INTRODUCTION: Lumbosacral (LS) plexopathy can be difficult to diagnose as it is not commonly encountered in clinical practice. Disease severity is related to the underlying etiology however, progressive neurological deterioration is often seen if proper intervention is not executed promptly. LS plexopathy secondary to severe rhabdomyolysis has been reported in a small number of case reports. We present a rare case of LS plexopathy caused by severe rhabdomyolysis following concurrent use of kratom, cocaine, and heroin. CASE PRESENTATION:A 25 year old male with a history of schizophrenia presented to the emergency department (ED) after experiencing numbness and tingling in his lower extremities following cocaine, heroin and kratom use the day prior. On presentation, the patient became increasingly lethargic and sustained a cardiac arrest while in the ED. CPR was performed for 9 minutes before ROSC was achieved. Labs were remarkable for potassium of 8, BUN 35, creatinine 4.03, and creatine kinase of >100,000 consistent with rhabdomyolysis. The patient was also found to have compartment syndrome of his left lower extremity requiring emergent fasciotomy. He was admitted to the medical intensive care unit where he remained intubated and underwent hemodialysis for acute renal failure. On day 4 of admission, the patient was successfully liberated from the ventilator. At this point, flaccid paralysis and loss of sensation of his bilateral lower extremities were noted on exam. Work up including CT and MRI of the spine were significant for severe paraspinal edema and myonecrosis consistent with rhabdomyolysis. EMG of the lower extremities revealed mild chronic partial denervation with abnormal spontaneous activity in the proximal and distal right leg muscles. Oral Prednisone was initiated with improvement in the patient's lower extremity paralysis after five days of therapy. The patient completed a three week steroid taper with continued improvement in his exam. He was discharged to rehab. At one month follow-up, he showed near complete resolution of his neurologic deficits. DISCUSSION:The LS plexus includes a network of nerves that are formed by the anterior rami of the lumbar and sacral spinal cord which supply the lower back, pelvis and legs. LS plexopathy often presents with lower back and lower extremity weakness, pain, paresthesias, numbness and tingling. LS plexopathy is typically caused by trauma, diabetes, neoplasms and pregnancy. Complications of LS plexopathy may include progressive neurological deterioration, intractable pain, recurrent infections, joint contracture and bedsores.CONCLUSIONS: LS plexopathy secondary to severe rhabdomyolysis is rare, described in only a few case reports. Treatment often relies on addressing the underlying etiology and should be geared towards preventing further nerve damage as LS plexopathy can cause significant detriment to the quality of life of a patient.
The COVID-19 pandemic has caused mass disruption to our daily lives. Mobility restrictions implemented to reduce the spread of COVID-19 have impacted walking behavior, but the magnitude and spatio-temporal aspects of these changes have yet to be explored. Walking is the most common form of physical activity and non-motorized transport, and so has an important role in our health and economy. Understanding how COVID-19 response measures have affected walking behavior of populations and distinct subgroups is paramount to help devise strategies to prevent the potential health and societal impacts of declining walking levels. In this study, we integrated mobility data from mobile devices and area-level data to study the walking patterns of 1.62 million anonymous users in 10 metropolitan areas in the United States (US). The data covers the period from mid-February 2020 (pre-lockdown) to late June 2020 (easing of lockdown restrictions). We detected when users were walking, measured distance walked and time of the walk, and classified each walk as recreational or utilitarian. Our results revealed dramatic declines in walking, especially utilitarian walking, while recreational walking has recovered and even surpassed the levels before the pandemic. However, our findings demonstrated important social patterns, widening existing inequalities in walking behavior across socio-demographic groups. COVID-19 response measures had a larger impact on walking behavior for those from low-income areas, of low education, and high use of public transportation. Provision of equal opportunities to support walking could be key to opening up our society and the economy.
BackgroundStudies suggest that COVID-19 infection may induce increased hypercoagulability, leading to thrombotic complications. The high rates of thrombotic complications among patients receiving standard-dose deep venous thrombosis (DVT) prophylaxis have prompted some clinicians to support the empiric increase of anticoagulation (AC) doses used for prophylaxis in patients with COVID-19. At present, the optimal anticoagulant agents, dosages, and duration have not been designated. We conducted a retrospective study to assess for outcomes in patients who received treatment for COVID-19 based on various dosings of AC. MethodsThis was a single-institution, retrospective cross-sectional study including patients with a positive COVID-19 test who were admitted within the St. Joseph's Health Network from September to November of 2020. The inclusion criteria were men and women aged 18 years or older who had confirmed COVID-19 by polymerase chain reaction (PCR). Medical charts of patients who met the inclusion criteria were audited to obtain information. The patients were separated into three cohorts: those who received DVT prophylactic dose of AC, those who received an intermediate dose of AC, and those who received therapeutic AC. ResultsA total of 440 patients were included in the study, of whom 236 were Hispanic (50.3%), 131 were Caucasian (27.1%), 47 were African American (10.7%), and 26 were Asian (5.9%). The most common comorbidities were hypertension (273/440 [62.2%]), diabetes 189/440 [43.1%]), and coronary artery disease (60/440 [13.7%]). In the DVT prophylactic dose of AC cohort, there were 215 patients, and the average length of stay was 10.3 days. Eleven patients experienced bleeding events, five patients experienced thrombotic events, 16 patients required mechanical ventilation, and 20 patients died. In the intermediate dose of AC cohort, there were 63 patients, and the average length of stay was 10.3 days. Three patients experienced bleeding events, two patients experienced thrombotic events, seven patients required mechanical invasive ventilation, and 11 patients died. In the therapeutic dose of AC cohort, there were 162 patients, and the average length of stay was 14 days. In this cohort, 19 patients experienced bleeding events, 12 patients experienced thrombotic events, 26 patients required invasive mechanical ventilation, and 29 patients died. Patients who received intermediate dosing of AC also had the lowest risk of thrombotic events (0.05). Patients who received intermediate dosing of AC had the lowest rates of requiring both high-flow nasal cannula (p = 0.0001) and invasive mechanical ventilation (p = 0.031). Patients who received intermediate dosing of AC had a lower rate of bleeding compared to those who received the DVT prophylaxis dose and systemic AC dose (p = 0.037). The DVT prophylactic and intermediate dosing of AC groups had a shorter length of stay in comparison to the systemic AC group (p = 0.0002). ConclusionIn comparison to the venous thromboembolism prophylaxis dose and systemic AC dose...
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