Oral Branched-Chain Amino Acid Supplements That Reduce Brain Serotonin During Exercise in Rats Also Lower Brain Catecholamines

Exercise raises brain serotonin release and is postulated to cause fatigue in athletes; ingestion of branched-chain amino acids (BCAA), by competitively inhibiting tryptophan transport into brain, lowers brain tryptophan uptake and serotonin synthesis and release in rats, and reputedly in humans prevents exercise-induced increases in serotonin and fatigue. This latter effect in humans is disputed. But BCAA also competitively inhibit tyrosine uptake into brain, and thus catecholamine synthesis and release. Since increasing brain catecholamines enhances physical performance, BCAA ingestion could lower catecholamines, reduce performance and thus negate any serotonin-linked benefit. We therefore examined in rats whether BCAA would reduce both brain tryptophan and tyrosine concentrations and serotonin and catecholamine synthesis. Sedentary and exercising rats received BCAA or vehicle orally; tryptophan and tyrosine concentrations and serotonin and catecholamine synthesis rates were measured 1 h later in brain. BCAA reduced brain tryptophan and tyrosine concentrations, and serotonin and catecholamine synthesis. These reductions in tyrosine concentrations and catecholamine synthesis, but not tryptophan or serotonin synthesis, could be prevented by co-administering tyrosine with BCAA. Complete essential amino acid mixtures, used to maintain or build muscle mass, were also studied, and produced different effects on brain tryptophan and tyrosine concentrations and serotonin and catecholamine synthesis. Since pharmacologically increasing brain catecholamine function improves physical performance, the finding that BCAA reduce catecholamine synthesis may explain why this treatment does not enhance physical performance in humans, despite reducing serotonin synthesis. If so, adding tyrosine to BCAA supplements might allow a positive action on performance to emerge

Phenazopyridine-Induced MethaemoglobinaemiaThe Aftermath of Dysuria Treatment

Introduction: Phenazopyridine is an over-the-counter urinary analgesic commonly used to alleviate the burning and urgency associated with lower urinary tract infections. Methaemoglobinaemia is an uncommon adverse effect of phenazopyridine use. We report a case of methaemoglobinaemia in a patient prescribed daily phenazopyridine to treat urethral and bladder irritation caused by a chronic indwelling Foley catheter.Case description: A 55-year-old female resident of a long-term acute care facility with a chronic Foley, tracheostomy and ventilator-dependent respiratory failure was observed to have generalized dusky skin and hypoxia. Pulse oximetry was reading in the high 80s despite administration of 100% FiO2. ABG revealed paO2 of 451, oxyhaemoglobin level 75% and methaemoglobin level 22%. Medication review indicated that the patient was prescribed phenazopyridine 400 mg TID for the previous 2 months. This medication was discontinued. Considering she was chronically taking mirtazapine, she can increase risk of serotonin syndrome should she be administered first-line treatment with methylene blue. Vitamin C was thus instead administered as a second-line agent. Serial ABGs showed a rapid decline in methaemoglobin levels and an increase in oxyhaemoglobin within 2 days.Discussion: Acquired methaemoglobinaemia is a rare adverse effect of treatment with phenazopyridine. This risk increases when drug dosage and duration exceed manufacturer specifications. Treatment typically includes cessation of the offending drug and administration of methylene blue in severe cases. A thorough medication reconciliation should be performed prior to methylene blue initiation, as patients taking serotonergic medications (for example, MAOIs, SSRIs, SNRIs, TCAs) are at increased risk of serotonin toxicity with co-administration of methylene blue. In these instances, ascorbic acid/vitamin C can be chosen as an alternative treatment agent.Conclusion: Work-up of refractory hypoxia should involve a thorough review of medications as even some over-the-counter drugs can cause the fatal side effect of methaemoglobinaemia. Treatment with vitamin C should be considered over methylene blue if serotonergic medications have been recently prescribed in order to avoid risk of serotonin syndrome

Shock.

Shock is a life-threatening condition of circulatory failure that causes an imbalance between cellular oxygen supply and demand resulting in organ dysfunction. It is important to recognize promptly as it is reversible in earlier stages but will transition to an irreversible phase if left untreated. This will result in multiorgan failure and subsequent death. The clinician should therefore consider shock in the differential for all patients with new organ failure. This article will review the pathophysiology, classification, evaluation, and management of shock

Institutional COVID-19 Protocols: Focused on Preparation, Safety, and Care Consolidation.

As the confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to grow with over 1 million documented infections in the United States alone, researchers and health care workers race to find effective treatment options for this potentially fatal disease. Mortality remains high in patients whose disease course requires mechanical ventilation and admission to intensive care units. While focusing on therapies to decrease mortality is essential, we must also consider the logistical hurdles faced with regard to safely and effectively delivering treatment while limiting the risk of harm to hospital staff and other noninfected patients. In this article, we discuss aspects of surge planning, considerations in limiting health care worker exposure, the logistics of medication delivery in a uniform and consolidated manner, protocols for delivering emergent care in a rapidly deteriorating coronavirus disease-2019 (COVID-19) patient, and safe practices for transporting infected patients

Comparing Clinical Outcomes of COVID-19 and Influenza-Induced Acute Respiratory Distress Syndrome: A Propensity-Matched Analysis

Acute respiratory distress syndrome (ARDS) is one the leading causes of mortality and morbidity in patients with COVID-19 and Influenza, with only small number of studies comparing these two viral illnesses in the setting of ARDS. Given the pathogenic differences in the two viruses, this study shows trends in national hospitalization and outcomes associated with COVID-19- and Influenza-related ARDS. To evaluate and compare the risk factors and rates of the adverse clinical outcomes in patients with COVID-19 associated ARDS (C-ARDS) relative to Influenza-related ARDS (I-ARDS), we utilized the National Inpatient Sample (NIS) database 2020. Our sample includes 106,720 patients hospitalized with either C-ARDS or I-ARDS between January and December 2020, of which 103,845 (97.3%) had C-ARDS and 2875 (2.7%) had I-ARDS. Propensity-matched analysis demonstrated a significantly higher in-hospital mortality (aOR 3.2, 95% CI 2.5–4.2, p p < 0.001), higher likelihood of requiring vasopressors (aOR 1.7, 95% CI 2.5–4.2) and invasive mechanical ventilation (IMV) (aOR 1.6, 95% CI 1.3–2.1) in C-ARDS patients. Our study shows that COVID-19-related ARDS patients had a higher rate of complications, including higher in-hospital mortality and a higher need for vasopressors and invasive mechanical ventilation relative to Influenza-related ARDS; however, it also showed an increased utilization of mechanical circulatory support and non-invasive ventilation in Influenza-related ARDS. It emphasizes the need for early detection and management of COVID-19

Impact of COVID-19 on Pregnancy Outcomes across Trimesters in the United States

Background: Current knowledge regarding the association between trimester-specific changes during pregnancy and COVID-19 infection is limited. We utilized the National Inpatient Sample (NIS) database to investigate trimester-specific outcomes among hospitalized pregnant women diagnosed with COVID-19. Results: Out of 3,447,771 pregnant women identified, those with COVID-19 exhibited higher in-hospital mortality rates in their third trimester compared with those without the virus. Notably, rates of mechanical ventilation, acute kidney injury, renal replacement therapy, and perinatal complications (preeclampsia, HELLP syndrome, and preterm birth) were significantly elevated across all trimesters for COVID-19 patients. COVID-19 was found to be more prevalent among low-income, Hispanic pregnant women. Conclusions: Our findings suggest that COVID-19 during pregnancy is associated with increased risk of maternal mortality and complications, particularly in the third trimester. Furthermore, we observed significant racial and socioeconomic disparities in both COVID-19 prevalence and pregnancy outcomes. These findings emphasize the need for equitable healthcare strategies to improve care for diverse and socioeconomically marginalized groups, ultimately aiming to reduce adverse COVID-19-associated maternal and fetal outcomes