The Determinants of Eosinophilia in Patients With Severe Asthma.

Background: Asthma is defined by the Global Initiative for Asthma (GINA) as a heterogeneous disease characterized by chronic airway inflammation. The pathogenesis of the disease is better understood with the comprehension of immunological pathways. These pathways differ by the type of recruited cells and released interleukin (IL). Thus, asthma can be classified into subtypes based on the underlying immune mechanism: eosinophilic asthma (EA) and non-eosinophilic asthma (NEA). Patients with EA tend to respond better to inhaled corticosteroid as compared to those with NEA. The distinction of EA is very important in the light of emergent type 2 inflammation targeted therapies. Methods: We performed a 1-year (2018) retrospective cohort analysis of the Nationwide Inpatient Database (NIS). We included all adult patients presenting with severe asthma. Patients were stratified into two groups: eosinophilic severe asthma and non-eosinophilic severe asthma. The primary outcomes measures were the prevalence of chronic steroid use, status asthmaticus, family history of asthma, food, drug and environmental allergies, presence of nasal polyps, allergic rhinitis, allergic dermatitis, need for mechanical ventilation, need for oxygen supplementation, gastroesophageal reflux disease, in-hospital mortality, and length of stay. We performed descriptive statistics. Continuous parametric variables were reported using a mean and standard deviation. Continuous nonparametric variables were reported using a median and interquartile range. To compare the characteristics of the two groups, we used the independent t-test for continuous parametric variables and the Mann-Whitney U test for continuous nonparametric variables. The Chi-square test was used to assess differences in categorical variables. Results: A total of 2,646 patients were included, out of which 882 belonged to the eosinophilic group and 1,764 were in the non-eosinophilic group. Comparing EA versus NEA, we have found that eosinophilic group was characterized by higher percentage of steroid use (18.3% vs. 9.5%, P < 0.001). This group also had higher rates of status asthmaticus and positive family history (P = 0.009 and 0.004, respectively). The presence of allergies, allergic rhinitis, nasal polyps, and allergic dermatitis was higher among patients with eosinophilia. The need for mechanical ventilation and supplemental oxygen was also higher among this group (P < 0.001 for both); however, there was no significant difference in mortality rate (P = 0.347) and the length of hospital stay was similar in both groups (P < 0.001). Conclusion: We showed herein that the eosinophilic subtype of asthma differs widely from the non-eosinophilic phenotype. Clinically, patients with eosinophilia might exhibit different symptomatology, more atopy, and concomitant comorbidities. However, this group might have better response to steroid therapy and might benefit from the new emergent T2 immune targeted therapy. The identification of EA is crucial for better disease control.

Alpha-synuclein pathology in isolated rapid eye movement sleep behaviour disorder: a meta-analysis.

Accumulating evidence indicates that patients with isolated rapid eye movement sleep behaviour disorder (iRBD), a prodromal stage of synucleinopathies, show abnormal deposition of misfolded alpha-synuclein (a-Syn) in peripheral tissues. The clinical utility of testing for a-Syn in iRBD is unclear. This meta-analysis focused on the utility of testing for the abnormal a-Syn phosphorylated at Ser129 (p-syn) and a-Syn seeding activity (a-Syn seed amplification assays [aSyn-SAA]). Following an electronic database search, 15 studies were included that provided at a minimum data on test positivity in participants with iRBD. Test positivity from cerebrospinal fluid (CSF) was 80% (95% confidence interval [CI] 68-88%, I2 = 71%) and for skin was 74.8% (95% CI 53.2-88.5%, I2 = 64%) for aSyn-SAA and 78.5% (95% CI 70.4-84.9%, I2 = 14%) for p-syn. The phenoconversion rate ratio of biopsy-positive versus biopsy-negative iRBD was 1.28 (95% CI 0.68-2.41, I2 = 0%). Skin as a source had a specificity of 99% (95% CI 95-100%, I2 = 0%; p = 0.01 compared to CSF). As a test, p-syn, had a specificity of 100% (95% CI 93-100%, I2 = 0%; p < 0.001) compared to aSyn-SAA. The odds ratio of a-Syn test positivity in iRBD versus other RBDs was 112 (95% CI 20-629, I2 = 0%). These results demonstrate clinically significant test positivity in iRBD and favour skin over CSF as the source of a-Syn pathological analysis, and p-syn over aSyn-SAA as the testing method. Overall, these findings indicate that testing for a-Syn could help in differentiating iRBD from RBD secondary to other conditions.

Risk of Nephrolithiasis in Patients with Inflammatory Bowel Disease Receiving Biologic Treatment.

INTRODUCTION: Inflammatory bowel disease is a chronic inflammatory disorder of the gastrointestinal tract. Biologic drugs target specific molecules in the body's immune system to control inflammation. Recent studies have suggested a potential link between their use and an increased risk of nephrolithiasis. We conducted a study to further investigate this association. METHODS: The study used multiple logistic regression analysis to assess the association between the use of biologic drugs and nephrolithiasis. A p-value of <0.05 was considered statistically significant. SAS 9.4 was used for statistical analysis. RESULTS: The final sample consisted of 22,895 cases, among which 5603 (24.51%) were receiving at least one biologic drug. The biologic drugs received were as follows: Adalimumab 2437 (10.66%), Infliximab 1996 (8.73%), Vedolizumab 1397 (6.11%), Ustekinumab 1304 (5.70%); Tofacitinib, 308 (1.35%); Certolizumab, 248 (1.08%); and Golimumab, 121 (0.53%). There were 1780 (7.74%) patients with Nephrolithiasis: 438 (8.0%) patients were receiving biologic treatment. We found that the use of Vedolizumab (OR = 1.307, 95% CI 1.076-1.588, p = 0.0071) increased the odds of Nephrolithiasis by 31%. CONCLUSION: Vedolizumab use was associated with an increased risk of nephrolithiasis. The use of two or more biologic drugs also increased the risk compared to no biologic treatment.

The Impact of Age on the Epidemiology and Cost of Atrial Fibrillation Hospitalizations.

Atrial fibrillation (AF) is the most common arrhythmia and increases with age. This rising prevalence of AF is contributing to an increasing public health and economic burden. The 2018 Healthcare Cost and Utilization Project National Inpatient Sample dataset was used. All patients ≥15 years with a principal discharge diagnosis of AF were included. The patient population was divided into an "older" cohort (aged ≥65 years) and a "younger" (aged <65 years). Desired outcomes included hospital length of stay, discharge disposition, hospital charges, and in-hospital mortality. A generalized linear mixed model was used to calculate hospitalization rates for the "younger" and "older" groups. We identified 896,328 AF hospitalizations. Younger patients (18.1%) were more likely to be male (65.5% vs 49.9%), to smoke (21.6% vs 6.1%), and to use alcohol (9.7% vs 2.1%). Older patients were more likely to have heart failure (49.6% vs 43.9%) and hypertension (84.6% vs 76.1%). Hospitalization rates increased with increasing age groups. Older patients had higher in-hospital mortality (4.6% vs 2.9%) and were more likely to be discharged to another facility (31.6% vs 13.2%). AF hospitalization rates vary between hospitals across the United States. Hospital divisions with greater than expected admissions for AF, when compared with the national mean, were driven by higher "older" patient hospitalizations. In conclusion, older patients account for most AF hospitalizations. Older patients have higher AF morbidity and mortality. Hospitalization rates for AF increase with increasing increments of age.

Metastatic melanoma to the lung cured with lobectomy: A case report.

We herein present the case of a 79-year-old female patient who presents with a single asymptomatic pulmonary nodule, melanocytic in nature, later identified as a remote secondary lesion of a primary cutaneous melanoma that was resected 22 years before presentation. Although quite atypical, the patient underwent resection of the affected pulmonary lobe; follow-up imaging did not reveal any local or distant recurrences.

Extracorporeal Membrane Oxygenation (ECMO): What We Need to Know.

Extracorporeal membrane oxygenation (ECMO) is a form of circulatory support used in patients with refractory cardiac and/or respiratory failure. The main role of such support is to allow the lungs and heart to rest and heal while providing adequate oxygenation to vital organs. During extracorporeal support, the venous blood removed is decarboxylated, oxygenated, warmed, and infused back into the circulation. Physicians and nursing staff should be familiar with ECMO in order to provide the best care for critically ill patients. The aim of this paper is to review the technical aspects, indications, contraindications, complications, and management of both veno-venous (VV) and veno-arterial (VA) ECMO.

Gemella endocarditis.

We herein present the case presenting to our facility complaining of a fever of two months duration, who underwent dental procedure. Patient was diagnosed with infective endocarditis secondary to an uncommon bacteria: Gemella haemolysans. Patient was found to have concomitant severe mitral valve regurgitation. Our patient did not have any comorbidity or risk factor beside his dental procedure. Our patient received intravenous antibiotic therapy for six weeks and was scheduled for mitral valve replacement.

Endobronchial Chondroma: A Rare Case of Benign Tumor With Atypical High Standardized Uptake Value.

Chondroma is a rare benign tumor of the cartilage and occurs in the tracheobronchial tree, either isolated or as part of the Carney triad. It has been sparsely described in the literature, and some were mislabeled as hamartomas. We herein report a case of a 63-year-old female who was initially treated for community-acquired right middle lobe pneumonia. However, the patient's symptoms persisted warranting further workup, which confirmed the diagnosis of post-obstructive pneumonia. Whole-body positron emission tomography (PET) scan showed a hypermetabolic soft tissue lesion within the middle lobe bronchus, with a standardized uptake value (SUV) of 5.4, which is highly concerning for a primary or a secondary lesion. Since no distant lesions were identified, the patient underwent bronchial sleeve lobectomy of the right middle lobe under the assumption of localized disease. Pathology revealed chondroma, which had an unexpectedly high SUV on the PET scan; follow-up imaging denied any recurrence. Our case presents a rare entity of bronchial tumors with high SUV that presented with post-obstructive pneumonia. The patient's consent for writing this report was obtained.

Babesiosis and the human immune system.

Immunological phenomena have been described in infections such as infective endocarditis. However, none has been reported in the context of Babesiosis. Babesiosis is a tick-borne illness caused by the protozoa of the genus Babesia and causes infections that range from asymptomatic to severe and sometimes are fatal. This report presents the first case of ANCA/ANA positive severe babesiosis in an asplenic patient treated with repeated red blood cell exchange transfusion.

Spontaneous Pneumothorax: A Tale of Two Unique Cases.

We herein present two cases of spontaneous pneumothorax. The first one is occurring in an elderly female who has an extensive history of smoking and an underlying chronic obstructive lung disease, whereas the second case represents a congenital bleb in a male patient who has no other underlying pulmonary disorder. Both cases presented to our facility with a spontaneous pneumothorax following pulmonary bleb rupture. Both patients underwent thoracoscopic surgery with subsequent partial pleurectomy and pleurodesis.

Sensor Enabled Catheter Ablation Study (SECAS).

Background EnSite Precision technology (Abbott, Chicago, Illinois) is a novel mapping and navigation system facilitating the visualization and manipulation of intracardiac catheters during arrhythmia ablation procedures. When using Sensor Enabled (SE) catheters (Abbott, Chicago, Illinois), the mapping system uses both electrical impedance and magnetic data to facilitate more accurate mapping and navigation. Whether this translates into better clinical outcomes is unknown. Methods This retrospective study will examine whether SE catheters improve the success rate or decrease the risks compared to Biosense Thermocool catheters (Biosense Webster Inc., Irvine, California) not employing sensor-enabled technology utilizing NavX EnSite Precision algorithms. Charts of 146 patients who underwent radiofrequency ablations for supraventricular and ventricular arrhythmias between 2016 and 2019 in the Beirut Cardiac Institute were reviewed and analyzed. It was concluded that SE catheters have the same success rate as electrical impedance catheters. Results A total of 70% of the ablations carried using the impedance-based catheter were successful compared to 74% using the SE catheter. However, the difference was statistically non-significant (p-value: 0.7). As for complications, the ventricular fibrillation rate was increased in the SE catheter group. Three procedures were complicated by pericardial effusion, three patients had reversible heart block, and one death was recorded, all reported while using the standard catheter (p-value: 0.01). Conclusion SE catheters have the same success rates compared to standard catheters using the EnSite Precision mapping system.

Dopamine in Idiopathic Polymorphic Ventricular Tachycardia/Ventricular Fibrillation.

The role of medical therapy in the treatment of idiopathic polymorphic ventricular tachycardia (IPMVT) and idiopathic ventricular fibrillation (IVF) is not well established. Current medications in use include amiodarone, lidocaine, isoproterenol, verapamil, and quinidine. However, the use of dopamine for controlling such arrhythmias has never been described. We present an interesting case of IPMVT/IVF storm induced by short-coupled premature ventricular contractions. The arrhythmia was terminated acutely using dopamine infusion and was suppressed chronically using verapamil.

Post-traumatic Late Presentation of Morel-Lavallée: Case Report and Review of Literature.

INTRODUCTION: Morel-Lavallée (MLL) is an uncommon entity that is missed by many physicians, it is the result of a shearing force that leads to degloving of the subcutaneous fat from the underlying deep fascia. CASE REPORT: We present a case of a 15-year-old male patient who presented 3 months after the initial crush injury with a large MLL lesion at the lateral aspect of the right proximal thigh. He was treated with incision and drainage with compressive dressing and a negative pressure drain. CONCLUSION: Diagnosis of MLL is usually clinical and can be aided with radiological tools like MRI that is the gold standard of imaging in this lesion. Several treatment options are available, ranging from conservative treatment with compressive bandages to percutaneous drainage, injection of sclerotic agents, and surgical treatment with incision, drainage, and debridement. Diagnosis and treatment should be familiar to all caregivers to prevent further complications that could be life or organ-threatening.

The Correlation Between Gender and Accessory Pathways.

Background Accessory pathways (APs) are muscular bundles capable of rapid conduction between atria and ventricles. They can be located anywhere along the atrioventricular groove or septum. The etiology of such pathways is generally unknown. This study aims to evaluate the correlation between gender, AP location, and clinical presentation. Methods This is a retrospective study of 139 patients who underwent radiofrequency ablations for newly diagnosed accessory pathways between years 2010 and 2016. Information extracted from the medical records included: age at the time of diagnosis, gender, characteristics, and anatomical location of the accessory pathways. Results A total of 139 patients with AP were enrolled in the study. The mean age of diagnosis was 32.2 ± 13.5 years. With regards to gender, APs were more common among men (p-value 0.04). Males were predominant in both the right and left AP groups (p-value 0.025), although, overall, most of the AP were left located. Also, males were more commonly diagnosed with right posteroseptal (RPS) accessory pathways while females with left lateral (LL) pathways. Concerning the clinical presentation, the manifest form was more frequent than concealed. Males were prevalent in both groups (p-value 0.38). Conclusion Gender components might have a role in the pathogenesis of AP formation.

Arrhythmogenic Right Ventricular Dysplasia and Brugada Syndrome Overlap.

Arrhythmogenic right ventricular dysplasia (ARVD) and Brugada syndrome( BS) are associated with an increased risk of sudden cardiac death. Although they are described as two different entities, research suggests that they are not entirely separate. This paper presents a 55 years old male who presented for syncope. Interestingly, his electrocardiogram met the diagnostic criteria for both ARVD and BS. Subsequently, an implantable cardioverter-defibrillator (ICD) was implanted before discharge due to his high risk of sudden cardiac death. This case revealed that ARVD and BS clinical features can coexist in a single patient, and therefore supports the existence of a common pathophysiological basis of both diseases.

Leukocytes in Critical Patients With Asthma Exacerbation.

Background Asthma exacerbations, defined as acute or subacute progressive worsening of airway spasm, are a significant cause of disease morbidity. Risk factors for exacerbation include sex, age, race, socioeconomic status, baseline lung function, smoking history, and exposure to respiratory viruses. It is believed that white cells play an essential role in the pathogenesis of such attacks; however, the current understanding of the relationship between cell lines during an asthma attack is minimal. Methods This report represents a retrospective study for patients admitted to ICU for asthma exacerbations. The Medical Information Mart for Intensive Care iii (MIMIC iii) version 1.4 database was used to identify patients admitted for asthma exacerbations. The demographics, laboratory data gathered in addition, to clinical variables and outcomes were determined. Results The length of stay increased with the increase in WBC (p = 0.001). Intubated patients had an increased white blood cell (WBC) count when compared with non-intubated patients (p-value 0.009). In addition, patients with normal basophil counts on presentation were less likely to need intubation than those presenting with low basophils (p-value 0.015, adjusted odds ratio = 0.074, CI [0.009-0.620]) and those presenting with basophilia (p-value 0.001, adjusted odds ratio = 0.025, CI [0.003-0.225]). Furthermore, prolonged intubation (for three days or more) was positively correlated with eosinophil counts. On the other hand, there was no statistically significant association between the length of ICU and the patient's age, smoking status, or gender (p-values 0.611; 0.761; and 0.201, respectively). Conclusion Asthma exacerbation is a disease of heterogeneous pathophysiology. The leukocyte count is associated with the length of stay and the need for mechanical ventilation.

Recurrent Asymptomatic Sigmoid Diverticular Perforation in a Patient with Pemphigus Vulgaris on Immunosuppressive Therapy: A Case Report.

BACKGROUND Perforation of the colon is associated with high mortality and requires early diagnosis. However, the diagnosis of perforation from atypical causes can be a diagnostic challenge. This report is of a rare case of recurrent sigmoid colonic perforation in a patient with diverticular disease who did not present with an acute abdomen but who had pemphigus vulgaris treated with immunosuppressive therapy. CASE REPORT A 57-year-old man with pemphigus vulgaris was treated with steroids, non-steroidal anti-inflammatory drugs (NSAIDS), and azathioprine. He had episodes of abdominal bloating but denied any other symptoms. He was diagnosed with spontaneous sigmoid diverticular perforation without presenting with an acute abdomen. CONCLUSIONS Diverticular perforation can be asymptomatic in patients on immunosuppressive therapy. Therefore, there should be a high index of suspicion for bowel perforation in patients with abdominal symptoms who are treated for skin diseases, such as pemphigus vulgaris, and are on steroids and other immunosuppressive treatments.