Stimulant medication cessation in the setting of non-compaction cardiomyopathy

Non-compaction cardiomyopathy (NCM) is largely a genetic condition due to failure of left ventricular compaction during embryogenesis. This results in extensions of bundles of muscle (known as trabeculations) into the chamber impairing the ability of cardiac muscle to contract or relax adequately. Individuals may be diagnosed at any age and present with shortness of breath, poor growth, dizziness, lightheadedness, syncope palpitations, swelling or unexpected weight gain. Though individuals may be asymptomatic, the risk of complications including cardiac arrest, blood clots and heart failure may be present. Understanding cardiac history is important prior to initiating psychotropics, especially psychostimulants for treatment of Attention deficit/hyperactivity disorder (ADHD). Stimulants can affect heart rate, rhythm and blood pressure. It is important to monitor patients on stimulant medications for cardiovascular complications throughout their treatment. This case represents a 31-year-old female with a past medical history of generalized anxiety disorder, ADHD, undiagnosed muscular weakness and clubbed feet. As well, her BMI: 15.71kg/m^2. No significant family history of cardiac issues. She had a history of taking Adderall (dextroamphetamine/amphetamine) for several years without known complications. On follow-up she was noted to be tachycardic (120bpm). Labs including: CBC, CMP, TSH, Vit B12, Folate, Ferritin, TIBC, Iron and urinalysis were unremarkable. BNP: 86 pg/mL. Urine pregnancy: negative. EKG displayed possible left atrial enlargement, non-specific T-wave abnormalities, right axis deviation and prolonged QTc. Medication regimen was adjusted by changing dose and type of psychostimulant medications which patient did not tolerate. On ECHO, ejection fraction was 30-35% with hypokinesis of entire LV wall and moderately reduced global RV systolic function. At this time, patient was recommended a trial off stimulants. Patient was evaluated by heart failure specialists, started on additional cardiac medications and recommended cardiac genetic counseling. She was finally diagnosed with non-compaction cardiomyopathy. Given patient’s history, her stimulants were held for due to risk of cardiac complications and recommendation for further monitoring of heart function. This case outlines the importance of monitoring and screening for cardiac issues during stimulant use in patients with ADHD. Cardiac complications can complicate stimulant and psychotropic prescribing and increase risk of life-threatening complications.https://scholarlycommons.henryford.com/merf2019caserpt/1073/thumbnail.jp

Case Report: New onset of febrile episodes on low doses of Clozapine in SICU setting

Clozapine, a tricyclic dibenzodiazepine derivative, is an antipsychotic used in treatment resistant Schizophrenia to treat positive and negative symptoms of psychosis (1). It is also used for reduction in the risk of suicidal behavior in individuals with Schizophrenia and Schizoaffective disorders (1). However, it is a medication that is often used after trials of other antipsychotics have failed due to the concerns related to side effects. Some common side effects of Clozapine include agranulocytosis, seizures, cardiovascular and pulmonary effects, neuroleptic malignant syndrome, hepatitis, anticholinergic toxicity and fever (3). The prevalence of febrile episodes range from 0.5% - 55% (depending on the source) and often occur in the first three weeks of treatment (1, 3, 4) however onset of fever has not been reported to occur immediately after treatment initiation. The proposed etiologies for fever in this setting include NMS, infection, allergic reaction or inflammatory cytokine changes (2). At times no etiology is found and is considered drug related. These febrile episodes are generally benign and self-limiting but may be associated with life threatening complications, especially in medically acute patients (5). In patients who are severely psychiatrically ill, a clinical dilemma exists to determine whether to continue Clozapine use in the setting of new-onset fever or discontinue treatment. This is a case presentation of a 60-year-old female with a past medical history of Schizoaffective disorder (depressed type) and multiple significant suicide attempts requiring hospitalization in the surgical intensive care unit. She had a history of catatonia, depressive symptoms, paranoia and multiple failed antipsychotic medication trials. She presented to the hospital after attempting suicide by jumping out of the second story of her residential building onto the cement, in the setting of paranoid delusions. Clozapine was started on post-operative day zero while patient received acute surgical interventions. At the initiation of treatment she displayed an improvement in symptoms of psychosis (with reduction in negative symptoms and reduction in paranoid delusions). However, she had febrile episodes up to 39.2C (102.5F) with a negative medical work-up. As other etiologies were ruled out, the febrile episodes were considered to be Clozapine induced. Close follow-up, team collaboration and slow adjustment of Clozapine were utilized to optimize patient’s treatment, especially in the setting of significant risk of suicide and decompensation. This case presents a unique scenario signifying the importance of continuing Clozapine treatment in the setting of febrile episodes; albeit with careful monitoring of labs, vitals and physical exam findings. To our knowledge this is the first documented case of a patient with an emerging fever on the first day of starting Clozapine.https://scholarlycommons.henryford.com/merf2020caserpt/1069/thumbnail.jp

Optical aberrations following implantation of multifocal intraocular lenses: a systematic review and meta-analysis protocol

INTRODUCTION: Multifocal intraocular lens (IOLs) are used to restore vision at different focal distances. The technology of multifocal IOLs is continually advancing. Optical aberrations a property of lenses that causes spreading of light over a region resulting in a blurred or distorted image. This study aims to systematically review investigator measured and patient reported optical aberrations following implantation of multifocal IOLs during phacoemulsification surgery to treat presbyopia in adults. METHODS AND ANALYSIS: We will conduct an electronic database search for randomised controlled trials, prospective non-randomised studies, observational studies in Ovid MEDLINE, Ovid EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus and ClinicalTrials.gov in March 2021. Eligibility criteria will include quantitative articles written in English and containing data on optical aberrations. Two independent reviewers will screen titles and abstracts and extract data from full texts, reporting outcomes according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data extraction of key characteristics will be completed using customised forms. Methodological quality will be assessed using Cochrane Handbook 6.2. ETHICS AND DISSEMINATION: Ethics approval is not required for this review, as it will only include published data. Findings will be published in a peer-reviewed journal and disseminated across ophthalmic networks. We anticipate that the findings of this work will be of interest to multiple stakeholders: people who have undergone cataract surgery, eye health professionals, ophthalmic surgeons, device manufacturers and policy-makers. It will also inform researchers to where there are gaps in evidence and identify areas for future research. PROSPERO REGISTRATION NUMBER: CRD42021271050

Advancements and progress in juvenile idiopathic arthritis: A Review of pathophysiology and treatment

Juvenile idiopathic arthritis (JIA) is a chronic clinical condition characterized by arthritic features in children under the age of 16, with at least 6 weeks of active symptoms. The etiology of JIA remains unknown, and it is associated with prolonged synovial inflammation and structural joint damage influenced by environmental and genetic factors. This review aims to enhance the understanding of JIA by comprehensively analyzing relevant literature. The focus lies on current diagnostic and therapeutic approaches and investigations into the pathoaetiologies using diverse research modalities, including in vivo animal models and large-scale genome-wide studies. We aim to elucidate the multifactorial nature of JIA with a strong focus towards genetic predilection, while proposing potential strategies to improve therapeutic outcomes and enhance diagnostic risk stratification in light of recent advancements. This review underscores the need for further research due to the idiopathic nature of JIA, its heterogeneous phenotype, and the challenges associated with biomarkers and diagnostic criteria. Ultimately, this contribution seeks to advance the knowledge and promote effective management strategies in JIA

Advancements and progress in juvenile idiopathic arthritis: A Review of pathophysiology and treatment.

Juvenile idiopathic arthritis (JIA) is a chronic clinical condition characterized by arthritic features in children under the age of 16, with at least 6 weeks of active symptoms. The etiology of JIA remains unknown, and it is associated with prolonged synovial inflammation and structural joint damage influenced by environmental and genetic factors. This review aims to enhance the understanding of JIA by comprehensively analyzing relevant literature. The focus lies on current diagnostic and therapeutic approaches and investigations into the pathoaetiologies using diverse research modalities, including in vivo animal models and large-scale genome-wide studies. We aim to elucidate the multifactorial nature of JIA with a strong focus towards genetic predilection, while proposing potential strategies to improve therapeutic outcomes and enhance diagnostic risk stratification in light of recent advancements. This review underscores the need for further research due to the idiopathic nature of JIA, its heterogeneous phenotype, and the challenges associated with biomarkers and diagnostic criteria. Ultimately, this contribution seeks to advance the knowledge and promote effective management strategies in JIA

The pathophysiology of fluid and electrolyte balance in the older adult surgical patient

Background & aims: Age-related physiological changes predispose even the healthy older adult to fluid and electrolyte abnormalities which can cause morbidity and mortality. The aim of this narrative review is to highlight key aspects of age-related pathophysiological changes that affect fluid and electrolyte balance in older adults and underpin their importance in the perioperative period. Methods: The Web of Science, MEDLINE, PubMed and Google Scholar databases were searched using key terms for relevant studies published in English on fluid balance in older adults during the 15 years preceding June 2013. Randomised controlled trials and large cohort studies were sought; other studieswere used when these were not available. The bibliographies of extracted papers were also searched for relevant articles. Results: Older adults are susceptible to dehydration and electrolyte abnormalities, with causes ranging from physical disability restricting access to fluid intake to iatrogenic causes including polypharmacy and unmonitored diuretic usage. Renal senescence, as well as physical and mental decline, increase this susceptibility. Older adults are also predisposed to water retention and related electrolyte abnormalities, exacerbated at times of physiological stress. Positive fluid balance has been shown to be an independent risk factor for morbidity and mortality in critically ill patients with acute kidney injury. Conclusions: Age-related pathophysiological changes in the handling of fluid and electrolytes make older adults undergoing surgery a high-risk group and an understanding of these changes will enable better management of fluid and electrolyte therapy in the older adult

Test beam performance of a CBC3-based mini-module for the Phase-2 CMS Outer Tracker before and after neutron irradiation

The Large Hadron Collider (LHC) at CERN will undergo major upgrades to increase the instantaneous luminosity up to 5–7.5×10$^{34}$ cm$^{-2}$s$^{-1}$. This High Luminosity upgrade of the LHC (HL-LHC) will deliver a total of 3000–4000 fb-1 of proton-proton collisions at a center-of-mass energy of 13–14 TeV. To cope with these challenging environmental conditions, the strip tracker of the CMS experiment will be upgraded using modules with two closely-spaced silicon sensors to provide information to include tracking in the Level-1 trigger selection. This paper describes the performance, in a test beam experiment, of the first prototype module based on the final version of the CMS Binary Chip front-end ASIC before and after the module was irradiated with neutrons. Results demonstrate that the prototype module satisfies the requirements, providing efficient tracking information, after being irradiated with a total fluence comparable to the one expected through the lifetime of the experiment

Combination of CMS searches for heavy resonances decaying to pairs of bosons or leptons

CMS Collaboration: et al.A statistical combination of searches for heavy resonances decaying to pairs of bosons or leptons is presented. The data correspond to an integrated luminosity of 35.9 fb collected during 2016 by the CMS experiment at the LHC in proton-proton collisions at a center-of-mass energy of 13 TeV. The data are found to be consistent with expectations from the standard model background. Exclusion limits are set in the context of models of spin-1 heavy vector triplets and of spin-2 bulk gravitons. For mass-degenerate W′ and Z′ resonances that predominantly couple to the standard model gauge bosons, the mass exclusion at 95% confidence level of heavy vector bosons is extended to 4.5 TeV as compared to 3.8 TeV determined from the best individual channel. This excluded mass increases to 5.0 TeV if the resonances couple predominantly to fermions.Individuals have received support from the Marie-Curie program and the European Research Council and Horizon 2020 Grant, contract Nos. 675440, 752730, and 765710 (European Union); the Programa Estatal de Fomento de la Investigación Científica y Técnica de Excelencia María de Maeztu, grant MDM-2015-0509 and the Programa Severo Ochoa del Principado de Asturias

MUSiC: a model-unspecific search for new physics in proton–proton collisions at √s=13TeV

Results of the Model Unspecific Search in CMS (MUSiC), using proton–proton collision data recorded at the LHC at a centre-of-mass energy of 13TeV, corresponding to an integrated luminosity of 35.9fb-1, are presented. The MUSiC analysis searches for anomalies that could be signatures of physics beyond the standard model. The analysis is based on the comparison of observed data with the standard model prediction, as determined from simulation, in several hundred final states and multiple kinematic distributions. Events containing at least one electron or muon are classified based on their final state topology, and an automated search algorithm surveys the observed data for deviations from the prediction. The sensitivity of the search is validated using multiple methods. No significant deviations from the predictions have been observed. For a wide range of final state topologies, agreement is found between the data and the standard model simulation. This analysis complements dedicated search analyses by significantly expanding the range of final states covered using a model independent approach with the largest data set to date to probe phase space regions beyond the reach of previous general searches

Evidence for light-by-light scattering and searches for axion-like particles in ultraperipheral PbPb collisions at root s(NN)=5.02 TeV

Evidence for the light-by-light scattering process, gamma gamma -> gamma gamma, in ultraperipheral PbPb collisions at a centre-of-mass energy per nucleon pair of 5.02 TeV is reported. The analysis is conducted using a data sample corresponding to an integrated luminosity of 390 mu b(-1) recorded by the CMS experiment at the LHC. Light-by-light scattering processes are selected in events with two photons exclusively produced, each with transverse energy E-T(gamma) > 2 GeV, pseudorapidity vertical bar eta(gamma)vertical bar 5 GeV, diphoton transverse momentum p(T)(gamma gamma) gamma gamma) = 120 +/- 46(stat) +/- 28(syst) +/- 12(theo) nb, is consistent with the standard model prediction. The m(gamma gamma) distribution is used to set new exclusion limits on the production of pseudoscalar axion-like particles, via the gamma gamma -> a -> gamma gamma process, in the mass range m(a) = 5-90 GeV. (C) 2019 The Author(s). Published by Elsevier B.V.Peer reviewe