Classic IgA-Vasculitis With Nephrotic Range Proteinuria - Rare Presentation in an Adult.

IgA vasculitis formerly known as Henoch-Schonlein Purpura is characterized by leukocytoclastic vasculitis and IgA immune complex in small vessels of the affected organ. IgA vasculitis can involve any organ system depending upon the deposition of the IgA immune complex. IgA vasculitis is a clinical diagnosis which manifest with abdominal pain, arthralgia/arthritis, palpable purpura, and kidney involvement. Occasionally, serum IgA levels or skin or kidney biopsy can help in confirming the diagnosis. Treatment is usually supportive, but studies have proved that prednisone or immunosuppressive agents can help in the prevention or progression of the disease. Hereby we present a case of 54-year-old Caucasian male who developed classic tetrad findings of IgA vasculitis most likely after receiving monkeypox vaccine which patient received three weeks prior to presentation to the hospital. Kidney involvement was present but surprisingly proteinuria was above nephrotic range making it as a rare presentation of IgA vasculitis.

Indian traditional rice variety "Gathuwan" suppresses T-cell-mediated immune responses via activation of ERK/Nrf2/HO-1 signalling pathway.

The impact of food on immune functions has been recognized for centuries and is now being increasingly explored for therapeutic applications. Rice, in addition to being the staple food in most developing countries, exhibits diverse complexities of phytochemicals among its wide germplasm repertoire, which supports its development as a functional food. In the present study, we have explored the immunomodulatory properties of Gathuwan rice, a local rice variety grown in Chhattisgarh, India, and traditionally used for the treatment of rheumatism. Methanolic Gathuwan Brown Rice Extract (BRE) inhibits T-cell activation and proliferation and cytokine secretion (IL-2, IL-4, IL-6 and IFN-γ) without inducing cell death. BRE exhibits radical scavenging activity in a cell-free system and decreases intracellular reactive oxygen species (ROS) and glutathione levels in lymphocytes. BRE induces nuclear translocation of the immune-regulatory transcription factor Nrf2 via activation of ERK and p-38 MAP kinase and up-regulates the expression of Nrf2-dependent genes (SOD, CAT, HO-1, GPx and TrxR) in lymphocytes. BRE treatment had no effect on cytokine secretion by lymphocytes from Nrf2 knockout mice, confirming the role of Nrf2 in the immunosuppressive effects of BRE. Feeding of Gathuwan brown rice to mice had no effect on the basal haematological parameters, but lymphocytes isolated from these mice were hypo-responsive to mitogenic stimuli. Treatment of allografts with BRE significantly prevented graft-versus-host disease (GVHD)-associated mortality and morbidity in mice. Metabolic pathway enrichment analysis of ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) data revealed a high enrichment ratio of amino acid and vitamin B metabolism pathways, and among metabolite sets, pyridoxamines, phytosphingosines, hydroxybenzaldehydes, hydroxycinnamic acids and indoles were highly enriched bioactive components. In conclusion, Gathuwan BRE suppresses T-cell-mediated immune responses by altering the cellular redox balance and activating the Nrf2 signalling pathway.

Sub-acute Painless Vision Loss Secondary to Neuro-Ocular Syphilis.

There has been a consistent increase in syphilis cases in the United States over the past two decades. The prevalence of neuro-ocular involvement in syphilis is rare; however, with the increase in the prevalence of syphilis in the United States, more frequent encounters with complications of syphilis may be expected. Here, we present a case of sub-acute painless vision loss secondary to neuro-ocular syphilis.

Adenoid squamous cell carcinoma of buccal mucosa - A rare case report.

Adenoid squamous cell carcinoma is a rare variant of squamous cell carcinoma. It is mainly reported in the sun-exposed areas of the head and neck. In literature, adenoid variants of squamous cell carcinoma are reported in the lip and tongue. Documented cases of buccal mucosa are very few. In this case report, we describe an adenoid variant of squamous cell carcinoma, which is an unusual presentation of a rare carcinoma.

Safety Profile of Mutant EGFR-TK Inhibitors in Advanced Non-Small Cell Lung Cancer: A Meta-analysis.

Background: Despite the use of platinum-based chemotherapy, lung cancer continues to be the leading cause of cancer-related death in the world. To overcome the rate of lung cancer-related death, scientists discovered advanced therapies, including mutant epidermal growth factor receptor-tyrosine kinase (EGFR-TK) inhibitors. Observations: We conducted a meta-analysis to determine the safety profile of mutant EGFR-TK inhibitors in the management of advanced non-small cell lung cancer (NSCLC). Included in this study are 9 phase 3 randomized controlled trials designed to study the safety profile of mutant EGFR-TK inhibitors in patients with advanced NSCLC. The study showed that mutant EGFR-TK inhibitors have an incidence of adverse effects that is less reported when compared with platinum-based chemotherapy. Conclusions: We recommend continuing using mutant EGFR-TK inhibitors in patients with advanced NSCLC especially in patients having mutant EGFR receptors. Adverse effects caused by mutant EGFR-TK inhibitors are significant but are usually tolerable and can be avoided by reducing the dosage of it with each cycle or by skipping or delaying the dose until patient is symptomatic.

Anomalous dielectric response in the triple perovskite ruthenate Ba3BiRu2O9.

We have investigated the magnetic, dielectric and thermal properties of theSRu= 1 magnetic dimer Ba3BiRu2O9, which is known to exhibit a spin-gap opening in conjunction with a first-order magneto-elastic phase transition at ∼175 K. Above the spin-gap temperature, the temperature dependence dielectric constant shows a peak like feature with pronounced frequency dependence. The critical slowing down behavior of this frequency dispersion suggests that a ferroelectric relaxor like electrical glassy state exists above the spin-gap opening temperature regime. The extermination of frequency dispersion-right at the magneto-elastic phase transition, is suggestive of a strong coupling between the lattice and charge-spin degrees of freedom in this triple perovskite system.

Understanding complex genetic architecture of rice grain weight through QTL-meta analysis and candidate gene identification.

Quantitative trait loci (QTL) for rice grain weight identified using bi-parental populations in various environments were found inconsistent and have a modest role in marker assisted breeding and map-based cloning programs. Thus, the identification of a consistent consensus QTL region across populations is critical to deploy in marker aided breeding programs. Using the QTL meta-analysis technique, we collated rice grain weight QTL information from numerous studies done across populations and in diverse environments to find constitutive QTL for grain weight. Using information from 114 original QTL in meta-analysis, we discovered three significant Meta-QTL (MQTL) for grain weight on chromosome 3. According to gene ontology, these three MQTL have 179 genes, 25 of which have roles in developmental functions. Amino acid sequence BLAST of these genes indicated their orthologue conservation among core cereals with similar functions. MQTL3.1 includes the OsAPX1, PDIL, SAUR, and OsASN1 genes, which are involved in grain development and have been discovered to play a key role in asparagine biosynthesis and metabolism, which is crucial for source-sink regulation. Five potential candidate genes were identified and their expression analysis indicated a significant role in early grain development. The gene sequence information retrieved from the 3 K rice genome project revealed the deletion of six bases coding for serine and alanine in the last exon of OsASN1 led to an interruption in the synthesis of α-helix of the protein, which negatively affected the asparagine biosynthesis pathway in the low grain weight genotypes. Further, the MQTL3.1 was validated using linked marker RM7197 on a set of genotypes with extreme phenotypes. MQTL that have been identified and validated in our study have significant scope in MAS breeding and map-based cloning programs for improving rice grain weight.

Validation of time-resolved, automated peak trans-mitral velocity tracking: Two center four-dimensional flow cardiovascular magnetic resonance study.

OBJECTIVE: We aim to validate four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) peak velocity tracking methods for measuring the peak velocity of mitral inflow against Doppler echocardiography. METHOD: Fifty patients were recruited who had 4D flow CMR and Doppler Echocardiography. After transvalvular flow segmentation using established valve tracking methods, peak velocity was automatically derived using three-dimensional streamlines of transvalvular flow. In addition, a static-planar method was used at the tip of mitral valve to mimic Doppler technique. RESULTS: Peak E-wave mitral inflow velocity was comparable between TTE and the novel 4D flow automated dynamic method (0.9 ± 0.5 vs 0.94 ± 0.6 m/s; p = 0.29) however there was a statistically significant difference when compared with the static planar method (0.85 ± 0.5 m/s; p = 0.01). Median A-wave peak velocity was also comparable across TTE and the automated dynamic streamline (0.77 ± 0.4 vs 0.76 ± 0.4 m/s; p = 0.77). A significant difference was seen with the static planar method (0.68 ± 0.5 m/s; p = 0.04). E/A ratio was comparable between TTE and both the automated dynamic and static planar method (1.1 ± 0.7 vs 1.15 ± 0.5 m/s; p = 0.74 and 1.15 ± 0.5 m/s; p = 0.5 respectively). Both novel 4D flow methods showed good correlation with TTE for E-wave (dynamic method; r = 0.70; P < 0.001 and static-planar method; r = 0.67; P < 0.001) and A-wave velocity measurements (dynamic method; r = 0.83; P < 0.001 and static method; r = 0.71; P < 0.001). The automated dynamic method demonstrated excellent intra/inter-observer reproducibility for all parameters. CONCLUSION: Automated dynamic peak velocity tracing method using 4D flow CMR is comparable to Doppler echocardiography for mitral inflow assessment and has excellent reproducibility for clinical use.

Frustration, strain and phase co-existence in the mixed valent hexagonal iridate Ba3NaIr2O9.

Using detailed synchrotron diffraction, magnetization, thermodynamic and transport measurements, we investigate the relationship between the mixed valence of Ir, lattice strain and the resultant structural and magnetic ground states in the geometrically frustrated triple perovskite iridate Ba3NaIr2O9. We observe a complex interplay between lattice strain and structural phase co-existence, which is typically not observed in this family of compounds. The low temperature magnetic ground state is characterized by the absence of long-range magnetic order, and points towards the condensation of a cluster glass state from an extended regime of short range magnetic correlations.

Subcutaneous gluteal abscess from Trichosporon asahii in an immunocompetent adult.

Fungal infections have been drastically increasing in incidence in recent years, preferentially affecting immunocompromised hosts and causing potentially fatal outcomes. One of the emerging fatal fungal pathogens is Trichosporon asahii, a non-Candida yeast that has been increasingly reported in recent years. Previous literature has described T. asahii as primarily affecting immunocompromised hosts, specifically those who are neutropenic, and causing fatal disseminated infections. Herein, we describe a case of an isolated subcutaneous abscess with T. asahii in an immunocompetent host without overlying skin manifestations or predisposing factors that resulted in complete mycotic cure when treated with voriconazole and terbinafine.

Myocardial inflammation and energetics by cardiac MRI: a review of emerging techniques.

The role of inflammation in cardiovascular pathophysiology has gained a lot of research interest in recent years. Cardiovascular Magnetic Resonance has been a powerful tool in the non-invasive assessment of inflammation in several conditions. More recently, Ultrasmall superparamagnetic particles of iron oxide have been successfully used to evaluate macrophage activity and subsequently inflammation on a cellular level. Current evidence from research studies provides encouraging data and confirms that this evolving method can potentially have a huge impact on clinical practice as it can be used in the diagnosis and management of very common conditions such as coronary artery disease, ischaemic and non-ischaemic cardiomyopathy, myocarditis and atherosclerosis. Another important emerging concept is that of myocardial energetics. With the use of phosphorus magnetic resonance spectroscopy, myocardial energetic compromise has been proved to be an important feature in the pathophysiological process of several conditions including diabetic cardiomyopathy, inherited cardiomyopathies, valvular heart disease and cardiac transplant rejection. This unique tool is therefore being utilized to assess metabolic alterations in a wide range of cardiovascular diseases. This review systematically examines these state-of-the-art methods in detail and provides an insight into the mechanisms of action and the clinical implications of their use.

Acute Interstitial Pancreatitis With a Normal Lipase Level in the Background of Inflammatory Bowel Disease: A Case Report.

Acute interstitial pancreatitis is usually diagnosed on the basis of clinical findings, elevated lipase level, and imaging. However, herein we present a case of a 44-year-old Caucasian male who presented with pancreatitis diagnosed on the clinical grounds in the background of inflammatory bowel disease.

Antibiotic-Resistant Pyrexia of Unknown Origin: An Unusual Presentation of Myelodysplastic Syndrome.

A 74-year-old male presented to the emergency department (ED) with complaints of high-grade fever, productive cough, and difficulty breathing for three weeks, and a significant weight loss in the past six months. Despite a detailed investigation, diagnosis could not be achieved. Multiple empiric regimens were tried but no response was observed. Bone marrow biopsy was conducted after suspicious peripheral film result, which concluded that the patient was having myelodysplastic syndrome. Although pyrexia of unknown origin has a diverse group of diseases to evaluate for, and rare entities are difficult to diagnose, meticulous evaluation may give significant evidence for targeted diagnostic workup.

Role of immature platelet fraction (IPF) in sepsis patients: A systematic review.

Sepsis is extremely common amongst critically ill patients and requires early diagnosis. Hence, identifying a biomarker that could acknowledge sepsis at its prior stage is of vital significance. Immature platelets are a percentage of circulating platelets that contain RNA and is a newer parameter that is measured using automated hematology analyzers in diagnosing sepsis. This review article discusses 10 articles that reveal the role of immature platelet fraction in predicting the onset of sepsis and its relationship with mortality in sepsis. Literature search was done using PubMed, Scopus and Google Scholar and words like platelet indices and immature platelet fraction were typed in the search bar. The aim of this review article is to present a precise form of data that talk about immature platelet fraction (IPF) and its association with the severity and mortality of sepsis. Five out of 10 articles suggest that immature platelet fraction can predict the onset of sepsis and eight out of 10 articles suggest that increased IPF values are associated with high mortality.

Clinical Characteristics of COVID-19 Patients in a Regional Population With Diabetes Mellitus: The ACCREDIT Study.

Objective: To identify clinical and biochemical characteristics associated with 7- & 30-day mortality and intensive care admission amongst diabetes patients admitted with COVID-19. Research Design and Methods: We conducted a cohort study collecting data from medical notes of hospitalised people with diabetes and COVID-19 in 7 hospitals within the Mersey-Cheshire region from 1 January to 30 June 2020. We also explored the impact on inpatient diabetes team resources. Univariate and multivariate logistic regression analyses were performed and optimised by splitting the dataset into a training, test, and validation sets, developing a robust predictive model for the primary outcome. Results: We analyzed data from 1004 diabetes patients (mean age 74.1 (± 12.6) years, predominantly men 60.7%). 45% belonged to the most deprived population quintile in the UK. Median BMI was 27.6 (IQR 23.9-32.4) kg/m2. The primary outcome (7-day mortality) occurred in 24%, increasing to 33% by day 30. Approximately one in ten patients required insulin infusion (9.8%). In univariate analyses, patients with type 2 diabetes had a higher risk of 7-day mortality [p < 0.05, OR 2.52 (1.06, 5.98)]. Patients requiring insulin infusion had a lower risk of death [p = 0.02, OR 0.5 (0.28, 0.9)]. CKD in younger patients (<70 years) had a greater risk of death [OR 2.74 (1.31-5.76)]. BMI, microvascular and macrovascular complications, HbA1c, and random non-fasting blood glucose on admission were not associated with mortality. On multivariate analysis, CRP and age remained associated with the primary outcome [OR 3.44 (2.17, 5.44)] allowing for a validated predictive model for death by day 7. Conclusions: Higher CRP and advanced age were associated with and predictive of death by day 7. However, BMI, presence of diabetes complications, and glycaemic control were not. A high proportion of these patients required insulin infusion warranting increased input from the inpatient diabetes teams.

Patient characteristics and compliance with positive airway pressure therapy during New York City's 2020 COVID-19 pandemic stay-at-home orders: The NYU comprehensive epilepsy center-sleep center telemedicine experience.

Objectives: We sought to evaluate the success of telemedicine during New York City's COVID-19 pandemic stay-at-home period, and understand the distribution of sleep complaints seen. We also compared positive airway pressure (PAP) therapy compliance for a random patient sample to determine whether the pandemic influenced PAP usage. Methods: Encounters from the stay-at-home period were reviewed for patient characteristics and clinician impressions, and were compared to administrative data from the prior 2.5 months ("control" period). PAP compliance was compared between the periods for a randomly selected group of forty patients. Results: The telemedicine show rate was 89.37%. Sleep apnea then insomnia were the predominant diagnoses. Insomnia complaints were higher during the stay-at-home period. PAP compliance and AHI were similar between the periods. Conclusions: Sleep apnea and insomnia were common complaints; insomnia was significantly more common during the pandemic. PAP compliance was similar between the two periods for a randomly selected cohort.

Simulation-based uptraining improves provider comfort in the management of critically ill patients with COVID-19.

PURPOSE: The COVID-19 surge required the deployment of large numbers of non-intensive care providers to assist in the management of the critically ill. Institutions took a variety of approaches to "uptraining" such providers though studies describing methods and effectiveness are lacking. MATERIALS AND METHODS: One hundred and seventy-five providers underwent a 3 h simulation-based session focused on management of shock, mechanical ventilation, acute respiratory distress syndrome, and critical care ultrasound. All participants were sent surveys to assess their comfort with various aspects of critical care following return to their usual work environments. RESULTS: One hundred and eight providers of 175 (62%) completed the survey. Overall, 104/108 responders (96%) felt training either significantly or somewhat improved their knowledge in the management of ICU patients. Responders felt most comfortable in the management of hypoxemia in intubated patients and the management of ventilated patients with acute respiratory distress syndrome (93% strongly agree or agree, and 86% strongly agree or agree, respectively). Fewer responders felt more comfortable using focused echocardiography (70% strongly agree or agree) and lung ultrasonography in following progression of COVID-19 (76% strongly agree or agree). CONCLUSIONS: Simulation-based training improved provider comfort in the management of critically ill patients with COVID-19.

Simulation-Based Up-Training in Response to the COVID-19 Pandemic.

STATEMENT: The dramatic outbreak of COVID-19 placed unprecedented strain on the critical care workforce of New York City. The enhanced precautions required to safely care for COVID-19 patients impacted the performance of even routine critical care procedures. Meanwhile, staff were stretched to care for exponentially rising case volume as COVID intensive care units (ICUs) expanded. Simulation was used to bridge these gaps-first to familiarize personnel within the Division of Pulmonary and Critical Care with revised COVID-19 care procedures, then to orient noncritical care clinicians volunteering from other specialties for COVID ICU deployment to general critical care and COVID-19 care principles. Using mannequin-based simulation scenarios followed by comprehensive debriefing sessions, simulation participants received high-intensity, high-fidelity training in respiratory failure, circulatory failure, bedside ultrasound, bedside ICU procedures, and elements of COVID-19-specific care. More than 200 physicians and advanced practice practitioners completed simulation training in preparation for deployment, supplementing and enhancing the ICU workforce at a decisive time during the outbreak.

Clinical Outcomes in Critically Ill Coronavirus Disease 2019 Patients: A Unique New York City Public Hospital Experience.

To explore demographics, comorbidities, transfers, and mortality in critically ill patients with confirmed severe acute respiratory syndrome coronavirus 2. DESIGN: Retrospective cohort study. SETTING: Data were collected from a large tertiary care public hospital ICU that is part of the largest public healthcare network in the United States. PATIENTS: One-hundred thirty-seven adult (≥ 18 yr old) ICU patients admitted between March 10, 2020, and April 7, 2020, with follow-up collected through May 18, 2020. INTERVENTIONS: None. MEASUREMENTS: Demographic, clinical, laboratory, treatment, and outcome data extracted from electronic medical records. MAIN RESULTS: The majority of patients were male (99/137; 72.3%) and older than 50 years old (108/137; 78.9%). The most reported ethnicity and race were Hispanic (61/137; 44.5%) and Black (23/137; 16.7%). One-hundred six of 137 patients had at least one comorbidity (77.4%). One-hundred twenty-one of 137 (78.1%) required mechanical ventilation of whom 30 (24.8%) moved to tracheostomy and 46 of 137 (33.6%) required new onset renal replacement therapy. Eighty-two of 137 patients (59.9%) died after a median of 8 days (interquartile range 5-15 d) in the ICU. Male sex had a trend toward a higher hazard of death (hazard ratio, 2.1 [1.1-4.0]) in the multivariable Cox model. CONCLUSIONS: We report a mortality rate of 59.9% in a predominantly Hispanic and Black patient population. A significant association between comorbidities and mortality was not found in multivariable regression, and further research is needed to study factors that impact mortality in critical coronavirus disease 2019 patients. We also describe how a public hospital developed innovative approaches to safely manage a large volume of interhospital transfers and admitted patients.