Incidental finding of renal cell carcinoma in an asymptomatic patient on low-dose computed tomography screening for lung cancer.

INTRODUCTION In 2013, the United States Preventive Services Task Force recommended annual low-dose computed tomography (CT) screening for lung cancer in high-risk adults with a significant smoking history. These screenings result in large numbers of incidental findings, and although most of these do not warrant further investigation, there have been reported cases of incidental findings identified on CT screening that led to successful treatment of a previously undiagnosed comorbidity. CASE HISTORY Here, we report a case of papillary renal cell carcinoma that was detected incidentally on low-dose CT in an asymptomatic individual, a rare diagnosis considering that renal neoplasms account for <1% of incidental findings on these screenings. CONCLUSION This case highlights the value of investigating these incidental findings, with the goal of detecting underlying disease in some cases before it would have presented symptomatically.

Altered mental status and pronounced febrile response after second mRNA-1273 (Moderna) COVID-19 vaccine administration in a patient with previously documented COVID-19 infection.

A 54-year-old man who was previously found to be COVID-19 positive received two doses of mRNA-1273 (Moderna) vaccine 4 weeks apart, as recommended by the manufacturer. He was brought to the emergency department 1 day after second dose of the vaccine with altered mental status, headache and high fever. The patient was hospitalised for 2 days and managed with supportive care. He completely recovered with return of mental status to baseline and resolution of fever.

Meningitis secondary to disseminated gonococcal infection.

We report one of the unusual presentations of disseminated gonococcal infection. This case report describes a 24-year-old woman who presented with disseminated gonococcal infection manifesting as meningitis. Cerebrospinal fluid (CSF) and throat swab PCR were positive for Neisseria gonorrhoeae Blood and CSF cultures were negative for bacterial growth. The patient was treated with a total of 14 days of intravenous ceftriaxone. She was discharged with no neurological sequelae.

Rare case of osteomyelitis caused by Gardnerella vaginalis and Streptococcus parasanguinis in a postmenopausal woman.

Vertebral osteomyelitis is an infection of the vertebrae that can lead to spinal degeneration, most commonly caused by Staphylococcus aureus Here, we report an unusual case of pyogenic osteomyelitis caused by Gardnerella vaginalis and Streptococcus parasanguinis in a 61-year-old postmenopausal woman. The patient presented with a 2-week history of worsening lower back pain and fever and a recent episode of cystitis following re-engagement of sexual activity. Imaging revealed a deterioration of vertebrae discs and spinal canal stenosis at the L3-L4 levels with a formation of abscess in the right psoas muscle. Needle aspiration of the abscess identified G. vaginalis and S. parasanguinis and the patient was successfully treated with a 6-week course of ceftriaxone and metronidazole. This case describes an unusual coinfection of two pathogens that normally reside in the urogenital tract and oral cavity, respectively, and highlights the risk posed when these organisms breach the body's normal barriers.

Intrathecal iodinated contrast-induced transient spinal shock.

Transient spinal shock is a previously unreported complication of intrathecal contrast. A 63-year-old man presented with the chief complaint of worsening back pain. Computed topography of lumbar spine without contrast showed a lytic lesion. After international normalized ratio (INR) correction, patient was sent for CT myelogram. After intrathecal contrast injection, the patient dropped his blood pressure profoundly and developed clinical manifestations of spinal shock. Emergent intravenous bolus fluids were initiated resulting in improvement in blood pressure. Patient's spinal shock resolved within hours. CT myelogram was normal except previously known lytic lesion. It was concluded that the transient shock was most likely due to contrast injection. We believe that this is the first reported case of transient spinal shock following CT myelogram using water-soluble iodinated non-ionic contrast agent administered intrathecally.

Hospital admissions for aortic stenosis in pregnancy in the United States - a thirteen year analysis.

Cardiac disease is still the leading cause of non-pregnancy related maternal morbidity and mortality. Valvular disease is one of the most concerning cardiac conditions in pregnancy. Aortic stenosis (AS) is rare in young populations but deadly complications have been reported in pregnant women. This study is a retrospective review of data from the HCUP-NIS Database from 2002-2014. There were 1108 weighted discharges for both pregnancy and AS. The data contained ten or fewer unweighted discharges with AS in pregnancy that underwent a cardiac intervention: open heart surgery or percutaneous cardiac intervention. Patients who had at least one diagnosis for AS had a greater mean cost per discharge than the comparison groups. No deaths were identified in this group. We found a statistically significant increase in the billing codes for pulmonary hypertension and heart failure. Conditions commonly associated with AS such as atrial arrhythmias, ventricular arrhythmias, diastolic dysfunction, ischemic heart disease and stroke were poorly reported. Our study identified a low incidence of AS and its complications in pregnancy in the USA over our 13-year study period. Even though, the morbidity and mortality are low, it is important that clinicians be aware of this diagnosis due higher costs and risk of complications.

A Case of Lethal Abdominal Compartment Syndrome due to Rapidly Expanding Ovarian Small Cell Carcinoma Pulmonary Type.

A 53-year-old woman presented with a rapidly growing pelvic mass suspected to be endometrial cancer due to endometrial biopsy showing grade 1 endometrioid adenocarcinoma. Due to severe aortic valve stenosis, she underwent a transcatheter aortic valve replacement (TAVR) for surgical optimization for a planned total abdominal hysterectomy, bilateral salpingo-oophorectomy, and tumor debulking. She was discharged on dual antiplatelet therapy with plans for future surgery, but was readmitted with abdominal distension, constipation, and urinary retention. The pelvic mass seen on prior imaging studies had increased in size. Unanticipated asystole cardiac arrest occurred two days after readmission, which on autopsy was found to be secondary to abdominal compartment syndrome from a rapidly enlarging ovarian small cell carcinoma pulmonary type.

A Complex Case of Polymyositis Overlapping With Hypothyroid Myopathy Without Underlying Autoimmune Thyroid Disorder.

A 78-year-old woman with a past medical history of hypothyroidism and Sjogren's syndrome presented with a two-month history of gradually progressive bilateral lower extremity weakness. Significant elevation in thyroid-stimulating hormone (TSH) and muscle enzyme, such as creatine kinase, was noticed on presentation. Due to concerns of hypothyroid myopathy, the patient was started on thyroxine and triiodothyronine supplementation. The patient reported no significant improvement in her weakness in the one-month follow-up. Laboratory workup revealed improving TSH levels but worsening creatine kinase levels. Electromyography study showed primarily myopathic features, such as abnormal insertional activity concerning for mild inflammatory myopathy. Muscle biopsy showed mild inflammatory exudate and features of myopathy with ongoing denervation. The patient was diagnosed with polymyositis and started on prednisone 0.5 mg/kg daily with a taper course and methotrexate. The patient reported significant improvement in her weakness when seen in six weeks with normalizing creatine kinase levels. The hallmark difference between hypothyroid myopathy (including polymyositis-like syndrome) and conventional polymyositis is the complete clinical recovery and resolution of laboratory abnormalities after treatment with thyroid hormone replacement in hypothyroid myopathy. There was no evidence of underlying autoimmune thyroid disorder which makes this case unique. This case highlights the complex case of polymyositis overlapping with hypothyroid myopathy with no underlying autoimmune disorder.

Assessment of antibiotic use and concordance with practice guidelines within 3 diverse ambulatory clinic systems.

OBJECTIVES: The objectives of this study were (1) to determine the rate of antibiotic prescribing at ambulatory clinics, and (2) to assess the concordance of antibiotic prescriptions with published guidelines and Food and Drug Administration-approved indications in terms of drug choices and dosing regimen. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Patients of all ages receiving at least 1 prescription during ambulatory visits in 2016 to 2017 were observed. OUTCOME MEASURES: For each of the 3 clinic systems included in this study, oral antibiotic prescribing rates were estimated per patient and per ambulatory visit. Then, the concordance of oral antibiotic prescribing was assessed with respect to (1) choice of agent and (2) the dosing regimen by comparing it to the recommended therapeutic regimen (RTR). RESULTS: A total of 284,348 patients receiving at least 1 prescription were included in the analysis. Between clinics, 17.4 to 43.7 per 100 patients received antibiotics. Of the antibiotics prescribed, 48.9% in Clinic A, 48.0% in Clinic B, and 60.7% in Clinic C were considered to be discordant in terms of drug choice. When the dosing regimen was taken into account in addition to the choice of agent, 72.6% in Clinic A, 76.7% in Clinic B, and 81.6% in Clinic C were discordant based on drug choice or dosing regimen. Of the prescriptions written with a discordant dosing regimen, 91.2% in Clinic A, 79.6% in Clinic B, and 91.0% in Clinic C were at a higher dosage than RTR. CONCLUSION: Antibiotic prescribing rates vary by clinics, whereas discordant prescribing is consistently prevalent across clinics. More efforts should be put into ambulatory care to address antibiotic misuse problems, and our method could improve ambulatory antimicrobial stewardship programs.

Simultaneous presentation of thyroid storm and diabetic ketoacidosis in a previously healthy 21-year-old man.

A 21-year-old young man with no history of diabetes or thyroid disease presented to the emergency department with simultaneous thyroid storm and diabetic ketoacidosis. Notable findings on admission were a ventricular rate of 235 beats/min, tachypnoea, tremors, polydipsia and a lack of fever. Due to the unusual constellation of symptoms, diagnosis was only possible after initial laboratory results came back. While the lack of fever is unusual in thyroid storm, diabetic ketoacidosis has previously been reported to suppress fever, and this case supports the occurrence of this phenomenon. This case was highly unusual because the patient had not previously been diagnosed with either type 1 diabetes or Graves' disease.

Blind After a Binge: Purtscher-like Retinopathy in Acute Alcoholic Pancreatitis.

Purtscher-like retinopathy is an occlusive microvasculopathy that causes sudden onset vision loss of varying severity. The condition is a rare complication of acute pancreatitis and is scarcely documented in the literature. In addition, it is vision-threatening, and there are no evidence-based therapies available. We report a 37-year-old woman presenting with abdominal pain and nausea in the setting of heavy alcohol use. She was diagnosed with acute pancreatitis. During hospitalization, she developed acute visual disturbance and was found to have significantly diminished visual acuity. A dilated funduscopic examination demonstrated multiple retinal cotton wool spots bilaterally and macular edema. The patient was diagnosed with Purtscher-like retinopathy in the setting of acute pancreatitis. Although the prognosis for her vision was guarded, given the ischemic nature of the insult, she had subjective improvement in visual acuity during the remainder of the hospital course with symptomatic management.

Iron Phosphate Coated Flexible Carbon Nanotube Fabric as a Multifunctional Cathode for Na-Ion Batteries.

Conventional slurry casted electrodes cannot stand high loads or be repeatedly flexed or bent without being fractured, which inhibits their use in flexible batteries. Carbon nanotube (CNT) fabric exhibits a paramount mechanical stability and, due to its porosity, can additionally accommodate an active material within its structure. While solution-based protocols cannot achieve conformal coatings of active materials, chemical vapor deposition (CVD) gives a unique opportunity to control and vary the thickness and homogeneity of the coating. Herein, a conformal CVD coating of amorphous iron (III) phosphate (a-FePO4 , FP) on flexible CNT fabric and its ability to reversibly accommodate large radius Na ions is reported. The freestanding binder-free CNT@FP electrodes exhibit high-rate capabilities and exceptional cycle stabilities with 98% of retention of initial capacity after 100 cycles. Such electrodes additionally demonstrate high mechanical stability under high loads, remarkable bending characteristics, and modulus of toughness (12 MJ m-3 ) exceeding that of Al. The presented concept of flexible CNT@FePO4 electrodes with high load-bearing characteristics opens new perspectives toward the formation of light-weight, flexible, multifunctional Na-ion battery electrodes based on abundant materials.

Carbon Nanotube-CoF2 Multifunctional Cathode for Lithium Ion Batteries: Effect of Electrolyte on Cycle Stability.

Transition metal fluorides (MFx ) offer remarkably high theoretical energy density. However, the low cycling stability, low electrical and ionic conductivity of metal fluorides have severely limited their applications as conversion-type cathode materials for lithium ion batteries. Here, a scalable and low-cost strategy is reported on the fabrication of multifunctional cobalt fluoride/carbon nanotube nonwoven fabric nanocomposite, which demonstrates a combination of high capacity (near-theoretical, 550mAhgCoF2-1) and excellent mechanical properties. Its strength and modulus of toughness exceed that of many aluminum alloys, cast iron, and other structural materials, fulfilling the use of MFx -based materials in batteries with load-bearing capabilities. In the course of this study, cathode dissolution in conventional electrolytes has been discovered as the main reason that leads to the rapid growth of the solid electrolyte interphase layer and attributes to rapid cell degradation. And such largely overlooked degradation mechanism is overcome by utilizing electrolyte comprising a fluorinated solvent, which forms a protective ionically conductive layer on the cathode and anode surfaces. With this approach, 93% capacity retention is achieved after 200 cycles at the current density of 100 mA g(-1) and over 50% after 10 000 cycles at the current density of 1000 mA g(-1) .

Ultra strong silicon-coated carbon nanotube nonwoven fabric as a multifunctional lithium-ion battery anode.

Materials that can perform simultaneous functions allow for reductions in the total system mass and volume. Developing technologies to produce flexible batteries with good performance in combination with high specific strength is strongly desired for weight- and power-sensitive applications such as unmanned or aerospace vehicles, high-performance ground vehicles, robotics, and smart textiles. State of the art battery electrode fabrication techniques are not conducive to the development of multifunctional materials due to their inherently low strength and conductivities. Here, we present a scalable method utilizing carbon nanotube (CNT) nonwoven fabric-based technology to develop flexible, electrochemically stable (∼494 mAh·g(-1) for 150 cycles) battery anodes that can be produced on an industrial scale and demonstrate specific strength higher than that of titanium, copper, and even a structural steel. Similar methods can be utilized for the formation of various cathode and anode composites with tunable strength and energy and power densities.