A Case of Neurosarcoid Presenting as Multiple Intraparenchymal Hemorrhages.

This report explores the case of a 49-year-old African American male with a six-month history of multifocal neurological deficits who presented to an outside hospital after a generalized seizure. Patient was transferred to our tertiary medical center after brain imaging showed multiple bilateral supratentorial intraparenchymal hemorrhages (IPH). A brain biopsy confirmed parenchymal and perivascular non-caseating granulomas with vasculitis. The patient was definitively diagnosed with neurosarcoidosis (NS) and his condition improved with high dose corticosteroids and additional immunosuppressive therapies. Intracranial hemorrhage in the setting of NS is extremely rare, with fewer than thirty documented cases; however, this is likely an underestimation of its true prevalence. This case illustrates the difficulty in diagnosis as many other etiologies of IPH must be considered. Additionally, the clinical course and manifestations of NS is often quite variable. The uniqueness of this case lies in the rapid progression from seemingly incidental microhemorrhages to multiple large IPHs over two months. While the cause of this progression is not immediately apparent, a possible cause may be inadequate initial treatment due to delayed diagnosis. Our case demonstrates the importance of early recognition and initiation of immunosuppressive therapy, potentially leading to dramatic clinical improvement, as seen in this patient.

The health belief model: How public health can address the misinformation crisis beyond COVID-19.

OBJECTIVES: This paper proposes an intervention into health misinformation that relies upon the health belief model as a means to bridge the risks associated with health misinformation and the impact on individual health, beyond the current recommendations for fact checking and information literacy. STUDY DESIGN: This is a short theoretical paper. METHODS: N/A. RESULTS: N/A. CONCLUSIONS: Misinformation researchers and public health practitioners and communicators can benefit using the infrastructures afforded by public health offices to mobilize the health belief model as a site for misinformation education.

Novel, improved sample preparation for rapid, direct identification from positive blood cultures using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry.

Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) is widely used for rapid and reliable identification of bacteria and yeast grown on agar plates. Moreover, MALDI-TOF MS also holds promise for bacterial identification from blood culture (BC) broths in hospital laboratories. The most important technical step for the identification of bacteria from positive BCs by MALDI-TOF MS is sample preparation to remove blood cells and host proteins. We present a method for novel, rapid sample preparation using differential lysis of blood cells. We demonstrate the efficacy and ease of use of this sample preparation and subsequent MALDI-TOF MS identification, applying it to a total of 500 aerobic and anaerobic BCs reported to be positive by a Bactec 9240 system. In 86.5% of all BCs, the microorganism species were correctly identified. Moreover, in 18/27 mixed cultures at least one isolate was correctly identified. A novel method that adjusts the score value for MALDI-TOF MS results is proposed, further improving the proportion of correctly identified samples. The results of the present study show that the MALDI-TOF MS-based method allows rapid (<20 minutes) bacterial identification directly from positive BCs and with high accuracy.

VO2 Max and anaerobic threshold in hypertension: a tissue Doppler study.

BACKGROUND: Hypertension can impair left ventricular (LV) relaxation causing shortness of breath and reduced exercise capacity, which may affect the clinical evaluation of the symptomatic hypertensive patient. In this study we used tissue Doppler imaging (TDI) to identify correlates of anaerobic threshold (AT) and maximum oxygen uptake (VO2 Max). Our goal was to assess the feasibility of TDI as a surrogate of functional capacity in hypertensive individuals. METHODS: We studied subjects without metabolic syndrome and with normal LV function (ejection fraction (EF) >50%). Traditional echocardiographic variables were obtained before and after a cardiopulmonary exercise test. Systolic (S) and diastolic (E'and A') myocardial velocities were measured at the basal septal (bs) and posterior (bp) walls. RESULTS: After multivariate analysis, resting E'bp (r =0.56, P < 0.002) and isovolumic relaxation time (IVRT) (r =-0.49, I < 0.03) correlated with VO2 Max, while A Valsalva correlated with AT (r =-0.46, P < 0.03). Peak stress E'/A'bp correlated with age and gender corrected METs (r =-0.63, P < 0.0004) and VO2 Max (r =-0.39, P< 0.04). CONCLUSIONS: Resting E'bp and peak stress E'/A'bp correlate with VO(2) Max in hypertensive patients. TDI may be an important tool when assessing symptoms in this population.

Quality of emergency care on the night shift.

OBJECTIVES: To determine whether performance decrements at night actually translate into worsened measures of quality of patient care in the emergency department (ED). Emergency physicians and healthcare workers are sleepier and less cognitively proficient at night than during the day. Despite a lack of data, medical errors have been attributed to these deficits, and pharmacologic solutions recently have been suggested. METHODS: The authors studied 36 months of emergency care and measured quality indicators, including early mortality (deaths occurring after arrival in the ED or within 48 hours of hospital admission), frequency of return after ED discharge, time to thrombolysis in acute myocardial infarction (AMI), frequency of aspirin use in AMI, and performance of endotracheal intubation. Comparisons were by time of day in eight-hour epochs. RESULTS: There were 345,000 patient encounters in the study period. The distribution in time was determined for 25,079 sampled ED visits, 3,666 admissions, and 507 early deaths. Estimated early mortality was 0.5% (95% CI = 0.0 to 1.0%) greater at night compared with during the day. There was no effect of time of day on 1,828 returns with admission after ED discharge. In 257 patients who received thrombolytics for AMI, mean time-to-treatment and frequency of aspirin use were not worse at night. In 443 emergent endotracheal intubations, there was no difference at night in the duration or number of attempts required, or in protocol adherence. CONCLUSIONS: Quality indicators used in this study do not demonstrate marked deficits in patient care occurring at night. A very small, but measurable, increase in early mortality was identified. Improved measures to counter circadian disruption warrant study but may result in minimal improvements in patient care.