Correction to: Amanita Mushroom Toxin Poisoning in Los Angeles County.

[This corrects the article DOI: 10.14309/crj.0000000000001246.].

Amanita Mushroom Toxin Poisoning in Los Angeles County.

Mushroom (amatoxin) poisoning from ingestion is a rare but life-threatening medical emergency characterized by gastrointestinal symptoms before progression to multisystem organ failure in severe cases. Many therapies of amatoxin intoxication have been described, including supportive care, medical therapies, detoxification strategies, and liver transplant. The evidence supporting these therapies remains limited due to the rarity of amatoxin poisoning and challenge of a timely diagnosis. We report a case of amatoxin poisoning in Los Angeles causing severe liver injury without acute liver failure treated successfully using medical therapies, gallbladder drainage, and plasma exchange.

Outcomes Following Percutaneous Cholecystostomy Tube Placement for Acalculous Versus Calculous Cholecystitis.

BACKGROUND: Acute acalculous cholecystitis (AAC) is often diagnosed in critically ill patients. Percutaneous cholecystostomy tube (PCT) placement facilitates less invasive gallbladder decompression in patients who are poor surgical candidates. Specific guidelines for optimal management of AAC patients following PCT placement remain to be defined. We hypothesize that AAC patients are at lower risk of recurrent cholecystitis than acute calculous cholecystitis (ACC) patients and do not require cholecystectomy after PCT placement. METHODS: A retrospective review of patients who underwent PCT placement for AAC or ACC between 6/1/2007 and 5/31/2019 was performed. Primary outcome was recurrent cholecystitis and interval cholecystectomy for patients surviving 30 days after PCT placement. Secondary outcome was 30 day mortality. A cox regression model calculated the adjusted hazard ratio (AHR) for the outcomes. RESULTS: Eighty-four AAC and 85 ACC patients underwent PCT placement. Compared to ACC patients, more AAC patients were male (72.6 vs. 48.2%; p < 0.01), younger (median age 62 vs. 73 years; p < 0.01), and required intensive care (69.0 vs. 52.9%; p = 0.04), with lower median Charlson Comorbidity Index (4.0 vs. 6.0; p < 0.01). 30 day mortality was higher among AAC patients than ACC patients (45.2 vs. 21.2%; p < 0.01). 2/24 (8.3%) AAC patients and 5/31 (16.1%) ACC patients developed recurrent cholecystitis at a median 208.0 days (IQR:64.0-417.0) after PCT placement and 115.0 days (IQR:7.0-403.0) following PCT removal. Cox regression analysis demonstrated that AAC patients had lower likelihood of interval cholecystectomy compared to ACC patients (AHR 2.35; 95% CI:1.11,4.96). CONCLUSION: Recurrent cholecystitis is rare in patients surviving 30 days following PCT placement. When compared with ACC patients, fewer AAC patients require cholecystectomy.

Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis.

BACKGROUND: Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center. METHODS: Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively. RESULTS: Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality. CONCLUSIONS: Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.

Effect of scheduling inferior vena cava filter removal during the placement encounter on filter removal rate.

OBJECTIVE: In the present study, we sought to determine whether early pre-emptive scheduling of inferior vena cava filter (IVCF) removal during the preoperative IVCF placement visit would affect the IVCF removal rate. METHODS: All electronically documented IVCF placements at a single institution were reviewed from April 2015 to July 2019. The baseline characteristics included age, the clinical indications for IVCF placement, inpatient/outpatient status, and type of IVCF placed. Statistical analysis was performed using the χ2 for discrete variables and the two-tailed paired t test for continuous variables. RESULTS: A total of 599 patients (mean age, 68 years; 273 women and 326 men) had undergone technically successful IVCF placement. During the preoperative consent process for placement, 232 patients had been scheduled for IVCF removal within 3 months after placement. However, 367 patients had not been scheduled for removal at the preoperative consent process. The indications for placement included failure of anticoagulation, a contraindication to anticoagulation (eg, bleeding), preoperative prophylaxis, and others. Of the 232 patients scheduled for IVCF removal during preoperative consent for IVCF placement, 103 (44%) had undergone successful IVCF removal (mean interval from placement, 107 ± 100 days). Of the 367 nonscheduled patients, 89 (24%) had undergone successful IVCF removal (mean time, 184 ± 215 days). We found a significant improvement in the IVCF removal rate between the scheduled and nonscheduled patients (P < .0001). Three patients (all from the scheduled group) had a clot burden within the IVCF, which meant they were inappropriate for removal. These patients were rescheduled and had eventually undergone uncomplicated removal. CONCLUSIONS: Scheduling IVCF removal during the placement encounter significantly increased the IVCF removal rate. This approach could be a viable option for institutions where clinic time and/or resources are limited or unavailable and for patients who have difficulty traveling for clinical evaluations.

Comparing clinical outcomes of image-guided percutaneous transperitoneal and transhepatic cholecystostomy for acute cholecystitis.

BACKGROUND: Percutaneous cholecystostomy is performed by interventional radiologists for patients with calculous/acalculous cholecystitis who are poor candidates for cholecystectomy. Two anatomical approaches are widely utilized: transperitoneal and transhepatic. PURPOSE: To compare the clinical outcomes of transperitoneal and transhepatic approaches to cholecystostomy catheter placement. MATERIAL AND METHODS: From December 2007 to August 2015, 165 consecutive patients (97 men, 68 women) underwent either transperitoneal (n = 89) or transhepatic (n = 76) cholecystostomy at a single center. Indications were calculous cholecystitis (n = 21), acalculous cholecystitis (n = 35), hydrops (n = 1), gangrenous cholecystitis (n = 1), and other cholecystitis (n = 107). The most common high-risk co-morbidities were sepsis (n = 53) and cardiac (n = 11). Outcomes were compared using univariate and multivariable analysis. RESULTS: Post-procedure outcomes included tube dislodgement (transperitoneal [n = 6] and transhepatic [n = 3], P = 0.44), bile leak (transperitoneal [n = 5], transhepatic [n = 1], P = 0.14), gallbladder hemorrhage (transperitoneal [n = 2]; transhepatic [n = 3], P = 0.52), duodenal fistula (transperitoneal [n = 0], transhepatic [n = 1], P = 0.27), repeat cholecystostomy (transperitoneal [n = 1], transhepatic [n = 3], P = 0.27), and repeat cholecystitis requiring separate admission (transperitoneal [n = 6], transhepatic [n = 10], P = 0.15). All complications were Common Terminology Criteria for Adverse Events grade <3. Twenty transperitoneal patients underwent post-procedure cholecystectomy: 13 laparoscopic, three open, and four unclear/outside records. The mean time from cholecystostomy to operation was 38 days (range 3-211 days). Twenty-three transhepatic patients underwent cholecystectomy: 14 laparoscopic, eight open, and one unclear/outside records, with the mean time from cholecystostomy being 98 days (range 0-1053 days). One transhepatic and three transperitoneal patients died during admission. CONCLUSION: There were no significant differences in short-term complications after transperitoneal and transhepatic approaches to percutaneous cholecystostomy catheter placement.

Median Arcuate Ligament Syndrome and Its Associated Conditions.

The risk factors and associated conditions of median arcuate ligament syndrome (MALS) have not been well characterized in the literature. In this study, we aim to investigate the presentation and outcomes of MALS patients with an emphasis on the prevalence of other uncommon disorders. To this end, data of patients with MALS who underwent surgery between 2013 and 2018 were collected and compiled into a retrospective database and analyzed. Eleven patients were identified. Seven of these eleven patients underwent diagnostics to evaluate gastric emptying. Five of these seven patients (71.4%) had radiographic evidence of delayed gastric emptying. Four of the eleven patients (36.4%) were found to have anatomic abnormalities of their visceral vasculature. Two of the eleven patients (18.2%) were found to have connective tissue disorders, both with Ehlers-Danlos syndrome. Three of the eleven (27.3%) had a diagnosis of postural orthostatic tachycardia syndrome. This is the first case series reporting on an association between MALS and delayed gastric emptying. We also explored the relationship between MALS and visceral vascular abnormalities, Ehlers-Danlos syndrome, and postural orthostatic tachycardia syndrome. It is notable that these conditions are more prevalent in the MALS population than in the general population, suggesting a possible pathophysiologic relationship.

Complications and retrieval characteristics of Celect Platinum inferior vena cava filters.

BACKGROUND: The purpose of this study was to retrospectively assess the retrieval characteristics and rate of filter-related complications associated with use of the Celect Platinum (Cook Medical, Bloomington, Ind) inferior vena cava filter (IVCF). METHODS: A single-center, retrospective review was conducted to identify patients who received a Celect Platinum IVCF between June 2013 and February 2016. The patients' charts and imaging records (computed tomography [CT] and cavography) associated with filter placement, follow-up, and filter retrieval procedures were assessed for attempted and successful retrieval rates and filter-related complications. RESULTS: During the review period, 562 Celect Platinum filters were placed in 556 patients. Outcome and evaluable imaging data (CT and cavography) were available from 335 patients, with median CT follow-up time of 45 days (average, 126 days) and median cavography follow-up time of 90 days (average, 102 days). IVCF leg perforation of the inferior vena cava wall >3 mm was identified in 65 cases (19.4%) on follow-up imaging (64 cases). In addition, filter tilt >15 degrees was identified in 4 filters (1.2%), filter migration >2 cm in 1 filter (0.3%), and occlusive filter or inferior vena cava or iliac vein thrombus in 11 filters; no filter fracture was observed. One case of breakthrough pulmonary embolism and two additional indeterminate cases were identified on follow-up CT pulmonary angiography (2.6%-7.7%). Retrieval was successful in 155 of 155 patients (median indwell time, 90 days; range, 1-445 days); an advanced retrieval technique was used in 11 retrievals. CONCLUSIONS: The outcomes for the Celect Platinum filter were comparable to those previously reported for the first-generation Celect filter in all categories assessed.

Health Worker Focused Distributed Simulation for Improving Capability of Health Systems in Liberia.

INTRODUCTION: The main goal of this study was to produce an adaptable learning platform using virtual learning and distributed simulation, which can be used to train health care workers, across a wide geographical area, key safety messages regarding infection prevention control (IPC). METHODS: A situationally responsive agile methodology, Scrum, was used to develop a distributed simulation module using short 1-week iterations and continuous synchronous plus asynchronous communication including end users and IPC experts. The module contained content related to standard IPC precautions (including handwashing techniques) and was structured into 3 distinct sections related to donning, doffing, and hazard perception training. OUTCOME: Using Scrum methodology, we were able to link concepts applied to best practices in simulation-based medical education (deliberate practice, continuous feedback, self-assessment, and exposure to uncommon events), pedagogic principles related to adult learning (clear goals, contextual awareness, motivational features), and key learning outcomes regarding IPC, as a rapid response initiative to the Ebola outbreak in West Africa. Gamification approach has been used to map learning mechanics to enhance user engagement. CONCLUSIONS: The developed IPC module demonstrates how high-frequency, low-fidelity simulations can be rapidly designed using scrum-based agile methodology. Analytics incorporated into the tool can help demonstrate improved confidence and competence of health care workers who are treating patients within an Ebola virus disease outbreak region. These concepts could be used in a range of evolving disasters where rapid development and communication of key learning messages are required.

Add-on histamine receptor-3 antagonist for allergic rhinitis: a double blind randomized crossover trial using the environmental exposure unit.

BACKGROUND: Oral antihistamines that target the histamine receptor-1, such as fexofenadine, offer suboptimal relief of allergic rhinitis-associated nasal congestion. Combinations with oral sympathomimetics, such as pseudoephedrine, relieve congestion but produce side effects. Previous animal and human studies with histamine receptor-3 antagonists, such as PF-03654764, demonstrate promise. METHODS: Herein we employ the Environmental Exposure Unit (EEU) to conduct the first randomized controlled trial of PF-03654764 in allergic rhinitis. 64 participants were randomized in a double-blind, placebo-controlled 4-period crossover study. Participants were exposed to ragweed pollen for 6 hours post-dose in the EEU. The primary objective was to compare the effect of PF-03654764 + fexofenadine to pseudoephedrine + fexofenadine on the subjective measures of congestion and Total Nasal Symptom Score (TNSS). The objectives of our post-hoc analyses were to compare all treatments to placebo and determine the onset of action (OA). This trial was registered at ClinicalTrials.gov (NCT01033396). RESULTS: PF-03654764 + fexofenadine was not superior to pseudoephedrine + fexofenadine. In post-hoc analyses, PF-03654764 + fexofenadine significantly reduced TNSS, relative to placebo, and OA was 60 minutes. Pseudoephedrine + fexofenadine significantly reduced congestion and TNSS, relative to placebo, with OA of 60 and 30 minutes, respectively. Although this study was not powered for a statistical analysis of safety, it was noted that all PF-03654764-treated groups experienced an elevated incidence of adverse events. CONCLUSIONS: PF-03654764 + fexofenadine failed to provide superior relief of allergic rhinitis-associated nasal symptoms upon exposure to ragweed pollen compared to fexofenadine + pseudoephedrine. However, in post-hoc analyses, PF-03654764 + fexofenadine improved TNSS compared to placebo. Side effects in the PF-03654764-treated groups were clinically significant compared to the controls.

Efficacy and safety of the oral p38 inhibitor PH-797804 in chronic obstructive pulmonary disease: a randomised clinical trial.

RATIONALE: Chronic obstructive pulmonary disease (COPD) is a common lung disease leading to progressive decline in lung function. Inhibition of release of inflammatory mediators by p38 inhibitors may be a useful treatment for chronic inflammation of the airways thought to underlie the pathogenesis of the disease. OBJECTIVES: To evaluate the efficacy and safety of PH-797804, a potent and selective p38 inhibitor, in adults with moderate to severe COPD (Global Initiative for Chronic Obstructive Lung Disease stage II/III). METHODS: This was a randomised, adaptive design, double-blind, placebo-controlled, parallel-group, multicentre trial. Patients were initially randomised to placebo, 0.5, 3, 6 or 10 mg PH-797804 once daily and treated for 6 weeks following a 2-week run-in. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was change from baseline in trough forced expiratory volume in 1 s (FEV1) compared with placebo after 6 weeks of treatment. Secondary endpoints included other spirometric parameters, transition dyspnoea index, rescue mediation use, high sensitivity C-reactive protein and symptoms. A total of 230 patients were assigned to treatment; placebo (n=45), 0.5 mg (n=20), 3 mg (n=47), 6 mg (n=70) and 10 mg (n=48). PH-797804 showed a statistically significant improvement in trough FEV1 at week 6 compared with placebo of 0.086 litre (95% Bayesian CI 0.008 to 0.164) and 0.093 litre (95% CI 0.018 to 0·166) at 3 and 6 mg PH-797804, respectively. PH-797804 3 mg and 6 mg showed an improvement in the baseline dyspnoea index/transition dyspnoea index total focal score at week 6. PH-797804 was well tolerated at all doses studied. CONCLUSIONS: PH-797804 demonstrated improvements over placebo in lung function parameters and dyspnoea in patients with moderate to severe COPD. TRIALREGNO: NCT00559910.

The effects of an H3 receptor antagonist (PF-03654746) with fexofenadine on reducing allergic rhinitis symptoms.

BACKGROUND: Nasal H(3) receptors might have a role in mediating the effects of histamine in patients with allergic rhinitis. OBJECTIVE: This study explored the effect of the potent oral H(3) receptor antagonist PF-03654746 in combination with an oral H(1) receptor antagonist on the objective (acoustic rhinometry) and subjective (symptoms) responses to nasal allergen challenge. METHODS: Twenty patients with out-of-season allergic rhinitis displaying a 30% or greater decrease in minimum nasal cross-sectional area (A(min)) after bolus (ragweed) complete nasal allergen challenge at screening were studied by using a randomized, double-blind, single-dose, 4-way crossover design. Treatments included 10 mg of PF-03654746 plus 60 mg of fexofenadine (group 1), 1 mg of PF-03654746 plus 60 mg of fexofenadine (group 2), 60 mg of fexofenadine/120 mg of pseudoephedrine (group 3), and placebo (group 4). After dosing, subjects underwent complete nasal allergen challenge. Nasal symptom scores (no. of sneezes and 0- to 5-point scores for severity of congestion, itching, and rhinorrhea), A(min) (in square centimeters), and nasal volume (in cubic centimeters) were recorded 15, 30, 45, and 60 minutes after allergen. There was a minimum 10-day washout between periods. RESULTS: The following symptom scores were significantly (P ≤ .05) reduced by active treatments versus placebo: group 1, congestion of -0.7 (SE, 0.3), itching of -1.0 (SE, 0.3), rhinorrhea of -1.3 (SE, 0.3), and sneeze of -8.8 (SE, 1.5); group 2, itching of -0.6 (SE, 0.3), rhinorrhea of -0.8 (SE, 0.3), and sneeze of -9.1 (SE, 1.5); and group 3, rhinorrhea of -0.7 (SE, 0.3) and sneeze of -7.0 (SE, 1.5). There was no significant effect of any treatment on mean A(min) proportion or nasal volume proportion after nasal allergen challenge. CONCLUSIONS: In combination with fexofenadine, single doses of PF-03654746 caused a reduction in allergen-induced nasal symptoms. H(3) receptor antagonism might be a novel therapeutic strategy to further explore in patients with allergic rhinitis.

Superior sensitivity of angiographic detection of arteriovenous fistula after biopsy in a renal allograft with CO2 compared with iodinated contrast medium.

Arteriovenous (AV) fistulas are potential complications of renal transplant biopsy procedures. In the setting of renal transplant failure, angiography with CO2 as a contrast agent is a useful adjunct to angiography with conventional contrast medium in the diagnosis and treatment of such fistulas with minimal nephrotoxicity. The present report describes a case of a renal transplant AV fistula seen after biopsy that could be detected angiographically only with CO2 contrast medium.