Area postrema syndrome: an atypical presentation of primary Sjogren's

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune condition characterized by antibodies against serum aquaporin-4 (AQP4), primarily affecting the optic nerves and spinal cord. This case report sheds light on the diagnostic challenges of area postrema syndrome (APS) as the initial manifestation of Sjogren's syndrome, often misidentified due to its diverse symptomatology. APS, seen in 10% of NMOSD cases, manifests as persistent nausea, vomiting, and uncontrollable hiccups. Left untreated, APS can progress to optic neuritis and longitudinally extensive myelitis, emphasizing the need for early intervention with corticosteroid therapy and immunomodulators. NMOSD commonly coexists with other autoimmune diseases like Sjogren's syndrome and systemic lupus erythematosus. Recent evidence also highlights NMOSD's impact on peripheral organs, particularly skeletal muscles, with elevated creatine kinase levels during acute phases. Understanding the relationship between NMOSD and autoimmune diseases is vital for accurate diagnosis and management, especially in cases of seronegative NMOSD and recurrent attacks, emphasizing comprehensive clinical evaluations and a broader diagnostic approach

Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: A randomized controlled trial

OBJECTIVE:To determine whether metoclopramide prevents nosocomial pneumonia in intensive care unit (ICU) patients receiving enteral feeding by a nasogastric tube. DESIGN:Prospective, randomized, controlled trial. SETTING:ICU of a university hospital. PATIENTS:A total of 305 consecutive patients requiring placement of a nasogastric tube for >24 hrs. INTERVENTIONS:Patients were randomized to receive either 10 mg of metoclopramide or placebo at 8-hr intervals through the nasogastric tube. MEASUREMENTS AND MAIN RESULTS:A total of 174 patients received placebo and 131 received metoclopramide. Baseline characteristics in the two treatment groups were comparable. Of the 305 patients, 46 developed nosocomial pneumonia, which was 24 patients (13.7%) in the placebo group and 22 (16.8%) in the metoclopramide group (p > .05). Patients in the placebo group developed pneumonia earlier than patients receiving metoclopramide (4.46 ± 1.72 days [mean ± SD[rsqb] after ICU admission compared with 5.95 ± 1.78 days; p = .006). Subgroup analysis showed that metoclopramide did not reduce the frequency rate of pneumonia in patients with tracheal intubation (19 [25.3%] of 75 patients receiving metoclopramide vs. 21 [21.2%] of 99 patients receiving placebo) or those receiving mechanical ventilation (17 [25.6%] of 58 patients receiving metoclopramide vs. 20 [29.3%] of 78 patients receiving placebo). The mortality rate also did not differ in the two treatments groups (56% in the metoclopramide group vs. 53% in the placebo group; p > .05). CONCLUSIONS:Although metoclopramide delayed the development of nosocomial pneumonia, it did not decrease its frequency rate and had no effect on the mortality rate in critically ill patients receiving nasogastric enteral feeding