An HIV patient with West Nile encephalitis and Amphiphysin antibodies - More on "West Nile infection triggering autoimmune encephalitis: Pathophysiological and therapeutic implications" by Moutsopoulos et al.

We have encountered a patient with HIV who developed rapid worsening altered mental status positive for both acute West Nile encephalitis and amphiphysin antibodies. Upon literature review, we read Dr. Moutsopoulos's paper from your journal with great interest (Karagianni et al., 2019 [1]). While an autoimmune encephalitis following West Nile encephalitis is not novel, there are several interesting features in a patient we have encountered. Firstly, amphiphysin antibodies coexisting with West Nile encephalitis has not been described before. Second, the fact that the clinical course is monophasic, not biphasic, may lead to the suggestion that autoimmune encephalitis triggered by, or coexisting with, West Nile encephalitis may be grossly underrecognized. Third, our patient was HIV positive, but not grossly immunocompromised, which may have played a factor in the autoimmune status.

Refining Cardiovascular Calcification in the Appraisal of Ischemic Heart.

BACKGROUND: Even in asymptomatic patients, there is a high association of ischemia on myocardial perfusion scans in those with coronary artery calcification or valvular calcifications. Patients without coronary artery calcifications have exceeding-low rates of cardiovascular events. The absence of cardiovascular calcification, including coronary artery, valvular, and thoracic aorta is a strong negative predictor of myocardial ischemia. In individuals with suspected ischemia who had chest computed tomography imaging, evaluation for cardiovascular calcification (coronary artery, valves, and thoracic aorta) is an invaluable tool to guide management for further diagnostic imaging. We hypothesize that the complete absence of cardiovascular calcification has a high negative predictive value for defects in myocardial perfusion imaging such as single-photon emission computed tomography (SPECT) or positron emission tomography (PET). METHODS: Non-contrast computed tomography performed for SPECT/PET CT attenuation correction from March 1, 2017, to September 30, 2017, were retrospectively reviewed for the absence of cardiovascular calcification by a cardiologist and radiologist who were blinded to patients' medical history. Medical records were reviewed to include patient demographics and medical history. A total of 132 patients were analyzed. RESULTS: Of the 132 patients without calcifications, seven patients had small myocardial perfusion defects suggestive of ischemia or infarct, but none were considered significant defects. Of these seven patients, six were managed medically and one was from an outside institution with no follow-up data. Two of the seven patients had follow-up invasive angiography or coronary CTA that did not show significant atherosclerotic coronary artery disease. CONCLUSION: A complete absence of cardiovascular calcification indicates a 100% negative predictive value for a significant perfusion defect on same-day confirmatory nuclear stress testing. Patients with suspected ischemia but absent cardiovascular calcifications can be safely managed medically without further testing for ischemia.

Effectiveness of Long-Term Opioid Therapy for Chronic Low Back Pain.

PURPOSE: Clinical trials generally have not assessed efficacy of long-term opioid therapy (LTOT) beyond 6 months because of methodological barriers and ethical concerns. We aimed to measure the effectiveness of LTOT for up to 12 months. METHODS: We conducted a retrospective cohort study among adults with chronic low back pain (CLBP) from April 2016 through August 2022. Participants reporting LTOT (>90 days) were matched to opioid nonusers with propensity scores. Primary outcomes involved low back pain intensity, back-related disability, and pain impact measured with a numerical rating scale, the Roland-Morris Disability Questionnaire, and the Patient-Reported Outcomes Measurement Information System, respectively. Secondary outcomes involved minimally important changes in primary outcomes. RESULTS: The mean age of 402 matched participants was 55.4 years (S.D., 11.9 years), and 297 (73.9%) were female. There were 119 (59.2%) LTOT users who took opioids continuously for 12 months. The mean daily morphine milligram equivalent dosage at baseline was 36.7 (95% CI, 32.8 to 40.7). There were no differences between LTOT and control groups in mean pain intensity (6.06, 95% CI, 5.80-6.32 vs 5.92, 95% CI, 5.68-6.17), back-related disability (15.32, 95% CI, 14.55-16.09 vs 14.81, 95% CI, 13.99-15.62), or pain impact (32.51, 95% CI, 31.33-33.70 vs 31.22, 95% CI, 30.00 to 32.43). Correspondingly, LTOT users did not report greater likelihood of minimally important changes in any outcome. CONCLUSIONS: Using LTOT for up to 12 months is not more effective in improving CLBP outcomes than treatment without opioids. Clinicians should consider tapering opioid dosage among LTOT users in accordance with clinical practice guidelines.

Weaker compressions after night shift? The WeCAN manikin study.

To assess whether the quality of chest compressions (CC) differs before and after a night shift. We carried out a cluster randomized study in three Emergency Departments and three ICUs in Paris, France. Physicians were assessed on a control day and immediately following after a night shift. The primary endpoint was the proportion of CC with a depth greater than 50 mm. We analyzed 67 participants. The proportion of CC with a depth greater than 50 mm was similar on a control day and after a night shift [52% in both groups, mean difference of 0 (95% confidence interval: -17 to 17)]. Other indicators of CC quality were unchanged after a night shift, except for the mean depth of CC (51 vs. 48 mm, P=0.01). We report in our sample that the quality of CC after a night shift is not inferior to a control day.