raybould
- Subjects
Adult ,Pediatrics ,medicine.medical_specialty ,Protein S Deficiency ,Human immunodeficiency virus (HIV) ,HIV Infections ,medicine.disease_cause ,Protein S ,Acquired immunodeficiency syndrome (AIDS) ,Recurrence ,Risk Factors ,medicine ,Humans ,Viral suppression ,Immunodeficiency ,Acquired Protein S Deficiency ,biology ,business.industry ,Warfarin ,Anticoagulants ,General Medicine ,Venous Thromboembolism ,medicine.disease ,Pulmonary embolism ,biology.protein ,Female ,business ,Pulmonary Embolism ,medicine.drug - Abstract
Current literature suggests an increased risk of venous thromboembolism (VTE) in people living with HIV (PLWH) with poorly controlled viraemia and immunodeficiency. VTE treatment guidelines do not specifically address anticoagulation management in PLWH. We report a case of a 33-year-old woman diagnosed with an unprovoked pulmonary embolism (PE) and deemed protein S deficient. Three years later, she was diagnosed with AIDS. Antiretroviral therapy (ART) was promptly initiated with viral suppression and immune reconstitution within 12 months. Eight years after her initial PE, the patient self-discontinued warfarin. Multiple repeat protein S values were normal. ART without anticoagulation has continued for 3 years with no thrombotic events. This case describes a patient with VTE presumably secondary to undiagnosed HIV with possible consequent acquired protein S deficiency. Additional research is needed to understand the characteristics of PLWH with VTE who may warrant long-term anticoagulation as opposed to shorter courses.
- Published
- 2023
33. Extramedullary relapse in a patient with multiple myeloma: a rare cause of gastrointestinal perforation and massive bleeding
- Author
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Michael Patrick Achiam, Christoffer Galletta Rene, Luit Penninga, and Morten Salomo
- Subjects
Billroth II ,Male ,medicine.medical_specialty ,Palliative care ,Bortezomib ,business.industry ,medicine.medical_treatment ,Perforation (oil well) ,General Medicine ,medicine.disease ,Surgery ,Gastrointestinal perforation ,medicine ,Plasmacytoma ,Humans ,Gastrectomy ,Prospective Studies ,Neoplasm Recurrence, Local ,business ,Multiple Myeloma ,Multiple myeloma ,medicine.drug ,Aged - Abstract
Multiple myeloma (MM) patients live longer due to more effective treatment, and we now see previously uncommon manifestations of MM, like extramedullary disease. We present a case of a 74-year-old man known with MM that relapsed with extramedullary manifestations at different locations. One of them as a gastric plasmacytoma (GP). He was successfully treated with chemoradiotherapy (Daratumumab, Bortezomib and Dexamethasone), which resulted in clinical response for 8 months, confirmed by biopsy and histopathology. Perforation of the GP occurred, and he underwent partial gastrectomy (Billroth II gastrojejunostomy). The patient’s disease progressed again 5 months after surgery, and he did not want any additional treatment. He accepted palliative care and died 10 months after the operation. A lack of knowledge about the characteristics and treatment of extramedullary MM exists, and prospective studies to investigate incidence, prognosis and treatment for extramedullary MM are needed for improving the poor prognosis of this manifestation.
- Published
- 2023
34. Inhaled anti-pseudomonal antibiotics for long-term therapy in cystic fibrosis
- Author
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Kate H Regan, Sherie Smith, and Nicola J. Rowbotham
- Subjects
Adult ,medicine.medical_specialty ,Exacerbation ,Adolescent ,Cystic Fibrosis ,medicine.drug_class ,Antibiotics ,Aztreonam ,Placebo ,Cystic fibrosis ,03 medical and health sciences ,chemistry.chemical_compound ,Young Adult ,0302 clinical medicine ,Internal medicine ,medicine ,Tobramycin ,Humans ,Pharmacology (medical) ,030212 general & internal medicine ,Adverse effect ,Child ,Randomized Controlled Trials as Topic ,business.industry ,Lysine ,Middle Aged ,medicine.disease ,Anti-Bacterial Agents ,030228 respiratory system ,chemistry ,Relative risk ,Child, Preschool ,Quality of Life ,business ,medicine.drug - Abstract
Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review.To evaluate the effects of long-term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug-sensitivity reactions and survival).We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022.We selected trials where people with cystic fibrosis received inhaled anti-pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic).Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system.The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta-analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low-certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) -5.30 days, 95% CI -8.59 to -2.01; 1 trial, 245 participants; low-certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta-analyses. We are uncertain of the effect of the intervention on adverse events (very low-certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEVsub1/sub) % predicted compared to tobramycin (MD -3.40%, 95% CI -6.63 to -0.17; 1 trial, 273 participants; moderate-certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate-certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high-certainty evidence). Important treatment-related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high.Long-term treatment with inhaled anti-pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer-term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes.
- Published
- 2023
35. IgG4-related tubulointerstitial nephritis
- Author
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Deepa Jacob, Tasnim Momoniat, Neelaveni Duhli, and Tom Jorna
- Subjects
Male ,Pathology ,medicine.medical_specialty ,Plasma Cells ,Arthritis ,Renal function ,Azathioprine ,Kidney ,Fibrosis ,medicine ,Humans ,Aged ,medicine.diagnostic_test ,business.industry ,Acute kidney injury ,General Medicine ,Eosinophil ,medicine.disease ,medicine.anatomical_structure ,Immunoglobulin G ,Nephritis, Interstitial ,Renal biopsy ,Immunoglobulin G4-Related Disease ,business ,medicine.drug ,Kidney disease - Abstract
A 67-year-old man was referred to the renal team following an episode of acute kidney injury on a background of chronic kidney disease. He had a 9-year history of steroid-sensitive arthritis, epigastric pain and isolated submandibular gland enlargement. He was noted to have a raised eosinophil count, total serum protein and total immunoglobulin G4 (IgG4) level as well as a serum hypocomplementaemia. A renal biopsy showed a tubulointerstitial nephritis with lymphoplasmacytic infiltrates, fibrosis and IgG4-positive plasma cells on immunohistochemistry. A diagnosis of IgG4-related disease was made based on clinical presentation and pathology. Renal function improved with glucocorticoids and the patient was successfully transitioned to azathioprine as a steroid-sparing agent.
- Published
- 2023
36. Recurrent painful ophthalmoplegic neuropathy: a cause for recurrent third nerve palsy in a child
- Author
-
Jayakumari Nandana, Sachin Girdhar, Sruthi S Nair, and Soumya Sundaram
- Subjects
medicine.medical_specialty ,Migraine Disorders ,Azathioprine ,Asymptomatic ,Tolosa-Hunt Syndrome ,Ophthalmoplegic Migraine ,medicine ,Oculomotor Nerve Diseases ,Humans ,Child ,Flunarizine ,Ophthalmoplegia ,business.industry ,Cranial nerves ,General Medicine ,medicine.disease ,Magnetic Resonance Imaging ,Surgery ,Migraine ,rpoN ,Female ,medicine.symptom ,business ,medicine.drug ,Tolosa–Hunt syndrome - Abstract
Recurrent painful ophthalmoplegic neuropathy (RPON), previously called ophthalmoplegic migraine, is a rare condition characterised by recurrent episodes of headache and ophthalmoplegia. We report a case of 11-year-old girl with recurrent painful ophthalmoplegia due to isolated right oculomotor nerve involvement. MR brain imaging showed enhancing lesion of cisternal segment of right oculomotor nerve. A possibility of Tolosa Hunt syndrome was considered and she was treated with glucocorticoids, followed by azathioprine due to recurrence. In the fourth episode, she developed migraine headache followed by right third nerve palsy, after which the diagnosis was revised to RPON. She was started on flunarizine along with short-term glucocorticoids. At 1-year follow-up, she remained asymptomatic. RPON should be considered in patients with recurrent third nerve palsy to avoid inadvertent long-term exposure to immunosuppressive agents.
- Published
- 2023
37. Intravitreal dexamethasone implant use as first-line therapy for cancer-associated retinopathy
- Author
-
Joel Mudri, Ravinder Singh Phagura, Wei-Sen Lam, and Xia Ni Wu
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Visual Acuity ,Malignancy ,Dexamethasone ,Blurred vision ,medicine ,Humans ,Glucocorticoids ,Early Detection of Cancer ,Aged ,Drug Implants ,Chemotherapy ,business.industry ,Paraneoplastic Syndromes, Ocular ,General Medicine ,medicine.disease ,Surgery ,Radiation therapy ,Intravitreal Injections ,Female ,Implant ,medicine.symptom ,business ,Chemoradiotherapy ,Retinopathy ,medicine.drug - Abstract
We present a 65-year-old female smoker who presented with acute bilateral blurred vision. Investigations led to an endobronchial ultrasound-guided fine-needle aspiration resulting in an early diagnosis of limited stage small cell lung cancer. Positive recoverin antibodies supported the diagnosis of cancer-associated retinopathy (CAR). CAR was the first manifestation of systemic malignancy in our patient and early diagnosis enabled curative intent systemic treatment with chemotherapy and radiotherapy. Ocular-specific treatment is required in CAR, although no standardised treatment exists. Current treatment options include steroids and immunosuppressive agents. Our patient was administered bilateral intravitreal dexamethasone implants, resulting in significant visual field and electroretinogram improvement at 8 weeks post-intervention. To our knowledge, this represents the first reported successful use of intravitreal dexamethasone implants as first-line therapy, in conjunction with chemoradiotherapy. Intravitreal dexamethasone implants therefore may provide an effective and safe treatment for CAR by reducing intraocular inflammation without systemic effects.
- Published
- 2023
38. Improvement of hyperadrenergic postural orthostatic tachycardia syndrome (POTS) with methylated B vitamins in the setting of a heterozygous COMT Val158Met polymorphism
- Author
-
Ariel Portera, Pam R. Taub, and Nikita Mittal
- Subjects
medicine.medical_specialty ,business.industry ,Conventional treatment ,General Medicine ,Middle Aged ,Catechol O-Methyltransferase ,Gastroenterology ,Norepinephrine (medication) ,B vitamins ,Norepinephrine ,Postural Orthostatic Tachycardia Syndrome ,Refractory ,Polymorphism (computer science) ,Heart Rate ,Tilt-Table Test ,Internal medicine ,Vitamin B Complex ,medicine ,Humans ,Female ,business ,medicine.drug - Abstract
A middle-aged woman was diagnosed with postural orthostatic tachycardia syndrome based on her clinical symptoms, elevated norepinephrine levels and positive tilt-table test. The patient was refractory to conventional treatment and improved only after she was treated with methylated B vitamins for her heterozygous catechol-O-methyltransferase Val158Met polymorphism.
- Published
- 2023
39. Graves' disease associated with cholestatic jaundice and persistent diarrhoea
- Author
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Siddhesh Vijay Rane, Pravin Rathi, Sanjay Chandnani, and Ravi Thanage
- Subjects
Adult ,Diarrhea ,Male ,endocrine system ,medicine.medical_specialty ,Malabsorption ,endocrine system diseases ,Carbimazole ,Graves' disease ,Disease ,Thyroid function tests ,Gastroenterology ,Autoimmune Process ,Internal medicine ,medicine ,Humans ,Cholestatic Jaundice ,medicine.diagnostic_test ,business.industry ,digestive, oral, and skin physiology ,General Medicine ,medicine.disease ,Graves Disease ,Jaundice, Obstructive ,Thyrotoxicosis ,Defecation ,business ,medicine.drug - Abstract
Liver involvement in Graves’ disease can be seen as a part of autoimmune process or rarely, due to the direct effects of thyrotoxicosis on liver. Hyperthyroidism can also have gastrointestinal manifestations like frequent bowel movements, diarrhoea, even malabsorption with steatorrhoea. We report a 36-year-old man with hyperthyroidism, presenting with cholestatic jaundice and persistent small bowel diarrhoea. He was diagnosed to have Graves’ disease and after ruling out more common causes, the cause of cholestatic jaundice was supposed to be Graves’ disease. Considering this possibility, the patient was started on treatment with carbimazole. As patient’s thyroid function tests started improving, he showed significant clinical and biochemical improvement from liver point of view as well.
- Published
- 2023
40. Life-threatening immune checkpoint inhibitor-induced myocarditis and myasthenia gravis overlap syndrome treated with abatacept: a case report
- Author
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Carl T. Shultz, Midhun Malla, Brijesh Patel, and Chelby Wakefield
- Subjects
medicine.medical_specialty ,Myocarditis ,business.industry ,medicine.medical_treatment ,Abatacept ,Overlap syndrome ,General Medicine ,Pembrolizumab ,medicine.disease ,Myasthenia gravis ,Immune checkpoint ,Myasthenia Gravis ,Medicine ,Humans ,Plasmapheresis ,Female ,business ,Intensive care medicine ,Adverse effect ,Immune Checkpoint Inhibitors ,Melanoma ,medicine.drug - Abstract
We present here the second documented case of severe immune checkpoint inhibitor-induced myocarditis successfully treated with abatacept. The patient was started on pembrolizumab for stage IIIA malignant melanoma, and after the first dose was admitted for worsening shortness of breath and weakness. Her symptoms were refractory to high-dose steroids and she decompensated rapidly necessitating cardiopulmonary resuscitation and subsequent intubation and mechanical ventilation. Intravenous immunoglobulin and plasmapheresis did not invoke significant improvement, so abatacept was then initiated. She began to show improvement and was eventually discharged to a skilled nursing facility. This case highlights a severe adverse reaction to an immunomodulator class steadily growing in its application. Providers of all specialties should be aware of the side effects and treatment options. Our case demonstrates that continued investigation into the utilisation of CTLA-4 agonists in the treatment of severe adverse reactions like myocarditis caused by pembrolizumab is required.
- Published
- 2023
41. Selective extraction of gambierone and related metabolites in Gambierdiscus silvae using m-aminophenylboronic acid–agarose gel and liquid chromatography–high-resolution mass spectrometric detection
- Author
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Christopher O. Miles, Alexander K. Leynse, Alison Robertson, Elizabeth M. Mudge, and Pearse McCarron
- Subjects
LC-HRMS ,Ciguatoxin ,Gambierdiscus ,boronic acid gel ,Clinical Biochemistry ,Secondary metabolite ,vic-diol ,Mass spectrometry ,Biochemistry ,Article ,Mass Spectrometry ,Analytical Chemistry ,chemistry.chemical_compound ,Biotransformation ,medicine ,Sample preparation ,ciguatera ,Chromatography ,gambierone ,Sepharose ,Extraction (chemistry) ,Cell Biology ,General Medicine ,Boronic Acids ,Solvent ,chemistry ,Dinoflagellida ,Agarose ,Chromatography, Liquid ,Ethers ,medicine.drug - Abstract
Gambierdiscus spp. are epi-benthic dinoflagellates that have been associated with ciguatera poisoning. These microalgae can have complex secondary metabolite profiles including ciguatoxins, maitotoxins, and gambierones, with varying compositions and toxicities across species and strains. Given this chemical diversity there is a need to develop selective and sensitive methods for secondary metabolite profiling. In this study, we used a cultured Caribbean strain of Gambierdiscus silvae to develop sample preparation and analysis strategies for characterizing vic-diol containing secondary metabolites. A pooled cellular extract was first screened by liquid chromatography–high–resolution mass spectrometry (LC–HRMS) for ciguatoxin-related compounds, which resulted in the confirmation of gambierone (1) and tentative identification of 29-methylgambierone (3). Treatment of the extract with periodate confirmed that the gambierones each contained one reactive vic-diol, which was exploited for the development of a selective extraction procedure using m-aminophenylboronic acid gel and the non-aqueous binding solvent chloroform. Using this non-traditional boronate affinity procedure, LC-HRMS also revealed the presence of additional sulfated polycyclic ethers in the gambierone-containing vic-diol fraction, while pigments and other contaminants were removed. The developed tools could be applied to screen collections of Gambierdiscus and other benthic algae to provide additional chemical characterization of gambierone-related compounds. The selective extraction procedure may also prove useful as a step in the isolation of these sulfated polyethers for structural, toxicological and biotransformation studies.
- Published
- 2023
42. Sex, Race, Insurance, and Pain: Do Patient Sociodemographics Influence Postoperative Opioid Prescriptions Among Hand Surgeons?
- Author
-
J. Grant Thomson, Kitae E Park, Adnan Prsic, Omar Allam, Alexandre Prassinos, Alexander S. Chiu, Connor J. Peck, and Martin J. Carney
- Subjects
Male ,medicine.medical_specialty ,Racial disparity ,Medicare ,03 medical and health sciences ,Race (biology) ,0302 clinical medicine ,medicine ,Humans ,Orthopedics and Sports Medicine ,Patient treatment ,030212 general & internal medicine ,Medical prescription ,Practice Patterns, Physicians' ,Aged ,Retrospective Studies ,Surgeons ,Morphine Derivatives ,business.industry ,Hand surgery ,Hand surgeons ,United States ,Analgesics, Opioid ,Prescriptions ,Opioid ,Prescription opioid ,Family medicine ,Surgery ,Female ,Chronic Pain ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Background: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. Methods: We performed a retrospective analysis of all hand surgeries (N = 5278) at a single academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, sex, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. Results: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without ( P < .0001), and patients with a history of chronic pain were prescribed 36.7 MME more than those without ( P < .0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men ( P = .0048), and Hispanics were prescribed 16.6 MME more than whites ( P = .0091) overall. Both Hispanic and black patients were also prescribed more than whites following carpal tunnel release (+19.0 and + 20.0 MME, respectively; P < .001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare ( P < .0001), but 25.0 MME less than those with Medicaid ( P < .0001). There were no differences across age groups. Conclusions: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons at our institution. These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations.
- Published
- 2023
43. Is Opioid-Limiting Legislation Effective for Hand Surgery Patients?
- Author
-
Alan H. Daniels, Benjamin H. Shapiro, Joseph A. Gil, Kalpit N. Shah, Peter James, Edward Akelman, Daniel B.C. Reid, and Jack H. Ruddell
- Subjects
Male ,medicine.medical_specialty ,Prescription Drugs ,Legislation ,030204 cardiovascular system & hematology ,Opioid prescribing ,Controlled Substances Act ,03 medical and health sciences ,0302 clinical medicine ,Island state ,medicine ,Humans ,Orthopedics and Sports Medicine ,030212 general & internal medicine ,Medical prescription ,Practice Patterns, Physicians' ,Intensive care medicine ,Pain, Postoperative ,Morphine Derivatives ,Controlled Substances ,business.industry ,Hand surgery ,Limiting ,Hand ,Opioid-Related Disorders ,Analgesics, Opioid ,Opioid ,Surgery ,business ,medicine.drug - Abstract
Background: The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. Methods: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as “major surgery” and carpal tunnel and trigger finger release as “minor surgery.” Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. Results: A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing “major surgery” saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing “major surgery” in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. Conclusions: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after “major hand surgery.” Additional research is needed to explore the association between legislation and clinical outcomes.
- Published
- 2023
44. Safety and Duration of Low-Dose Adjuvant Dexamethasone in Regional Anesthesia for Upper Extremity Surgery: A Prospective, Randomized, Controlled Blinded Study
- Author
-
Armen Voskerijian, Nura Gouda, Mark L. Wang, Michael Rivlin, Pedro K. Beredjiklian, and Julian Zangrilli
- Subjects
medicine.medical_treatment ,Dexamethasone ,Upper Extremity ,03 medical and health sciences ,0302 clinical medicine ,030202 anesthesiology ,medicine ,Humans ,Orthopedics and Sports Medicine ,Ropivacaine ,Prospective Studies ,Anesthetics, Local ,Pain, Postoperative ,business.industry ,Low dose ,Upper extremity surgery ,030208 emergency & critical care medicine ,Brachial Plexus Block ,Regional anesthesia ,Anesthesia ,Nerve block ,Surgery ,business ,Adjuvant ,Brachial plexus ,Blinded study ,medicine.drug - Abstract
Background Orthopedic procedures concerning the upper extremity commonly use a brachial plexus nerve block to achieve postoperative analgesia. The addition of dexamethasone to peripheral nerve blocks has been shown to significantly prolong its effect. We hypothesize that 1 mg doses of dexamethasone will prolong brachial plexus nerve block with similar efficacy to 4 mg and better than ropivacaine alone. Methods Seventy-nine patients who received a brachial plexus nerve block prior to undergoing upper extremity surgery were randomized to 1 of 4 treatment groups: group 1 received only 30 mL of 0.5% ropivacaine without dexamethasone (control); groups 2, 3, and 4 received 4, 2, and 1 mg of dexamethasone, respectively, added to 30 mL of 0.5% ropivacaine. Results Comparison of block duration, specifically “first signs of the block wearing off” to the 0-mg group, referencing the 1-, 2-, and 4-mg groups ( P = .02, .04, and .01, respectively) that received steroid adjuvant therapy demonstrated a significant increase in time until the block began to wear off. All study groups receiving steroids also demonstrated a significant increase in duration of the block prior to its effects being completely gone when compared with the control group ( P < .01 for all groups). Conclusions Our findings demonstrate that adjuvant dexamethasone can prolong brachial plexus nerve blocks effectively at low doses compared with high doses, in addition to prolonging analgesia compared with local anesthetic alone.
- Published
- 2023
45. Recurrence of endometrial cancer in a hysterectomised patient treated with tamoxifen for breast cancer: a case report
- Author
-
James Woolas, Megan Davis, and Siavash Rahimi
- Subjects
Oncology ,medicine.medical_specialty ,Antineoplastic Agents, Hormonal ,Breast Neoplasms ,Gynaecological cancer ,03 medical and health sciences ,0302 clinical medicine ,Breast cancer ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Aged ,Past medical history ,business.industry ,Endometrial cancer ,General Medicine ,medicine.disease ,030227 psychiatry ,Endometrial Neoplasms ,Tamoxifen ,Female ,Neoplasm Recurrence, Local ,business ,medicine.drug - Abstract
Tamoxifen exposure is a recognised risk for primary endometrial cancer. This case serves as a reminder to meticulously check the past medical history and inform patients of the risk-benefit of treatment as part of a shared-decision making process.
- Published
- 2023
46. Disseminated blastomycosis in a patient with polycythemia vera on ruxolitinib
- Author
-
Sally Alrabaa, Kristen Zeitler, Chakrapol Sriaroon, and Ripal Jariwala
- Subjects
Ruxolitinib ,business.industry ,General Medicine ,medicine.disease ,Blastomycosis ,Polycythemia vera ,Immune system ,Pyrimidines ,Primary Myelofibrosis ,Immunology ,Nitriles ,medicine ,Humans ,Pyrazoles ,Disseminated blastomycosis ,A kinase ,business ,Myelofibrosis ,Polycythemia Vera ,medicine.drug - Abstract
Ruxolitinib (RUX) is a kinase inhibitor used in the treatment of various medical conditions and its mechanism of action involves suppression of the immune system. While beneficial in treatment of polycythemia vera, myelofibrosis and other indications, it can also increase a patient’s susceptibility to various infections, including bacterial, viral and fungal. We present a case of a patient being treated with RUX who presented with a disseminated fungal infection. This case emphasises the need for vigilance of endemic fungal infections in individuals who are on RUX therapy.
- Published
- 2023
47. The Hemp Loophole: A Need to Clarify the Legality of Delta-8-THC and Other Hemp-Derived Tetrahydrocannabinol Compounds
- Author
-
Eric C. Leas
- Subjects
Delta ,Traditional medicine ,business.industry ,Public Health, Environmental and Occupational Health ,Principle of legality ,United States ,Connecticut ,Medicine ,Drug and Narcotic Control ,Humans ,Dronabinol ,business ,Tetrahydrocannabinol ,medicine.drug ,Cannabis - Published
- 2023
48. Strategies to Increase Testosterone in Men Seeking Fertility
- Author
-
Ranjith Ramasamy, Kevin Y. Chu, and Justin K. Achua
- Subjects
Cultural Studies ,endocrine system ,History ,Literature and Literary Theory ,media_common.quotation_subject ,Population ,Anastrozole ,Physiology ,Ocean Engineering ,Transportation ,Fertility ,Hypothalamic–pituitary–gonadal axis ,Education ,Human chorionic gonadotropin ,Gender Studies ,Pharmacotherapy ,medicine ,education ,Engineering (miscellaneous) ,Water Science and Technology ,General Environmental Science ,media_common ,education.field_of_study ,business.industry ,Process Chemistry and Technology ,General Arts and Humanities ,Testosterone (patch) ,General Medicine ,Testosterone Gel ,General Earth and Planetary Sciences ,business ,Social Sciences (miscellaneous) ,medicine.drug - Abstract
Prevalence of testosterone deficiency is increasing in the adolescent and young adult male population. As the average paternal age rises, there is a significant population of men with hypogonadism seeking testosterone therapy wishing to achieve or maintain fertility potential. Identification of potential lifestyle modifications that may improve the testosterone deficiency is one of the initial interventions of the holistic strategy in treatment. This is followed by drug therapy; however, traditional testosterone therapy acts as a contraceptive by suppressing the hypothalamus-pituitary-gonadal (HPG) axis and therefore cannot be used as a treatment strategy. A solution has been the off-label use of selective estrogen receptor modulators, human chorionic gonadotropin (hCG), and anastrozole inhibitors to treat hypogonadal symptoms while increasing intratesticular testosterone, a necessity for spermatogenesis. Recently, a novel therapy, Natesto intranasal testosterone gel, has been shown to increase serum testosterone levels while maintaining semen parameters. This is hypothesized to be because of its short-acting properties having lesser effect on the HPG axis, in contrast to the long-acting properties of traditional testosterone therapy. It is important to differentiate hypogonadal men between those seeking to achieve or maintain fertility status because the drug therapy of choice differs. This can be accomplished by determining the levels of 17-hydroxyprogesterone (17-OHP), because it is a biomarker for intratesticular testosterone. Those with low 17-OHP may wish to initiate treatment with alternative therapies, whereas those with high 17-OHP may trial short-acting testosterone therapies. As the urologist's armamentarium continues to increase, better strategies to increase testosterone levels in men seeking fertility can be achieved.
- Published
- 2023
49. Phase III Study of Pemetrexed in Combination With Cisplatin Versus Cisplatin Alone in Patients With Malignant Pleural Mesothelioma
- Author
-
Ulrich Gatzemeier, Michael Boyer, Paolo Paoletti, Salih Emri, Christian Manegold, Claude Denham, Nicholas J. Vogelzang, James J. Rusthoven, James T. Symanowski, Clet Niyikiza, E. Kaukel, and Pierre Ruffié
- Subjects
Oncology ,Adult ,Male ,Mesothelioma ,medicine.medical_specialty ,Cancer Research ,Guanine ,Maximum Tolerated Dose ,medicine.drug_class ,medicine.medical_treatment ,Pleural Neoplasms ,Pemetrexed ,Antimetabolite ,Risk Assessment ,Drug Administration Schedule ,Pleural disease ,Glutamates ,Reference Values ,Internal medicine ,Antineoplastic Combined Chemotherapy Protocols ,medicine ,Humans ,Single-Blind Method ,Survival analysis ,Aged ,Neoplasm Staging ,Probability ,Cisplatin ,Aged, 80 and over ,Chemotherapy ,Dose-Response Relationship, Drug ,business.industry ,Hazard ratio ,Middle Aged ,medicine.disease ,Prognosis ,Survival Analysis ,Surgery ,Treatment Outcome ,Multivariate Analysis ,Female ,business ,medicine.drug - Abstract
PURPOSE Patients with malignant pleural mesothelioma, a rapidly progressing malignancy with a median survival time of 6 to 9 months, have previously responded poorly to chemotherapy. We conducted a phase III trial to determine whether treatment with pemetrexed and cisplatin results in survival time superior to that achieved with cisplatin alone. PATIENTS AND METHODS Chemotherapy-naive patients who were not eligible for curative surgery were randomly assigned to receive pemetrexed 500 mg/m2 and cisplatin 75 mg/m2 on day 1, or cisplatin 75 mg/m2 on day 1. Both regimens were given intravenously every 21 days. RESULTS A total of 456 patients were assigned: 226 received pemetrexed and cisplatin, 222 received cisplatin alone, and eight never received therapy. Median survival time in the pemetrexed/cisplatin arm was 12.1 months versus 9.3 months in the control arm ( P = .020, two-sided log-rank test). The hazard ratio for death of patients in the pemetrexed/cisplatin arm versus those in the control arm was 0.77. Median time to progression was significantly longer in the pemetrexed/cisplatin arm: 5.7 months versus 3.9 months ( P = .001). Response rates were 41.3% in the pemetrexed/cisplatin arm versus 16.7% in the control arm ( P < .0001). After 117 patients had enrolled, folic acid and vitamin B12 were added to reduce toxicity, resulting in a significant reduction in toxicities in the pemetrexed/cisplatin arm. CONCLUSION Treatment with pemetrexed plus cisplatin and vitamin supplementation resulted in superior survival time, time to progression, and response rates compared with treatment with cisplatin alone in patients with malignant pleural mesothelioma. Addition of folic acid and vitamin B12 significantly reduced toxicity without adversely affecting survival time.
- Published
- 2023
50. Elective cardioversion of atrial fibrillation is safe without transesophageal echocardiography in patients treated with non-vitamin K antagonist oral anticoagulants: Multicenter experience
- Author
-
Paweł Wałek, Magdalena Chrapek, Małgorzata Krzciuk, Anna Szpotowicz, Beata Wożakowska-Kapłon, Beata Uziębło-Życzkowska, Bernadetta Bielecka, Iwona Gorczyca, Paweł Krzesiński, and Agnieszka Woronowicz-Chróściel
- Subjects
Rivaroxaban ,medicine.medical_specialty ,medicine.drug_class ,business.industry ,medicine.medical_treatment ,Atrial fibrillation ,General Medicine ,Vitamin K antagonist ,medicine.disease ,Cardioversion ,Dabigatran ,Anesthesia ,Internal medicine ,medicine ,Cardiology ,Observational study ,Apixaban ,Thrombus ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Background: Current guidelines recommend electrical cardioversion (ECV) in patients with atrial fibrillation (AF) after at least 3 weeks of adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE). However, in clinical practice in some centres, TEE is performed before ECV in patients with AF. The aim of the study was to evaluate prevalence of thromboembolic and hemorrhagic complications in patients with AF treated with NOACs and undergoing ECV without prior TEE. Methods: This observational, multicentre study included consecutive patients with AF treated with NOACs who were admitted for ECV without prior TEE. Thromboembolic events and major bleeding complications were investigated during a 30-day follow-up. Results: In the study group there were 611 patients, mean age was 66.3 ± 9.2 years, 40% were women. 52 (8.5%) patients had a low thromboembolic risk, 148 (24.2%) patients had an intermediate thromboembolic risk and 411 (67.2%) patients had a high thromboembolic risk. In the study group 253 (41.4%) patients were treated with rivaroxaban, 252 (41.2%) patients were treated with dabigatran and 106 (17.3%) patients were treated with apixaban. Reduced doses of NOACs were administered to 113 (18.9%) patients. In the entire study group, there were no thromboembolic events or major bleeding complications during the in-hospital stay and the 30-day follow-up. Conclusions: In this “real-world” study of AF patients treated with NOACs, it was proved that ECV is safe without a preceding TEE, regardless of the risk of thromboembolic complications and of the type of NOAC used.
- Published
- 2023
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