Iatrogenic Cushing syndrome following lumbar medial branch block in a patient with HIV on ritonavir and darunavir

2021 ◽  
Author(s):  
Abhinav Mohan ◽  
Steven Tijmes ◽  
Jackson Cohen ◽  
Elizabeth M Sherman ◽  
Paula Eckardt
Keyword(s):  
Protease Inhibitor ◽  
Cushing Syndrome ◽  
Enzyme Inhibitor ◽  
Medial Branch ◽  
Nerve Blocks ◽  
Medial Branch Block ◽  
Cyp3a4 Enzyme ◽  
Anxiety Depression ◽  
Acute Anxiety

We present a case report of a 62-year old female with HIV and chronic facetogenic back pain who underwent bilateral L3–L4 and L4–L5 medial branch nerve blocks using triamcinolone acetonide 80 mg. 2 weeks later she presented to the emergency department with acute anxiety/depression and was discharged with psychiatric follow-up. 2 weeks after this she presented to the outpatient HIV clinic with persistent uncontrolled depression alongside classic cushingoid features (e.g., buffalo hump, moon facies). She was diagnosed with iatrogenic Cushing syndrome caused by a drug–drug interaction between triamcinolone and ritonavir, a protease inhibitor and a CYP3A4 enzyme inhibitor. While the literature describes the interaction of ritonavir with intra-articular/intranasal/epidural triamcinolone, this is the first documented occurrence following a nerve block procedure. Symptoms resolved within 6 months alongside discontinuation of protease inhibitor therapy.

scholarly journals Iatrogenic Cushing Syndrome in a 47-Year-Old HIV-Positive Woman on Ritonavir and Inhaled Budesonide

2017 ◽  
Vol 16 (6) ◽  
pp. 531-534 ◽  
Author(s):  
Lily Colpitts ◽  
Thomas B. Murray ◽  
Sami G. Tahhan ◽  
Jody P. Boggs
Keyword(s):  
Cushing Syndrome ◽  
Enzyme Inhibitor ◽  
Early Recognition ◽  
Alternative Therapy ◽  
Hiv Positive ◽  
Impaired Metabolism ◽  
Cyp3a4 Enzyme ◽  
Inhaled Budesonide ◽  
Hiv Lipodystrophy ◽  
Systemic Accumulation

Iatrogenic Cushing syndrome (CS) is a well-known complication of treating patients with systemic steroids. More rarely, it has been described in HIV-positive patients on ritonavir (RTV) while using the inhaled corticosteroid fluticasone, which is metabolized through the cytochrome P450 3A4 (CYP3A4) enzyme system. In the presence of RTV, a known CYP3A4 enzyme inhibitor, the interaction can result in impaired metabolism and systemic accumulation of inhaled fluticasone resulting in iatrogenic CS. Iatrogenic CS has been less often described with inhaled budesonide compared to inhaled fluticasone. Therefore, inhaled budesonide is often used as an alternative therapy for patients on RTV to avoid iatrogenic CS. We report the fifth case report of budesonide-induced iatrogenic CS in an HIV-positive patient on RTV. We highlight the importance of early recognition of the syndrome and distinguishing it from HIV lipodystrophy. Finally, we review the literature for cases of iatrogenic CS involving RTV and commonly used steroids.

The Benefit of Therapeutic Medial Branch Blocks after Cervical Operations

2010 ◽  
Vol 6;13 (6;12) ◽  
pp. 527-534
Author(s):  
Stephan Klessinger
Keyword(s):  
Cervical Spine ◽  
Neck Pain ◽  
Joint Pain ◽  
Facet Joint ◽  
Medial Branch ◽  
Level Of Evidence ◽  
Nerve Blocks ◽  
Medial Branch Block ◽  
Cervical Facet ◽  
Cervical Facet Joint

Background: Persistent neck pain is a common problem after surgery of the cervical spine. No therapy recommendation exists for these patients. Objectives: The objective of this study was to determine if a therapeutic medial branch block is a rational treatment for patients with postoperative neck pain after cervical spine operations. Study Design: Retrospective practice audit. Setting: Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 3 years. Methods: Patients with persistent postsurgical pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). A positive treatment response was defined if at least 80% reduction of pain could be achieved or if the patient was sufficiently satisfied with the relief. All patients with a minimum follow up time of 6 month were included. Results: Of the 312 operations performed, 128 were artificial disc operations, 125 were stand alone cages, and 59 were fusions with cage and plate. Persistent neck pain occurred in 33.3 % of the patients. There was no difference between the patients with neck pain and the whole group of patients. More than half of the patients with neck pain—52.9%—were treated successfully with therapeutic medial branch blocks. Since no further treatment was necessary, the initial treatment was considered successful. Nearly a third—32.2%—of the patients were initially treated successfully, but their pain recurred and further diagnostics and treatments were necessary. In this group of patients, significantly more with double level operations were found (P = 0.003). Patients not responding to the medial branch block were 14.9%. Limitations: This audit is retrospective and observational, and therefore does not represent a high level of evidence. However, to our knowledge, since this information has not been previously reported and no recommendation for the treatment of post-operative zygapophysial joint pain exists, it appears to be the best available research upon which to recommend treatment and to plan higher quality studies. Conclusions: For persistent postsurgical neck pain only limited therapy recommendations exist. This study suggests treating these patients in a first instance with therapeutic medial branch blocks. The success rate is 52.9 %. Key words: Chronic neck pain, cervical zygapophysial pain, cervical facet joint pain, medial branch blocks, therapeutical cervical facet joint nerve blocks, postsurgery syndrome, pain therapy Pain Physician

scholarly journals Polypill eligibility and equivalent intake in a Swiss population-based study

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Julien Castioni ◽  
Nazanin Abolhassani ◽  
Peter Vollenweider ◽  
Gérard Waeber ◽  
Pedro Marques-Vidal
Keyword(s):  
Enzyme Inhibitor ◽  
Large Fraction ◽  
Population Based ◽  
Cvd Risk ◽  
Population Based Study ◽  
Current Smoking ◽  
Swiss Population ◽  
Men Elderly ◽  
Multivariable Adjustment

AbstractThe polypill has been advocated for cardiovascular disease (CVD) management. The fraction of the population who could benefit from the polypill in Switzerland is unknown. Assess (1) the prevalence of subjects (a) eligible for the polypill and (b) already taking a polypill equivalent; and (2) the determinants of polypill intake in the first (2009–2012) and second follow-ups (2014–2017) of a population-based prospective study conducted in Lausanne, Switzerland. The first and the second follow-ups included 5038 and 4596 participants aged 40–80 years, respectively. Polypill eligibility was defined as having a high CVD risk as assessed by an absolute CVD risk ≥ 5% with the SCORE equation for Switzerland and/or presenting with CVD. Four polypill equivalents were defined: statin + any antihypertensive with (A) or without (B) aspirin; statin + calcium channel blocker (CCB) (C); and statin + CCB + angiotensin-converting enzyme inhibitor (D). The prevalence of polypill eligibility was 20.6% (95% CI 19.5–21.8) and 27.7% (26.5–29.1) in the first and second follow-up, respectively. However, only around one-third of the eligible 29.5% (95% CI 26.7–32.3) and 30.4% (27.9–33.0) respectively, already took the polypill equivalents. All polypill equivalents were more prevalent among men, elderly and in presence of CVD. After multivariable adjustment, in both periods, male gender was associated with taking polypill equivalent A (OR: 1.93; 95% CI 1.45–2.55 and OR: 1.67; 95% CI 1.27–2.19, respectively) and polypill equivalent B (OR: 1.52; 95% CI 1.17–1.96 and OR: 1.41; 95% CI 1.07–1.85, respectively). Similarly, in both periods, age over 70 years, compared to middle-age, was associated with taking polypill equivalent A (OR: 11.71; CI 6.74–20.33 and OR: 9.56; CI 4.13–22.13, respectively) and equivalent B (OR: 13.22; CI 7.27–24.07 and OR: 20.63; CI 6.51–56.36, respectively). Former or current smoking was also associated with a higher likelihood of taking polypill equivalent A in both periods. A large fraction of the population is eligible for the polypill, but only one-third of them actually benefits from an equivalent, and this proportion did not change over time.

scholarly journals Z-score neurofeedback, heart rate variability biofeedback, and brain coaching for older adults with memory concerns

2020 ◽  
pp. 1-29
Author(s):  
Kyle D. Meeuwsen ◽  
Kayleah M. Groeneveld ◽  
Linda A. Walker ◽  
Anna M. Mennenga ◽  
Rachel K. Tittle ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Boot Camp ◽  
Relative Power ◽  
Z Score ◽  
Subjective Memory Complaints ◽  
Subjective Memory ◽  
Memory Complaints ◽  
Anxiety Depression

Background: The three-month, multidomain Memory Boot Camp program incorporates z-score neurofeedback (NFB), heart rate variability (HRV) biofeedback, and one-on-one coaching to teach memory skills and encourage behavior change in diet, sleep, physical fitness, and stress reduction. Objective: This prospective trial evaluates the Memory Boot Camp program for adults ages 55 to 85 with symptoms of Mild Cognitive Impairment (MCI) and subjective memory complaints. Methods: Participants were evaluated via the Montreal Cognitive Assessment (MoCA), NeuroTrax Global Cognitive Index, measures of anxiety, depression, sleep, quality of life, quantitative electroencephalography (QEEG), and HRV parameters at four timepoints: baseline, pre-program, post-program, and follow-up. The trial included a three-month waiting period between baseline and pre-program, such that each participant acted as their own control, and follow-up took place six months after completion of the program. Results: Participants’ MoCA scores and self-reported measures of anxiety, depression, sleep quality, and quality of life improved after treatment, and these changes were maintained at follow-up. Physiological changes in HRV parameters after treatment were not significant, however, breathing rate and QEEG parameters were improved at post-program and maintained at follow-up. Finally, participants’ improvement in MoCA score over the treatment period was correlated with their improvement in two brain oscillation parameters targeted by the z-score NFB protocol: relative power of delta and relative power of theta. Conclusions: Trial results suggest that the Memory Boot Camp program is a promising treatment strategy for older adults with symptoms of MCI and subjective memory complaints.

scholarly journals A Low Level of Darunavir Resistance–Associated Mutation Emergence in Patients With Virological Failure During Long-term Use of Darunavir in People With HIV. The ANRS CO3 Aquitaine Cohort

2020 ◽  
Vol 7 (12) ◽  
Author(s):  
Hélène Chaussade ◽  
Camille Tumiotto ◽  
Fabien Le Marec ◽  
Olivier Leleux ◽  
Lucile Lefèvre ◽  
...  
Keyword(s):  
Protease Inhibitor ◽  
Virological Failure ◽  
Resistance Test ◽  
Resistance Testing ◽  
Factors Associated ◽  
Viral Loads ◽  
Hiv Resistance ◽  
Baseline Characteristics

Abstract Background Ritonavir-boosted darunavir (DRV/r) is a protease inhibitor (PI) indicated for the treatment of naïve and pretreated HIV-infected patients since 2007. Our study aims to describe DRV/r-treated patients experiencing virological failure (VF) documented with HIV resistance testing. Methods Data from patients belonging to the ANRS CO3 Aquitaine Cohort treated with a regimen including DRV/r between February 2007 and December 2015 were analyzed. Baseline characteristics of patients experiencing VF (defined by 2 consecutive plasma viral loads >50 copies/mL) were compared with those without VF. We then described factors associated with VF as emergence of IAS DRV resistance–associated mutations (RAMs). Results Among the 1458 patients treated at least once with a DRV/r-based regimen, 270 (18.5%) patients experienced VF during follow-up, including 240 with at least 1 genotype resistance test (GRT). DRV RAMs were detected in 29 patients (12%). Among them, 25/29 patients had ≥2 DRV RAMs before DRV/r initiation, all of whom had experienced VF during previous PI treatments. For 18/29, DRV/r was maintained after VF, and controlled viremia was restored after modification of DRV-associated antiretroviral molecules or increased DRV dose. Finally, only 6/29 patients selected new DRV RAMs after DRV/r initiation. All of these experienced previous VFs while on other PIs. Conclusions These results highlight the efficacy and robustness of DRV/r, as the emergence of DRV RAMs appeared in <0.4% of patients receiving a DRV/r-based regimen in our large cohort.

Comparison of Intra-articular Thoracic Facet Joint Steroid Injection and Thoracic Medial Branch Block for the Management of Thoracic Facet Joint Pain

Spine ◽  
2018 ◽  
Vol 43 (2) ◽  
pp. 76-80 ◽  
Author(s):  
Dong Gyu Lee ◽  
Sang Ho Ahn ◽  
Yun Woo Cho ◽  
Kyung Hee Do ◽  
Sang Gyu Kwak ◽  
...  
Keyword(s):  
Joint Pain ◽  
Facet Joint ◽  
Steroid Injection ◽  
Medial Branch ◽  
Medial Branch Block ◽  
Facet Joint Pain

Automated text messaging follow-up for patients who receive peripheral nerve blocks

2021 ◽  
pp. rapm-2021-102472
Author(s):  
Daniel Gessner ◽  
Oluwatobi O Hunter ◽  
Alex Kou ◽  
Edward R Mariano
Keyword(s):  
Regional Anesthesia ◽  
Nerve Block ◽  
Text Messaging ◽  
Low Cost ◽  
Automated System ◽  
Phone Call ◽  
Nerve Blocks ◽  
Patient Response ◽  
Patient Reported

BackgroundRoutine follow-up of patients who receive a nerve block for ambulatory surgery typically consists of a phone call from a regional anesthesia clinician. This process can be burdensome for both patients and clinicians but is necessary to assess the efficacy and complication rate of nerve blocks.MethodsWe present our experience developing an automated system for completing follow-up via short message service text messaging and our preliminary results using it at three clinical sites. The system is built on REDCap, a secure online research data capture platform developed by Vanderbilt University and currently available worldwide.ResultsOur automated system queried patients who received a variety of nerve block techniques, assessed patient-reported nerve block duration, and surveyed patients for potential complications. Patient response rate to text messaging averaged 91% (higher than our rates of daily phone contact reported previously) for patients aged 18 to 90 years.ConclusionsGiven the wide availability of REDCap, we believe this automated text messaging system can be implemented in a variety of health systems at low cost with minimal technical expertise and will improve both the consistency of patient follow-up and the service efficiency of regional anesthesia practices.

Cervical Medial Branch Block

2012 ◽  
Vol 37 (2) ◽  
pp. 219-223 ◽  
Author(s):  
Roderick J. Finlayson ◽  
Gaurav Gupta ◽  
Mohammed Alhujairi ◽  
Shubada Dugani ◽  
De Q.H. Tran
Keyword(s):  
Medial Branch ◽  
Medial Branch Block
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