Ab initio insight into the physical properties of MgXH3 (X = Co, Cu, Ni) lead-free perovskite for hydrogen storage application

Renewable energy systems are vital for a sustainable future, where solid-state hydrogen storage can play a crucial role. Perovskite hydride materials have attracted the scientific community for hydrogen storage applications. The current work focuses on the theoretical study using density functional theory (DFT) to evaluate the characteristics of MgXH3 (X = Co, Cu, Ni) hydrides. The structural, vibrational, electronic, mechanical, thermodynamic, and hydrogen storage properties of these hydrides were investigated. The equilibrium lattice parameters were calculated using the Birch-Murnaghan equation of state-to-energy volume curves. The elastic constants (Cij) and relevant parameters, such as Born criteria, were calculated to confirm the mechanical stability of the hydrides. The Cauchy pressure (Cp) revealed brittle or ductile behavior. The outcomes of the Pugh ratio, Poisson ratio, and anisotropy were also calculated and discussed. The absence of negative lattice vibrational frequencies in phonon dispersion confirmed the lattice's dynamic stability. The heat capacity curves of thermodynamic properties revealed that hydrides can conduct thermal energy. The metallic character and ample interatomic distances of hydrides were confirmed by the band structure and population analysis, which confirmed that hydrides can conduct electrical energy and adsorb hydrogen. The density of state (DOS) and partial DOS unveiled the role of specific atoms in the DOS of the crystal. The calculated gravimetric hydrogen storage capacity of MgCoH3, MgCuH3, and MgNiH3 hydrides was 3.64, 3.32, and 3.49wt%, respectively. Our results provide a deeper understanding of its potential for hydrogen storage applications through a detailed analysis of MgXH3 (X = Co, Cu, Ni) perovskite hydride material.

Deciphering cervical cancer-associated biomarkers by integrated multi-omics approach

OBJECTIVES

Cervical Squamous Cell Carcinoma (CESC) is one of the most fatal female malignancies, and the underlying molecular mechanisms governing this disease have not been fully explored. In this research, we planned to conduct the analysis of Gene Expression Omnibus (GEO) cervical squamous cell carcinoma microarray datasets by a detailed in silico approach and to explore some novel biomarkers of CESC.

METHODS

The top commonly differentially expressed genes (DEGs) from the GSE138080 and GSE113942 datasets were analyzed by Limma package-based GEO2R tool. The protein-protein interaction (PPI) network of the DEGs was drawn through Search Tool for the Retrieval of Interacting Genes (STRING), and top 6 hub genes were obtained from Cytoscape. Expression analysis and validation of hub genes expression in CESC samples and cell lines were done using UALCAN, OncoDB, GENT2, and HPA. Additionally, cBioPortal, Gene set enrichment analysis (GSEA) tool, Kaplan-Meier (KM) plotter, ShinyGO, and DGIdb databases were also used to check some important values of hub genes in CESC.

RESULTS

Out of 79 DEGs, the minichromosome maintenance complex component 4 (MCM4), nucleolar and spindle-associated protein 1 (NUSAP1), cell division cycle associated 5 (CDCA5), cell division cycle 45 (CDC45), denticleless E3 ubiquitin protein ligase homolog (DTL), and chromatin licensing and DNA replication factor 1 (CDT1) genes were regarded as hub genes in CESC. Further analysis revealed that the expressions of all these hub genes were significantly elevated in CESC cell lines and samples of diverse clinical attributes. In this study, we also documented some important correlations between hub genes and some other diverse measures, including DNA methylation, genetic alterations, and Overall Survival (OS). Last, we also identify hub genes associated ceRNA network and 31 important chemotherapeutic drugs.

CONCLUSION

Through detailed in silico methodology, we identified 6 hub genes, including MCM4, NUSAP1, CDCA5, CDC45, DTL, and CDT1, which are likely to be associated with CESC development and diagnosis.

Exploring macrophage mannose receptor expression after myocardial infarction by Al[18F]F-NOTA-DCM positron emission tomography

Introduction

Mannose receptor (CD206) is primarily expressed on the surface of alternatively activated macrophages that are involved in resolution of inflammation after myocardial injury [1]. The purpose of this study was to evaluate mannose receptor targeting positron emission tomography (PET) tracer Al[18F]F-NOTA-DCM consisting of dextran backbone with cysteine-mannose moieties for imaging of experimental acute myocardial infarction (MI) [2].

Methods

First, ALEXA-488 fluorophore-labelled DCM was used for specificity studies using flow cytometry of M1 and M2 polarized macrophages derived from human blood monocytes. Secondly, Sprague-Dawley rats were studied on day 3 and day 7 after permanent ligation of left coronary artery or after sham-operation. [18F]FDG PET (35 MBq, 10 min static scan) was performed to visualize myocardium and on the next day, 60 min dynamic PET was performed after injection of 50 MBq of Al[18F]F-NOTA-DCM. Then, rats were euthanized for biodistribution study by gamma counting followed by digital autoradiography and histology (H&E, CD206 staining) of left ventricle cryosections. In vitro Al[18F]F-NOTA-DCM blocking study was performed on left ventricle cryosection with molar excess of unlabelled DCM.

Results

Flow cytometry confirmed that ALEXA-488-DCM bound specifically to M2 macrophages. In rats, the infarcted area was clearly detected in vivo with Al[18F]F-NOTA-DCM PET and its SUV was significantly higher than that of remote area or myocardium of sham-operated rats both on day 3 (SUV 0.78±0.18 vs. 0.47±0.13 vs. 0.43±0.07, p<0.005) and day 7 post-MI (SUV 0.64±0.10 vs. 0.47±0.12 vs. 0.51±0.07, p<0.05). Autoradiography confirmed increased uptake in the infarcted area compared to the remote area or to the myocardium of sham-operated rats on day 3 (PSL/mm2 141.21±46.06 vs. 49.76±20.37 vs. 57.97±6.77, p<0.005) and day 7 (PSL/mm2 139.22±19.44 vs. 55.38±28.83 vs. 60.83±7.63, p<0.0001). In vitro blocking study indicated that the tracer binding in infarcted area was specific. The area-% of CD206-positive staining in the infarcted area was significantly higher on day 3 post-MI than on day 7 (p<0.05), and higher at both time points than in remote area or myocardium of sham-operated rats (p<0.0001). Area-% of CD206 staining in the MI area positively correlated with Al[18F]F-NOTA-DCM uptake and MI size (p<0.05 and p<0.01, respectively).

Conclusions

Al[18F]F-NOTA-DCM PET detects overexpression of mannose receptor after ischemic myocardial injury and may be a suitable biomarker for early detection of the inflammation resolution process after MI.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Jane and Aatos Erkko FoundationSigrid Juselius FoundationFInnish Foundation for Cardiovascular Research

Development of Antibacterial, Degradable and pH-Responsive Chitosan/Guar Gum/Polyvinyl Alcohol Blended Hydrogels for Wound Dressing

The present research is based on the fabrication preparation of CS/PVA/GG blended hydrogel with nontoxic tetra orthosilicate (TEOS) for sustained paracetamol release. Different TEOS percentages were used because of their nontoxic behavior to study newly designed hydrogels' crosslinking and physicochemical properties. These hydrogels were characterized using Fourier-transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), and wetting to determine the functional, surface morphology, hydrophilic, or hydrophobic properties. The swelling analysis in different media, degradation in PBS, and drug release kinetics were conducted to observe their response against corresponding media. The FTIR analysis confirmed the components added and crosslinking between them, and surface morphology confirmed different surface and wetting behavior due to different crosslinking. In various solvents, including water, buffer, and electrolyte solutions, the swelling behaviour of hydrogel was investigated and observed that TEOS amount caused less hydrogel swelling. In acidic pH, hydrogels swell the most, while they swell the least at pH 7 or higher. These hydrogels are pH-sensitive and appropriate for controlled drug release. These hydrogels demonstrated that, as the ionic concentration was increased, swelling decreased due to decreased osmotic pressure in various electrolyte solutions. The antimicrobial analysis revealed that these hydrogels are highly antibacterial against Gram-positive (Staphylococcus aureus and Bacillus cereus) and Gram negative (Pseudomonas aeruginosa and Escherichia coli) bacterial strains. The drug release mechanism was 98% in phosphate buffer saline (PBS) media at pH 7.4 in 140 min. To analyze drug release behaviour, the drug release kinetics was assessed against different mathematical models (such as zero and first order, Higuchi, Baker-Lonsdale, Hixson, and Peppas). It was found that hydrogel (CPG2) follows the Peppas model with the highest value of regression (R2 = 0.98509). Hence, from the results, these hydrogels could be a potential biomaterial for wound dressing in biomedical applications.

"I Can't Move My Arms and Legs": A Rare Cause of Hypokalemia-Induced Quadriparesis

Hypokalemia is a relatively common electrolyte abnormality in hospitalized patients. Severe hypokalemia (<2.5 mEq/L) can lead to profound muscle weakness or paralysis, especially in the setting of acute onset of hypokalemia. Multiple mechanisms of hypokalemia have been described, such as decreased potassium intake, increased losses, and increased transcellular shift of potassium. Drugs can rarely cause hypokalemia by one of the above-mentioned mechanisms. Here, we report a case of cocaine use leading to severe hypokalemia manifesting as quadriparesis. The aggressive repletion of potassium led to a complete resolution of muscular weakness.

Acute Inflammatory Demyelinating Polyneuropathy (AIDP) Masked by Autoimmune Thyroiditis

Hashimoto’s thyroiditis and Guillain-Barre syndrome (GBS) are autoimmune disorders that are both well-known in their own right. Hashimoto’s is one of the most common causes of primary hypothyroidism, and GBS involves immune mediated damage to the peripheral nervous system. The association between the two is a rare clinical entity. This case demonstrates that these entities can occur together and could be related in similar pathophysiology.

A 37 year old male presented with complaints of bilateral hand and feet numbness for one month. The numbness started in the hands, then involved the feet, and was mostly felt in tips of extremities. He also complained of weakness in arms and legs. Neurology exam showed bilateral patellar, ankle, and biceps hyporeflexia. Muscle strength was 5/5 in all extremities, but decreased grip strength was noted in the hands. Initial lab work including complete blood count, comprehensive metabolic profile and urinalysis were all in normal range. Computerized tomographic scan (CT) head was normal while CT abdomen/pelvis showed hepatic fatty infiltration. Other lab tests including HIV, syphilis, Hepatitis B, Hepatitis C, glycosylated hemoglobin A1c, lipid panel, anti-nuclear antibody, anti-neutrophil cytoplasmic antibodies, serum/urine protein electrophoresis, alcohol level, vitamin B1, B6, folate, copper, and creatine kinase were all negative or within normal range. Lab abnormalities included elevated thyroid stimulating hormone (TSH) of 20.2 mIU/l and low normal B12 level of 289 pg/ml. His triiodothyronine (T3) and thyroxine (T4) hormone levels were in normal range. A thyroid peroxidase antibody level came back as high as 966 IU/ml. A diagnosis of Hashimoto’s thyroiditis leading to subclinical hypothyroidism was made. Patient was discharged on vitamin B12 and 112mcg of Synthroid. Instead of getting better, he returned 1 week later with worsening numbness and tingling which was now ascending upward to bilateral knees and elbows. Meanwhile TSH improved to 10 mIU/l and vitamin B12 increased to 1162 pg/ml. A magnetic resonance imaging (MRI) of the cervical/thoracic spine was unremarkable. A lumbar puncture showed negative xanthochromia, 0 WBC, 0 RBC, 0 neutrophils, 0 lymphocytes, 0 monocytes, glucose 63 mg/dl, elevated protein of 57 mg/dl, and culture was negative. Guillain-Barre syndrome was then the working diagnosis, more specifically its most common subtype, acute inflammatory demyelinating polyneuropathy (AIDP). Patient received five days of intravenous immunoglobulins and his symptoms improved. He was then discharged to follow up with endocrinologist.

This subtle presentation of GBS/AIDP masked by Hashimoto’s thyroiditis and vitamin B12 deficiency suggests a close association of autoimmune etiology between these disorders. Although rare, endocrinologists should consider this rare association in cases of paresthesias with unexplained symptoms.

An Interesting Case of Isolated Bone Marrow Sarcoidosis

Introduction: About 30% cases of sarcoidosis have extrapulmonary manifestations but only 7% of patients present without any lung involvement. Among those 7%, most of the patients have manifestations on the skin but isolated bone marrow sarcoidosis has not been commonly reported. This case represents an unusual manifestation of isolated bone marrow sarcoidosis presenting with very high calcium levels.

Case Presentation: A 58-year-old female presented to us with fatigue, poor appetite, and nausea. She did not report any weight changes. Her cancer screening was up to date. On examination, she appeared dehydrated. No neck swelling was appreciated. Cardiac, respiratory, abdominal, and neurological examinations were normal. Complete blood count showed hemoglobin of 10.6 mg/dL, white blood cell count of 3.8 k/dL, and platelet count of 87 x10⁹/L. Metabolic panel revealed hypercalcemia with corrected calcium levels as high as 12.6 mg/dL. Ionized calcium was 8.1 mg/dL (normal 4.8 - 5.6). Her parathyroid hormone (PTH) level was elevated up to 64.6 mg/dL and then further increased to 134.3 mg/dL. A 24-hour urinary calcium level was normal. 1, 25-dihydroxy (1,25-OH) and 25-OH vitamin D levels were 97 mg/dL (normal 18–72) and 31.2 mg/dL, respectively. Serum protein electrophoresis and light chain analysis were normal. Hyperparathyroidism was suggested as a cause of hypercalcemia. Ultrasound of the neck and sestamibi scan showed a right lower pole parathyroid adenoma. Paraneoplastic hypercalcemia was also one of the differentials. Parathyroid hormone related peptide (PTHrP) was 9 pg/mL (normal 14 - 27). Colonoscopy was normal. Computerized tomography showed normal lungs, liver and spleen. No masses and lymphadenopathy was seen. A bone marrow biopsy was done for pancytopenia. Patient underwent parathyroid adenoma removal followed by a drop in serum calcium level (8.2 mg/dL). Patient was discharged on calcium carbonate and vitamin D tablets. Upon outpatient follow-up, calcium level started to rise again up to 9.8 mg/dL. Despite discontinuation of supplemental calcium and vitamin D, calcium continued to uptrend (11.5 mg/dL 4 weeks later). Angiotensin converting enzyme (ACE) level came back as high as 129 (normal level < 40 mcg/L). Meanwhile, the bone marrow biopsy results showed that 40% of bone marrow was occupied by non-caseating granulomas suggesting sarcoidosis. Patient was started on steroids for isolated bone marrow sarcoidosis, and eventually her serum calcium level normalized.

Conclusion: An isolated bone marrow sarcoidosis is an extremely rare manifestation of extrapulmonary sarcoidosis. It can present with pancytopenia and should be sought in patients with persistent hypercalcemia. In addition, our case was challenging due to the presence of a concurrent hyperparathyroidism which was initially thought to be the only explanation of our patient’s hypercalcemia.

Role of Bariatric Surgery in Managing Metabolic Syndrome

Background: Lifestyle modifications provide a limited control of diabetes mellitus type 2 (DM2), especially in patients with morbid obesity and uncontrolled DM. Compared with non-surgical treatment, bariatric surgery achieved more sustained weight loss and higher remission rates of DM2. Roux-en-Y gastric bypass (RYGB) has been the most common procedure in the past but sleeve gastrectomy (SG) with duodenal switch (DS) is gaining more popularity now. Objective: To compare the significant differences in the outcomes of these procedures; such as the reduction in hemoglobin A1c (HbA1c), weight, basic metabolic index (BMI) and atherosclerotic cardiovascular disease (ASCVD) risk score of the patients at our community hospital.

Methods: This was a retrospective observational study consisting of a chart review of 151 patients during 2016 to 2019. Patients included were >18 years old, and underwent one of the three types of bariatric surgeries, including RYGB, SG and sleeve with DS. Comparison between different continuous variables was made using analysis of variance. Chi square analysis was used to determine associations between different outcomes and various categorical variables.

Results: Among all, 33.1% had SG, 33.8% had RYGB and 33.1% had DS. The median age was 66 years and 71.5% were females. Median height was 63 inches. 84.8% were white, 14.6% were African American and 0.7% were Asian. The associated comorbidities were asthma, hypertension, dyslipidemia, DM, smoking and coronary artery disease. Median weight prior to surgery was 280 pounds (lb) and reduced to a median weight of 240 lb. Median BMI before surgery was 44 kg/m2 and reduced to 39 kg/m2. Median blood pressure (BP) was 128/74 mmHg and reduced to 120/68 mmHg. Patients with elevated BP reduced from 70% to 20% in SG, 66.7% to 49% in RYGB and 82% to 54% in DS. Fasting blood sugar reduced from a median of 98 mg/dl to 87 mg/dl. HbA1c reduced from a median of 6 to 5.4. ASCVD risk score reduced from 4 to 2. Mean difference in HbA1c reduction was 0.81 for SG, 1.44 for RYGB and 2.19 for DS. Prior to surgery, 43% patients had DM, 16.6% had prediabetes and 40.4% were nondiabetic. Three months later, patients with DM2 reduced to 14.8% and prediabetes reduced to 10.7%. Patients with DM in SG group reduced from 14% to 12.2% and prediabetics reduced from 12 to 6%. In RYGB group, DM reduced from 56.9% to 16% and prediabetics increased from 13.7% to 24%. In DS group, DM reduced from 58% to 16% and prediabetics reduced from 24% to 2%. Insulin users reduced from 4% to 2 % in SG, 21.6% to 3.9% in RYGB and 22% to 6% in DS. Median number of DM2 medications reduced from 1 to 0. Conclusion: Our study demonstrates the differences in the reduction of HbA1c, weight, BMI and ASCVD risk score among various bariatric surgery procedures. It suggests that DS leads to a greater reduction in the HbA1c and ASCVD risk scores as compared to RYGB, although the risks of malabsorption complications are considerable.

Peritonsillar Phlegmon: An Addition to the Spectrum of COVID-19

The coronavirus disease 2019 (COVID-19) epidemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in December 2019 in Wuhan, China, then declared to be a pandemic associated with substantial morbidity and mortality. It has shown to exhibit a vast array of symptoms, among which fever, shortness of breath, and cough are the most commonly reported. Lymphadenopathy and tonsillar enlargement is a less common finding reported with this infection. This case describes a patient with tonsillar inflammation which was complicated by peritonsillar phlegmon, with negative throat culture and positive COVID-19 test, suggesting a COVID-19-related etiology of the disease. After the literature search, to the best of our knowledge, this is the first reported case of COVID-related peritonsillar inflammation and phlegmon formation. 

A Mysterious Paratracheal Mass: Parathyroid Carcinoma

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. We detail a 60-years-old gentleman who was otherwise healthy presented to the hospital due to acute encephalopathy. He was subsequently found to have parathyroid carcinoma as the cause of the acute encephalopathy with impressive serum calcium and parathyroid hormone levels. The parathyroid carcinoma was later surgically resected with the diagnosis confirmed via pathology specimen. The patient was safely discharged from the hospital with recommendations of close routine outpatient followup.

SUN-183 Adrenalitis Induced by Nivolumab

Introduction: Tumor cells often express a programmed death-ligand 1 (PD-L1), which binds to the programmed death receptor-1 (PD-1) on activated T-cells to induce immune tolerance. Among the class of immune checkpoint inhibitors (ICI), Nivolumab is an anti-PD-1 antibody which blocks these tumor cell interactions. Although some endocrinopathies have been reported for other PD-1 inhibitors, the adverse event of adrenalitis with nivolumab has not been reported before. Clinical Case: A 65-year-old female presented to the hospital with complaints of nausea, vomiting, fatigue, and headache for five days. She was recently diagnosed with metastatic lung adenocarcinoma, complicated by cerebellar metastases, and the left cerebellar mass was resected. She was also started on Nivolumab. Her blood pressure was 98/65 mmHg on the presentation. Serum sodium was 122mEq/L (normal 135–145) and potassium was 5mEq/L (3.5–5). TSH, LH, and prolactin were all normal. Aldosterone was low: 23pmol/L (27.7–582.5) and renin was high: 11 ng/ml/h (0.167- 1.38). Morning cortisol levels were low: 2.2 ug/dl (5- 25) and concomitant ACTH was high: 78 pg/ml (7.2- 63.3). Upon standard high dose cosyntropin stimulation test, basal cortisol was 2.0 ug/dl (5- 25). Cortisol level 30 minutes post cosyntropin was 7.1 ug/dl, while Cortisol 60 minutes post cosyntropin was 12.2 ug/dl (normal >18 -20 ug/dl). Considering the low cortisol levels with high ACTH, and an inadequate rise in cortisol after the ACTH stimulation test, adrenal insufficiency was suspected as a result of adrenalitis due to Nivolumab. Hyponatremia along with low aldosterone and high renin levels also reinforced this clinical diagnosis. A computerized tomographic scan of the chest abdomen and pelvis only showed calcified uterine fibroids. She was initially resuscitated with intravenous fluids. Hydrocortisone 100 mg every 8 hours was started and then gradually tapered down to 60mg every 12 hours. Fludrocortisone was also initiated at 0.2mg daily. Symptoms began to improve, and sodium levels normalized to136 mEq/dl. She was discharged on 30mg of hydrocortisone and 0.1 mg of fludrocortisone daily and is stable since then. Conclusion: This is a rare case of Nivolumab-induced adrenalitis. It highlights the importance of checking for adrenal insufficiency in a patient who presents with symptoms of hypotension and hyponatremia while being on ICI drugs, as unidentified adrenal insufficiency and adrenal crisis can be fatal.

Nivolumab-induced adrenalitis

Immune checkpoint inhibitors (ICIs) are an evolving class of drugs for the treatment of various cancers; for example, their use is recommended as a second-line chemotherapy for non-small cell lung cancer. With the expanding use of ICIs, we are discovering their unique side effects, called immune-related adverse events (irAEs), which can impair gastrointestinal, hepatic, dermatological, endocrine and other systems. Nivolumab is an ICI that blocks the human programmed death receptor-1 (PD-1) on T cells to prevent the interaction between the receptor, PD-1, and human programmed death ligand-1 expressed on tumour cells. Here, we report a case of a 65-year-old woman with recurrent lung adenocarcinoma who was treated with nivolumab and developed immune-related adrenalitis, which was managed with hydrocortisone and fludrocortisone. This case highlights the importance of understanding the irAEs of ICIs to allow prompt recognition and management of life-threatening complications of the treatment.

Hypercalcemia Due to Paraneoplastic Production of 1,25- Dihydroxyvitamin D in a Young Female with Dysgerminoma

Humoral hypercalcemia of malignancy (HHM) can be caused by ectopic paraneoplastic production of 1, 25 dihydroxy vitamin D due to the hyperactivity of the 1 alpha-hydroxylase enzyme. We present a case of a 19-year-old female who was admitted with bilateral dysgerminomas and significant hypercalcemia. Hypercalcemia was initially managed medically and then resolved with the surgical resection of the tumors. Although most cases are attributed to a high parathyroid hormone-related peptide (PTHrP) and bone metastases, <1% of cases can result from paraneoplastic production of 1,25 dihydroxyvitamin D due to increased activity of 1 alpha-hydroxylase.This is one of the rare cases of hypercalcemia, which not only adds to the limited number of cases of hypercalcemia associated with dysgerminoma but also is the first case report showing that vitamin D can be a paraneoplastic factor itself.

Dapagliflozin-induced Late-onset Euglycemic Diabetic Ketoacidosis

Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a class of oral hypoglycemics that improve glycemic control by increasing the urinary excretion of glucose. They gained widespread popularity because they not only showed improved glycemic control but also had a favorable effect on weight loss, blood pressure, and cardiovascular mortality. One of their rare side effects is euglycemic diabetic ketoacidosis (eDKA) although the diagnosis is sometimes difficult to make due to near-normal glucose levels. We present a case of eDKA in a patient who presented with confusion, acute kidney injury (AKI), and metabolic acidosis after having an influenza-like illness with a minimally elevated blood glucose of 187 mg/dL. She had already stopped taking dapagliflozin (an SGLT-2 inhibitor) two weeks before the presentation. She was initially treated as sepsis and required hemodialysis. Later on, metabolic acidosis was attributed to eDKA from dapagliflozin, which resolved after the administration of intravenous insulin. Her eDKA developed while she had already stopped dapagliflozin two weeks ago, which makes this an interesting case finding. It is one of those rare cases where dapagliflozin led to a delayed complication of eDKA.

Can inhaled heroin be a cause of bilateral globus pallidus ischemic injury?

Introduction

Bilateral globus pallidus lesions have been characteristically thought to be associated with global cerebral hypoperfusion and hypoxic changes. One of the important causative factors that need to be considered is the opiate drug abuse.

Case presentation

We present a case of a 50-year-old male who came to the hospital after being found down for 3 hours. He was found to have weakness of right upper and lower extremity. MRI showed bilateral globus pallidus infarcts. He later admitted to inhalation of heroin. Over the next few days, weakness started to improve and he was eventually discharged to rehabilitation. This case is a unique presentation of bilateral globus pallidus lesions after a one-time inhalation of heroin.

Conclusion

We, therefore, advocate that inhaled heroin should be considered as one of the causes of bilateral globus pallidus lesions, in addition to IV heroin and cocaine and physicians should be aware of the possibility of alternate forms of heroin abuse in such patients.

Thyrotoxicosis factitia: a rare cause of junctional rhythm and cardiac arrest

Thyrotoxicosis factitia is a hyperthyroid state due to the accidental or deliberate thyroxine ingestion. It can have many complications depending upon the organ involved. We present a case of a heavy built athlete presenting with cardiac arrest, who was found to be abused the thyroxine hormone for bodybuilding. Electrocardiogram (EKG) was significant for junctional arrhythmias along with interval supraventricular tachycardia (SVT) and bradycardia. The patient ultimately expired due to a failed resuscitation. To our knowledge, this is the first reported case of junctional arrhythmias caused by exogenous thyroxine.

A Case of Fibroelastoma with Widespread Embolism to the Brain, Kidney, and Spleen

Cardiac papillary fibroelastoma (CPF) is the second most common primary cardiac tumor, which is diagnosed incidentally or with embolic phenomena, mostly in the form of a transient ischemic attack (TIA) and stroke. We present a case of a 58-year-old female who presented with fatigue and low-grade fever and was found to have multiple systemic infarcts. Her blood cultures and transthoracic echocardiography (TTE) were negative, ruling out infective endocarditis. However, transesophageal echocardiography (TEE) revealed a mobile mass at the aortic valve. The mass was surgically removed, and the aortic valve was repaired. The histological examination of the mass finally revealed a papillary fibroelastoma. To our knowledge, this is the first reported case where fibroelastoma presented with splenic and renal infarcts in combination with the cerebral infarcts. Since cardiac fibroelastoma can cause embolization to the cerebral, splenic, and renal vessels, we, therefore, advocate that it should be considered as one of the possible causes of widespread embolism. We also stress upon the importance of doing TEE in case of a suspected cardiac mass, as the TTE is more likely to give false-negative results.

Elicitation of health state utilities associated with differing durations of morning stiffness in rheumatoid arthritis

OBJECTIVE

Specific symptoms of rheumatoid arthritis (RA), including joint stiffness and functional disability, are most severe in the morning. 'Morning stiffness' has a negative impact on health-related quality-of-life (HRQoL); however, how HRQoL is correlated to morning stiffness duration is unknown. The objective of this study was to obtain population-based utility values associated with different durations of morning stiffness in RA.

DESIGN AND METHODS

The time-trade-off (TTO) approach was used to elicit utility values for four different health states (HS), which differed in morning stiffness duration. One hundred and nine members of the UK general public rated each HS in individual face-to-face interviews with trained investigators. TTO scores were converted into utility values. Visual Analog Scale (VAS) scores were obtained to validate TTO scores.

RESULTS

On a scale of 0 (death) to 1 (full health), a mean utility value of 0.45±0.29 was elicited for ∼3 h of morning stiffness (anchor HS), 0.50±0.28 for 2-3 h of morning stiffness (HS1), 0.61±0.25 for 1-2 h of morning stiffness (HS2) and 0.78±0.20 for <1 h of morning stiffness (HS3). The difference between each HS was statistically significant (p<0.01). Mean VAS utility scores followed the same trend. Utility incrementally increased with each HS associated with a shorter duration of morning stiffness. Limitations of this research include potential bias from the TTO method due to the discounting effect of time, scale compatibility, and loss aversion.

CONCLUSIONS

The UK population-based utility values show a reduction in morning stiffness duration in RA is associated with improved HRQoL. Despite the impact of morning stiffness on HRQoL, it is rarely evaluated and little is known as to how it is affected by current treatments. The results of this study can be applied in future cost-utility analyses of healthcare interventions which target an improvement in morning stiffness duration for RA patients.

Can WHO therapy failure criteria for non-severe pneumonia be improved in children aged 2-59 months?

SETTING

In the recent past, there have been reports of rising treatment failure rates for non-severe pneumonia. It is felt that World Health Organization (WHO) criteria for therapy failure are too sensitive and that many children are unnecessarily classified as failures. We studied alternative, less sensitive therapy failure criteria.

METHODS

In this nested study we followed the clinical course of non-severe pneumonia in children aged 2-59 months using alternative therapy failure criteria. All children received amoxicillin and were followed up on days 3, 5 and 14 after enrollment. On day 3, children were labelled as therapy failure only if their condition had deteriorated. These failure rates were compared with those using WHO definitions.

RESULTS

During the study period, 876 children with non-severe pneumonia were followed up until day 14. On day 3, using alternative therapy failure criteria, 31 (3.5%) children were labelled as therapy failure compared to 95 (10.8%) using current WHO criteria. The difference was statistically significant (P = 0.001).

CONCLUSIONS

The alternative therapy failure criteria work reasonably well, without causing any higher risk to children with non-severe pneumonia. Antibiotics should be changed only in those children who show signs of deterioration on day 3. This would prevent unnecessary changes in antibiotic treatment in many children.

Leflunomide

Leflunomide (Arava) was approved for the treatment of rheumatoid arthritis by the regulatory authorities in the US and Europe in 1998. This approval was based on three pivotal randomised clinical trials conducted in the US and Europe. This report will focus on the use of leflunomide in rheumatoid arthritis based on the data from these trials as well information on the efficacy and safety learned from post release clinical experience.

Difficult cases in heart failure: Left ventricular assist device implantation for the treatment of recurrent ventricular tachycardia in end stage heart failure

The authors describe the surgical implantation of a left ventricular assist device (LVAD) in a patient with ischemic cardiomyopathy and recurring episodes of ventricular tachycardia with associated sudden death, as a therapeutic intervention for the recurrent ventricular arrhythmias. The clinical inference of this report demonstrates that these devices are useful as a bridge to heart transplantation, not only improving the symptoms of heart failure but also suppressing malignant ventricular arrhythmias. (c) 1999 by CHF, Inc.

Difficult cases in heart failure: Bilateral renal artery fibrous dysplasia and heart failure

The clinical characteristics as well as treatment of a patient with renal artery stenosis associated with uncontrolled hypertension and heart failure is described. Patients with similar findings should alert clinicians of this entity, since rapid diagnosis and treatment will assure a prompt relief not only of the increased blood pressure but also of the symptoms of heart failure. (c)1999 by CHF, Inc.

A comparative study of cefixime and chloramphenicol in children with typhoid fever

We compared cefixime with chloramphenicol in a trial for treatment of children with culture positive typhoid fever. Twenty children were given cefixime 10 mg/kg/day orally for 14 days and twenty received chloramphenicol 50 mg/kg/day orally for 14 days. On entry the clinical characteristics of the two groups were comparable. Clinical cure was observed in 18 (90%) patients treated with cefixime and 9 (45%) treated with chloramphenicol. Of 11 patients who did not respond to chloramphenicol, 10 were switched over to cefixime and all were cured. Overall 28 out of 30 cases (93.3%) were cured by cefixime.

A comparative study of cefixime and chloramphenicol in children with typhoid fever

We compared cefixime with chloramphenicol in a randomized trial for treatment of children with culture positive typhoid fever. Twenty children were given cefixime 10 mg/kg/day orally and twenty received chloramphenicol 50 mg/kg/day orally. On entry in the study, the clinical characteristics of the two groups were comparable. Duration of therapy was 14 days. Clinical cure was observed in 18 (90%) patients treated with cefixime and 9 (45%) treated with chloramphenical. Out of the 11 patients who did not respond to chloramphenicol, 10 were switched over to cefixime and all of them were cured. Over all 28 cases out of 30 (93.3%) P = 0.0049 were cured by cefixime.

Management of children with acute respiratory infections (ARI) by general practitioners in Multan - an observational study

A knowledge, attitude and practices (K.A.P.) survey was conducted among doctors working as general practitioners (GP) in Multan, for diagnosis and management of acute respiratory infections (ARI) in children under five years of age. GPs in Multan were not familiar with national ARI control programme and rational drug use guidelines. They rarely asked about symptoms describing severity of disease while taking patient histories and did not look for signs of severe pneumonia during physical examinations. Most patients diagnosed as URTI (upper respiratory tract infection) received oral antibiotics and those with pneumonia received injectable antibiotics. Other drugs prescribed included cough syrups, antihistamines and antipyretics. The average number of drugs prescribed per patient was 3.4. The doctors were deficient in providing home care advice for sick children to the caretakers. Average time spent by doctors on each patient was two minutes and twenty-three seconds. A combination of biomedical and social factors help to perpetuate this irrational prescribing behaviour of the GPs. Continuing education programmes for doctors in general practice about ARI management in children and rational use of drugs and health education of the public may improve the current prescribing practices.

Childhood chronic inflammatory demyelinating neuropathies: clinical course and long-term follow-up

Chronic inflammatory demyelinating neuropathy (CIDP) is a rare disease in childhood. We reviewed the clinical characteristics, response to therapy, and long-term prognosis in 13 children (1.5 to 16 years of age) diagnosed with CIDP at Washington University Medical Center, St. Louis, and the Royal Children's Hospital, Melbourne, Australia, between 1979 and 1994. The most common presenting symptom (in 11/13 [85%]) was lower extremity weakness associated with difficulty in walking. Preceding events within 1 months of onset, mostly intercurrent infections or vaccinations, occurred in seven children (54%). The disease was monophasic in three children (23%). One relapse occurred in four (30%) and multiple relapses in six (46%). All patients had at least short-term response to steroids. Three children (23%) recovered completely during the first year. Ten children (77%) had residual weakness after an average follow-up of 6 years. There seems to be two populations of children with CIDP. One subgroup, with a favorable prognosis, progressed to peak disability over less than 3 months; these children often have a monophasic course with complete resolution of symptoms and signs and withdrawal from all medications by 1 year after onset. A second subgroup progressed for 3 months or longer; these children all required substantial does of prednisone for prolonged periods and had considerable long-term morbidity with persistent weakness.

Influence of a perpetual-daylight Arctic environment on periodicity in human cholesterol synthesis

To identify factors associated with control of human cholesterol synthesis, periodicity in cholesterogenesis, hormonal levels and food consumption behavior were examined in 5 healthy individuals at the beginning and end of 18 d in a perpetual daylight Arctic environment devoid of time cues. At d 2 (phase I) and d 16 (phase II), cholesterol fractional synthesis rate was determined at 6 h intervals over 30 h as deuterium incorporation into plasma free cholesterol. Total plasma cholesterol, insulin and glucose-dependent insulinotropic polypeptide were also measured at each timepoint. Food intake and sleeping patterns were recorded prior to and during each phase. Cholesterol fractional synthesis rate (FSR) exhibited periodicity in all subjects on each phase, but did not differ between phase I (FSR rate = 0.038 +/- 0.038 pools.d-1) and phase II (FSR rate = 0.037 +/- 0.072 pools.d-1) phases. Phase II FSR period length was associated with both the duration between first and last meals (r2 = 0.81, p = 0.037) and total hours spent awake (r2 = 0.99, p = 0.001). Insulin and glucose-dependent insulinotropic polypeptide levels were not associated with FSR periodicity. These results suggest that meal timing and sleep/wake cycles are more important factors than insulin and glucose-dependent insulinotropic polypeptide in controlling the rhythms of whole body cholesterol synthesis.