Rheumatoid Arthritis and Its Implications on Inflammatory Bowel Disease.

Background: The association between inflammatory bowel disease (IBD) and arthritis has long been known, but it was not until the 1950s that IBD-associated arthritis was recognized as a distinct pathology independent from rheumatoid arthritis (RA). There is evidence that RA and other autoimmune conditions exist at higher rates in patients with IBD compared to the general population. We aimed to determine if the presence of RA in IBD patients is a factor for mortality and IBD-related surgery in this population. Methods: Using Epic's Slicer Dicer function, we queried the International Classification of Diseases, 10th Revision (ICD-10) codes K50 and K51 to identify patients with IBD. Duplicates and those with incomplete information were excluded, leaving a total of 3,613 patients. Data collected included basic demographic information, surgical history, and the presence of RA. We used Student's t-test to analyze between group differences for the continuous variables. When it was determined that variances for the comparisons of continuous data were unequal, Welch-Satterthwaite t-test statistics were used. We used the Chi-square test to analyze between group differences for the categorical variables. The Fisher's exact test was employed when any of the expected frequencies was 5 or less. All tests were two-sided with criterion for statistical significance at a P value less than 0.05. All the analyses were done by SAS 9.4 (SAS Institute, Cary, NC). Results: Of the approximately 2.7 million adults in Slicer Dicer, there were 3,613 patients (0.13%) identified with IBD. Patients with ulcerative colitis (UC) accounted for 37% of the total group (n = 1,343) and 2,270 patients (62.8%) had Crohn's disease (CD). From the total, 2,084 were women (57.68%) and 1,529 (42.32%) were men. More than 90% of the patients were white (n = 3,321). The mean age was 53.3 ± 18.5. Eight hundred forty-eight patients (23.47%) had documented RA. Mortality was higher in patients with IBD and RA than those with IBD alone (7.31% vs. 3.98%, P value ≤ 0.0001). Conclusions: IBD patients with RA have higher mortality rates and need for IBD-related surgery than patients with IBD alone.

Is It All COVID-19? Resident Distress and Reasons for It in 2020.

OBJECTIVE: For resident wellness, it is important to understand and discern the relative contributions of each factor to resident stress. METHODS: After institutional review board approval, a 20-question survey instrument was provided to 90 residents across four specialties (Internal Medicine, Emergency Medicine, General Surgery, and Orthopedic Surgery) at a university-affiliated health system. The survey was completed from October through November 2020 by 63 residents for a 70% participation rate. Qualitative and quantitative analyses were used. RESULTS: The results showed a mean change in status in either direction of 2.66 points on an 11-point scale. Status changes were both positive (less stress) and negative (more stress). Related to the source of change in stress levels, 8 items were seen as predominantly influenced by residency training and 11 factors were predominantly influenced by the pandemic. One item was equally influenced by both. No item was primarily influenced by the sociopolitical climate. For 16 of the 20 items, changes in a negative direction were statistically greater than in a positive direction. CONCLUSIONS: Both positive and negative changes in resident stress status occurred during the pandemic period. Traditional residency stressors remained and because all of the factors were affected by both the pandemic and residency training, efforts to mitigate the negative effects of both need to continue.

Primary Central Nervous System Lymphoma: A Case of Solitary Brain Lesion.

Primary central nervous system lymphoma (PCNSL) is an uncommon variant of extranodal non-Hodgkin's lymphoma (NHL) that involves the brain, leptomeninges, eyes, or spinal cord without evidence of systemic disease. This article presents a case of a 63-year-old Caucasian female with high-grade B-cell lymphoma who was found to have a solitary brain lesion and no distant metastasis upon diagnosis. The patient had left-sided weakness and difficulty standing on presentation and was found to have a right frontal lobe mass with surrounding mild vasogenic edema and a small focal area of hemorrhage concerning for high-grade glioma versus lymphoma on MRI. However, pathology results revealed high-grade B-cell lymphoma. The case reinforces the importance of working up any lesion suspicious for lymphoma/glioma. Diagnosis of high-grade B-cell lymphoma can be difficult based on morphological and cytological appearance due to varying gene expression and presentation at diagnosis. It can closely mimic diffuse B-cell lymphoma. Extensive workup including HIV serology, MRI imaging, evaluation for spinal cord involvement, and lumbar puncture (LP), to rule out cerebrospinal fluid (CSF) involvement, prior to initiating treatment needs to be done. The case also addresses high-grade methotrexate (MTX)-based chemotherapy as a treatment that improves mortality in patients with primary central nervous system (CNS) lymphoma.

Factitious Disorder Masquerading as a Life-Threatening Anaphylaxis.

Factitious disorder is a psychiatric disorder in which sufferers intentionally fabricate physical or psychological symptoms in order to assume the role of the patient, without any obvious gain. We present a case of a 23-year-old female with chronic urticaria who presented with dyspnea, dysphasia, mild generalized erythema, abdominal cramps, and headache. She was tachypneic and hypotensive. This was her third admission with similar symptoms within the last 7 months. Tryptase, complement, anti-SM/RNP, Sjogren, Scl-70, C3, and C4 were negative. Computed tomography-guided bone marrow biopsy showed no mast cells. Flow cytometry did not show any immunophenotypic reaction. Other possible differentials including pregnancy, autoimmune disorders, and infections including hepatitis, thyroid disorder, and age-related malignancies were ruled out. After a thorough review, malingering disorder was ruled out, but we noticed the patient's intent of assuming a sick role. Later, the patient was diagnosed with major depressive disorder. Factitious anaphylaxis can present with multiple presentations including a life-threatening condition that mimics true anaphylaxis. A better approach would be thorough clinical evaluation and early multidisciplinary involvement. This case highlights the importance of further evidence-based studies in factitious disorder to decrease the disease burden and reduce the health care cost.