First report of a patient meeting criteria for both multisystem inflammatory syndrome in children and adult onset Still's disease.

BACKGROUND: COVID-19 is associated with a postinfectious hyperinflammatory disorder, multisystem inflammatory syndrome in children (MIS-C), that shares characteristics with still's disease, known as systemic juvenile idiopathic arthritis (SJIA) in children younger than 16, and adult onset Still's disease (AOSD) in children 16 and older. Both MIS-C and SJIA/AOSD can be complicated by macrophage activation syndrome (MAS), a potentially fatal condition of cytokine storm. CASE PRESENTATION: We present a 16 year-old male who developed quotidian fever, headache, conjunctival injection, sore throat, nausea and vomiting, diarrhea, rash, and symmetrical polyarticular arthralgia/arthritis 4 weeks after exposure to SARS-CoV-2 and 2 weeks after his first vaccination against COVID-19. Our patient's laboratory results were significant for elevated inflammatory markers and acute phase reactants. He met criteria for diagnosis with both MIS-C and AOSD. After receiving first-line treatment for both diseases, IVIG and methylprednisolone, our patient improved. CONCLUSION: MAS is a life-threatening rheumatological emergency, and physicians must be able to identify diseases, like MIS-C and AOSD, that may be complicated by MAS. Our patient's distinguishing feature on presentation was symmetrical polyarticular arthralgia/arthritis, which has not been associated with MIS-C. Simultaneously, AOSD-which is associated with polyarticular arthralgia/arthritis-is only now being recognized as a possible post-infectious entity in the aftermath of COVID-19 infection. In patients like our own, who meet criteria for both MIS-C and AOSD, administering first line treatment for both diseases may be best practice.

Wernicke's encephalopathy and cranial nerve VII palsy in a 24-year-old patient with COVID-19.

BACKGROUND: Many documented secondary neurologic manifestations are associated with COVID-19, including mild peripheral and central nervous system disorders (such as hypo/anosmia, hypo/ageusia, and cranial nerve VII palsy) and severe problems (such as ischemic stroke, Guillain-Barré syndrome, and encephalitis). The list is growing. A new addition is non-alcohol Wernicke's encephalopathy. CASE PRESENTATION: We present the case of a 24-year-old male with no past medical history who developed stroke-like symptoms two days after testing positive for COVID-19. MRI of his brain showed T2 FLAIR hyperintensity in the splenium of the corpus collosum, mamillary bodies, periaqueductal gray matter, tectum, and ventral and dorsal medulla, an MRI signal concerning for non-alcohol Wernicke's encephalopathy. Our patient had no risk factors for Wernicke's encephalopathy. He was admitted and started on thiamine for Wernicke's encephalopathy and steroids for his cranial VII nerve palsy. Both his symptoms and imaging improved. He was discharged on oral thiamine. Follow-up in the Neurology Clinic has confirmed his continued stable state. CONCLUSIONS: This case is one of three documented cases of Wernicke's encephalopathy believed to be caused by COVID-19 in patients without risk factors or chronic alcohol use. Ours is also the first case in which Wernicke's encephalopathy presents with a concomitant cranial nerve VII palsy. While Emergency Medicine doctors must maintain a high index of suspicion for stroke in younger patients with COVID-19, our patient's case augments the correlation between COVID-19 and Wernicke's encephalopathy in patients without other risk factors for developing the syndrome.

Nontransient third-degree heart block and persistent respiratory findings as sequelae of acute occupational exposure to pyrethroids insecticide.

We present the case of a worker with occupational exposure to a pyrethroid insecticide who acutely developed nontransient third-degree heart block. In 2000, a 57-year-old male truck driver on his delivery route was accidentally exposed to pyrethroid insecticide being sprayed for West Nile virus containment. Both the driver and his vehicle were coated with the spray. The exposure was prolonged because he did not change his clothes until after his shift ended and he used the same contaminated truck for a week. Within days, he presented with a third-degree heart block, for which he was emergently treated, and a pacemaker was placed. He had no past history of arrhythmias. In the weeks thereafter, he also developed reactive airway dysfunction syndrome (RADS). In the second decade following the exposure, the patient replaced his pacemaker, confirming the permanent nature of his heart block. In addition to the persistence of his exposure-related RADS, he developed restrictive lung disease and was diagnosed with pulmonary interstitial fibrosis in the absence of established risk factors. The patient died in October 2019 from respiratory illness. Most previous reports of pyrethroid-related disorders are limited to acute exposures, in which transient symptoms predominate. To our knowledge, this is the first report of an exposed worker experiencing permanent third-degree heart block, as well as persistent respiratory findings, as possible short- and long-term sequelae of pyrethroid exposure.

Mesothelioma Associated With the Use of Cosmetic Talc.

OBJECTIVE: To describe 33 cases of malignant mesothelioma among individuals with no known asbestos exposure other than cosmetic talcum powder. METHODS: Cases were referred for medico-legal evaluation, and tissue digestions were performed in some cases. Tissue digestion for the six cases described was done according to standard methodology. RESULTS: Asbestos of the type found in talcum powder was found in all six cases evaluated. Talcum powder usage was the only source of asbestos for all 33 cases. CONCLUSIONS: Exposure to asbestos-contaminated talcum powders can cause mesothelioma. Clinicians should elicit a history of talcum powder usage in all patients presenting with mesothelioma.

"A PCMH mind and a PCMH heart": Patient, faculty, and learner perspectives on collaborative care in an interprofessional team-based training programme.

RATIONALE, AIMS, AND OBJECTIVES: Providing high-quality primary care in patient-centred medical homes (PCMHa) requires competencies that can only be provided by interprofessional (IP) education. The benefits of collaborative training have been documented for learners, but less is known about the perceptions of the clinical professionals who train the learners or the patients receiving IP primary care. This investigation compared stakeholder attitudes about IP education, training, and providing collaborative care prior to developing a new IP training programme. METHODS: We conducted five focus groups at a large general internal medicine training practice. Learner and faculty groups included participants from medicine, psychology, pharmacy, and physician assistant professions; three patient groups were held to obtain perspectives on receiving health care from IP trainees. We used inductive analysis to identify themes across the three stakeholder groups. RESULTS: We identified seven convergent themes across all three stakeholder groups: (a) team engagement, (b) technology in care delivery, (c) cost of care, (d) involving patients in learning, (e) time constraints, (f) scope of practice, and (g) autonomy/interdependence. Each group emphasized the need to define and communicate team members' roles. Learners anticipated high-quality IP interactions, and patients noted the benefits of receiving care from well-supervised trainees. Faculty struggled to navigate the training needs of diverse learner groups and to integrate PCMH mandates focused on documentation with authentic patient-centred care. CONCLUSIONS: This is the first reported data comparing perceptions about IP training and care across these three stakeholder groups. Results suggest the need to clarify scope of practice, define professional roles, and bridge gaps between teaching PCMH principles and subsequently providing high-quality health care. Results inform faculty development needs in learning ways to train learners across professions and outline ways to structure interactions with patients.