Alzheimer's disease biomarker burden in primary motor cortices is associated with poorer dexterity performance.

INTRODUCTION: Motor function has correlated with longevity and functionality; however, there is limited research on those with Alzheimer's disease (AD). We studied the association between motor functionality and AD pathology in primary motor and medial temporal cortices. METHODS: A total of 206 participants with a clinical diagnosis of cognitively healthy, AD, or mild cognitive impairment (MCI) underwent imaging and motor assessment. Linear regressions and analyses of variance were applied to test the prediction from AD imaging biomarkers to motor performance and the diagnosis group differences in motor performance. RESULTS: Increased neurodegeneration was associated with worsening dexterity and lower walking speed, and increased amyloid and tau were associated with worsening dexterity. AD and MCI participants had lower motor performance than the cognitively healthy participants. DISCUSSION: Increased AD pathology is associated with worsening dexterity performance. The decline in dexterity in those with AD pathology may offer an opportunity for non-pharmacological therapy intervention. HIGHLIGHTS: Noted worsening dexterity performance was associated with greater Alzheimer's disease (AD) pathology (tau, amyloid beta, and neurodegeneration) in primary motor cortices. Similarly, increased neurodegeneration and tau pathology in parahippocampal, hippocampal, and entorhinal cortices is associated with worsening dexterity performance. Motor performance declined in those with clinical and preclinical AD among an array of motor assessments.

Extracorporeal membrane oxygenation for COVID-19 induced hypoxia: Single-center study.

INTRODUCTION: The pandemic of the coronavirus disease 2019 (COVID-19) and associated pneumonia represent a clinical and scientific challenge. The role of Extracorporeal Membrane Oxygenation (ECMO) in such a crisis remains unclear. METHODS: We examined COVID-19 patients who were supported for acute respiratory failure by both conventional mechanical ventilation (MV) and ECMO at a tertiary care institution in Washington DC. The study period extended from March 23 to April 29. We identified 59 patients who required invasive mechanical ventilation. Of those, 13 patients required ECMO. RESULTS: Nine out of 13 ECMO (69.2%) patients were decannulated from ECMO. All-cause ICU mortality was comparable between both ECMO and MV groups (6 patients [46.15%] vs. 22 patients [47.82 %], p = 0.92). ECMO non-survivors vs survivors had elevated D-dimer (9.740 mcg/ml [4.84-20.00] vs. 3.800 mcg/ml [2.19-9.11], p = 0.05), LDH (1158 ± 344.5 units/L vs. 575.9 ± 124.0 units/L, p = 0.001), and troponin (0.4315 ± 0.465 ng/ml vs. 0.034 ± 0.043 ng/ml, p = 0.04). Time on MV as expected was significantly longer in ECMO groups (563.3 hours [422.1-613.9] vs. 247.9 hours [101.8-479] in MV group, p = 0.0009) as well as ICU length of stay 576.2 hours [457.5-652.8] in ECMO group vs. 322.2 hours [120.6-569.3] in MV group, p = 0.012). CONCLUSION: ECMO is a supportive intervention for COVID-19 associated pneumonia that could be considered if the optimum mechanical ventilation is deemed ineffective. Biomarkers such as D-dimer, LDH, and troponin could help with discerning the clinical prognosis in patients with COVID-19 pneumonia.

Cryptococcal empyema treated with tube thoracostomy and intrapleural fibrinolysis.

A 55-year old woman with a history of relapsed T-cell ALL presented with right pleuritic chest pain and decreased breath sounds over the right hemithorax. Imaging of the chest showed loculated effusions. Tube thoracostomy was performed with intrapleural application of alteplase and dornase alpha over a 3-day period. Repeat imaging demonstrated a marked decrease in the volume of the effusion. In most prior published cases of pleural cryptococcosis, surgical drainage was required in addition to prolonged antifungal agents. More than 50% of patients with cryptococcal infection have severe underlying disease or immunodeficiency state making them high risk for surgery. This is the first case to our knowledge of cryptococcal empyema successfully treated with tube thoracostomy and intrapleural fibrinolysis.

Using Expectancy Theory to quantitatively dissociate the neural representation of motivation from its influential factors in the human brain: An fMRI study.

Researchers have yet to apply a formal operationalized theory of motivation to neurobiology that would more accurately and precisely define neural activity underlying motivation. We overcome this challenge with the novel application of the Expectancy Theory of Motivation to human fMRI to identify brain activity that explicitly reflects motivation. Expectancy Theory quantitatively describes how individual constructs determine motivation by defining motivation force as the product of three variables: expectancy - belief that effort will better performance; instrumentality - belief that successful performance leads to particular outcome, and valence - outcome desirability. Here, we manipulated information conveyed by reward-predicting cues such that relative cue-evoked activity patterns could be statistically mapped to individual Expectancy Theory variables. The variable associated with activity in any voxel is only reported if it replicated between two groups of healthy participants. We found signals in midbrain, ventral striatum, sensorimotor cortex, and visual cortex that specifically map to motivation itself, rather than other factors. This is important because, for the first time, it empirically clarifies approach motivation neural signals during reward anticipation. It also highlights the effectiveness of the application of Expectancy Theory to neurobiology to more precisely and accurately probe motivation neural correlates than has been achievable previously.

Immune Reconstitution Syndrome Caused by Nontuberculous Mycobacteria: A Case Report and Review of Literature.

Immune reconstitution inflammatory syndrome (IRIS) is a potentially life-threatening phenomenon associated with the initiation of antiretroviral therapy in patients with acquired immunodeficiency syndrome due to a human immunodeficiency virus (HIV) infection. It is thought to be an exaggerated inflammatory response to an existing pathogen or even its antigen. We present a case of IRIS due to a non-tuberculous mycobacteria infection in a young patient with HIV infection who was recently started on therapy. This case highlights the challenges of making such a diagnosis and the importance of multidisciplinary team discussions with pulmonary and infectious diseases for optimal management of these patients.

Unexpected Relapse: Insights Into Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA) is a rare vasculitis that can pose a significant mortality risk given its multiorgan involvement and is the most common of the three anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. Cardinal pathological features include necrotizing granulomas of the respiratory tract, small and medium vessel vasculitis, and glomerulonephritis. Early treatment is imperative to reduce permanent organ damage such as end-stage kidney disease. We describe the first case of GPA relapse 38 years after the initial pulmonary presentation. The patient previously had isolated lung involvement with preserved renal function, but presented with an acute kidney injury, uremia, and several constitutional symptoms. The patient was treated with corticosteroids and intermittent hemodialysis and initiated on immunosuppressants; the clinical course is highlighted by eventual renal recovery. Our purpose is to highlight the importance of treating patients to complete immunological recovery, particularly in GPA vasculitis, to prevent unnecessary relapse and further loss of renal function.

Exploring a Rare Pulmonary Coinfection: Cryptococcal Pneumonia and Exophiala dermatitidis in an Immunocompetent Host.

Pulmonary cryptococcosis is becoming increasingly common in immunocompetent hosts, manifesting with variable clinical presentations ranging from asymptomatic colonization to severe pneumonia. Radiological findings are non-specific, such as nodular infiltrates, mass-like lesions, and mediastinal lymphadenopathy. We present a case of a 61-year-old woman with Cryptococcus neoformans pneumonia coinfected with Exophiala dermatitidis, an unusual occurrence in an immunocompetent host and the first of its kind. This coinfection posed significant diagnostic challenges due to the rare occurrence of each individual organism in immunocompetent patients as well as the difficulty of their laboratory diagnosis. Treatment regimens, particularly in coinfections, warrant careful consideration to mitigate mortality risk. This case underscores the importance of comprehensive diagnostic strategies and optimized treatment regimens for rare fungal coinfections in immunocompetent hosts.

Impact of the COVID-19 Pandemic on Hospital Admission Rate, Length of Stay, and Mortality Rate for Patients with Chronic Obstructive Pulmonary Disease Exacerbation: A Retrospective Study.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause of hospital admissions. Coronavirus disease 2019 (COVID-19) has large impact on patients with pulmonary diseases. The purpose of the study is to evaluate the impact of COVID-19 on patients with AECOPD. Method: Retrospective study with two cohorts, the first period included patients with AECOPD before COVID-19 pandemic; the second period included patients with AECOPD since the beginning of COVID-19 pandemic. The length of stay (LOS), number of patients requiring mechanical ventilation, and allcause mortality were calculated. Results: There was a total of 55 (44.72%) patients in the pre-COVID period compared to 68 (55.28%) patients in the COVID period. In the pre-COVID period: 14 (19.44%) had hypertension, 26(36.11%) had diabetes, 27(37.50%) had ischemic heart disease, 3(4.17%) had myocardial infarction; in the COVID period: 20 (29.41%) had hypertension, 24(35.29%) had diabetes, 27(39.71%) had ischemic heart disease, 1(1.47) had myocardial infarction. The LOS was shorter in pre-COVID period compared to COVID period, 6.51(SD 5.02) days vs 8.91(SD7.88) days with P-value of 0.042 respectively. The total number of patients needing mechanical ventilation in pre-COVID period was similar to the COVID period with P-value of 0.555. All-cause mortality number was 2 (3.64%) in the pre-COVID period compared to 6 (8.82%) in COVID period with P-value of 0.217. Conclusion: Study results revealed significant difference in length of stay for patients with AECOPD, patient in COVID period had increased LOS compared to pre-COVID period. There was no significant difference in the other parameters.

Mantle Cell Lymphoma Causing Recurrent Pleural Effusions: A Case Report.

Mantle cell lymphoma (MCL) is a rare type of B cell non-Hodgkin's lymphoma. MCL is most commonly identified in the gastrointestinal tract. Yet, many other extranodal sites have been described in the literature, including the rare instances of the primary site being the pleura of the lung. We present a case with a 73-year-old female who presented with a three-month history of unintentional weight loss, nocturnal fever, and night sweats. She had recurrent left pleural effusions; however, thoracentesis and pleural fluid cytology were negative for malignancy. A definitive diagnosis was achieved after the patient underwent video-assisted thoracic surgery. MCL presenting as a pleural effusion is rarely reported in the literature.

Wound care management: tracheostomy and gastrostomy.

Percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) tube placements are routine procedures performed in the intensive care units (ICUs). They are performed to facilitate care and promote healing. They also help prevent complications from prolonged endotracheal intubation and malnutrition. In most cases, both are performed simultaneously. Physicians performing them require knowledge of local anatomy, tissue and vascular relationships, along with advance bronchoscopy and endoscopy skills. Although PDTs and PEGs are considered relatively low-risk procedures, operators need to have the knowledge and skill to recognize and prevent adverse outcomes. Current published literature on post-procedural care and stoma wound management was reviewed. Available recommendations for the routine care of tracheostomy and PEG tubes are included in this review. Signs and symptoms of early PDT- and PEG-related complications and their management are discussed in detail. These include hemorrhage, infection, accidental decannulation, tube obstruction, clogging, and dislodgement. Rare, life-threatening complications are also discussed. Multidisciplinary teams are needed for improved patient care, and members should be aware of all pertinent care aspects and potential complications related to PDT and PEG placement. Each institute is strongly encouraged to have detailed protocols to standardize care. This review provides a state-of-the-art guidance on the care of patients with tracheostomies and gastrostomies specifically in the ICU setting.

The relationship of glucose-stimulated insulin secretion to cerebral glucose metabolism and cognition in healthy middle-aged and older adults.

Insulin resistance (IR) has been related to reduced cerebral glucose metabolism in regions identified as hypometabolic in Alzheimer's clinical syndrome. Insulin secretion (IS) has been less studied than IR despite findings that decreased IS is an early indicator of future type 2 diabetes and a potential predictor of Alzheimer's clinical syndrome. We investigated whether higher IR and lower IS would be associated with greater age-related reductions in regional cerebral glucose metabolism and worse cognitive performance. Two-hour oral glucose tolerance testing and 18F-fluorodeoxyglucose positron emission tomography were performed on 1-2 occasions on a sample of healthy middle-aged and older adults from the Wisconsin Alzheimer's Disease Research Center. Neuropsychological tests were completed during Alzheimer's Disease Research Center Clinical Core visits. Pattern of findings suggested that lower (not higher) IS was related to higher regional cerebral glucose metabolism in middle aged but not older adults, and lower (not higher) IS was also related to better immediate recall. In the context of healthy insulin sensitivity, lower IS may be beneficial to brain health.

Amiodarone-Induced Neutropenia: An Uncommon Side Effect of a Common Drug.

Amiodarone is widely used as an antiarrhythmic agent for the treatment of both supraventricular and ventricular arrhythmias in various inpatient as well as outpatient settings. Classified as a class III antiarrhythmic agent, it acts mainly by inhibition of potassium channels in the cardiac muscle. Adverse effects are quite common and usually involve pulmonary, gastrointestinal, endocrine, dermatologic, or neuromuscular systems. Although hematologic side effects including thrombocytopenia have also been reported, amiodarone-induced neutropenia is quite rare. We present a case of amiodarone-induced neutropenia in a 66-year-old Caucasian gentleman. He presented to our hospital with cardiac arrest due to ventricular-fibrillation and had received amiodarone as a part of his therapy. His hospital course was complicated by neutropenia which was found to have a clear temporal relation with amiodarone. His initial white blood cell count was 6400/mm3 with an absolute neutrophil count (ANC) of 4800/mm3. His ANC started to downtrend and reached a nadir of 400/mm3 at day six of therapy. This improved significantly after stopping amiodarone, without any change in other medications. Given the rapid improvement of his neutropenia with the discontinuation of amiodarone, further workup with a bone marrow biopsy was not performed. Severe selective neutropenia, also known as agranulocytosis, is a life-threatening condition due to increased risk of severe infections. Antiarrhythmic agents such as tocainamide, procainamide, and flecainide are generally known to cause agranulocytosis. The mechanism of agranulocytosis or neutropenia is thought to be mediated by either immune-mediated destruction or direct and indirect toxicity to myeloid precursors. Although amiodarone has been in use for over 20 years in the management of tachyarrhythmias, agranulocytosis as a direct side effect of amiodarone therapy has been rarely reported. It is important to keep in mind this rare but potentially life-threatening adverse effect of amiodarone when initiating therapy.