Long term temporal trends in synoptic-scale weather conditions favoring significant tornado occurrence over the central United States.

We perform a statistical climatological study of the synoptic- to meso-scale weather conditions favoring significant tornado occurrence to empirically investigate the existence of long term temporal trends. To identify environments that favor tornadoes, we apply an empirical orthogonal function (EOF) analysis to temperature, relative humidity, and winds from the Modern-Era Retrospective analysis for Research and Applications Version 2 (MERRA-2) dataset. We consider MERRA-2 data and tornado data from 1980 to 2017 over four adjacent study regions that span the Central, Midwestern, and Southeastern United States. To identify which EOFs are related to significant tornado occurrence, we fit two separate groups of logistic regression models. The first group (LEOF models) estimates the probability of occurrence of a significant tornado day (EF2-EF5) within each region. The second group (IEOF models) classifies the intensity of tornadic days either as strong (EF3-EF5) or weak (EF1-EF2). When compared to approaches using proxies such as convective available potential energy, our EOF approach is advantageous for two main reasons: first, the EOF approach allows for the discovery of important synoptic- to mesoscale variables previously not considered in the tornado science literature; second, proxy-based analyses may not capture important aspects of three-dimensional atmospheric conditions represented by the EOFs. Indeed, one of our main novel findings is the importance of a stratospheric forcing mode on occurrence of significant tornadoes. Other important novel findings are the existence of long-term temporal trends in the stratospheric forcing mode, in a dry line mode, and in an ageostrophic circulation mode related to the jet stream configuration. A relative risk analysis also indicates that changes in stratospheric forcings are partially or completely offsetting increased tornado risk associated with the dry line mode, except in the eastern Midwest region where tornado risk is increasing.

Bilateral adrenal hemorrhage in a man with severe COVID-19 pneumonia.

This case report demonstrates bilateral adrenal hemorrhage in a fifty-year old man with severe COVID-19 pneumonia. We discuss how adrenal hemorrhage can be one of the possible complications of COVID-19. The case also shows how adrenal hemorrhage can be diagnosed incidentally in a scan performed for a different reason given the difficulty of clinical diagnosis and the non-specific clinical presentation.

Drug-Induced Acute Pancreatitis in Adults: An Update.

Drug-induced acute pancreatitis (DIAP) is a rare entity that is often challenging for clinicians. The aim of our study was to provide updated DIAP classes considering the updated definition of acute pancreatitis (AP) and in light of new medications and new case reports. A MEDLINE search (1950-2018) of the English language literature was performed looking for all adult (≥17 years old) human case reports with medication/drug induced as the cause of AP. The included case reports were required to provide the name of the drug, and diagnosis of AP must have been strictly established based on the revised Atlanta Classification criteria. A total of 183 medications were found to be implicated in 577 DIAP cases. A total of 78 cases were excluded because of minimal details or lack of definite diagnosis of AP. Drug-induced AP is rare, and most drugs cause mild DIAP. Only 2 drugs are well described in the literature to explain causation rather than association (azathioprine and didanosine). Larger case-control studies and a formal standardized DIAP reporting system are essential to study the true potential of the DIAP-implicated drugs described in this review.

Hypertriglyceridemia-Associated Drug-Induced Acute Pancreatitis.

OBJECTIVES: The aim of our study was to investigate the cases of drug-induced acute pancreatitis (DIAP) with hypertriglyceridemia as the mechanism of injury. METHODS: A MEDLINE search (1963-2018) of the English language literature was performed looking for all human case reports of adults (>18 years old) with hypertriglyceridemia as the mechanism of DIAP. The latest search date was February 28, 2018. Drugs were classified into probability groups based on a classification used by Badalov et al (Clin Gastroenterol Hepatol. 2007;5:648-661). RESULTS: The search revealed a total of 76 cases in 59 published reports. A total of 25 medications were found to be implicated in DIAP secondary to hypertriglyceridemia mechanism. Most of acute pancreatitis cases were mild or moderately severe with favorable outcomes. In 3 cases involving tamoxifen, pagaspargase, and quetiapine, patient death was the outcome. Plasmapheresis was only used in 9 cases in an effort to decrease triglyceride levels. CONCLUSIONS: Hypertriglyceridemia-associated DIAP is a rare phenomenon, and the current systematic review provides a summary of drugs that have been implicated in this phenomenon, which allow physicians to be oriented about this adverse effect when these drugs are used.

Defining a glycated haemoglobin (HbA1c) level that predicts increased risk of penile implant infection.

OBJECTIVES: To re-evaluate the role of diabetes mellitus (DM) as a risk factor for penile implant infection by exploring the association between glycated haemoglobin (HbA1c) levels and penile implant infection rates and to define a threshold value that predicts implant infection. PATIENTS AND METHODS: We conducted a multicentre prospective study including all patients undergoing penile implant surgery between 2009 and 2015. Preoperative, perioperative and postoperative management were identical for the entire cohort. Univariate analysis was performed to define predictors of implant infection. The HbA1c levels were analysed as continuous variables and sequential analysis was conducted using 0.5% increments to define a threshold level predicting implant infection. Multivariable analysis was performed with the following factors entered in the model: DM, HbA1C level, patient age, implant type, number of vascular risk factors (VRFs), presence of Peyronie's disease (PD), body mass index (BMI), and surgeon volume. A receiver operating characteristic (ROC) curve was generated to define the optimal HbA1C threshold for infection prediction. RESULTS: In all, 902 implant procedures were performed over the study period. The mean patient age was 56.6 years. The mean HbA1c level was 8.0%, with 81% of men having a HbA1c level of >6%. In all, 685 (76%) implants were malleable and 217 (24%) were inflatable devices; 302 (33.5%) patients also had a diagnosis of PD. The overall infection rate was 8.9% (80/902). Patients who had implant infection had significantly higher mean HbA1c levels, 9.5% vs 7.8% (P < 0.001). Grouping the cases by HbA1c level, we found infection rates were: 1.3% with HbA1c level of <6.5%, 1.5% for 6.5-7.5%, 6.5% for 7.6-8.5%, 14.7% for 8.6-9.5%, 22.4% for >9.5% (P < 0.001). Patient age, implant type, and number of VRFs were not predictive. Predictors defined on multivariable analysis were: PD, high BMI, and high HbA1c level, whilst a high-volume surgeon had a protective effect and was associated with a reduced infection risk. Using ROC analysis, we determined that a HbA1c threshold level of 8.5% predicted infection with a sensitivity of 80% and a specificity of 65%. CONCLUSION: Uncontrolled DM is associated with increased risk of infection after penile implant surgery. The risk is directly related to the HbA1c level. A threshold HbA1c level of 8.5% is suggested for clinical use to identify patients at increased infection risk.

Acute Disseminated Histoplasmosis with Atypical Lymphocytosis in an Immunocompetent Host.

65 year-old-male presented with a one-week history of high grade fever, fatigue and confusion which began abruptly two days after a cystoscopy procedure. Past medical history included pulmonary sarcoidosis diagnosed by mediastinal lymph biopsy, diabetes and hypertension. On admission he was febrile and confused with stable vital signs. Initial workup included negative Head CT and lumbar puncture. Blood work revealed normal metabolic and liver function tests with progressive anemia, thrombocytopenia and atypical lymphocytosis of 15-20%. Blood, urine and respiratory cultures all were negative for bacteria and. A bone marrow biopsy was done given the abnormal lymphocytes in peripheral smear, revealing budding yeast consistent with Histoplasma capsulatum. Histoplasma antigen was positive in urine and eventually blood and bone marrow grew H. capsulatum. Patient was started on amphotericin-B for diagnosis of disseminated histoplasmosis. After a 2 week period of amphotericin B, patient was switched to oral Itraconazole to complete 12 months course of treatment.

Conservative Therapy is an Effective Option in Patients With Localized Infection After Penile Implant Surgery.

INTRODUCTION: Traditionally, penile implant (PI) infections have been managed by removal with immediate or delayed replacement. Recently, interest has been focused on conservative therapy (CT) using antibiotic therapy. AIM: To investigate the success rate and predictive factors affecting the outcome of CT in PI infection patients. METHODS: Patients diagnosed with early, localized PI infection were considered candidates for CT. Exclusion criteria included temperature >37.5°C, WBC >13,000/µL, and appearance of any sign of sepsis. In patients with purulent drainage, culture swabs were taken and an antibiotic was chosen based on sensitivity results. Oral antibiotics were used until the local infection was completely resolved. Patients were evaluated weekly during this process. RESULTS: Thirty-seven patients were retrospectively reviewed and constituted the study population. Mean age was 58.1 (range 37-85; SD 9.9) years. All were diabetic. Mean BMI was 31.8 (range 24-47; SD 5.0). PI was malleable in 33 cases and inflatable in 4 cases. Culture results (n = 19) included Staphylococcus epidermidis (42 %), pseudomonas (21%), Escherichia coli (21%), and S aureus (16%). Four of 37 patients needed the PI removed due to CT failure and onset of systemic symptoms, at a mean time-point of 75 ± 1.8 days after CT commencement. In men who were cured, mean time to complete healing was 49 (range 29-97; SD 15.8) days. Two of 37 patients (5%) had PI removal because of persistent penile pain despite complete wound healing, at a mean time point of 128 ± 2.5 days after CT commencement. All men managed conservatively resumed sexual intercourse. CONCLUSION: CT of localized PI infection appears to be a viable option for such patients, with the majority of patients retaining their implant and resuming sexual activity.

Analysis of the Interobserver Variability in Penile Length Assessment.

INTRODUCTION: Many men seek penile augmentation treatments-a standard tool for their counseling is to inform them of what is "normal." Although some studies suggest good correlation between stretched and erect penile length, those that have measured stretched and erect length simultaneously have shown significant variability. AIM: To assess the accuracy of differing penile measurements with multiple observers. METHODS: We recruited 201 adult men (mean age 49.6 years) who achieved full erection using intracavernosal injection. MAIN OUTCOME MEASURES: Penile measurements were taken by one of seven andrology specialists in a private, temperature-controlled (21°C, 72°F) environment. Stretched flaccid and erect length and circumference were measured. We analyzed the accuracy of each flaccid measurement using the erect measurements as a reference, for the overall patient population and for each observer. RESULTS: The mean underestimate of length from stretched flaccid to erect was 2.64 cm (21.4%) and girth 2.27 cm (19.5%). Interobserver variability ranged from a mean underestimate of 16-27% (length) and 15-27% (girth). CONCLUSIONS: In this large, multicenter, multi-observer study of penis size, flaccid measurements underestimated erect size. It also seems likely that there is significant interobserver variability. We believe erect penis measurements should be used for men being considered for treatment of small penis anxiety.