Prevalence and Risk Factors of Distal Symmetric Polyneuropathy Among Predominantly Non-Hispanic Black, Low-Income Patients.

BACKGROUND AND OBJECTIVES: Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations. METHODS: Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97. RESULTS: Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001). DISCUSSION: DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.

Acute confusional state as a prognostic sign of COVID-19 large-vessel occlusion (LVO).

COVID-19 is well known for its respiratory symptoms, but severe presentations can alter haemostasis, causing acute end-organ damage with poor outcomes. Among its various neurological presentations, cerebrovascular events often present as small-vessel strokes. Although uncommon, in predisposed individuals, large-vessel occlusions (LVOs) can occur as a possible consequence of direct viral action (viral burden or antigenic structure) or virus-induced cytokine storm. Subtle presentations and complicated stroke care pathways continue to exist, delaying timely care. We present a unique case of COVID-19 LVO manifesting as an acute confusional state in an elderly man in April 2020. CT angiography revealed 'de novo' occlusions of the left internal carotid artery and proximal right vertebral artery, effectively blocking anterior and posterior circulations. Delirium can lead to inaccurate stroke scale assessments and prolong initiation of COVID-19 stroke care pathways. Future studies are needed to look into the temporal relationship between confusion and neurological manifestations.

Isolated myxoid degeneration of aortic valve: diagnostic dilemma.

Myxoid degeneration of the aortic valve as a cause of acute aortic valve regurgitation in young age is uncommon. We report a 39-year-old African-American man with a history of epilepsy and hypertension who presented with a 1-month history of worsening shortness of breath. He was diagnosed with acute pulmonary oedema. Transoesophageal echocardiogram showed normal ejection fraction but severe aortic valve insufficiency with small masses on the ventricular side of the right and non-coronary cusps, small vegetations cannot be ruled out but other valves were normal. Subsequent cultures were negative for endocarditis. Myocardial positron emission tomography (PET) scan was strongly suggestive of cardiac sarcoidosis. However, this diagnosis was ruled out as well when he underwent aortic valve replacement with bioprosthetic valve as he did not want to take long-term anticoagulation. Histological examination of the aortic valve showed myxoid degeneration. The patient was doing very well 1 year after the surgery.

Salmonella Typhimurium para-aortic root abscess managed non-surgically.

Introduction: Para-aortic root abscess is a destructive vascular condition that can result in significant morbidity and mortality. We describe a rare case of para-aortic root abscess due to Salmonella Typhimurium that was successfully managed medically. Presentation of case: A 72-year-old diabetic man with a prosthetic aortic graft presented with fever and expressive aphasia with left sided weakness. Magnetic resonance imaging (MRI) of the brain showed multiple embolic cerebral vascular accidents. Computed tomography angiography (CTA) of the chest showed a 5.7 × 2.7 cm (cm) para-aortic root abscess. Blood cultures grew Salmonella Typhimurium. The patient was started on ceftriaxone initially, and then ciprofloxacin was added on day 5. Given an unacceptably high risk of mortality expected with surgery, the patient was managed medically.After five months of both ceftriaxone and ciprofloxacin, ceftriaxone was stopped. Twelve months later, the patient is doing well on ciprofloxacin alone with a plan for lifelong suppression. Discussion: Cases of para-aortic root abscess due to Salmonella Typhimurium have not been reported in the literature. There are no guidelines to dictate the antibiotic choice or management of para-aortic root abscess due to Salmonella Typhimurium. Conclusion: This report adds to the body of literature regarding the treatment of this infection including successful non-surgical management.

Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital.

Background: Pulmonary embolism (PE) is a common disease in the USA responsible for up to 10% of hospital mortality. Modified wells score (MWS) and D-dimer assay are used to categorize patients into high or low probability of PE. Patient with high probability need Computed tomography pulmonary angiography (CTPA), while patients with low probability and low D-dimer can safely forgo the CTPA. Objectives: The aim of this study was to investigate the rate of inappropriate CTPA use in the emergency department of a community teaching hospital. Methods: A retrospective chart review of adult patients who underwent CTPA for suspected PE in the emergency department for 2015 was done. CTPA use was considered inappropriate if MWS was less than or equal to 4 and D-dimer was either not ordered or its value was less than 500 µg/L. Bivariate analysis with Fisher's exact tests and Student's t-tests as well as multivariate logistic regression analysis were done to examine relationship between study explanatory variables and study outcome. Results: 295 patients were included in the study. The mean age was 51.2(±14.5) years, 68.8% were females. The prevalence of PE was 5.4% and 41% of the CTPAs -were inappropriately ordered. Males were twice (OR 2.1; 95% CI 1.2, 3.6) as likely as females to have an inappropriately ordered CTPA after controlling for a high MWS, age, and tobacco history. Conclusion: CTPA is overused to diagnose PE in the emergency department. Quality improvement projects are needed to encourage physicians to adhere to the current guidelines.

Mycoplasma pneumoniae-associated Fuchs syndrome.

Fuchs syndrome is a milder form of the Stevens-Johnson syndrome (SJS) spectrum with only mucosal involvement which can be triggered by Mycoplasma pneumonia (MP) infection. Treatment should be directed toward supportive care including ocular and mucous membrane care, fluids and nutritional support, and pain control. In addition, antibiotic and immunomodulatory treatments are discussed for this entity.

Primary Idiopathic Osteoarthropathy: Could It Be Related to Alcoholism?

Background. Hypertrophic osteoarthropathy (HOA) is a syndrome characterized by abnormal proliferation of the skin and bony structures at the distal extremities resulting in digital clubbing, periosteal bony reaction, and joint effusion. It can be primary (idiopathic) without any clear identifiable etiology as well as secondary to variety of systemic diseases most notably lung pathology. Case Presentation. We describe a rare case of primary idiopathic osteoarthropathy in a male patient who presented with severe pain and tenderness in his legs. His history was significant for long standing alcoholism. Physical examination showed severe fingers and toes clubbing. He reported similar changes in his mother. Clinical and radiological findings were remarkable for distal leg tenderness and diffuse periosteal bony reactions, respectively. Computerized tomography scan failed to show any pathology apart from fatty liver infiltration. In the absence of obesity or diabetes, this was consistent with alcoholic steatosis. He was started on nonsteroidal anti-inflammatory drug which dramatically improved his symptoms. Conclusion. Primary hypertrophic osteoarthropathy should be considered in a previously healthy person presenting with bony pain and finger clubbing especially after ruling out the common secondary causes. Moreover, alteration of prostaglandin metabolism secondary to alcoholic consumption might be a contributing factor.