Psychosis Management in Lewy Body Dementia: A Comprehensive Clinical Approach.

Lewy body dementia (LBD) is asynucleinopathy that results in clinical manifestation of motor and neuropsychiatric symptoms. The disease burden associated with psychosis in LBD patients is significantly higher compared to other types of dementia or even to LBD without psychosis. Effective care management processes should include consideration of de-prescribing any offending agents including anticholinergics and dopaminergic agents, followed by nonpharmacological and low risk pharmacological approach. If addition of pharmacological agents is required, consideration should be given to acetylcholinesterase inhibitors, pimavanserin and atypical antipsychotics such as quetiapine or clozapine. Side effects of these medications should be considered prior to selection and initiation of a medication regimen. Goals of care and functional assessment are a crucial part of the optimized care plan, given overall guarded prognosis, in the context of numerous complications observed in this population. Palliative care consultation could facilitate symptom control and timely enrollment into hospice if consistent with patient's goals.

Combined vitamin D, ibuprofen and glutamic acid decarboxylase-alum treatment in recent onset Type I diabetes: lessons from the DIABGAD randomized pilot trial.

AIM: Double-blind placebo-controlled intervention using glutamic acid decarboxylase (GAD)-alum, vitamin D and Ibuprofen in recent onset Type I diabetes (T1D). METHODS: 64 patients (T1D since <4 months, age 10-17.99, fasting sC-peptide ≥0.12 nmol/l, GADA-positive) were randomized into Day(D) 1-90 400 mg/day Ibuprofen, D1-450 vitamin D 2000 IU/day, D15, 45 sc. 20 µg GAD-alum; as A but placebo instead of Ibuprofen; as B but 40 µg GAD-alum D15, 45; placebo. RESULTS: Treatment was safe and tolerable. No C-peptide preservation was observed. We observed a linear correlation of baseline C-peptide, HbA1c and insulin/per kilogram/24 h with change in C-peptide AUC at 15 months (r = -0.776, p < 0.0001). CONCLUSION: Ibuprofen, vitamin D + GAD-alum did not preserve C-peptide. Treatment efficacy was influenced by baseline clinical and immunological factors and vitamin D concentration. Clinical Trial Registration: NCT01785108 (ClinicalTrials.gov).

Idiopathic Edema: A Case Report.

Edema occurs when excess fluid is retained by interstitial tissue and is associated with several systemic conditions. The diagnosis of edema is generally made by physical and clinical assessment, and diuretics are the common treatment. Idiopathic edema predominantly affects women and occurs in patients who do not have any other pre-existing systemic problems. The etiology behind idiopathic edema has yet to be determined. We present a case of a 46-year-old woman diagnosed with idiopathic edema.

Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient Presenting with Acute Pancreatitis.

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are a class of medications used for glycemic control in type II diabetes mellitus. Their mechanism of action involves preventing resorption of glucose at the proximal kidney, thereby promoting glucosuria and weight loss. However, they have also been found to be associated with euglycemic diabetic ketoacidosis (euDKA). This case describes a 25-year-old male with a history of type II diabetes on metformin, sitagliptin, and dapagliflozin who was admitted with his third episode of pancreatitis secondary to hypertriglyceridemia. His home oral glycemic agents were continued as inpatient. Despite tight euglycemic control, the patient developed profound metabolic acidosis and was found to have an elevated beta-hydroxybutyrate level and normal lactic acid level. He was admitted into the intensive care unit and started on an insulin drip, and after resolution of his acidosis he was transitioned to basal insulin successfully. He was discharged with an insulin regimen while his oral glycemic agents were discontinued indefinitely. SGLT-2 inhibitors are associated with euDKA, most likely as a result of their non-insulin-dependent glucose clearance, hyperglucagonemia, and decreased ketone clearance. The aim of this case report is to inform the physician about the possibility of euDKA in a patient with type II diabetes on a SGLT-2 inhibitor presenting with an acute illness.

Spontaneous Intramural Esophageal Rupture: An Uncommon Presentation of Eosinophilic Esophagitis Requiring Endoscopic Clipping.

Spontaneous intramural esophageal rupture (SIER) is a form of acute esophageal trauma defined as an injury deeper than a Mallory-Weiss tear but not extending completely through the muscular propria as in Boerhaave syndrome. SIER is a rare complication of eosinophilic esophagitis (EoE); after extensive literature review, we found 7 case reports of SIER complicating EoE. We present a case of SIER complicating EoE in a 46-year-old man with an atypical presentation requiring endoscopic clipping to achieve successful hemostasis.

Rare case of Rhizobium radiobacter bioprosthetic mitral valve endocarditis.

Rhizobium radiobacter is an aerobic, gram negative, rod-shaped, bacterium typically found in the soil. Commonly a plant pathogen, it is also a rare human pathogen causing serious disease. Risk factors for infection include neutropenia, leukopenia, catheters, hospitalization, and low CD4+ lymphocyte count, especially in patients with malignancy or human immunodeficiency virus. There is currently limited literature to establish a definitive guideline for antimicrobial therapy and obtaining susceptibilities from a specialized laboratory is appropriate. We present a successfully treated case of R. radiobacter bioprosthetic mitral valve endocarditis in a patient with previous S. epidermidis endocarditis.