Angiotensin type 1A receptor expression in C1 neurons of the rostral ventrolateral medulla contributes to the development of angiotensin-dependent hypertension.

Chronic low-dose systemic infusion of angiotensin II induces hypertension via activation of the angiotensin II type 1A receptor (AT1AR). Previously, we have demonstrated that expression of the AT1AR on catecholaminergic neurons is necessary for the full development of angiotensin-dependent hypertension. In the present study, we examined the mechanism by which selective deletion of the AT1AR from these cells affects the development of hypertension. We also tested the hypothesis that AT1ARs expressed by catecholaminergic C1 neurons in the rostral ventrolateral medulla play an important role in angiotensin-induced hypertension. A Cre-lox approach was used to delete the AT1AR from all catecholaminergic cells or from C1 neurons selectively. Subcutaneous administration of angiotensin II induced hypertension in all mice, with delayed onset and reduced maximal response in the global AT1AR catecholaminergic knockout mice. The AT1AR catecholaminergic knockout mice had decreased renal fluid and electrolyte retention and urinary noradrenaline excretion. The blood pressure response was reduced only during the second week of angiotensin II infusion in the mice with selective C1 AT1AR deletion, demonstrating that AT1AR expression by C1 neurons plays a moderate role in angiotensin-induced hypertension. The difference in the time course of development of hypertension between the mice with global AT1AR knockout from catecholaminergic cells and the mice with C1 AT1AR deletion suggests that other catecholaminergic neurons are important.

Implementation of medication for opioid use disorder treatment during a natural disaster: The PROUD-LA study.

BACKGROUND: The impacts of climate change-related extreme weather events (EWEs) on Medication for Opioid Use Disorders (MOUD) implementation for Medicaid beneficiaries are relatively unknown. Such information is critical to disaster planning and other implementation strategies. In this study we examined implementation determinants and strategies for MOUD during EWEs. METHODS: The Louisiana-based Community Resilience Learning Collaborative and Research Network (C-LEARN) utilized Rapid Assessment Procedures-Informed Community Ethnography (RAPICE), involving community leaders in study design, execution, and data analysis. We conducted qualitative semi-structured interviews with 42 individuals, including MOUD Medicaid member patients and their caregivers, healthcare providers and administrators, and public health officials with experience with climate-related disasters. We mapped key themes onto updated Consolidated Framework for Implementation Research domains. RESULTS: MOUD use is limited during EWEs by pharmacy closures, challenges to medication prescription and access across state lines, hospital and clinic service limits, overcrowded emergency departments, and disrupted communications with providers. MOUD demand simultaneously increases due to the stress associated with displacement, resource loss, the COVID-19 pandemic, and social determinants of health. Effective implementation strategies include healthcare system disaster plans with protocols for clear and regular patient-provider communication, community outreach, additional staffing, and virtual delivery of services. Providers can also increase MOUD access by having remote access to EHRs, laptops and contact information, resource lists, collaborative networks, and contact with patients via call centers and social media. Patients can retain access to MOUD via online patient portals, health apps, call centers, and provider calls and texts. The impact of EWEs on MOUD access and use is also influenced by individual characteristics of both patients and providers. CONCLUSIONS: The increasing frequency and severity of climate-related EWEs poses a serious threat to MOUD for Medicaid beneficiaries. MOUD-specific disaster planning and use of telehealth for maintaining contact and providing care are effective strategies for MOUD implementation during EWEs. Potential considerations for policies and practices of Medicaid, providers, and others to benefit members during hurricanes or major community stressors, include changes in Medicaid policies to enable access to MOUD by interstate evacuees, improvement of medication refill flexibilities, and incentivization of telehealth services for more systematic use.

A Rare Presentation of Scurvy in a Well-Nourished Patient.

Vitamin C deficiency, otherwise known as scurvy, is a rare diagnosis among populations with adequate nutritional resources. We present a 37-year-old female patient with bilateral lower extremity edema, episodic anasarca, petechiae, and easy bruising who was diagnosed with scurvy. Given the clinical presentation, a broad differential was investigated with no findings suggestive of hematologic or cardiovascular pathology. Initial laboratory studies were unremarkable. Progression of cutaneous symptoms and subsequent laboratory findings demonstrating low vitamin C levels supported a diagnosis of scurvy. Classical symptoms of scurvy include mucocutaneous petechiae, poor wound healing, ecchymosis, hyperkeratosis, corkscrew hair, gingival swelling, and bleeding gums. Following standard enteral supplementation of vitamin C, repeat vitamin C levels failed to adequately respond with the patient remaining to be symptomatic. Given a lack of insufficient nutritional intake or known systemic illness, gastrointestinal malabsorptive etiology was suspected. Though rare in the United States, scurvy should be considered in patients with manifestations of a bleeding disorder. A gastrointestinal workup may be indicated if other nutritional deficiencies are identified, or a source of inadequate intake cannot be established.