In hyponatremia, rapid intermittent bolus vs. slow continuous infusion of hypertonic saline did not differ for overcorrection of serum sodium.

SOURCE CITATION: Baek SH, Jo YH, Ahn S, et al. Risk of overcorrection in rapid intermittent bolus vs slow continuous infusion therapies of hypertonic saline for patients with symptomatic hyponatremia: the SALSA randomized clinical trial. JAMA Intern Med. 2021;181:81-92. 33104189.

An Updated Approach to Evaluation and Treatment of Helicobacter pylori Infection.

Helicobacter pylori is a chronic bacterial infection that can lead to peptic ulcer disease, chronic gastritis, and gastric cancer. Its prevalence in the United States is lower than in most of the world, although specific populations are at particular risk for disease-related complications, including those with lower socioeconomic status and older adults. Since its discovery, there have been advances in H. pylori diagnosis and treatment, which are the focus of this review for general practice. Practice guidelines have expanded the role for treatment, despite traditional management algorithms resulting in diminished effectiveness as a result of increasing antibiotic resistance. In this context, new approaches warrant discussion. As such, this review aims to provide a clinical context and framework for the testing and rational treatment of H. pylori infection consistent with the available evidence.

CuticleTrace: A toolkit for capturing cell outlines from leaf cuticle with implications for paleoecology and paleoclimatology.

Premise: Leaf epidermal cell morphology is closely tied to the evolutionary history of plants and their growth environments and is therefore of interest to many plant biologists. However, cell measurement can be time consuming and restrictive with current methods. CuticleTrace is a suite of Fiji and R-based functions that streamlines and automates the segmentation and measurement of epidermal pavement cells across a wide range of cell morphologies and image qualities. Methods and Results: We evaluated CuticleTrace-generated measurements against those from alternate automated methods and expert and undergraduate hand tracings across a taxonomically diverse 50-image data set of variable image qualities. We observed ~93% statistical agreement between CuticleTrace and expert hand-traced measurements, outperforming alternate methods. Conclusions: CuticleTrace is a broadly applicable, modular, and customizable tool that integrates data visualization and cell shape measurement with image segmentation, lowering the barrier to high-throughput studies of epidermal morphology by vastly decreasing the labor investment required to generate high-quality cell shape data sets.

A Case Report of Steroid-Resistant Cryptogenic Organizing Pneumonia Managed with Intravenous Immunoglobulins.

Fewer than ten reported cases of cryptogenic organizing pneumonia (COP) have been managed with intravenous immunoglobulins (IVIg). We report a case of a 72-year-old man who presented with a worsening cough and diffuse opacities on chest radiograph. Following no improvement with antibiotics and negative complementary investigations for infectious, malignant, and autoimmune etiologies, COP was confirmed on lung biopsy. Due to continued clinical deterioration despite high-dose steroids and new severe steroid-induced hallucinations, the patient was placed on intravenous immunoglobulins (IVIg) and mycophenolate mofetil and made a satisfactory recovery. IVIg should be considered as an important steroid-sparing alternative in patients with COP.

Prior tonsillectomy is associated with an increased risk of esophageal adenocarcinoma.

BACKGROUND: Esophageal cancer is a deadly cancer with 5-year survival <20%. Although multiple risk factors for esophageal adenocarcinoma (EAC) including obesity, GERD and smoking have been identified, these risk factors do not fully explain the rising incidence of EAC. In this study, we evaluated the association between prior history of tonsillectomy and EAC. Our goal was to determine whether tonsillectomies were more frequent in patients with EAC (cases) than in our thoracic surgery controls. METHODS: Cases included 452 esophagectomy cases, including 396 with EAC and 56 who underwent esophagectomy for Barrett's esophagus (BE) with high grade dysplasia (HGD). 1,102 thoracic surgery patients with surgical indications other than dysplastic BE or esophageal cancer represented the controls for our analysis. The association of tonsillectomy and HGD/EAC were primarily evaluated by using univariate tests and then verified by logistic regression analysis. Baseline demographics, medical history, and thoracic surgery controls were compared by using χ2 tests or 95% CIs. Significant risk factors were considered as covariates in the multivariate models while evaluating the association between tonsillectomy and HGD/EAC. P-values or odds ratios were estimated with 95% confidence limits to identify significances which was more appropriate. RESULTS: Tonsillectomy was more common in cases than controls and was found to have a significant association with esophageal cancer (19.9% vs. 12.7%; p-value = 0.0003). This significant association persisted after controlling for other known risk factors/covariates. CONCLUSION: A prior history of tonsillectomy was significantly associated with HGD/EAC and may represent an independent risk factor for the development of EAC. However, the underlying biology driving this association remains unclear.

Role and regulation of iron-sulfur cluster biosynthesis genes in Shigella flexneri virulence.

Shigella flexneri, a causative agent of bacterial dysentery, possesses two predicted iron-sulfur cluster biosynthesis systems called Suf and Isc. S. flexneri strains containing deletion mutations in the entire suf operon (UR011) or the iscSUA genes (UR022) were constructed. Both mutants were defective in surviving exposure to oxidative stress. The suf mutant showed growth that was comparable to that of the parental strain in both iron-replete and iron-limiting media; however, the isc mutant showed reduced growth, relative to the parental strain, in both media. Although the suf mutant formed wild-type plaques on Henle cell monolayers, the isc mutant was unable to form plaques on Henle cell monolayers because the strain was noninvasive. Expression from both the suf and isc promoters increased in iron-limiting media and in the presence of hydrogen peroxide. Iron repression of the suf promoter was mediated by Fur, and increased suf expression in iron-limiting media was enhanced by the presence of IscR. Iron repression of the isc promoter was mediated by IscR. Hydrogen peroxide-dependent induction of suf expression, but not isc expression, was mediated by OxyR. Furthermore, IscR was a positive regulator of suf expression in the presence of hydrogen peroxide and a negative regulator of isc expression in the absence of hydrogen peroxide. Expression from the S. flexneri suf and isc promoters increased when Shigella was within Henle cells, and our data suggest that the intracellular signal mediating this increased expression is reduced iron levels.

Efficacy of multiple influenza vaccine delivery systems in a single facility.

We retrospectively investigated different inpatient influenza delivery strategies used during 3 consecutive years at a single institution. Vaccination rates were 3% for a physician reminder system, 21% for a manual standing order program, and 43% for a manual standing order program with a provider education program.

There may be more than meets the eye with Clostridium perfringens bacteremia.

We present the case of an 89-year-old man with a 1 month history of fevers and fatigue. Blood cultures were positive for Clostridium perfringens. The patient had worsening abdominal distension in which an abdominal computed tomography scan uncovered a colonic mass, and further work-up revealed poorly differentiated adenocarcinoma. The patient was treated with antibiotics, but unfortunately, given his age and the new malignancy, he was discharged to hospice care. The association between clostridial bacteremia and colon cancer has been well described in the literature and is further discussed in this article. This case highlights the importance of recognizing possible occult malignancy in the right clinical setting in patients found to have clostridial bacteremia.

Rare case of stress cardiomyopathy due to intramuscular epinephrine administration.

We report a case of a 37-year-old woman who presented to our hospital with retrosternal chest pain following intramuscular administration of epinephrine due to presumed anaphylaxis. On arrival, she was found to have ST segment depression in the anterolateral leads on ECG and elevated cardiac troponins. She was diagnosed with stress cardiomyopathy based on left ventricle dysfunction and angiographically normal coronary arteries on cardiac catheterisation. To the best of our knowledge, this is the third reported case of takotsubo cardiomyopathy following appropriately dosed intramuscular administration of epinephrine for anaphylaxis. This case highlights the importance of considering stress cardiomyopathy in patients presenting with chest pain syndrome following systemic administration of epinephrine.

Window to the heart: the value of a native and paced QRS duration. Current perspective and review.

Given the technological advances and reliance upon expensive testing for guiding therapy, it is surprising how an inexpensive, low tech electrocardiogram can provide a wealth of information pertaining to the underlying cardiovascular status of a patient. In this article we review the changes in hemodynamics, prognosis and guidance of therapeutic options associated with a prolonged QRS duration.

Lime-induced phytophotodermatitis.

This case describes a scenario of lime-induced phytophotodermatitis. Phytophotodermatitis is a dermatitis caused after the skin is exposed to photosensitizing compounds in plants and then exposed to sunlight. Many common plants including citrus fruits, celery, and wild parsnip contain these photosensitizing compounds which cause phytophotodermatitis. It is important for a physician to be aware of phytophotodermatitis because it may often be misdiagnosed as other skin conditions including fungal infection, cellulitis, allergic contact dermatitis, and even child abuse.

Pneumocystis pneumonia in a non-HIV patient on chronic corticosteroid therapy: a question of prophylaxis.

A man in his late 50s with a history of membranoproliferative glomerulonephritis presented with fever and mild dyspnoea. He was HIV-negative and had been on corticosteroids as immunosuppression for 6 months prior to tapering them off 1 week before presentation. He was not taking prophylaxis for Pneumocystis jirovecii pneumonia. After unsuccessful treatment for community-acquired pneumonia, his condition worsened and he required intubation and mechanical ventilation. Full respiratory workup including bronchoscopy revealed P jirovecii as a source for the patient's infection. He was treated successfully with a 21-day course of trimethoprim-sulfamethoxazole  and eventually weaned off the ventilator. He has had no complications to date. In our review of this case and the existing literature, we believe that proper utilisation of prophylaxis for pneumocystis pneumonia may have prevented our patient's transfer to intensive care unit. In our article, we discuss this issue and explore current evidence for prophylaxis.

Recurrent case of ibuprofen-induced aseptic meningitis in mixed connective tissue disease.

Although relatively uncommon, the incidence of non-steroidal anti-inflammatory drug-induced aseptic meningitis appears to be increasing among patients with connective tissue disease and also among the healthy population. Ibuprofen is the most common culprit identified. We report a case of a 28-year-old woman with mixed connective tissue disease and recent intake of ibuprofen, presenting with a recurrent episode of ibuprofen-induced aseptic meningitis.

Quality review: Fleischner criteria adherence by radiologists in a large community hospital.

PURPOSE: Solitary pulmonary nodules are a common incidental finding on CT and unnecessary follow-up affects cost, radiation exposure, and patient anxiety. The aim of this study was to evaluate the adherence of one institution's radiologists with published criteria in their follow-up recommendations. METHODS: A data set of 3,000 CT scans with the word nodule used in the report history or conclusion from 2008 to 2010 was generated. This pool was increased as each study was traced back to the examination when the pulmonary nodule was first identified. The follow-up recommendation of the radiologist was then classified as "adherent," "incomplete/no recommendation," "earlier than recommended by the criteria," "later than recommended," or a "wider follow-up time frame than recommended." RESULTS: After the implementation of exclusion criteria, 1,432 examinations were satisfactory for classification. The adherence rates of radiologists for nodules followed in up to 4 consecutive examinations were 57%, 48%, 70%, and 79%, respectively. Overmanagement was the most common deviation from the Fleischner criteria, ranging from 15% to 28% of evaluated reports. CONCLUSIONS: Radiologists at the authors' hospital do not always adhere to the Fleischner criteria, most often recommending closer follow-up. The possibility of missing a malignancy while it is still treatable, medicolegal concerns, and lack of familiarity with the Fleischner criteria are all potential factors in nonadherence.

Peptide YY levels across pubertal stages and associations with growth hormone.

CONTEXT: Changes in appetite-regulating peptides may impact food intake during puberty and facilitate the pubertal growth spurt. Peptide YY (PYY) is an anorexigenic hormone that is high in anorexia nervosa and low in obesity, inhibits GnRH secretion, and is suppressed by GH administration. The relationship between PYY and GH has not been examined across puberty. OBJECTIVES: We hypothesized that PYY would be inversely associated with GH in adolescents and would be lowest when GH is highest. DESIGN AND SETTING: We conducted a cross-sectional study at a Clinical Research Center. SUBJECTS: We studied 87 children, 46 boys and 41 girls ages 9-17 yr at Tanner stages 1-5 of puberty (10th-90th percentiles for body mass index). OUTCOME MEASURES: We measured fasting PYY and nadir GH levels after administration of an oral glucose load. Leptin levels were also measured. RESULTS: Fasting PYY was lowest and nadir GH highest in boys in Tanner stages 3-4 (P = 0.02) and in girls in Tanner stages 2-3 (P = 0.02). Leptin levels were highest in early pubertal boys and late pubertal girls. For the group as a whole and within genders, even after controlling for body mass index, log nadir GH correlated inversely with log PYY (P = 0.003, 0.07, and 0.02). PYY levels did not correlate with leptin levels. CONCLUSIONS: During mid-puberty, at a time when GH levels are the highest, PYY is at a nadir, and these low PYY levels may facilitate pubertal progression and growth.