Neck Pain and Symptomatic Hypothyroidism: An Atypical Presentation of Subacute Thyroiditis.

Subacute thyroiditis (SAT) is a rare form of thyroid disease characterized by fever, neck pain, and dysregulated thyroid hormone levels. It is caused by the post-viral inflammation and destruction of thyroid follicles. Patients typically present with symptoms of hyperthyroidism, as stored thyroid hormone is released into the blood. In this case, we describe a 34-year-old female who presented to the clinic complaining of neck pain and a headache for two days. She endorsed fatigue, myalgias, dizziness, and constipation but denied any fever. She reported only minimal pain relief with ibuprofen and denied a history of recent illness. On exam, she was afebrile and normotensive. Her physical exam was notable for neck tenderness over the right lobe and isthmus of the thyroid, thyromegaly, and a palpable thyroid nodule. Her complete blood count showed no sign of infection or hematologic abnormality, but her thyroid studies showed an elevated thyroid stimulating hormone of 2.1 mIU/L and a decreased thyroxine (T4) level below 0.01 ng/dL. The laboratory results, history, and physical exam led to the diagnosis of the hypothyroid stage of subacute thyroiditis. She was initially treated with ibuprofen 600mg without resolution of her symptoms. She was then treated with prednisone 40mg with symptom relief. This case highlights an atypical presentation of subacute thyroiditis and adds a new presentation to the discussion for patients with this condition.

Facilitators and Barriers to PrEP Acceptability and Initiation Among Opioid Treatment Program Patients and Staff.

The Centers for Disease Control and Prevention recommends PrEP (pre-exposure prophylaxis) for people who use drugs, yet uptake remains low. This study explores the acceptability and potential uptake of PrEP among participants in an opioid treatment program (OTP). We conducted 26 in-depth, semistructured interviews with staff and patients at an OTP in Baltimore, Maryland. Overall, participants felt that providing PrEP within the program would be beneficial, but they noted competing priorities among populations engaging in high-risk behaviors and lack of willingness among groups with lower risk behaviors. Participants reported several barriers to PrEP use among people who use drugs and who use medications for opioid use, including cost, competing priorities, stigma, and misconceptions about who should use PrEP. Facilitators to PrEP use were described as health benefits, trusted relationships with providers, and existing resources in the opioid treatment program. Practitioners should consider addressing barriers to access and stigma within an OTP setting for HIV prevention tools.

Social support network factors associated with verbal fluency among vulnerable persons living with HIV.

Vulnerable persons living with HIV (PLWH) are at high risk of cognitive impairment and challenges accessing quality social support in later life. Impaired verbal fluency (VF), a cognitive domain linked to HIV, could impede social support associated with health and well-being for already vulnerable PLWH. We examined the structure of social support, using latent class analysis, and the associations among quantity, specific forms and quality of social support and VF among PLWH. Participants enrolled in the BEACON study (n = 383) completed the Controlled Oral Word Association test (COWAT) and a social support network inventory. Latent class analysis with count variables was used to determine the number of classes of PLWH based on their social network characteristics. The majority of PLWH were male (61.4%) and African American (85.9%). Two distinct latent classes, with a major distinction in the number of network members who were female, knew participants' HIV status and HIV medication usage. Fewer support network members (ß = -.13, p < 0.01), greater negative interactions (ß = -.16, p < 0.01), and less positive interactions with network members (ß = .15, p < 0.05) were significantly associated with lower COWAT scores. Comprehensive screening of high-risk PLWH and early intervention with those with cognitive impairment are important for addressing social support needs.

Patient-centered Engagement as a Mediator in the Associations of Healthcare Discrimination, Pain Care Denial, and Later Substance Use Among a Sample of Predominately African Americans Living with HIV.

Chronic pain is prevalent and often under-addressed among people with HIV and people who use drugs, likely compounding the stress of discrimination in healthcare, and self-medicating along with its associated overdose risk or other problematic coping. Due to challenges in treating pain and HIV in the context of substance use, collaborative, patient-centered patient-provider engagement (PCE) may be particularly important for mitigating the impact of pain on illicit drug use and promoting sustained recovery. We examined whether PCE with primary care provider (PCE-PCP) mediated the effects of pain, discrimination, and denial of prescription pain medication on later substance use for pain among a sample of 331 predominately African Americans with HIV and a drug use history in Baltimore, Maryland, USA. Baseline pain level was directly associated with a higher chance of substance use for pain at 12 months (Standardized Coefficient = 0.26, p < .01). Indirect paths were observed from baseline healthcare discrimination (Standardized Coefficient = 0.05, 95% CI=[0.01, 0.13]) and pain medication denial (Standardized Coefficient = 0.06, 95% CI=[0.01, 0.14]) to a higher chance of substance use for pain at 12 months. Effects of prior discrimination and pain medication denial on later self-medication were mediated through worse PCE-PCP at 6 months. Results underscore the importance of PCE interpersonal skills and integrative care models in addressing mistreatment in healthcare and substance use in this population. An integrated approach for treating pain and substance use disorders concurrently with HIV and other comorbidities is much needed. Interventions should target individuals at multiple risks of discriminations and healthcare professionals to promote PCE.

The Relationship between Vaping Cannabis and Frequency of Cannabis Use and Cannabis-Related Problems among Urban High School Students.

Background: Vaping, including vaping cannabis, is increasing among adolescents. In this longitudinal study, we examined the relationship between vaping cannabis and frequency of cannabis use and related problems over 6 months among adolescents. Material and Methods: Data were from 233 participants (46.8% male, 93.1% African American, mean age = 16.4 years) reporting cannabis use. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) assessed frequency of past 30-day cannabis use and cannabis-related problems at baseline, 3- and 6-months post-baseline. We used latent growth curve modeling to compare vaping to non-vaping adolescents on trends in cannabis use frequency and ASSIST cannabis scores. Results: Adolescents who vaped cannabis (11.7%) had higher past 30-day frequency (mean = 17.89 days, SD = 10.49) of cannabis use at baseline compared to adolescents who had not vaped (mean = 12.1 days, SD = 10.93), but reported a significantly sharper decline in frequency of cannabis use (b = -0.34, p = 0.017). A significantly steeper decrease existed in the mean cannabis ASSIST scores for the vaping group than for the non-vaping group (b = -0.34, p = 0.014). Mean ASSIST scores on the cannabis subscale between the two groups were significantly different at 6-month follow-up (Vape mean = 6.00, SD = 8.12 vs. Non-vape mean = 9.6, SD = 9.39; p < 0.021). Conclusions: In a sample of cannabis-using adolescents, adolescents with experience vaping cannabis, compared to adolescents without vaping experience, on average reported sharper decreases in frequency of cannabis use and cannabis-related problems such as health or social problems.

Latent class analysis of perceived stigma among older adults receiving medications for opioid use disorder.

RATIONALE: Public stigma surrounds individuals who use medication for their recovery from a substance use disorder. However, we know little about subgroups of individuals with varying levels of perceived stigma and how these levels may be associated with physical and mental health-related quality of life (HRQOL) and social support. METHODS: We used latent class analysis to define subgroups of people aged 50-72 years of age (N = 104) who were enrolled in eight medication for opioid use disorder (MOUD) programs to explore subgroupings and correlates of group membership. RESULTS: We found evidence for three distinct classes of individuals and named the classes 1) the high stigma class, 2) the embarrassed class, and 3) the low stigma class. We found that people in the high-stigma class reported more rejection, more abstinence-based support group involvement, and reduced mental HRQOL. CONCLUSIONS: Results suggest reducing stigma among people on MOUD may help to boost mental HRQOL and improve social support receipt. The results are consistent with iatrogenic effects of AA/NA support groups such that these treatment modalities may increase stigma due to their focus on abstinence-only treatment for substance use disorders.

Optic inversion of scleral-fixated intraocular lens after vitrectomy with fluid-air exchange: case series and review of the literature.

Lens dislocation is a significant complication after cataract surgery. Scleral fixation of 3-piece intraocular lens provides favorable visual outcome and can spare patients the need for lens exchange. Two patients presented with dislocated 3-piece lenses implanted over 10 years earlier. Both patients underwent pars plana vitrectomy and dropped lens rescue with scleral fixation. Postoperatively, the lens optic was found flipped nearly 90° at the optic-haptic junctions secondary to fluid-air exchange performed during vitrectomy. Both patients underwent intraocular lens exchange with a four point sclera fixated lens. Our study found that air tamponade is better avoided during rescue of old dislocated 3-piece lens implants. Intraocular lens exchange is preferred, when possible, to avoid complications associated with old dislocated lenses. Larger studies are needed to determine the effect of time on dislocated lens implants materials.

Metastatic Leptomeningeal Carcinomatosis From Primary Lobular Breast Cancer Found in a Medical School Cadaveric Dissection.

Leptomeningeal carcinomatosis (LC) is an uncommon sequelae of metastatic cancer affecting the pia and arachnoid mater. It has been postulated that recent improvements in cancer patient survival time have increased the frequency of LC and other rare metastatic conditions that patients previously would not have lived long enough to experience. LC carries a universally poor prognosis with a mean survival of between two to four months if treated; however, the recent increase in incidence has allowed for further research into the condition and potential treatments. Options for administering chemotherapy have been limited in the past, but recent developments in surgical chemotherapeutic ports have allowed for intrathecal delivery of drugs like methotrexate without systemic exposure. In fact, innovative delivery systems undergoing clinical trials can deliver these drugs in a metronomic fashion to limit the leukoencephalopathy complications of methotrexate. Primary breast cancer is the most common source of metastatic leptomeningeal lesions, and such a lesion was observed by the authors in the cadaver of a 70-year-old Caucasian female with unspecified breast cancer in a medical school anatomic laboratory. The cause of death was listed as "complication of malignant neoplasm of unspecified site of unspecified female breast." Through this case report, we seek to develop our understanding of this rare metastatic phenomenon and highlight the importance of student cadaveric dissection.

A Case of Cocaine-Induced Acute Liver Failure Reversed With N-Acetylcysteine.

Acute liver failure (ALF) is a life-threatening injury that is most often caused by drug-induced injury, including acetaminophen overdose, in the United States. The hallmarks of ALF are hepatic encephalopathy and coagulopathy in a patient without an established history of liver disease. While acetaminophen overdose has an antidote, that is N-acetylcysteine (NAC), when given acutely, most other causes of hepatic failure require an urgent liver transplant. In this paper, we report a case of cocaine-induced acute liver failure that was reversed with the administration of NAC. Our case began when a middle-aged male presented to the emergency department complaining of nausea, vomiting, fatigue, and confusion for the past three days. His past medical history was pertinent for a history of opioid use disorder and his physical exam was remarkable for somnolence, asterixis, and periumbilical ecchymoses. His initial lab results showed markedly elevated liver function tests, prolonged coagulation studies, and a urine drug screen that was positive for cocaine. During the patient's interview, his vital signs became unstable. He was intubated for airway protection and transferred to a tertiary care facility for liver transplant evaluation with the diagnosis of cocaine-induced acute liver failure. There he received NAC, lactulose, rifaximin, and vasopressors. On day two of treatment, his clinical condition greatly improved, and he was extubated. He continued to receive NAC until day five when his liver function tests and coagulopathy improved enough to stop treatment. This case report highlights the clinical benefit of NAC in a case of cocaine-induced acute liver failure, improving the patient's survival and eliminating his need for a liver transplant.

Biosynthetic Enzyme-guided Disease Correlation Connects Gut Microbial Metabolites Sulfonolipids to Inflammatory Bowel Disease Involving TLR4 Signaling.

The trillions of microorganisms inhabiting the human gut are intricately linked to human health. At the species abundance level, correlational studies have connected specific bacterial taxa to various diseases. While the abundances of these bacteria in the gut serve as good indicators for disease progression, understanding the functional metabolites they produce is critical to decipher how these microbes influence human health. Here, we report a unique biosynthetic enzyme-guided disease correlation approach to uncover microbial functional metabolites as potential molecular mechanisms in human health. We directly connect the expression of gut microbial sulfonolipid (SoL) biosynthetic enzymes to inflammatory bowel disease (IBD) in patients, revealing a negative correlation. This correlation is then corroborated by targeted metabolomics, identifying that SoLs abundance is significantly decreased in IBD patient samples. We experimentally validate our analysis in a mouse model of IBD, showing that SoLs production is indeed decreased while inflammatory markers are increased in diseased mice. In support of this connection, we apply bioactive molecular networking to show that SoLs consistently contribute to the immunoregulatory activity of SoL-producing human microbes. We further reveal that sulfobacins A and B, two representative SoLs, primarily target Toll-like receptor 4 (TLR4) to mediate immunomodulatory activity through blocking TLR4's natural ligand lipopolysaccharide (LPS) binding to myeloid differentiation factor 2, leading to significant suppression of LPS-induced inflammation and macrophage M1 polarization. Together, these results suggest that SoLs mediate a protective effect against IBD through TLR4 signaling and showcase a widely applicable biosynthetic enzyme-guided disease correlation approach to directly link the biosynthesis of gut microbial functional metabolites to human health.

Long Chain Fatty Acids and Virulence Repression in Intestinal Bacterial Pathogens.

When bacterial pathogens enter the gut, they encounter a complex milieu of signaling molecules and metabolites produced by host and microbial cells or derived from external sources such as the diet. This metabolomic landscape varies throughout the gut, thus establishing a biogeographical gradient of signals that may be sensed by pathogens and resident bacteria alike. Enteric bacterial pathogens have evolved elaborate mechanisms to appropriately regulate their virulence programs, which involves sensing and responding to many of these gut metabolites to facilitate successful gut colonization. Long chain fatty acids (LCFAs) represent major constituents of the gut metabolome that can impact bacterial functions. LCFAs serve as important nutrient sources for all cellular organisms and can function as signaling molecules that regulate bacterial metabolism, physiology, and behaviors. Moreover, in several enteric pathogens, including Salmonella enterica, Listeria monocytogenes, Vibrio cholerae, and enterohemorrhagic Escherichia coli, LCFA sensing results in the transcriptional repression of virulence through two general mechanisms. First, some LCFAs function as allosteric inhibitors that decrease the DNA binding affinities of transcriptional activators of virulence genes. Second, some LCFAs also modulate the activation of histidine kinase receptors, which alters downstream intracellular signaling networks to repress virulence. This mini-review will summarize recent studies that have investigated the molecular mechanisms by which different LCFA derivatives modulate the virulence of enteric pathogens, while also highlighting important gaps in the field regarding the roles of LCFAs as determinants of infection and disease.

Family Conflict Non-negotiation and HIV Disclosure Associated With ART Adherence in a Disadvantaged Population.

Adherence to antiretroviral therapy (ART) is vital for reducing racial and gender disparities in morbidity and mortality among people living with HIV/AIDS (PLWH). Little research attention has been given to aspects of family functioning affecting ART adherence among PLWH vulnerable to disparities. Data were from n = 313 participants (93% African American) in the BEACON study, which recruited injection-drug-using PLWH on ART. Using factor analysis and longitudinal structural equation modeling, we found that current substance use and negative family conflict tactics (i.e., non-negotiation) predicted PLWH's lower probability of ART adherence at 12-month follow-up; and greater HIV disclosure to support network members predicted a higher probability of adherence. These findings suggest the importance of family and other support network members in this vulnerable population's ART adherence. Social network-focused interventions promoting prosocial response to conflict and negotiation skills are important for improving vulnerable PLWH's HIV outcomes and reducing health disparities.

Caregiver role strain in caring for vulnerable persons living with HIV: correlates of caregiver and care recipient reports.

Informal care of family and friends is important for the health and well-being of disadvantaged persons living with HIV (PLWH). Caregiver role strain may threaten the function and continuity of their main relationships and their health impacts. Data were from a disadvantaged, primarily African American, sample of PLWH care recipients. Caregiver role strain was operationalized as a latent factor measured by variables including PLWH's perceptions of their caregiver not wanting or complaining about helping them or wanting a break. We found that greater caregiver role strain was associated with higher levels of HIV-related stigma and depressive symptoms. Lower role strain was associated with more collaborative problem solving and shared medical treatment decision-making. Caregiver role strain was linked to disadvantaged PLWHs' worse stigma and mental health; collaborative engagement in care and coping assistance were protective of role strain. Caregiving relationship-focused research and interventions are needed for resourcing and sustaining disadvantaged African American communities' caregiving and health.

Association between continued cannabis use during pregnancy and symptoms of anxiety and depression.

Cannabis use in pregnancy is common, as are mental health disorders, but the association between the two is not well established. This study is a single-site retrospective cohort. Urine testing for cannabis was evaluated at two-time points to categorize women as having never used, quit or continued to use. Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder (GAD) screen results were compared across groups using multinomial logistic regression. In addition, EPDS and GAD change scores between initiation of care and delivery were analyzed. 604 women were included, 221 (36.3%) with positive toxicology testing for cannabis at the initiation of care. Women who continued cannabis use were significantly more likely to have elevated GAD and EPDS scores (2.55 [1.31, 4.99]) and EPDS score (2.75 [1.43, 5.28]), respectively as compared to those with no use. No significant differences were found between groups in GAD or EPDS change scores t women with higher depression scores on the EPDS had 2.70 times the odds of being in the continuous use group compared to the quit using group (aOR = 2.70, 95% CI = [1.30, 5.88]). Both anxiety and depression symptoms were found to be associated with cannabis use and continued use during pregnancy.

The effect of a low-nickel diet and nickel sensitization on gastroesophageal reflux disease: A pilot study.

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) is a common medical condition, frequently refractory to medical therapy. Nickel is a leading cause of allergic contact dermatitis. Although nickel is widely found in foods, the effect of nickel on GERD is unknown. This pilot study sought to evaluate the effect of a low-nickel diet on GERD and determine if epicutaneous patch testing to nickel could predict responsiveness to a low-nickel diet. METHODS: This prospective, single-site pilot study recruited 20 refractory GERD patients as determined by GERD Health-Related Quality of Life (GERD-HRQL) scores. All patients had epicutaneous patch testing for nickel and were then instructed to follow a low-nickel diet for 8 weeks regardless of patch test results. GERD-HRQL was recorded at baseline and following 8 weeks of a low-nickel diet. Demographic and clinical data associated with GERD and nickel allergy were recorded. A Wilcoxon signed-rank test and nonparametric analysis of longitudinal data were run to determine statistical significance in pre- and post- GERD-HRQL scores in nickel patch test-positive and negative groups. RESULTS: Nearly all (19/20 [95%]) participants reported reduced GERD symptoms after 8 weeks on a low-nickel diet. Mean total GERD-HRQL, regurgitation, and heartburn scores declined (27.05 ± 16.04, 11.45 ± 6.46, 10.85 ± 8.29). Participants with positive vs. negative patch testing to nickel responded equivalently to a low-nickel diet. CONCLUSIONS: A low-nickel diet improves GERD symptoms, but responsiveness to a low-nickel diet does not correlate with epicutaneous patch testing to nickel. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT03720756.

An alternative analysis of illicit opioid use during treatment in a randomized trial of extended-release naltrexone versus buprenorphine-naloxone: A per-protocol and completers analysis.

BACKGROUND: The distinct pharmacological properties and clinical uses of extended-release naltrexone (XR-NTX) and sublingual buprenorphine-naloxone (BUP-NX) present challenges in analyzing patient outcomes. METHODS: We conducted a secondary analysis of a multi-site randomized trial comparing XR-NTX with sublingual BUP-NX treatment for opioid use disorder initiated during inpatient detoxification and continued in outpatient treatment. Urine testing data for non-study opioids from the last 22 weeks of the 24-week trial were analyzed in both a per-protocol sample (n = 474 participants who received at least one dose of medication) and a completers sample (n = 211 participants who received all XR-NTX doses or all BUP-NX prescriptions). The present analyses sought to identify differences in the weekly percentages of opioid-positive urine tests between participants treated with the two medications. RESULTS: The proportion of opioid-positive tests in both conditions was less than 20 % for 21 of the 22 weeks in the per-protocol sample and all 22 weeks in the completers sample. Generalized linear mixed model analyses revealed a significant treatment (XR-NTX vs. BUP-NX) X week (weeks 3-24) interaction in the per-protocol sample but not the completers sample. In the per-protocol analysis, the BUP-NX, compared to XR-NTX, had significantly greater proportions of opioid-positive tests in 14 out of the 22 weeks. CONCLUSIONS: Longitudinal modeling approaches that utilize flexible procedures for handling missing data can offer a different perspective on study findings. Results from the present analyses suggest that XR-NTX appeared to be somewhat more effective than BUP-NX in reducing illicit opioid use in the per-protocol sample.

Quality of Life Among Caregivers of a Vulnerable Population Living with HIV: Caregiving and Relationship Factors.

Literature on health-related quality of life (HRQOL) has focused on people living with chronic conditions, with less attention given to HRQOL among informal caregivers. We used cross-sectional dyadic data from both care recipients (CR) living with HIV and the person they identified as their primary informal (unpaid) caregiver (CG) to identify psychosocial and caregiving relationship factors (including, CG role ambivalence and caregiving-related stress) associated with CG HRQOL. We conducted confirmatory factor analysis and structural equation modeling testing. The results highlight interdependent effects of the CG-CR relationship and reveal pathways whereby relationship interactions positively and negatively impact CGs' HRQOL. Affiliative stigma, CG-CR communication, CRs' reciprocity of support and other psychosocial factors indirectly and differentially affected physical and mental HRQOL through effects on secondary stress and role ambivalence. Dyad-focused intervention on interpersonal communication and support exchange may improve HRQOL and resilience of CGs of vulnerable people living with HIV.

RESUMEN: La literatura sobre calidad de vida relacionada con la salud (CVRS) se ha centrado en las personas que viven con enfermedades crónicas, con menos atención a la CVRS entre los cuidadores informales. Utilizamos datos diádicos transversales de recibidores de cuidado (RC) que viven con VIH y de la persona que identificaron como su principal cuidador informal (no remunerado) (CI) para identificar los factores psicosociales y en la relación de cuidado (incluyendo la ambivalencia del rol de CI y del estrés) asociado con calidad de vida. Realizamos análisis factoriales confirmatorios y pruebas de modelación de ecuaciones estructurales. Los resultados demostraron los efectos interdependientes de la relación entre el cuidador y el recibidor de cuidado y revelan cómo las interacciones de la relación impactan la calidad de vida de los cuidadores. El estigma, la comunicación en la relación, la reciprocidad de apoyo de los recibidores de cuidado y otros factores psicosociales afectaron indirecta y diferencialmente la calidad de vida física y mental a través de los efectos sobre el estrés secundario y la ambivalencia de roles. Las intervenciones diádicas centradas en la comunicación interpersonal y la facilitación de apoyo pueden mejorar la calidad de vida y la capacidad de recuperación de los cuidadores de las personas vulnerables que viven con el VIH.