Bilateral anterior and posterior scleritis in a patient with acute myelogenous leukemia.

Purpose: To report a novel case of bilateral anterior and posterior scleritis in a patient with acute myelogenous leukemia (AML). Observations: A 69-year-old African American man was admitted to the hospital for relapse of AML. After admission, but prior to induction of chemotherapy, the patient developed ocular redness and proptosis. The diagnosis of bilateral anterior and posterior scleritis was made following an ophthalmic examination, infectious and autoimmune lab work-up, and neuroimaging. The patient was administered immunosuppressive therapy, clinically monitored, and initiated on chemotherapy for AML relapse. About one week later, the patient showed clinical improvement and resolution of the scleritis and proptosis. Conclusion: Scleritis may present during AML relapse, and it may be due to a paraneoplastic syndrome or a reactive anti-leukemic inflammatory response. Clinicians should monitor patients with AML relapse for symptoms such as ocular redness, proptosis, pain, photophobia, and decreased vision, which may indicate development of scleritis.

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates.

BACKGROUND: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes. PURPOSE: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers. METHODS: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated. RESULTS: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions. CONCLUSIONS: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.

Term Singleton Vertex Cesarean Birth Rates in the Military Health System.

Cesarean births have increased in the United States, accounting for approximately one-third of all births. There is concern that cesarean birth is overused, due to the wide variation in rates geographically and at different institutions within the same region. Despite the rising rate, there has not been an improvement in maternal or neonatal outcomes. Consequently, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine published recommendations aimed at the safe prevention of primary cesarean births in 2014. The purpose of this project was to identify the term singleton vertex cesarean birth rates in the Military Health System's hospitals; to compare the Military Health System's rate of term singleton vertex cesarean birth to published benchmarks; and to compare term singleton vertex cesarean birth rates over time and among facilities within the Military Health System to determine whether variation existed. This was a retrospective review of aggregate data reported by the National Perinatal Information Center. Data were analyzed over 9 years at 2-year intervals from 2011 through 2019 inclusively. The Military Health System exceeded national benchmarks for term singleton vertex cesarean birth rates and had less variation over time and among facilities.

Wernicke's encephalopathy mimicking multiple sclerosis in a young female patient post-bariatric gastric sleeve surgery.

We describe a case of Wernicke's encephalopathy secondary to thiamine (B1) deficiency in a patient status post-bariatric sleeve gastrectomy. The presenting symptoms of new-onset weakness, diplopia, and confusion in a young female patient raised suspicion for multiple sclerosis (MS), but given a history of bariatric surgery, thiamine levels were checked, revealing significant Vitamin B1 (thiamine) deficiency. This case highlights the importance of thorough history taking, as a misdiagnosis of MS in this case could have resulted in irreversible neurological deterioration and hematological and infectious consequences associated with the inappropriate administration of disease-modifying therapies. It is also important to note that severe vitamin deficiency occurred despite medication compliance.

Clinical and neurohormonal characteristics in African Americans with neurogenic orthostatic hypotension.

PURPOSE: Neurogenic orthostatic hypotension (nOH) is the hallmark of neurodegenerative forms of autonomic failure, including pure autonomic failure, multiple system atrophy, and Parkinson's disease. Studies have shown autonomic physiological differences in Africans Americans (AA) such as lower heart rate variability, enhanced blood pressure reactivity, and blunted sympathetic neural response compared to non-Hispanic whites. However, the clinical characteristics and neurohormonal profile of autonomic failure in AA is unknown. METHODS: A total of 65 patients with nOH participated in this study (9 AA and 56 non-Hispanic whites). Both groups were of similar age and comorbidity status, and they underwent standardized autonomic testing and assessment of neurohormonal levels and renin activity and aldosterone in supine and upright positions. RESULTS: There were no significant differences in baseline autonomic clinical characteristics between non-Hispanic whites and AA with nOH. Non-Hispanic whites demonstrated a significant increase in upright renin activity compared to AA (295 ± 88% vs. 13 ± 13%, respectively). AA showed a blunted increase in aldosterone compared to non-Hispanic whites (188 ± 27% vs. 59 ± 38%, respectively). These results indicated persistent suppression of the renin-angiotensin system in AA, particularly during upright posture. CONCLUSION: Our findings demonstrate that AA with nOH have similar clinical characteristics and hemodynamic autonomic profiles, but lower upright renin activity and aldosterone levels, compared to non-Hispanic whites. Renin suppression persists in AA with severe autonomic failure and can potentially contribute to postural changes and supine hypertension.

Morbidity and mortality in orthostatic hypotension.

This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as neurogenic OH (nOH); these two conditions have distinct pathophysiologies and affect different patient populations. The prevalence of OH in the elderly varies depending on the study population. In community dwellers, OH prevalence is estimated at 16%, whereas in institutionalized patients, it may be as high as 60%. The prevalence of OH increases exponentially with age, particularly in those 75 years and older. Multiple epidemiological studies have identified OH as a risk factor for all-cause mortality and cardiovascular disease including heart failure and stroke. Real-world data from administrative databases found polypharmacy, multiple co-morbid conditions, and high health-care utilization as common characteristics in OH patients. A comprehensive evaluation of medications associated with OH is discussed with particular emphasis on the use of anti-hypertensive therapy from two large clinical trials on high-intensive versus standard blood pressure management. Finally, we also review the epidemiology of nOH based on the underlying neurodegenerative disorder (either Parkinson's disease or multiple system atrophy), and the presence of co-morbid conditions such as hypertension and cognitive impairment.

Race and sex differences in cardiovascular autonomic regulation.

Racial and ethnic differences in cardiovascular morbidity and mortality persist despite advances in risk factor identification and implementation of evidence-based treatment strategies. African American men and women are disproportionately affected by cardiovascular risk factors, particularly hypertension. In this context, previous studies have identified sex and racial differences in autonomic cardiovascular regulation which may contribute to the development of hypertension and its high morbidity burden among African Americans. In this review, we provide a comprehensive evaluation of the potential pathophysiological mechanisms of blood pressure control and their differences based on sex and race. These mechanisms include obesity-induced sympathetic activation, sympatho-vascular transduction, baroreflex sensitivity and adrenoreceptor vascular sensitivity, which have been the subjects of prior investigation in this field. Understanding the racial differences in the pathophysiology of hypertension and its co-morbid conditions would allow us to implement better treatment strategies tailored to African Americans, with the ultimate goal of reducing cardiovascular mortality in this population.

Leaving half the population behind-the continued fight to cover America's mothers: a call to action.

For the last century, healthcare coverage in the United States has been a debated topic. The passage of the Social Security Act Amendments and the Patient Protection and Affordable Care Act has improved the available coverage of vulnerable populations, but access to healthcare is still fraught with barriers. This is particularly true for women in the postpartum period. It is widely accepted that the postpartum period is the optimal time to address health issues that developed during pregnancy or predated pregnancy. With more than half of maternal deaths occurring in the year after a birth and disproportionately affecting women of color, the postpartum time period is critical. The United States is the only industrialized country with a rising maternal mortality rate and therefore must take advantage of the 12 months postpartum, or "fourth trimester," to aid in addressing this national health crisis. As an incentivized provision, most states have expanded Medicaid since the signing of the Patient Protection and Affordable Care Act. However, pregnancy-related coverage still ceases after 60 days postpartum. Although states can apply for a waiver to extend this coverage, this process is unnecessarily laborious. The time has far passed for the federal government to act. Presently, there are numerous pieces of legislation before Congress to provide Medicaid coverage for pregnant patients through 365 days postpartum. Insurance coverage alone will not reverse the rising maternal mortality rate in this country, but it is a crucial first step.

Behaviors Associated with Internet Use in Military Medical Students and Residents.

INTRODUCTION: Problematic use of video games, social media, and Internet-related activities may be associated with sleep deprivation and poor work performance. The Internet Addiction Test was given to military medical and nursing students and housestaff to assess problematic Internet use. METHODS: Medical and nursing students at the Uniformed Services University of the Health Sciences and residents from Naval Medical Center San Diego were contacted via email (n = 1,000) and given a survey that included the Internet Addiction Test (IAT) and questions asking about other specific lifestyle variables. Individuals who received an Internet Addiction Score (IAS) ≥50 were identified as likely experiencing harmful effects of Internet addiction (IA). RESULTS: Of 399 surveys submitted, 68 were omitted due to gross incompletion or failing to finish the entirety of the IAT. Of the participants included, 205 (61.1%) were male and 125 (37.9%) were female. The mean age was 28.6 years old (S.D. = 5.1 years). In regards to training status, completed surveys were assessed for 94 medical residents, 221 School of Medicine students, and 16 Graduate School of Nursing students. Our survey showed 5.5% of the participants (n = 18) indicated problems with Internet use that are concerning for IA. CONCLUSIONS: The study results indicated that our population showed problematic Internet use in the lower range of global estimates of IA. Rates of IA further decreased between medical students and residents. Multiple lifestyle variables were significantly associated with IA score and may serve as indicators of a higher score. Interestingly, the use of social media during sleeping hours was most significantly associated with increased IAS. This paper discusses IA among military medical and nursing trainees and how problematic Internet use may affect work performance and force readiness.

Relation of Body Mass Index to Symptom Burden in Patients withAtrial Fibrillation.

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and increased mortality. As body mass index (BMI) is increasingly recognized as an important risk factor for the development of AF, we tested the hypothesis that BMI modulates symptomatic AF burden. Cross-sectional data collected from 1,382 patients in the Vanderbilt AF Registry were analyzed. AF severity was assessed using the Toronto atrial fibrillation severity scale (AFSS). BMI was categorized according to World Health Organization guidelines and patients were grouped according to their present AF treatment regimen: no treatment (n = 185), rate control therapy with atrioventricular nodal blocking agents (n = 351), rhythm control with antiarrhythmic drugs (n = 636), and previous AF ablation (n = 210). Patients with BMI >35 kg/m2 had higher AFSS scores than those with BMI <30 kg/m2 in the rate control (43.57 vs 38.21: p = 0.0057), rhythm control (46.61 vs 41.08: p = 1.6 × 10-4), and ablation (44.01 vs 39.02: p = 0.047) groups. Inunivariate linear models, BMI was associated with an increase in the AFSS score in the rate control (0.27, 95% confidence interval [CI] 0.05 to 0.5, p = 0.02), rhythm control (0.38, 95% CI 0.21 to 0.56, p = 2.49 × 10-5), and ablation (0.38, 95% CI 0.03 to 0.73, p = 0.03) groups. The association remained significant in the rhythm control groups after adjusting for age, gender, race, and comorbidities (0.29, 95% CI 0.11 to 0.49, p = 0.002). In conclusion, increasing BMI was directly associated with patient reported measures of AF symptom severity, burden, and quality of life. This was most significant in patients treated with rhythm-control strategies.

Autoimmune Progesterone Dermatitis Mistaken for Stevens-Johnson Syndrome.

BACKGROUND: Autoimmune progesterone dermatitis is an uncommon disease presenting with cyclical skin eruptions corresponding with the menstrual cycle luteal phase. Because symptoms are precipitated by rising progesterone levels, treatment relies on hormone suppression. CASE: A 22-year-old nulligravid woman presented with symptoms mistaken for Stevens-Johnson syndrome. A cyclic recurrence of symptoms occurred, and the diagnosis of autoimmune progesterone dermatitis was made by an intradermal progesterone challenge. After 48 months, her disease remained refractory to medical management, and definitive surgical treatment with bilateral oophorectomy was performed. CONCLUSIONS: Autoimmune progesterone dermatitis is a challenging diagnosis as a result of its rarity and variety of clinical presentations. Treatment centers on suppression of endogenous progesterone and avoidance of exogenous triggers. When these modalities fail, surgical management must be undertaken.

Sex- and Gamete-Specific Patterns of X Chromosome Segregation in a Trioecious Nematode.

Three key steps in meiosis allow diploid organisms to produce haploid gametes: (1) homologous chromosomes (homologs) pair and undergo crossovers; (2) homologs segregate to opposite poles; and (3) sister chromatids segregate to opposite poles. The XX/XO sex determination system found in many nematodes [1] facilitates the study of meiosis because variation is easily recognized [2-4]. Here we show that meiotic segregation of X chromosomes in the trioecious nematode Auanema rhodensis [5] varies according to sex (hermaphrodite, female, or male) and type of gametogenesis (oogenesis or spermatogenesis). In this species, XO males exclusively produce X-bearing sperm [6, 7]. The unpaired X precociously separates into sister chromatids, which co-segregate with the autosome set to generate a functional haplo-X sperm. The other set of autosomes is discarded into a residual body. Here we explore the X chromosome behavior in female and hermaphrodite meioses. Whereas X chromosomes segregate following the canonical pattern during XX female oogenesis to yield haplo-X oocytes, during XX hermaphrodite oogenesis they segregate to the first polar body to yield nullo-X oocytes. Thus, crosses between XX hermaphrodites and males yield exclusively male progeny. During hermaphrodite spermatogenesis, the sister chromatids of the X chromosomes separate during meiosis I, and homologous X chromatids segregate to the functional sperm to create diplo-X sperm. Given these intra-species, intra-individual, and intra-gametogenesis variations in the meiotic program, A. rhodensis is an ideal model for studying the plasticity of meiosis and how it can be modulated.

Non-pulmonary vein mediated atrial fibrillation: A novel sub-phenotype.

BACKGROUND: Atrial fibrillation (AF) is a mechanistically heterogeneous disorder, and the ability to identify sub-phenotypes ("endophenotypes") of AF would assist in the delivery of personalized medicine. We used the clinical response to pulmonary vein isolation (PVI) to identify a sub-group of patients with non-PV mediated AF and sought to define the clinical associations. METHODS: Subjects enrolled in the Vanderbilt AF Ablation Registry who underwent a repeat AF ablation due to arrhythmia recurrence were analyzed on the basis of PV reconnection. Subjects who had no PV reconnection were defined as "non-PV mediated AF". A comparison group of subjects were identified who had AF that was treated with PVI-only and experienced no arrhythmia recurrence >12 months. They were considered a group enriched for "PV-mediated AF". Univariate and multivariable binary logistic regression analysis was performed to investigate clinical associations between the PV and non-PV mediated AF groups. RESULTS: Two hundred and twenty nine subjects underwent repeat AF ablation and thirty three (14%) had no PV reconnection. They were compared with 91 subjects identified as having PV-mediated AF. Subjects with non-PV mediated AF were older (64 years [IQR 60,71] vs. 60 [52,67], P = 0.01), more likely to have non-paroxysmal AF (82% [N = 27] vs. 35% [N = 32], P<0.001), and had a larger left atrium (LA) (4.2cm [3.6,4.8] vs. 4.0 [3.3,4.4], P = 0.04). In univariate analysis, age (per decade: OR 1.56 [95% CI: 1.04 to 2.33], P = 0.03), LA size (per cm: OR 1.8 [1.06 to 3.21], P = 0.03) and non-paroxysmal AF (OR 8.3 [3.10 to 22.19], P<0.001) were all significantly associated with non-PV mediated AF. However, in multivariable analysis only non-paroxysmal AF was independently associated with non-PV mediated AF (OR 7.47 [95% CI 2.62 to 21.29], P<0.001), when adjusted for age (per decade: OR 1.25 [0.81 to 1.94], P = 0.31), male gender (OR 0.48 [0.18 to 1.28], P = 0.14), and LA size (per 1cm: 1.24 [0.65 to 2.33], P = 0.52). CONCLUSIONS: Non-paroxysmal AF was the only clinical variable found to be independently associated with non-PV mediated AF. We demonstrated that analysis of AF ablation outcomes data can serve as a tool to successfully identify a sub-phenotype of subjects who have non-PV mediated AF. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov ID # NCT02404415.