Naltrexone can be safely administered to patients with alcohol use disorder (AUD) and compensated cirrhosis to help them achieve abstinence and decrease craving, results of the first such randomized controlled trial show. The prospective, double-blind, single-center study at the ILBS, in New Delhi, enrolled 100 patients with alcohol dependence and cirrhosis between 2020 and 2022. Participants were randomly assigned in a 1:1 ratio to receive naltrexone (50 mg/d) or placebo for 12 weeks.
History: A 8 yr old boy came to the ED with accidental ingestion of an Endodontic file while having a dental procedure. Pt. was asymptomatic at the time of presentation with no SOB, abdominal complaints & vomiting. What’s the next step you will do in ED?
Answer: CXR -AP view & abdominal x-ray – Erect & supine was done on arrival after initial assessment. Pt. was hemodynamically stable. Pt was admitted to the surgery ward for observation. There were no signs of peritonitis or perforation. In this case, FB passed spontaneously with the stool on its own & no surgical intervention was required.
Foreign body ingestion is a common clinical problem. Commonly seen in children, older people, people with intellectual disability, psychiatric pathologies & prisoners/inmates.
Most ingested foreign bodies will pass through GI tract without symptoms & cause only minor mucosal injury. However, 10% – 20% of cases will require non-operative intervention, 1% may develop complications (e.g. bowel obstruction, perforation, severe hemorrhage, abscess formation, or septicemia) & require surgical interventions.
Look for dysphagia, abdominal pain, signs of peritonitis, stridor, wheezing, gagging, nausea/vomiting, neck/throat pain, atypical chest pain or non-cardiac chest pain, choking & LGIB.
Endoscopy is the first-line intervention for the removal of FB. However, Button battery ingestion can be potentially fatal and thus requires immediate intervention. Check out the management algorithm for sharp FB ingestion.
History: A 56 yr old k/c/o CKD-5 on MHD thrice weekly with HTN presented to ED with SOB, drowsy, anasarca. He has missed his hemodialysis this week. BP-170/102 mmhg, P-84 bpm, Spo2 – 82% on RA (99% on NRBM 14/L O2), B\L crepts +nt. Serum K+ – 8.4 mmol/L. What’s the finding in ECG?
Answer: ECG shows sine wave appearance in severe hyperkalemia. Hyperkalaemia is defined as a serum potassium level of > 5.2 mmol/L. ECG changes generally do not manifest until there is a moderate degree of hyperkalaemia (≥ 6.0 mmol/L). The earliest manifestation of hyperkalaemia is an increase in T wave amplitude.
The patient was treated with 10% 10ml of IV calcium gluconate, nebulised with Salbutamol, 10 units of regular insulin IV combined with dextrose 50%, IV sodium bicarbonate 50 mEq and Inj. Furosemide 40mg IV. Emergent haemodialysis was initiated. Pt was shifted to ICU.
Sotagliflozin, a novel agent that inhibits sodium-glucose co transporter SGLT 1 & SGLT2 both as a treatment for adults with heart failure with or without diabetes and for T1DM & T2DM.
Dose: 200mg/400mg 1 OD.
MOA: Inhibiting SGLT2 reduces renal reabsorption of glucose and sodium which may influence several physiological functions, such as lowering both pre-and afterload of the heart and downregulating sympathetic activity. Inhibiting SGLT1 reduces intestinal absorption of glucose and sodium which likely contributes to diarrhea.
Adverse Effects: >10% UTI, Diarrhea, Hypoglycemia, Dizziness, Genital mycotic infection.
Other approved drugs are SGLT2 inhibitors empagliflozin & dapagliflozin , both of which now have labeled indications across the spectrum of LVEF.
The US FDA has approved extended-release injection buprenorphine (Brixadi, Braeburn Inc) for the treatment of moderate to severe opioid use disorder (OUD). The medication comes in two formulations: a weekly and a monthly version. The adverse reactions include headache, constipation, nausea, injection-site erythema, injection-site pruritus, insomnia & UTI.
History: A 56 year old female presented to ED with 1 episode of GTC seizure. Neurological examination was normal except for postictal confusion. NCCT brain showed multiple calcified granuloma, some showing perilesional oedema in the frontal, parietal & occipital lobes. Routine CXR showed typical rice-grain-shaped calcification in the chest wall muscles. Xray thigh and forearm were ordered which showed similar lesions. What’s the diagnosis?
Answer: Rice grain calcification is characteristic of infection with Taenia solium (cysticercosis); when the inflammatory response of the host kills the larval cysts (cysticerci), they undergo granulomatous change and become calcified. Demonstration of rice-grain clacification on plain radiograph is a minor diagnostic criterion for neurocysticercosis (NCC). Their presence support NCC as the cause of ring-enhancing lesions in brain imaging.
Atogepant is the first and only, oral calcitonin gene-related peptide (CGRP) receptor antagonist approved for migraine. Dose: 60 mg dose 1 OD in chronic migraine. 30 mg and 60 mg for prevention of episodic migraine.
The 2023 GOLD report contains numerous updates:
Chapter 1
► A new definition of COPD has been proposed (Page 5)
► A section on Chronic Bronchitis has been added (Page 13)
► A table has been added with Proposed Taxonomy (Etiotypes) for COPD (Table 1.1)
Chapter 2
► Additional information on screening for COPD and case-finding has been included (Page 36)
► Information on Imaging and Computed Tomography (CT) has been included (Page 43)
► A table with information on the Use of CT in Stable COPD has been added (Table 2.8)
Chapter 3
► Vaccination Recommendations for people with COPD have been updated in line with current guidance from the CDC (Page 54)
► Further information on therapeutic interventions to reduce COPD mortality has been added (Page 67)
► A table has been added with information on the Evidence Supporting a Reduction in Mortality with Pharmacotherapy and Non-pharmacotherapy in COPD Patients (Table 3.6)
► Issues Related to Inhaled Delivery have been addressed (Page 69)
► Information on the topic of Adherence to Inhaled COPD Medications has been included (Page 71)
► A section on Tele-rehabilitation has been added (Page 76) Page 2 of 16
► The section on Interventional & Surgical Therapies for COPD has been expanded (Page 82)
► A figure has been added giving an Overview of Current and Proposed Surgical and Bronchoscopic Interventions for People with COPD (Figure 3.2)
Chapter 4
► A section on the choice of inhaler device has been added (Page 112)
► A table has been added with information on Basic Principles for Appropriate Inhalation Device Choice (Table 4.5)
► The ABCD Assessment Tool has been revised to the ABE Assessment Tool to recognize the clinical relevance of exacerbations, independent of the level of symptoms (Page 115)
► The information and figures outlining Initial Pharmacological Treatment and Follow-up Pharmacological Treatment have been updated. In particular, the positioning of LABA+LAMA and of LABA+ICS has been changed (Page 115)
Chapter 5
► The topic of management of exacerbations has been expanded to include details of possible alternative causes
of symptoms
► A new definition of COPD Exacerbation and a new set of parameters to assess exacerbation severity at the point of care has been included (Page 134)
► A new paragraph and a new figure on the Classification of the Severity of COPD Exacerbations have been added (Figure 5.1)
► A new table on Diagnosis and Assessment has been added (Table 5.3)
Chapter 6
► The chapter on COPD and Co-morbidities has been updated with the latest evidence.
Chapter 7
► The chapter on COVID-19 and COPD has been updated with new references and the latest evidence.
The US FDA has approved dabrafenib with trametinib for children aged 1 year or older who need systemic treatment for low-grade gliomas that have a BRAF V600E mutation. Dabrafenib/trametinib is the first systemic therapy approved for frontline treatment of low-grade, BRAF-mutated pediatric gliomas, the FDA said. Dabrafenib was given orally twice daily, and trametinib was given orally once daily. Children in the chemotherapy arm received a 10-week induction course followed by eight 6-week maintenance cycles.
Adverse effects: pyrexia (66%), rash (54%), headache (40%), vomiting (38%), musculoskeletal pain (36%), fatigue (31%), dry skin (31%), diarrhea (30%), nausea (26%), epistaxis and other bleeding events (25%), abdominal pain (24%), and dermatitis acneiform (23%). The more common grade 3 or 4 laboratory abnormalities were decreased neutrophil count (20%) and increases in alanine aminotransferase (3.1%) and aspartate aminotransferase levels (3.1%).
History: A 14 year-old boy presented with progressive proximal weakness of the lower limbs starting at 4 years of age followed by involvement of the upper limbs. He is the product of a consanguineous marriage. Clinically, he had flaccid quadriparesis with wasting and contractures without any sensory or neurological involvement. His weakness worsened leading to an inability to walk without support by the age of 8 and total wheelchair dependence by the age of 11. He was frequently admitted to hospital with chest infections. The patient’s creatine kinase was 2600 IU/L (normal 50–150 IU/L) and muscle biopsy from left quadriceps showed rounded small muscle fibres with evidence of degeneration and an absence of dystrophin protein. What’s the diagnosis?
Answer: Duchenne muscular dystrophy is a X-linked recessive genetic disorder.
Cause: Gene mutation of dystrophin protein.
Signs and symptoms: Muscle weakness, scoliosis, Respiratory Infections, Gowers’s sign.
Diagnosis: Creatine kinase (CPK-MM), DNA test, Muscle biopsy, Prenatal tests.
Treatment:
