Cannabis Hyperemesis Syndrome in a Recently Abstinent Chronic User: Assessment and Intervention.

BACKGROUND: Cannabis Hyperemesis Syndrome (CHS) is a condition characterized by episodic bursts of vomiting and abdominal pain linked to cannabis use. The clinical picture mimics an acute abdomen and is often misdiagnosed, especially when the patient avoids reporting their cannabis use for legal reasons. CASE REPORT: We report on the case of a 33-year-old man that was brought to the emergency room with a history of 3 days of non-bloody, non-projectile, and non-bilious brownish vomit, coupled with severe epigastric and left hypochondriac pain, and a slight fever. He was a daily cannabis user for several years and had stopped using a week or so before the onset of the symptoms, as he was traveling to a country with more restrictive cannabis laws. His condition deteriorated rapidly, followed by emergency room attendance, thorough diagnostic work-up, and unsuccessful interventions, including intravenous treatment with the anti-emetic Ondansetron. The patient was referred to a psychiatrist after a suspected psychogenic etiology by the medical team. The history was suggestive of CHS and also included anxious, depressed mood with 'brain fog'. The abdominal pain was the most severe complaint. A combination of tramadol, promethazine, and mirtazapine given on an outpatient basis led to full recovery within 10 days. CONCLUSION: CHS can occur soon after the interruption of chronic cannabis use and overlap with withdrawal symptom. A combination of anti-histaminergic, opioid-based medication, and antidepressant mirtazapine seemed an effective treatment of CHS, which resulted in a relatively quick recovery.

The hyperemesis gravidarum and pulmonary embolism: A case report and review of literature.

Background: Nausea and vomiting occur in more than 70% of pregnant women,1 and only 2% of these females progress into hyperemesis gravidarum (HG).2 HG is the persistent and excessive vomiting before the 22nd week of gestation. HG patients can develop life-threatening electrolyte disturbances or thromboembolism. Pulmonary embolism (PE) is a thromboembolism that blocks and stops blood flow to an artery in the lung. Both HG and PE increase morbidity and mortality in pregnant patients. HG patients developing PE are reported only in two patients with fatal outcomes in the literature. We report a case of PE in a hospitalized HG patient with a better outcome. Case Presentation: A 26-year-old previously healthy gravida 3 and para 2 patient was admitted to the Women Wellness and Research Center with HG at 10 weeks of gestation. She developed nausea and vomiting at 6 weeks of gestation and was treated in the emergency department, where she was started on intravenous (IV) fluids for hydration, an antiemetic, and deltaparin for prevention of deep venous thrombosis (DVT), as she was pregnant and dehydrated. She was on potassium replacement therapy for hypokalemia. The patient was improving; still had vomiting, but less frequent. On day 3, following admission, the patient suddenly developed hemoptysis, chest pain, and palpitation. She was tachycardic (120 bpm) and tachypneic (30 breaths per minute). She was feeling dizzy, and her oxygen saturation (Spo2) was around 95%. Her chest was clear on examination. Computerized tomographic pulmonary angiography showed bilateral PE. She was admitted to the highdependency unit. The patient was tachypneic and tachycardic and required non-invasive ventilation. A therapeutic dose of enoxaparin (1 mg/kg) was started and supplemented with fentanyl plus paracetamol for analgesia, continued IV fluids, and promethazine.Her respiratory symptoms and tachycardia improved by day 6, she was transferred to the ward from there and discharged home by day 10, on enoxaparin therapeutic dose (1 mg/kg), and follow up in outpatient clinics showed no issues, and she is doing fine. Discussion: HG is a severe clinical disease in pregnancy where patients have intractable nausea and vomiting with increased morbidity and even mortality. These patients frequently present with ketonuria, dehydration, electrolyte abnormalities, and a weight loss of 7%. Rarely, these patients' present with severe vitamin deficiency, causing a neurological emergency called Wernicke's encephalopathy. The occurrence of DVT is one of the main risk factors due to prothrombotic conditions in pregnancy in combination with dehydration in these patients. The occurrence of PE is reported in two cases of HG in the post-mortem. Our patient developed bilateral PE, a medical emergency due to immobility, dehydration, and prothrombotic predominance during pregnancy. PE was detected early and managed, leading to a better outcome. Conclusion: HG should be diagnosed early, followed by admission of the patient to the hospital. Our patient with HG was complicated by a rare bilateral PE due to a combination of pregnancy, dehydration, and immobility, despite DVT prophylaxis with a favorable outcome. Clinicians should have an index of suspicion for DVT and PE in these dehydrated pregnant patients. A high index of suspicion, early diagnosis, and management by a multidisciplinary team are key for better outcomes of PE in our HG patient.

Brain MRI: A safe and a specific tool in the diagnosis of Gayet Wernicke's encephalopathy in pregnant women: Case report.

Gayet-Wernicke encephalopathy (GWE) is a neuropsychiatric syndrome due to Vitamin B1 (thiamine) deficiency, fatal in 30% of cases and preventable if treatment is initiated early, characterized by the classic triad of encephalopathy, ocular involvement: ophthalmoplegia and/or nystagmus and ataxia. GWE is mainly observed in alcoholics, but can also appear in any state of malnutrition. In obstetrics, hyperemesis gravidarum can be complicated by GWE due to low thiamine stores and increased thiamine requirements. We report a case of Gayet-Wernicke encephalopathy complicating incoercible vomiting in a pregnant woman.

The IRIS clinic: A Protocol for a mixed-methods study evaluating the management of Hyperemesis Gravidarum.

Background: Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting in pregnancy that affects 0.3-3% of women and has profound nutritional, physical and psychological consequences. Research is lacking regarding the most effective management of the condition. In response to patient feedback, a multidisciplinary HG day-case service (IRIS Clinic) was launched in 2020 at The National Maternity Hospital, Ireland. The clinic provides routine, day-case care in a comfortable space with pre-booked appointments. The MDT involves midwives, dietitians, perinatal mental health, obstetrics and pharmacy, and the nature of the clinic enables peer-to-peer support. As this clinic is the first of its kind in Ireland, we aim to assess its effectiveness and feasibility, and suggest recommendations for improvement. Methods: This is a sequential, mixed-methods study that commenced in August 2021. The prospective arm of the study is ongoing and involves enrolling women (n = 50) who are attending the IRIS clinic. Data are collected on first admission (pre-intervention) and approximately 8 weeks' later (post-intervention) relating to symptoms of HG, well-being, food tolerances, quality of life and nutritional intake. Qualitative, semi-structured interviews will be conducted to evaluate women's experiences of attending the clinic. The retrospective arm of the study will be a chart review (n = 200) of women diagnosed with HG to describe assessments, treatments and pregnancy and birth outcomes. Conclusion: The IRIS clinic has the potential to improve pregnancy outcomes and nutritional status among women with HG. If found to be effective and feasible, the model for this clinic could be replicated elsewhere.

Exploring Marchiafava-Bignami Disease: A Rare Presentation in a Young Pregnant Female.

Marchiafava-Bignami disease (MBD) is uncommon and typically linked with persistent alcohol consumption; nevertheless, instances have been reported in non-alcoholic individuals with nutritional deficiencies. Depending on the severity, this condition may manifest as acute, subacute, or chronic neurological signs and symptoms, ranging from moderate dysarthria or mild disorientation to coma and death. We report a case of a 30-year-old, 14-week pregnant female who presented with complaints of persistent vomiting and loss of appetite. She was found to have achalasia cardia on upper GI endoscopy. Later, she developed confusion, irrelevant talks and her speech was incomprehensible. An MRI of the brain was done which showed features likely that of MBD. She was started high dose intravenous thiamine to which she responded brilliantly.

Diagnosis of Advanced Gastric Cancer Occasioned by Persistent Postpartum Fever: A Case Report.

Pregnancy-associated gastric cancer is extremely rare. In many cases, the cancer is already advanced at the time of diagnosis, and the prognosis is often poor. A 39-year-old primigravida, with dichorionic diamniotic twins, was admitted to our hospital for threatened preterm labor at 31 weeks of gestation. At 32 weeks of gestation, she developed a fever and tested positive for influenza A. She recovered from influenza A on the following day but had an emergency cesarean section for premature rupture of the membranes at 32 weeks of gestation. She was discharged on postpartum day six. Thereafter, she was again infected with influenza A. On day 18, she underwent an abdominal ultrasound revealing multiple mass lesions in the liver, because she had an uncomfortable upper gastric with persistent fever. She was referred to the internal medicine team, who made a diagnosis of stage IV gastric cancer. Importantly, non-specific symptoms and physical signs that are not explicable by the normal course of pregnancy may be recognized through conscientious history-taking and physical observations. If gastrointestinal symptoms are prolonged, or if symptoms such as severe weight loss, melena, a tender abdominal mass, or persistent and unexplained fever develop, an endoscopic assessment should be conducted to suspect other diseases. In addition, proactive ultrasound scanning, including the upper abdomen, may detect pregnancy-associated gastric cancer and lead to further in-depth investigations.

Pregnancy outcomes by hyperemesis gravidarum severity and time of diagnosis: A retrospective cohort study.

OBJECTIVE: With inconsistencies regarding the possible effect of hyperemesis gravidarum on the course of pregnancy, this research aimed to study the association between hyperemesis gravidarum and pregnancy outcomes, while also addressing the trimester of diagnosis and severity. METHODS: A retrospective cohort study was performed, including all singleton deliveries of mothers from the largest health maintenance organization in the country, in a single tertiary hospital between 1991 and 2021. The incidence of adverse pregnancy outcomes was compared between pregnancies with and without hyperemesis gravidarum diagnosis. Multivariable generalized estimation equation binary models were used to study the association between maternal hyperemesis gravidarum, trimester of diagnosis and hyperemesis gravidarum severity and the studied outcomes. RESULTS: The study population included 232 476 pregnancies, of which 3227 (1.4%) were complicated with hyperemesis gravidarum. Women with hyperemesis gravidarum were more likely to deliver preterm (adj. OR = 1.33, 95% CI: 1.18-1.50), a newborn with low birthweight (adj. OR = 1.52, 95% CI: 1.16-1.98, only if diagnosed in the second trimester), and to have a cesarean delivery (adj. OR = 1.20, 95% CI: 1.09-1.32). They were less likely to deliver small gestational age newborn (adj. OR = 0.82, 95% CI: 0.69-0.99) and their offspring to experience perinatal mortality (adj. OR = 0.54, 95% CI: 0.31-0.93, among mild cases only). A dose-response association was observed between preterm birth and hyperemesis gravidarum (adj. OR = 1.26; 95% CI: 1.11-1.44, for mild cases and adj. OR = 2.04; 95% CI: 1.31-3.19, for severe cases). CONCLUSIONS: Hyperemesis gravidarum is associated with an increased risk for adverse pregnancy outcomes including mainly preterm delivery in a dose-response manner and when diagnosed during the second trimester.

Hyperemesis gravidarum and the risk of offspring morbidity: a longitudinal cohort study.

PURPOSE: Hyperemesis gravidarum has the potential to affect the long-term health of offspring. We examined whether maternal hyperemesis gravidarum was associated with the risk of hospitalization for childhood morbidity. METHODS: We conducted a longitudinal cohort study of 1,189,000 children born in Quebec, Canada, between April 2006 and March 2021. The main exposure measure was maternal hyperemesis gravidarum requiring hospitalization in the first or second trimester. The outcome was any pediatric admission between birth and 16 years of age, with follow-up ending in March 2022. We used Cox regression models adjusted for maternal and socioeconomic factors to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between maternal hyperemesis gravidarum and childhood hospitalization. RESULTS: Among 1,189,000 children, 6904 (0.6%) were exposed to maternal hyperemesis gravidarum. Hospitalization rates at age 16 years were higher for children exposed to hyperemesis gravidarum than unexposed children (47.6 vs 43.9 per 100 children). Relative to no exposure, hyperemesis gravidarum was associated with a 1.21 times greater risk of any hospitalization before 16 years (95% CI 1.17-1.26). Hyperemesis gravidarum was associated with hospitalization for neurologic (HR 1.50, 95% CI 1.32-1.71), developmental (HR 1.51, 95% CI 1.29-1.76), digestive (HR 1.40, 95% CI 1.30-1.52), and allergic disorders (HR 1.39, 95% CI 1.24-1.56). When contrasted with preeclampsia, hyperemesis gravidarum was a stronger risk factor for these outcomes. CONCLUSIONS: Maternal hyperemesis gravidarum is associated with an increased risk of childhood hospitalization, especially for neurologic, developmental, digestive, and atopic disorders. WHAT IS KNOWN: • Hyperemesis gravidarum is associated with neurodevelopmental disorders in offspring. • However, the effect of hyperemesis gravidarum on other childhood morbidity is unclear. WHAT IS NEW: • In this longitudinal cohort study of 1.2 million children, maternal hyperemesis gravidarum was associated with a greater risk of hospitalization before age 16 years. • Exposure to hyperemesis gravidarum was associated with developmental, neurologic, atopic, and digestive morbidity in childhood.

Prevalence of hyperemesis gravidarum and associated factors among pregnant women at comprehensive specialized hospitals in northwest Ethiopia: Multicenter cross-sectional study.

Background: Hyperemesis gravidarum is one of the problems encountered among pregnant women due to persistent and excessive vomiting starting before the end of the 22nd week of gestation. The current study aimed to assess the prevalence of hyperemesis gravidarum and associated factors among pregnant women at comprehensive specialized hospitals in northwest Ethiopia. Methods: A multi-facility-based cross-sectional study was conducted at comprehensive specialized hospitals from 1st June 2022 to 30th July 2022. The data were entered using EPI Data Version 4.6 statistical software and analyzed using SPSS Version 26. Descriptive statistics such as frequency, mean, and percentage were calculated. Univariable and multivariable binary logistic regression analyses were carried out to identify the associated factors of hyperemesis gravidarum. Results: In all, 404 study participants were enrolled. About 16.8% of pregnant women were found to have hyperemesis gravidarum. Age < 20 year (AOR = 3.170; 95% CI: 1.119, 8.980), study participants who cannot read and write (AOR = 5.662; 95% CI: 2.036, 15.7470), grade 1-8 (AOR = 4.679; 95% CI: 1.778, 12.316), and grade 9-10 (AOR = 8.594; 95% CI: 3.017, 24.481), being housewife (AOR = 6.275; 95% CI: 1.052, 37.442), living in urban area (AOR = 2.185; 95% CI: 1.035, 4.609), having previous hyperemesis gravidarum (AOR = 2.463; 95% CI: 1.210, 5.012), having family history of hyperemesis gravidarum (AOR = 2.014; 95% CI: 1.002, 4.047), unplanned pregnancy (AOR = 2.934; 95% CI: 1.030, 8.351), having recent abortion (AOR = 2.750; 95% CI: 1.010, 7.483), and gravidity (AOR = 1.956; 95%CI: 1.023, 3.737) were factors associated with hyperemesis gravidarum. Conclusion: The prevalence of hyperemesis gravidarum is higher. Low maternal age, lower educational level, being a housewife, being an urban resident, having previous hyperemesis gravidarum, having a family history, having an unplanned pregnancy, and having a recent abortion were significantly associated with hyperemesis gravidarum.

Severe and rapidly changing hypophosphatemia in cannabinoid hyperemesis syndrome: a case report.

The increasing prevalence of cannabis worldwide requires awareness of a potential, less recognized, paradoxical entity, the cannabinoid hyperemesis syndrome (CHS). This includes cyclic episodes of nausea, vomiting, and compulsive hot water bathing for alleviation in individuals with chronic cannabis use. An 18-year-old male with daily and prolonged cannabis use has excessive nausea and vomiting, is diagnosed with CHS, and is further complicated by severe and rapidly fluctuating hypophosphatemia. He was successfully managed with intravenous (IV) antiemetic (metoclopramide) and IV normal saline in the emergency department. Hypophosphatemia was treated with IV phosphorous. Although hypophosphatemia in CHS is a rare encounter, the authors share their experience to promote broader recognition and insight into successful management.

Evaluation of controlling nutritional status (CONUT) score in the prognosis of hyperemesis gravidarum.

OBJECTIVE: To investigate the predictive value of the Controlling Nutritional Status (CONUT) score on hyperemesis gravidarum (HG) severity, hospitalization, and length of stay. MATERIALS AND METHODS: This retrospective cross-sectional study, conducted between December 2022 and June 2023, involved two groups. Group 1 comprised 52 pregnant women diagnosed with HG in the first trimester, receiving hospitalization and treatment. Group 2 included 105 pregnant women diagnosed with HG in the first trimester, managed and treated as outpatients. The CONUT score was calculated with the formula: Serum albumin score + total lymphocyte score + total cholesterol score. This score is calculated with a number of points between 0 and 12. The interpretation of the score involves four categories: normal (0-1), light (2-4), moderate (5-8), and severe (9-12). RESULTS: The CONUT score differed significantly between the hospitalized (4, IQR: 2.25-5) and outpatient groups (2, IQR: 2-3) (p < 0.001). A CONUT score >3 was associated with the need for hospitalization, demonstrating a sensitivity of 60%, a specificity of 84% (p < 0.001). The CONUT score was the parameter with the highest odds ratio (OR) value among the parameters related to the need for hospitalization, and each unit increase in the CONUT score increased the need for hospitalization by 1.683 times [OR = 1.683 (95% CI: 1.042-2.718), p = 0.033]. A positive correlation was found between the CONUT score and the duration of hospital stay (r = 0.316, p = 0.023). CONCLUSIONS: This study suggests CONUT score as a valuable tool for predicting HG severity, hospitalization need, and duration of hospital stay.

The effect of educational intervention on the quality of life of women suffering from pregnancy-related nausea and vomiting: a systematic review.

OBJECTIVE: The present study aimed to determine the influence of educational interventions on improving the quality of life (QOL) of women suffering from pregnancy-related nausea and vomiting (NVP) as a systematic review. METHODS: The current systematic review followed the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guideline. The English electronic databases were used to identify relevant studies published 2000 until 14 August 2023. The search strategies employed were based on Mesh browser keywords and free-text words. The study risk of bias was evaluated using the Cochrane Collaboration's tool for assessing the risk of bias tools and publication bias was evaluated using a funnel plot and Begg and Egger tests. The heterogeneity of the studies was evaluated using I2 and tau-squared tests. Data were analyzed using the RevMan 5 software. Results of the random-effects meta-analysis were presented using the standard mean difference, along with a 95% confidence interval (CI). RESULTS: Out of the seven randomized clinical/control trial (RCT) studies with a total of 946 subjects included in the review, five studies reported a significant result, indicating that the interventions had a statistically significant effect on the QOL of women suffering NVP and in two studies did not have a significant result. A subgroup analysis was done based on the type of quality-of-life measurements. The pooled standardized mean difference (SMD) of four articles (Nausea and Vomiting Pregnancy Quality of Life, NVPQOL) with a total of 335 subjects was -2.91, and CI of -4.72 to -1.11, p value = .002, I2 = 97.2%. The pooled SMD of three articles (SF36) with a total of 611 subjects was -0.05, and CI of -0.23 to -0.12, p value = .550, I2 = 10%. CONCLUSIONS: The overall results of the analysis indicated that educational intervention had a small positive impact on the QOL of women experiencing NVP. However, to draw a better conclusion, it is recommended to conduct further studies with larger sample sizes and longer follow-up periods.

"Navigating in a maze without a map". Partners' experiences of hyperemesis gravidarum- a qualitative study.

OBJECTIVE: A supportive environment for women with Hyperemesis Gravidarum is crucial but not always provided. There is a lack of research regarding Hyperemesis Gravidarum, its impact on the family, and the partner's perception of supporting their spouse. Thus, this study aims to explore partners' experiences of Hyperemesis Gravidarum during their spousés pregnancy. METHODS: Data were gathered through 13 individual, semi-structured, in-depth, digital interviews with partners of women who had experienced Hyperemesis Gravidarum and analysed with Qualitative Content Analysis. The partners were recruited through advertisement on a social media platform and were exclusively males, representing 8 of 21 Swedish regions. The mean age was 34, and they had, on average, 1 previous child. The mean time from the experience to the interview was 12 months. FINDINGS: The main theme, "Navigating in a maze without a map", explains partners' situation as stressful and demanding when their spouse suffers from Hyperemesis Gravidarum, with insufficient support and guidance from healthcare providers. The analysis resulted in three themes: "Standing alone with a demanding responsibility", "Being in a lottery when facing healthcare", and "Climbing the mountain together." The themes display challenges within everyday life and healthcare, as well as strained relations within the family. CONCLUSION: Partners experience a need to support their spouse in every aspect of daily life and advocate for adequate healthcare. Healthcare professionals must support and acknowledge the partners' struggles during the demanding situation with Hyperemesis Gravidarum.

Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.

The fourth Society for Academic Emergency Medicine (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) is on the topic of the emergency department (ED) management of nonopioid use disorders and focuses on alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS). The SAEM GRACE-4 Writing Team, composed of emergency physicians and experts in addiction medicine and patients with lived experience, applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding six priority questions for adult ED patients with AWS, AUD, and CHS. The SAEM GRACE-4 Writing Team reached the following recommendations: (1) in adult ED patients (over the age of 18) with moderate to severe AWS who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone [low to very low certainty of evidence]; (2) in adult ED patients (over the age of 18) with AUD who desire alcohol cessation, we suggest a prescription for one anticraving medication [very low certainty of evidence]; (2a) in adult ED patients (over the age of 18) with AUD, we suggest naltrexone (compared to no prescription) to prevent return to heavy drinking [low certainty of evidence]; (2b) in adult ED patients (over the age of 18) with AUD and contraindications to naltrexone, we suggest acamprosate (compared to no prescription) to prevent return to heavy drinking and/or to reduce heavy drinking [low certainty of evidence]; (2c) in adult ED patients (over the age of 18) with AUD, we suggest gabapentin (compared to no prescription) for the management of AUD to reduce heavy drinking days and improve alcohol withdrawal symptoms [very low certainty of evidence]; (3a) in adult ED patients (over the age of 18) presenting to the ED with CHS we suggest the use of haloperidol or droperidol (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence]; and (3b) in adult ED patients (over the age of 18) presenting to the ED with CHS, we also suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence].

Hyperemesis gravidarum theories dispelled by recent research: a paradigm change for better care and outcomes.

Nausea and vomiting (NVP) affect most pregnant women. At the severe end of the clinical spectrum, hyperemesis gravidarum (HG) can be life-threatening. The condition is fraught with misconceptions that have slowed progress and left women undertreated. Herein, recent scientific advances are presented that dispel common myths associated with HG related to maternal/offspring outcomes, etiology, and evolution. There is now strong evidence that (i) HG is associated with poor outcomes, (ii) a common cause of NVP and HG has been identified, and (iii) NVP is likely a protective evolutionary mechanism that occurs throughout the animal kingdom but is no longer necessary for human survival. Therefore, it is encouraging that we are finally on the cusp of testing treatments that may put an end to unnecessary suffering.

Cyclic vomiting syndrome: Future clinical and research priorities for: Special supplement/proceedings of 3rd international symposium.

BACKGROUND: An increasing number of studies have explored the clinical features, epidemiology, pathophysiology, and management of cyclic vomiting syndrome (CVS). CVS is common in adults and children and negatively impacts patients, families, and the healthcare system. A related condition, cannabinoid hyperemesis syndrome (CHS), has been a focus of interest in the lay press and published literature. PURPOSE: Clinical presentations of CVS have been defined by small series and expert opinion, but recent prospective studies are refining our understanding of the spectrum of emetic episodes and the breadth of comorbid conditions. Large cross-sectional population analyses are clarifying CVS prevalence and factors related to age, ethnicity, and geographic region. CVS pathophysiology is multifactorial with contributions from migraines, dysautonomia, endogenous cannabinoids, mitochondrial dysfunction, genetic abnormalities, and rapid gastric emptying. CVS treatment relies on antiemetics and antimigraine therapies to abort acute episodes coupled with prophylactic regimens employing neuromodulators and antiepileptics. CHS represents a challenge partly because of difficulties in achieving sustained cannabis abstinence. Benefits of other therapies in CHS remain poorly defined. Several areas warrant further scrutiny including better identification of CVS triggers and characterization of different CVS subsets including those with frequent severe episodes, refined description of epidemiology to allow targeting of populations predisposed to CVS development, rigorous definition of pathogenic factors to provide a foundation for exploratory studies of novel therapies, and conduct of controlled trials by multicenter collaborations to confirm benefits of existing and new therapies in development. Progress in these areas will be facilitated by generous governmental and industry support.

The Response of Osmotic Demyelination Syndrome to Plasmapheresis in a Patient Presenting with Catatonia after Correction of Hyponatraemia in Hyperemesis Gravidarum.

Osmotic demyelination syndrome (ODS) is a disorder characterised by the widespread development of demyelination in both pontine and extrapontine regions. It has been recognised as a complication arising from the rapid correction of hyponatraemia. This study presents the case of a 20-year-old Thai female patient at 10 weeks gestation, exhibiting an initial presentation of catatonia - an uncommon manifestation of ODS. The patient developed symptoms following the rapid correction of hyponatraemia in the context of hyperemesis gravidarum. Magnetic resonance imaging (MRI) of the brain revealed a trident or bat-wing-shaped pattern in T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences at the central pons. The patient underwent five cycles of plasmapheresis and received rehabilitation, leading to clinical improvement. LEARNING POINTS: Osmotic demyelination syndrome (ODS) is a rare but potentially devastating neurological complication, such as catatonia, resulting from the correction of hyponatraemia.Pregnancies complicated by hyperemesis gravidarum tend to exhibit hyponatraemia and hypokalaemia, which serve as contributing risk factors for ODS.Plasmapheresis is considered as an option in the treatment of ODS for the removal of inflammatory substances.

Causal association between gut microbiota and hyperemesis gravidarum: a two-sample Mendelian randomization study.

Background: Observational studies have reported an association between the gut microbiota (GM) and hyperemesis gravidarum (HG). However, the causal relationship is unclear. In this study, Mendelian randomization (MR) was used to infer causal relationships between GM and HG. Methods: Inverse-variance weighted MR was performed using summary statistics for genetic variants from genome-wide association studies (GWAS). Sensitivity analyses were performed to validate the MR results and assess the robustness of the causal inference. Reverse MR analysis was performed for bacterial taxa that were causally linked to the HG risk in the forward MR analysis to evaluate reverse causality. Results: MR analysis revealed that the genera Defluviitaleaceae UCG011, Ruminococcus1, Ruminococcus2, Turicibacter, and unknowngenus and phylum Verrucomicrobiota are positively associated with the risk of HG. Additionally, the genus Coprococcus2 was related to a decreased risk of HG. Sensitivity studies validated the strength and reliability of the link between the composition of the GM and HG. No evidence for reverse causality from HG to identified bacterial taxa was found. Conclusion: Our MR analysis provided novel insight into the association between GM and HG. In particular, our results indicated that targeting the GM could serve as an effective therapeutic strategy for HG.