Preference for and impact of telehealth vs in-person asthma visits among Black and Latinx adults.

BACKGROUND: Black and Latinx adults experience disproportionate asthma-related morbidity and limited specialty care access. The severe acute respiratory syndrome coronavirus 2 pandemic expanded telehealth use. OBJECTIVE: To evaluate visit type (telehealth [TH] vs in-person [IP]) preferences and the impact of visit type on asthma outcomes among Black and Latinx adults with moderate-to-severe asthma. METHODS: For this PREPARE trial ancillary study, visit type preference was surveyed by e-mail or telephone post-trial. Emergency medical record data on visit types and asthma outcomes were available for a subset (March 2020 to April 2021). Characteristics associated with visit type preferences, and relationships between visit type and asthma outcomes (control [Asthma Control Test] and asthma-related quality of life [Asthma Symptom Utility Index]), were tested using multivariable regression. RESULTS: A total of 866 participants consented to be surveyed, with 847 respondents. Among the participants with asthma care experience with both visit types, 42.0% preferred TH for regular checkups, which associated with employment (odds ratio [OR] = 1.61; 95% confidence interval [CI], 1.09-2.39; P = .02), lower asthma medication adherence (OR = 1.06; 95% CI, 1.01-1.11; P = .03), and having more historical emergency department and urgent care asthma visits (OR = 1.10 for each additional visit; 95% CI, 1.02-1.18; P = .02), after adjustment. Emergency medical record data were available for 98 participants (62 TH, 36 IP). Those with TH visits were more likely Latinx, from the Southwest, employed, using inhaled corticosteroid-only controller therapy, with lower body mass index, and lower self-reported asthma medication adherence vs those with IP visits only. Both groups had comparable Asthma Control Test (18.4 vs 18.9, P = .52) and Asthma Symptom Utility Index (0.79 vs 0.84, P = .16) scores after adjustment. CONCLUSION: TH may be similarly efficacious as and often preferred over IP among Black and Latinx adults with moderate-to-severe asthma, especially for regular checkups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02995733.

Strategies for choosing a biologic for your patient with allergy or asthma.

OBJECTIVE: To summarize the therapeutic effects and safety of biologics either approved or in clinical development for asthma, chronic obstructive pulmonary disease, urticaria, nasal polyps, atopic dermatitis, and eosinophilic esophagitis. This review attempts to provide some guidance when choosing among agents. DATA SOURCES: Recently published articles obtained through PubMed database searches including research articles, review articles, and case reports. STUDY SELECTIONS: PubMed database searches were conducted using the following keywords: biologics, asthma, COPD, urticaria, atopic dermatitis, food allergy, nasal polyps, and eosinophilic esophagitis. RESULTS: The approval of omalizumab by the Food and Drug Administration in 2003 for patients with asthma paved the way for the development of multiple biologics for a variety of respiratory and allergic diseases. Agents approved by the Food and Drug Administration include mepolizumab, reslizumab, benralizumab, and dupilumab, and several more are in the late stages of clinical development. Owing to the overlap in the pathogenesis of respiratory and allergic diseases, many of these biologics target multiple respiratory and allergic diseases simultaneously. CONCLUSION: The numerous biologic options have made the selection of the best biologic for each patient a potential conundrum for clinicians. Adequate point of care biomarkers to facilitate personalized medical therapy are generally lacking. Furthermore, although clinically effective and generally safe, none of the biologics discussed in this review have induced long-standing disease remission. Nevertheless, these agents have given us the opportunity to treat the most severe patients and to better understand the biology of respiratory and allergic diseases. As knowledgeable physicians, we should embrace and be educated on these novel therapies and the pathways they target.

A Novel Case of Acute Respiratory Distress Syndrome Following Radiofrequency Ablation for Atrial Fibrillation.

Radiofrequency ablation (RFA) is a minimally invasive cardiac catheterization procedure employed in patients whose atrial fibrillation (AF) is not well-controlled on medical therapy. While serious complications after the RFA are uncommon, we present the unique case of a 71-year-old male who suffered from acute respiratory distress syndrome (ARDS) and pneumomediastinum post-procedure. He presented to the ED with dyspnea, non-massive hemoptysis, and fever three days following RFA. Admission CT thorax demonstrated patchy ground glass opacities (GGOs) and stable fibrotic changes. He was admitted for suspected pneumonia, however, he failed to significantly improve on broad-spectrum antibiotics. Bronchoscopy found blood in proximal airways, however, lavage with serial aliquots were without worsening hemorrhage, ruling out suspected diffuse alveolar hemorrhage. Cytology resulted in rare iron polymorphonuclear neutrophils and no malignant cells. With worsening clinical status, the patient was eventually intubated. Repeat CT thorax showed new moderate pneumopericardium, small pneumomediastinum, and progressed GGOs. The respiratory course continued to worsen, and the patient passed away approximately one month after admission. We also present a brief literature review with the aim of identifying prognostic risk factors regarding post-RFA ARDS development. Additionally, this case identifies a novel complication of RFA, as post-procedural pneumomediastinum has not been previously described.

Evaluation of Resident Physicians' Knowledge of and Attitudes Towards Prescribing Buprenorphine for Patients With Opioid Use Disorder.

OBJECTIVE: To determine internal medicine (IM) residents' knowledge of, attitudes towards, and barriers to prescribing buprenorphine for opioid use disorder (OUD). METHODS: We conducted a cross-sectional study of IM residents across all 35 Accreditation Council for Graduate Medical Education (ACGME) accredited Florida IM residency programs. We used an online survey to collect information about resident demographics, substance use curriculums, career interests, content knowledge about diagnosing and managing OUD, and attitudes about and barriers to prescribing buprenorphine for OUD. We used Chi-square test to explore differences in interest in prescribing buprenorphine. We created a composite knowledge score and investigated distribution of knowledge among characteristics via Mann-Whitney U test. RESULTS: There were 161 participants (response rate 16.0%, n = 1008) across 35 programs Seventy-seven percent of residents provided care for patients with OUD more than once per month. Seventy-four percent report no buprenorphine prescribing training. Higher knowledge scores, interest in primary care, being an intern, and caring for patients with OUD more than monthly were associated with interest in obtaining a buprenorphine waiver (P < 0.05). Limited knowledge about OUD was the most important barrier to prescribing buprenorphine. Eighty-nine percent support legislation to deregulate buprenorphine. CONCLUSIONS: Knowledge about managing OUD was poor and represented the most commonly cited barrier to prescribing buprenorphine. Residents want to expand their role in treating OUD. Our findings warrant incorporating addiction medicine into residency curriculum standards. Legislation removing the buprenorphine waiver requirement may increase the number of resident buprenorphine prescribers and improve treatment options for patients with opioid addiction.

Negative electron transfer dissociation of deprotonated phosphopeptide anions: choice of radical cation reagent and competition between electron and proton transfer.

Despite significant developments in mass spectrometry technology in recent years, no routine proteomics sequencing tool is currently available for peptide anions. The use of a molecular open-shell cation is presented here as a possible reaction partner to induce electron transfer dissociation with deprotonated peptide anions. In this negative electron transfer dissociation (NETD) scheme, an electron is abstracted from the peptide anion and transferred to the radical cation. This is demonstrated for the example of the fluoranthene cation, C(16)H(10)(+*), which is reacted with deprotonated phosphorylated peptides in a 3-D ion trap mass spectrometer. Selective backbone cleavage at the C(alpha)-C bond is observed to yield a and x fragments, similarly to electron detachment dissociation (EDD) of peptide anions. Crucially, the phosphorylation site is left intact in the dissociation process, allowing an identification and localization of the post-translational modification (PTM) site. In contrast, NETD using Xe(+*) as the reagent cation results in sequential neutral losses (CO(2) and H(3)PO(4)) from a/x fragments, which complicate the interpretation of the mass spectra. This difference in dissociation behavior can be understood in the framework of the reduced recombination energy of the electron transfer process for fluoranthene, which is estimated at 2.5-4.5 eV, compared to 6.7-8.7 eV for xenon. Similarly to ETD, proton transfer is found to compete with electron transfer processes in NETD. Isotope fitting of the charge-reduced species shows that in the case of fluoranthene-mediated NETD, proton transfer only accounts for <20%, whereas this process highly abundant for Xe(+*) (43 and 82%). Since proton abstraction from Xe(+*) is not possible, this suggests that Xe(+*) ionizes other transient species in the ion trap, which then engage in proton transfer reactions with the peptide anions.

Lung Adenocarcinoma Presenting as Multiple Thromboembolic Events: A Case Report and Review of the Literature.

Patients with malignancy may present with significant thromboembolic complications including deep vein thrombosis (DVT), pulmonary embolism, arterial thrombosis, nonbacterial thrombotic endocarditis, and stroke due to abnormal coagulation cascades. Although these events are typically recognized later in the disease process, complications of a hypercoagulable state can rarely present as the first manifestation of an occult malignancy. We report a case of a young male who was ultimately found to have an aggressive form of lung adenocarcinoma after the initial presentation of multiple thromboembolic events. DVT and stroke as an initial presentation of an active lung adenocarcinoma in a young patient is extremely rare as patients presenting in a hypercoagulable state usually are older. Though testing for a hypercoagulable state is not recommended for the first unprovoked DVT, clinicians should be prompted to screen for malignancy in the setting of cryptogenic strokes, especially in younger patients with no prior risk factors.

Fluoroquinolone resistant tuberculosis: A case report and literature review.

Despite the advancements made in medicine and treatment of tuberculosis over the last century, it remains a significant healthcare challenge. It remains the leading cause of death from a single infectious agent and the ninth leading cause of death worldwide. A 23-year-old male with a history of tuberculosis treated in Nepal seven years prior, presented to the emergency department with one week of hemoptysis, fever, chills, night sweats and weight loss. A CT scan of the chest showed multiple cavitary lesions at the superior segment of the left lower lobe. He had persistent massive hemoptysis and required blood transfusions. He underwent bronchial artery embolization followed by lobectomy. He was ultimately diagnosed with fluoroquinolone-resistant tuberculosis, and required a prolonged intensive care unit with transfer to a regional tuberculosis center to successfully complete treatment.

The forgotten electrolyte, when hypercalcaemia manifest as gait instability and altered mental status.

An altered mental status presents a diagnostic challenge for many clinicians. Described here is a case of primary hyperparathyroidism not initially suspected until after a thorough neurological and infectious cause were excluded. A 60-year-old woman presented with altered mental status and gait instability. Her family noticed progressive gait instability and mood swings for the past 4 months. Initial imaging and laboratory values were unable to explain her symptoms. On transfer out of the intensive care unit, her corrected calcium was found to be 13.3 mg/dL with an elevated parathyroid hormone. Her hypercalcaemia was refractory to medical management. Ultrasound found a 2 cm nodule, which was surgically removed and found to be a parathyroid adenoma. Her calcium normalised and neurological deficits subsided. Hypercalcaemia can lead to a constellation of symptoms that include the classical 'stones, bones, abdominal moans and psychic groans' and electrolyte derangements should be considered in the differential of altered mental status.

Myocardial Infarction Presenting as Ear Fullness and Pain.

Acute coronary syndrome usually presents with retrosternal chest pain, nausea, vomiting, sweating, and jaw and arm pain. Some patients only present with neck, epigastric, or ear discomfort. A 47-year-old male with a history of hypertension and coronary artery disease presented to the emergency department complaining of bilateral otalgia. He never felt chest pain, jaw pain, nausea, diaphoresis, or shortness of breath. He had a history of 2 acute coronary events and had a stress test 2 months prior to admission, which was unremarkable. The initial electrocardiography was sinus rhythm with Q-waves in the inferior leads and nonspecific ST changes in the lateral leads. His troponin on admission was normal but subsequently elevated to 20.00 mg/mL after 24 hours. He underwent left heart catheterization, which found significant occlusive disease of the second and fourth obtuse marginal branches and 2 drug-eluting stents were placed. His ear pain resolved soon after cardiac catheterization. The pathophysiology of this referred pain is thought to be related to the neuroanatomy of the nerves innervating the heart and ear. The auricular nerve branch of the vagus nerve supplies the inner portion of the external ear. Only a few cases with the complaint of otalgia have been reported. Patients were older, more frequently women, and with diabetes or heart failure. Clinicians should be aware of the atypical presentation of angina that may be life-threatening cardiac ischemia. Ear pain and fullness could be the sole presenting symptom in a patient with acute coronary syndrome.

Fatal Pulmonary Embolism in the Setting of Immune Reconstitution Inflammatory Syndrome Attributed to Ovarian Tuberculosis.

In developed countries, tuberculosis remains a health care challenge due to human immunodeficiency virus (HIV) and immigration from endemic regions. The Centers for Disease Control and Prevention reported 9557 new cases in 2015, with extrapulmonary involvement in 20.2% of the cases. We present a 33-year-old woman from Cape Town, South Africa, who developed abdominal pain and fever while working on a cruise ship. She sought medical where she underwent computed tomography of her chest, abdomen, and pelvis with findings suggestive of pulmonary tuberculosis and an 8.9-cm pelvic mass. HIV testing was positive and the patient was started on antiretroviral therapy. Bronchoscopy confirmed the presence of acid-fast bacilli, and she was started on rifampin, isoniazid, pyrazinamide, and ethambutol. She remained persistently febrile, raising suspicion for immune reconstitution inflammatory syndrome. However, despite empiric antibiotics, the patient remained persistently febrile, tachycardic, and on day 10 of admission she went into ventricular fibrillation and expired. Autopsy revealed an occlusive thrombus in the left main pulmonary artery in addition to necrotizing granulomata in multiple organs and bilateral tubo-ovarian abscesses. Postmortem cultures for were positive for Mycobacterium tuberculosis, all consistent with disseminated Mycobacterium tuberculosis. Although previous reports underscore the association between tuberculosis and hypercoagulability, the exact mechanism remains unknown. In this article, we report a case of disseminated tuberculosis complicated by bilateral tubo-ovarian abscesses with fatal pulmonary thrombus formation.