A 32-year-old multigravida woman, with known familial hypokalaemic periodic paralysis, underwent spinal anaesthesia for an elective lower segment caesarean section. There are several case reports in the literature discussing the optimal anaesthetic technique. In the past there has not been an emphasis on aggressive and early potassium replacement. A target level to commence replacement of potassium at 4.0 mmol/L or less is proposed. Careful preoperative preparation, frequent perioperative monitoring and early potassium replacement resulted in no perioperative episodes of weakness in this case, in contrast with other case reports where potassium was either not monitored or not replaced early enough, resulting in postoperative attacks. Another factor to consider in hypokalaemic periodic paralysis is the avoidance of triggers, including certain medications. Misoprostol was used in this instance to avoid potential electrolyte derangements from other uterotonics.

Localized bullous pemphigoid (LBP) is an infrequent bullous pemphigoid (BP) variant restricted to a body region. According to the most compelling evidence, LBP occurs in patients with pre-existent serum antibodies against the basement membrane zone, which occasionally acquire the capacity to induce disease after the influence of different local factors acting as triggers.
We hereby present a multicenter cohort of 7 patients with LBP developed after local triggers: radiotherapy, thermal burns, surgery, rosacea, edema and a paretic leg. In addition, we conducted a review of the literature, and we propose a set of diagnostic criteria for LBP, also based on our case series and the 2022 BP guidelines from the European Academy of Dermatology and Venereology.
During follow-up, three of the patients from our series evolved to a generalized BP, with only one requiring hospitalization. Our literature search retrieved 47 articles including a total of 108 patients with LBP, with a 63% with a potential local precipitating factor previous to their diagnosis. LBP mostly affected older females, and a subsequent generalized progression occurred in 16.7% of the cases. The most frequently involved areas were the lower limbs. Radiation therapy and surgery were responsible for the inducement of nearly 2 in 3 cases of LBP. We observed a significantly higher risk of generalization in cases where the trigger led to the developing of LBP earlier (p=0.016). Our statistical analysis did not detect any other prognosis factor for generalization when assessing direct immunofluorescence, histological and serological results, or other patient related factors.
LBP should be suspected in patients with recurrent localized bullous eruptions. The presence of a trauma history in the same anatomic area is reported in most cases.

Ulcerative colitis is a chronic inflammatory bowel condition. One of the theories for its etiopathogenesis is gastrointestinal infections. Although COVID-19 primarily affects the respiratory tract, gastrointestinal involvement is also common. We have reported a case of a 28-year-old male who presented with bloody diarrhea, diagnosed with acute severe ulcerative colitis, triggered by COVID-19 infection after known triggers were excluded.

OBJECTIVE: To describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values.
METHODS: We present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP).
RESULTS: Five sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the \'Surprise Question\'), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning-based analytical approaches.
CONCLUSIONS: Involving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients-those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.

BACKGROUND: Acute myocardial infarction (AMI) is one of the most preventable non-communicable diseases in human. Identifying triggers of myocardial infarction (MI) and prevention ways of exposure-induced complications can reduce morbidity and mortality in people at risk.
OBJECTIVE: The aim of this study was to identify the emotional, environmental, physical and chemical dimensions of acute triggers in patients with AMI.
METHODS: This case-crossover study was conducted on 269 patients with AMI, hospitalized at two remedial centers in Rasht in 2015. The study samples were selected by convenient sampling method. Data were collected using researcher-made questionnaire through interviews. Hazard and control periods for each trigger and its effects on the development of MI were studied. The collected data were analyzed using descriptive and analytical statistical methods, Cochran test, and generalized estimating equation (GEE) model with logistics function default in SPSS version 21, and p < 0.05 was considered statistically significant.
RESULTS: The results showed that quarrel (P = 0.008, OR = 2.01) and hearing the sudden news (P = 0.001, OR = 2.19) were the most common emotional triggers. Respiratory infections (P = 0.0001, OR = 6.78) and exposure to hot or cold weather (P = 0.005, OR = 2.19) were the most frequent environmental triggers. Doing heavy activities (P = 0.005, OR = 1.66) and sexual activities (P = 0.003, OR = 2.36) were among the most common physical triggers. High-fat foods consumption and overeating (P = 0.0001, OR = 3.79) were the most frequent chemical triggers of AMI.
CONCLUSIONS: It seems that given the importance of the triggers in the incidence of AMI, planning is necessary to train vulnerable individuals to reduce exposure to triggers.

The use of specific triggers has been suggested to help identify patients with progressive neurological disease who would benefit from palliative care.
This study aimed to improve the evidence base for the use of triggers for patients with progressive neurological disease.
An evaluation of palliative care services was undertaken using a retrospective case note review of the timing and presence of triggers in the last 2 years of life.
A total of 12 specialist palliative care units across the United Kingdom provided data from 300 patients: mean patient age 70 years, 50% male, diagnoses included motor neurone disease 58%, Parkinson\'s disease 17% and Parkinson\'s Plus syndromes 12%.
There was a high burden of triggers - 17 in the last 2 years of life and 10 in the last 6 months of life. The most frequent triggers were deteriorating physical function, complex symptoms and dysphagia. Four factors were found to explain 64% of the total variance: Factor 1 - Deterioration in physical function, dysphagia, significant complex symptoms and pain; Factor 2 - Weight loss and respiratory symptoms; Factor 3 - Recurrent infections and cognitive decline; Factor 4 - Aspiration pneumonia. Cox regression analyses found different triggers were associated with survival from diagnosis versus survival from referral to palliative care. Different triggers were also associated with survival for different neurological conditions.
This study demonstrates that there is a high burden of triggers in the last months and years of life and that these could potentially be reduced to fewer components. Prospective studies assessing which triggers are useful for different conditions are now required.

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is a clinico-radiologic syndrome characterized by thunderclap headache and reversible multifocal arterial constrictions that resolves within 3 months. RCVS can be either spontaneous or related to a trigger; vasoactive drugs including over-the-counter medicine are common culprits. Nevertheless, there are sparse data on the association of herbal supplements in the genesis of unexplained RCVS.
METHODS: We describe a case of RCVS with a temporal association with the consumption of a diet pill composed of green tea, L-carnitine, and conjugated linoleic acid. We reviewed the literature describing RCVS cases associated with consumption of herbal supplements or plants.
RESULTS: A 50-year-old black woman presented at the emergency room with a thunderclap headache less than 1 week after beginning a new herbal supplement with weight loss purpose. Angiographic study revealed multiple arterial constriction of virtually all intracranial territories that were reversed 28 days later. The patient was discharged with minimal symptoms. From our review, we identified 5 previous reports of herbal product-related triggers.
CONCLUSIONS: Different factors can trigger RCVS. Besides our case, at least 5 other nutraceutical products were described to be associated with the disorders, 3 of them in patients without any other clear cause. Clinicians should be aware of the possible role of herbal supplements in RCVS, and their use should be systematically assessed in large RCVS cohorts to clarify this association.

A previous study has shown that transient physical and psychosocial activities increased the risk of developing low back pain. However, the link between these factors in triggering nonpersistent or persistent episodes remains unclear.
We aimed to investigate the association of transient exposures to physical and psychosocial activities with the development of nonpersistent or persistent low back pain.
This was a case-crossover study with 12 months follow-up.
We included 999 consecutive participants seeking care for a sudden onset of low back pain.
Development of low back pain was the outcome measure.
At baseline, participants reported transient exposures to 12 predefined activities over the 4 days preceding pain onset. After 12 months, participants were asked whether they had recovered and the date of recovery. Exposures in the 2-hour period preceding pain onset (case window) were compared with the 2-hour period, 24 hours before pain onset (control window) in a case-crossover design for all participants. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CI), and interaction analyses were used to compare estimates of nonpersistent (i.e., <6 weeks duration) and persistent cases. This study received funding from Australia\'s National Health and Medical Research Council (APP1003608).
There were 832 participants (83%) who completed the 12 months follow-up successfully. Of these, 430 participants had nonpersistent low back pain (<6 weeks duration), whereas 352 reported persistent symptoms (≥6 weeks duration). Exposure to several transient activities, such as manual tasks involving heavy loads, awkward postures, live people or animals, moderate or vigorous physical activity, and being fatigued or tired during a task or activity, significantly increased the risk of both nonpersistent and persistent low back pain, with ORs ranging from 2.9 to 11.7. Overall, the risk of developing a persistent or a nonpersistent episode of low back pain associated with the included physical factors did not differ significantly.
Our results revealed that previously identified triggers contribute equally to the development of both nonpersistent and persistent low back pain. Future prevention strategies should focus on controlling exposure to these triggers as they have the potential to decrease the burden associated with both acute and chronic low back pain.

OBJECTIVE: Although beer and liquor have been associated with risk of incident gout, wine has not. Yet anecdotally, wine is thought to trigger gout attacks. Further, how much alcohol intake is needed to increase the risk of gout attack is not known. We examined the quantity and type of alcohol consumed on risk of recurrent gout attacks.
METHODS: We conducted a prospective Internet-based case-crossover study in the US among participants with gout and who had at least one attack during the 1 year of follow-up. We evaluated the association of alcohol intake over the prior 24 hours as well as the type of alcoholic beverage with risk of recurrent gout attack, adjusting for potential time-varying confounders.
RESULTS: This study included 724 participants with gout (78% men, mean age 54 years). There was a significant dose-response relationship between amount of alcohol consumption and risk of recurrent gout attacks (P <.001 for trend). The risk of recurrent gout attack was 1.36 (95% confidence interval [CI], 1.00-1.88) and 1.51 (95% CI, 1.09-2.09) times higher for >1-2 and >2-4 alcoholic beverages, respectively, compared with no alcohol consumption in the prior 24 hours. Consuming wine, beer, or liquor was each associated with an increased risk of gout attack.
CONCLUSIONS: Episodic alcohol consumption, regardless of type of alcoholic beverage, was associated with an increased risk of recurrent gout attacks, including potentially with moderate amounts. Individuals with gout should limit alcohol intake of all types to reduce the risk of recurrent gout attacks.

BACKGROUND: Isolated neuralgic pain in the deep ear may arise from either nervus intermedius (NIN) or glossopharyngeal (GPN) neuralgias. Current International Headache Society (IHS) International Classification of Headache Disorders, second edition (ICHD-2) criteria for these cranial neuralgias require the presence of a characteristic trigger.
OBJECTIVE: The aim of this article is to report cases of triggerless neuralgic otalgia to better understand a subset of patients for whom there may be diagnostic uncertainty.
METHODS: Methods included an observational cohort series and systematic literature review.
RESULTS: We identified five female patients with a median age at symptom onset of 58 (range: 47 to 73). Our patients generally experienced an excellent clinical response to carbamazepine. Patients were contacted by telephone at a median follow-up duration of seven years (range: four to 32) from symptom onset, at which time carbamazepine-free remissions were reported by five of five (100%) of the patients. A systematic review of the literature on neuralgic otalgia led us to conclude that NIN was most common among young women (age < 50), and GPN across a wider range of ages of either gender. Among surgically validated cases reported in the literature, triggers were frequently absent in NIN, and variably noted in GPN.
CONCLUSIONS: We conclude that the presence of a trigger is not fundamental, and may be impractical, to the diagnosis of neuralgic otalgia, but remains important for specificity between NIN and GPN.