White Matter Hyperintensities and Microstructural Alterations in Contact Sport Athletes from Adolescence to Early Midlife.

Studies have demonstrated associations between cumulative concussion and repetitive head impact exposure (RHI) via contact sports with white matter (WM) alterations later in life. The course of WM changes associated with exposure earlier in the lifespan are unclear. This study investigated alterations in white matter (WM hyperintensity [WMH] volume and microstructural changes) associated with concussion and RHI exposure from adolescence to early midlife, as well as the interaction between exposure and age-cohort (i.e., adolescent/young adult compared to early midlife athlete cohorts) on WM outcomes. Participating football players included an adolescent/young adulthood cohort (n=82; Mage=18.41.7) and an early midlife cohort (37 former collegiate players approximately 15-years removed from sport; Mage=37.71.4). Years of football participation and number of prior concussions were exposures of interest. White matter outcomes included log-transformed manually segmented total WMH volume and neurite orientation dispersion and density imaging metrics of microstructure/organization (isotropic volume fraction[Viso], intra-cellular volume fraction[Vic], and orientation dispersion[OD]). Regression models were fit to test effects of concussion history, years of football participation, and age-cohort by years of football participation with WM outcomes. Spearman's correlations assessed associations between significant WM metrics and measures of cognitive and psychological function. A significant age-cohort by years of participation effect was observed for whole brain white matter OD, B=-0.002, SE=0.001, p=0.001. The interaction was driven by a negative association between years of participation and OD within the younger cohort, B=-0.001, SE=0.0004, p=0.008, whereas a positive association between participation and OD in the early midlife cohort, B=0.001, SE=0.0003, p=0.039, was observed. Follow-up ROI analyses showed significant interaction effects for OD in the body of the corpus callosum, genu of the corpus callosum, cingulum, inferior fronto-occipital fasciculus, superior longitudinal fasciculus, posterior thalamic radiation (ps<0.05). Greater concussion history was significantly associated with greater Viso in the early midlife cohort, B=0.001, SE= 0.0002, p=0.010. Years of participation and concussion history were not associated with WMH volume, ps>0.05. Performance on a measure of executive function was significantly associated with years of participation, =.34, p=.04, and a trend was observed for OD, =.28, p=.09 in the early midlife cohort only. The global characterization of white matter changes associated with years of football participation were broadly similar and stable from adolescence through early midlife (i.e., microstructural alterations, but not macroscopic lesions). An inverse association between years of participation and orientation dispersion across age-cohorts may represent a process of initial recovery/reorganization proximal to sport, followed by later reduction of white matter coherence.

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema With Resultant Airway Obstruction Following Endotracheal Intubation.

Angiotensin-converting enzyme inhibitor (ACEi)-induced angioedema is a consequence of excessive levels of bradykinin and accounts for nearly a third of angioedema cases when patients present to emergency rooms. While rare, patients can present with swelling in the face, tongue, and airways making it a life-threatening emergency. To secure an airway, endotracheal intubation may be conducted; however, tracheal stenosis is a known complication. In this report, we present a 61-year-old female with a history of ACEi-induced angioedema care in which she was intubated with facial swelling. Upon a repeat hospitalization, the patient developed stridor with respiratory distress. Bronchoscopy revealed severe tracheal stenosis with multilevel damage to tracheal rings, warranting urgent tracheostomy. One month after discharge, the patient was seen by an ENT specialist who performed a transnasal laryngoscopy revealing near total subglottic and tracheal stenosis of 3 cm stenosis length, presumed secondary to traumatic intubation for prior angioedema management. This case highlights the importance of careful intubation practices in patients with suspected airway edema.

Mortal Dangers of Adult-Onset IgA Vasculitis.

IgA vasculitis (IgAV), previously known as Henoch Schoenlein purpura (HSP), is a leukocytoclastic vasculitis subtype predominantly amongst the pediatric patient population involving IgA dominant immune complex deposits attacking small vessel walls. While it oftentimes follows upper respiratory infections and presents with palpable purpuras, IgAV can also present in the adult patient population and lead to systemic inflammation. In this case report, we present the case of an adult-onset IgAV complicated via gastrointestinal perforation, acute kidney injury secondary to IgA nephritis, and circulatory shock. A review of prognosis, complicating factors, and treatment methods was also conducted for reported adult-onset IgAV with an aim to elucidate similarities and differences to pediatric-onset IgAV. While there is no unified treatment approach, glucocorticoids and immunosuppressors such as rituximab have been observed to be an effective protocol.

Perception of Burnout and Its Impact on Academic Hospitalists During COVID-19 and Institutional Strategies to Combat Burnout and Improve Wellness.

INTRODUCTION: Physician burnout has been alarmingly high, particularly among general internal medicine, which displays some of the highest rates. A recent study of academic hospitalists reported a higher level of burnout (62%) than the rates found in similar studies, but with agreement about factors leading to burnout, consequences of burnout, and importance of steps to prevent burnout. This study seeks to expand upon these results by investigating the impact of COVID-19 on burnout among hospitalists and uncovering the perspectives of frontline clinicians to formulate effective mitigation strategies. METHODS: Academic hospitalists were recruited to participate in a series of focus group interviews. The questions focused on contributors to burnout, the impact of COVID-19, and strategies to improve wellness and reduce burnout. The focus groups were audio-recorded, transcribed, and coded for emergent themes using Taguette, an open-source qualitative data analysis software. RESULTS: Burnout-inducing themes included workload, bureaucratic hurdles, and lack of control. COVID-19-specific themes included fear of exposing family and social isolation. The most common mitigation strategy was to increase social interactions to foster a sense of community. Additional solutions included adhering to a census cap of patients, streamlining clinical work, and providing avenues for two-way communication between leadership and clinicians to share concerns and elicit feedback. CONCLUSIONS: Streamlining clinical work allows more time for patient care. Enhancing community and fostering collaboration in decision-making allows clinicians to feel more empowered. A crucial first step to combat burnout is to encourage a work environment that values clinician well-being and proactively works to increase job satisfaction.

Testosterone Replacement Therapy in the Treatment of Depression.

Background: Depression is a common disorder that affects millions globally and is linked to reduced quality of life and mortality. Its pathophysiology is complex and there are several forms of treatment proposed in the literature with differing side effect profiles. Many patients do not respond to treatment which warrants augmentation with other treatments and the investigation of novel treatments. One of these treatments includes testosterone therapy which evidence suggests might improve depressed mood in older patients with low levels of testosterone and helps restore physical impairments caused by age-related hormonal changes. Objective: The objective of this review is to synthesize information regarding clinical depression, its treatment options, and the efficacy and safety of testosterone treatment for the treatment of depression. Methods: This review utilized comprehensive secondary and tertiary data analysis across many academic databases and published work pertaining to the topic of interest. Results: Within some subpopulations such as men with dysthymic disorder, treatment resistant depression, or low testosterone levels, testosterone administration yielded positive results in the treatment of depression. Additionally, rodent models have shown that administering testosterone to gonadectomized male animals reduces symptoms of depression. Conversely, some studies have found no difference in depressive symptoms after treatment with testosterone when compared with placebo. It was also noted that over administration of testosterone is associated with multiple adverse effects and complications. Conclusion: The current evidence provides mixed conclusions on the effectiveness of testosterone therapy for treating depression. More research is needed in adult men to see if declining testosterone levels directly influence the development of depression.

Sutured Custom Foldable Silicone Artificial Iris Implantation Combined With Intraocular Lens Implantation and Penetrating Keratoplasty: Safety and Efficacy Outcomes.

PURPOSE: To assess safety and efficacy outcomes of sutured custom silicone artificial iris and intraocular lens implantation combined with penetrating keratoplasty (triple procedure). METHODS: Prospective consecutive surgical case series of patients who underwent the triple procedure between 2010 and 2019 at Stein Eye Institute, UCLA, followed up for 1 year minimum. Safety outcomes were changes from preoperative to last follow-up in corrected distance visual acuity (CDVA), endothelial cell count, intraocular pressure (IOP), and postoperative complications. Efficacy outcomes included changes in subjective glare (none to severe), cosmetic appearance (worse to very much improved), and visual function as assessed by the Visual Function Questionnaire-25 at 1-year follow-up. RESULTS: Among 82 eyes implanted with an artificial iris, 14 eyes (17.1%) underwent the triple procedure. The median follow-up was 18.1 months (range 12.0-54.9 months). The median CDVA improved from 2.0 log of minimum angle of resolution (logMAR) (range 0.9-2.3 logMAR) to 0.7 logMAR (range 0.2-2.6 logMAR) (P = 0.02). Average endothelial cell count decreased 57.6% (P < 0.01). Six eyes (42.9%) experienced IOP elevations, 13 eyes (92.3%) developed iritis, and 11 eyes (78.6%) underwent secondary surgery. Graft rejection or secondary graft failure occurred in 7 eyes each (50.0%). Cosmesis improved in 12 eyes (85.7%; P < 0.01). The Visual Function Questionnaire-25 score improved from 72 to 77 (P < 0.01). Glare symptoms did not change significantly. CONCLUSIONS: The triple procedure was effective at improving CDVA, cosmesis, and quality of life; however, it was associated with frequent postoperative complications, of which iritis, IOP elevation, and secondary graft failure were the most common.