Comparison of chest- and wrist-based actigraphy in pulmonary arterial hypertension.

Aims: Activity trackers for clinical trials and remote monitoring are appealing as they provide objective data outside of the clinic setting. Algorithms determine physical activity intensity and count steps. Multiple studies show physical inactivity in pulmonary arterial hypertension (PAH). There are no studies comparing different activity trackers worn on different parts of the body in PAH. We had patients with PAH simultaneously wear two different accelerometers, compared measures between the two devices, and correlated the measures with standard clinical metrics in PAH. Methods and results: This was a single-centre, prospective observational study. Daily physical activity and daily total steps were measured using Actigraph GT9X Link and MC10 Biostamp nPoint for 5-10 days. Actigraph was worn on the non-dominant hand and the MC10 Biostamp nPoint was worn on the chest and leg with disposable adhesives. Twenty-two participants wore both accelerometers >12 h/day for an average 7.8 days. The average activity time measured by Actigraph was significantly higher than that measured by MC10 (251 ± 25 min vs. 113 ± 18 min, P = 0.0001). Actigraph's algorithm reported more time in light activity than moderate (190 ± 62 min vs. 60 ± 56 min, P = 0.0001). REVEAL 2.0 scores correlated highly with activity time measured using either device. Invasively measured haemodynamics within 7 days did not correlate with activity time or daily steps. Conclusion: Different activity trackers yield discordant results in PAH patients. Further studies are needed in determining the best device, optimal wear time, and different thresholds for activities in chronic diseases.

Asthma biologics: Real-world effectiveness, impact of switching biologics, and predictors of response.

BACKGROUND: Confirmation of effectiveness of asthma biologics in the real world is desirable because patient characteristics and experiences may differ from those included in randomized controlled trials. OBJECTIVE: To evaluate real-world effectiveness of asthma biologics and identify predictors of response. METHODS: We performed a retrospective study in patients with severe asthma receiving biologics. The primary outcome was change in clinically significant exacerbations at 12 months after starting biologic therapy, compared with 12 months before. Secondary outcomes were change in severe exacerbations, maintenance oral corticosteroid (OCS) dose, prebronchodilator forced expiratory volume in 1 second (FEV1), and asthma control test scores. Subgroup analyses were performed for subjects who were biologic naive or not. A stepwise logistic regression model was performed to compare responders to nonresponders. RESULTS: A total of 112 patients were included. Biologic therapy was associated with a 59% reduction in clinically significant exacerbations (P < .001), 65% reduction in severe exacerbations (P < .001), and 54% reduction in maintenance OCS dose (P = .001) in the 12 months after starting therapy. Biologics also resulted in improvement in prebronchodilator FEV1 (P = .002) and Asthma Control Test score (P < .001). Subjects who were previously on another biologic also experienced significant improvements in exacerbation frequency, maintenance OCS dose, and asthma control. Responders were more likely to be nonsmokers and have higher baseline FEV1, gastroesophageal reflux disease, and eosinophil counts greater than 500 cells/µL. CONCLUSION: In a real-world setting, biologic therapy in asthma is effective in improving exacerbations, asthma control, and lung function. Patients who have a suboptimal response to 1 biologic can still benefit from treatment with a different biologic.

A 46-Year-Old Woman Who Presented with Diabetic Ketoacidosis and COVID-19 Pneumonia with Multiple Pulmonary Thromboemboli: A Case Report.

BACKGROUND Coronavirus disease 2019 (COVID-19) occurs because of a novel enveloped ribonucleic acid coronavirus called severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2). One of the major reported complications of COVID-19 includes both arterial and venous thromboembolism (VTE). Here we describe a case of COVID-19 provoked pulmonary embolism in a young patient already receiving prophylactic treatment for VTE. CASE REPORT A 46-year-old female with past medical history of diabetes mellites, hypertension, and asthma presented in the emergency department (ED) with dyspnea requiring 6 liters per minute of oxygen on presentation. Her main complaints were cough and vomiting. In the ED, hypoxemia worsened, and she ultimately required endotracheal intubation. Labs were suggestive of diabetic ketoacidosis (DKA) and showed increase in all inflammatory markers and absolute lymphocytopenia. Chest X-ray showed bilateral diffuse patchy airspace opacities. Standard DKA management was started. She was also started on ceftriaxone, azithromycin, hydroxychloroquine, and subcutaneous heparin (5000 U every 8 h) for VTE prophylaxis. SARS-Cov2 reverse transcription-polymerase chain reaction returned positive. Ceftriaxone and azithromycin were discontinued the very next day because of low suspicion of bacterial infection while hydroxychloroquine was completed for 5 days. On the third day of admission, the patient self-extubated and was immediately placed on nonrebreather with spO2 in low 90s. On the fourth day of admission, D-dimer came back 4.74 mg/L, which was elevated from a prior value, so computed tomography angiography of the lungs was done, which disclosed multiple emboli in the lungs. She was started on therapeutic doses of enoxaparin sodium, which was continued through her admission. She was switched to Apixaban on discharge. CONCLUSIONS The finding of the case suggested that low-molecular-weight heparin prophylaxis may not be sufficient to prevent VTE in COVID-19 pneumonia. Some of these patients may benefit from receiving prophylactic half doses or full doses of anticoagulants.

Why now? Delayed drug-induced pancreatitis due to dapsone for dermatitis herpetiformis.

Drug-induced pancreatitis can be caused by a wide array of medications. In fact, the diagnosis is likely commonly missed due to the difficulty in diagnosing one agent as the sole cause. We present a case of dapsone-induced pancreatitis in a 75-year-old male with history of celiac disease. He presented with abdominal pain and was found to have acute pancreatitis. Interestingly, he had been on dapsone for 5 years and had no other recent medication changes, significant alcohol use, or gallbladder disease. It was determined this was an episode of delayed acute pancreatitis due to dapsone. This is a rarely addressed entity in the literature and is the first case in which pancreatitis occurred so late in a patient's treatment course on dapsone.

Guillain-Barré Syndrome Presenting with Sinus Node Dysfunction and Refractory Shock.

BACKGROUND Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy that is usually associated with preceding respiratory or gastrointestinal infection and has the hallmark manifestation of ascending flaccid paralysis. We report an atypical presentation of GBS. CASE REPORT A 76-year-old male presented with acute onset of diaphoresis and altered mental status. He subsequently developed severe bradycardia and refractory hypotension, which initially responded to dopamine infusion. A temporary pacemaker wire was placed to stabilize the heart rate but hypotension persisted. Acute autonomic dysfunction was suspected. Head and chest imaging was unrevealing. Lumbar puncture revealed albuminocytologic dissociation that was consistent with a diagnosis of GBS. Hospital course was complicated with acute kidney injury and metabolic acidosis. Plasmapharesis was initiated. The patient eventually died of multi-organ failure. CONCLUSIONS Autonomic dysfunction is a known but rare presentation of GBS. In patients presenting with refractory bradycardia and hypotension, GBS should be considered in the differential diagnosis.