Genome sequences of isolates from high-touch surfaces in washrooms at a post-secondary institution.

We report here the draft genome sequences of Brevibacterium casei (n = 1), Heyndrickxia oleronia (n = 1), Kocuria palustris (n =1), Microbacterium spp. (n = 5), Staphylococcus cohnii (n = 3), and Staphylococcus epidermidis isolated from high-touch surfaces in washrooms at a post-secondary institution.

Diminutive Ureteral Stone Causing Caylyceal Rupture: Case Report and a Review of the Treatment Options.

Rupture of the renal collecting system is a rare event, usually occurring at the ureterovesical junction (UVJ). The most common cause is nephrolithiasis, usually directly correlated with the size of the stone. Other causes include bladder outlet obstruction, ureteropelvic junction obstruction, and extrinsic ureteral compression by a malignant pathology. The mechanism is increased pressure within the collecting system, and symptoms vary from vague mild abdominal pain to severe excruciating pain. We present a case of a 19-year-old female with obstructive uropathy and renal calyceal rupture caused by a 3 mm stone at the UVJ. Due to the small size of the stone and her hemodynamic stability, she was treated conservatively with tamsulosin and IV ceftriaxone. The following day she passed sediment in the urine and noted pain improvement. Calyceal rupture with small stones is exceedingly rare, may be missed on a CT without contrast, and should be suspected when perinephric edema or fluid is seen. This is the smallest recorded stone causing calyceal rupture to the best of our knowledge. CT with contrast is indicated for diagnosis when calyceal rupture is suspected and is suggested by extravasation of contrast. Early diagnosis and intervention, in collaboration with urologists, can help to avoid long-term complications such as acute kidney injury, urosepsis, and urinoma. Conservative management may still be considered after a calyceal rupture in patients with small, potentially passable stones. However, if there is associated obstructive uropathy, infection, or significant rupture, then stenting may be indicated. This case highlights the diagnosis of calyceal rupture in the setting of tiny stones and the efficacy of conservative therapy versus early stenting in the management of stable patients.

BARTONELLA HENSELAE -ASSOCIATED OPTIC NEUROPATHY PRESENTING AS A CENTRAL SCOTOMA IN THE ABSENCE OF OVERT PAPILLITIS: A MULTIMODAL IMAGING STUDY.

BACKGROUND/PURPOSE: The purpose of this report was to describe the use of multimodal imaging to establish the diagnosis of Bartonella henselae -associated optic neuropathy in a patient who presented with a central scotoma without overt evidence of optic nerve involvement. METHODS: This was a case report. Main outcome measures included clinical, optical coherence tomography, and fluorescein angiography findings. OBSERVATIONS: A 72-year-old woman presented with a 3-day history of central scotoma in the left eye. Her examination was remarkable for faint exudation in the nasal macula of the left eye but was otherwise normal for her age. Spectral domain optical coherence tomography of the macula revealed mild thickening of the papillomacular bundle with scattered small cystoid spaces and several intraretinal exudates, none of which were visible clinically. Fluorescein angiography revealed localized leakage of the inferotemporal optic disc. When prompted, the patient recalled being scratched multiple times by her two pet kittens. Serial testing showed rising anti- B. henselae ( B. henselae ) immunoglobulin G antibody titers to 1:1,280, confirming the suspected diagnosis of B. henselae -associated optic neuropathy. CONCLUSION: Bartonella -associated optic nerve involvement can occur without overt evidence of optic disc swelling. Multimodal imaging can be used to suggest the diagnosis and support appropriate serologic testing.

Variation in carbon and nitrogen concentrations among peatland categories at the global scale.

Peatlands account for 15 to 30% of the world's soil carbon (C) stock and are important controls over global nitrogen (N) cycles. However, C and N concentrations are known to vary among peatlands contributing to the uncertainty of global C inventories, but there are few global studies that relate peatland classification to peat chemistry. We analyzed 436 peat cores sampled in 24 countries across six continents and measured C, N, and organic matter (OM) content at three depths down to 70 cm. Sites were distinguished between northern (387) and tropical (49) peatlands and assigned to one of six distinct broadly recognized peatland categories that vary primarily along a pH gradient. Peat C and N concentrations, OM content, and C:N ratios differed significantly among peatland categories, but few differences in chemistry with depth were found within each category. Across all peatlands C and N concentrations in the 10-20 cm layer, were 440 ± 85.1 g kg-1 and 13.9 ± 7.4 g kg-1, with an average C:N ratio of 30.1 ± 20.8. Among peatland categories, median C concentrations were highest in bogs, poor fens and tropical swamps (446-532 g kg-1) and lowest in intermediate and extremely rich fens (375-414 g kg-1). The C:OM ratio in peat was similar across most peatland categories, except in deeper samples from ombrotrophic tropical peat swamps that were higher than other peatlands categories. Peat N concentrations and C:N ratios varied approximately two-fold among peatland categories and N concentrations tended to be higher (and C:N lower) in intermediate fens compared with other peatland types. This study reports on a unique data set and demonstrates that differences in peat C and OM concentrations among broadly classified peatland categories are predictable, which can aid future studies that use land cover assessments to refine global peatland C and N stocks.

Phase separation in mullite-composition glass.

Aluminosilicates (AS) are ubiquitous in ceramics, geology, and planetary science, and their glassy forms underpin vital technologies used in displays, waveguides, and lasers. In spite of this, the nonequilibrium behavior of the prototypical AS compound, mullite (40SiO2-60Al2O3, or AS60), is not well understood. By deeply supercooling mullite-composition liquid via aerodynamic levitation, we observe metastable liquid-liquid unmixing that yields a transparent two-phase glass, comprising a nanoscale mixture of AS7 and AS62. Extrapolations from X-ray scattering measurements show the AS7 phase is similar to vitreous SiO2 with a few Al species substituted for Si. The AS62 phase is built from a highly polymerized network of 4-, 5-, and 6-coordinated AlOx polyhedra. Polymerization of the AS62 network and the composite morphology provide essential mechanisms for toughening the glass.

Bilateral Lingual Nerve Injury Following Endotracheal Intubation: Risk Factors and Diagnostic Considerations.

BACKGROUND Endotracheal intubation is an essential procedure to protect the airway. However, immediate complications like voice hoarseness, cervical spine injury, and tooth trauma are common. One of the rarest complications is lingual nerve palsy. Risk factors include small airway instruments, non-supine position, nitrous oxide use, and difficult intubation. Only 15 cases of lingual nerve injury were identified worldwide, and only 2 of them were bilateral. This case report describes the third case of bilateral lingual nerve palsy after intubation. CASE REPORT We present a 52-year-old woman admitted for a total abdominal hysterectomy. Postoperatively, the patient noted voice hoarseness, left tongue numbness, and loss of taste on both sides of the tongue. MRI brain revealed no new masses or lesions, and a diagnosis of bilateral lingual nerve palsy was made. She was treated conservatively with symptom observation for 14 weeks. On follow-up, she remained with only a patch of numbness and dryness, and loss of taste on the top middle area of the tongue. CONCLUSIONS Lingual nerve palsy is a very rare but devastating adverse effect of airway manipulation. Symptoms can include dryness, loss of sensation, and loss of taste of the anterior two-thirds of the tongue on the ipsilateral side. Salivary function assessment is important to determine the location of peripheral nerve injury. All possible causes like stroke, hemorrhage, and nerve impingement should be evaluated. MRI is advised to exclude central etiologies. Steroids may be used to decrease tissue edema and inflammation.

A 77-Year-Old Man with Heparin-Induced Aldosterone Suppression Causing Hyperkalemia.

BACKGROUND Anticoagulation with heparin infrequently causes elevated serum potassium via a reduction in the number and affinity of adrenal angiotensin II receptors, causing reversible aldosterone suppression, thereby leading to enhanced sodium excretion and hyperkalemia. CASE REPORT A 77 year-old man presented with productive cough and shortness of breath and was subsequently found to have non-ST-elevation myocardial infarction and concomitant symptomatic COVID-19 infection, for which he was started on a high-dose unfractionated heparin infusion. A gradual increase in serum potassium followed, with a subsequent return to a normal potassium level after stopping treatment with heparin. An evaluation for hemolysis was unrevealing, and the patient was not on any other medications known to cause hyperkalemia. On day 6, heparin was restarted owing to a high suspicion of pulmonary embolism. There was a subsequent increase in serum potassium level, which was followed by a return to baseline after discontinuation of heparin, thereby confirming the suspected diagnosis. CONCLUSIONS Acute increases in serum potassium levels in hospitalized patients can result in weakness, paralysis, conduction abnormalities, and cardiac arrhythmias that, if left untreated, can result in serious morbidity and potentially death in a short period of time. As this clinical entity is infrequently encountered in clinical practice, it can easily be overlooked by clinicians. The prompt exclusion of alternative causes of acutely elevated serum potassium levels and the identification of heparin administration as an easily reversible trigger is imperative and can potentially be life-saving.

Latent Tuberculosis Infection Testing and Treatment at a Federally Qualified Health Center in Southern California: A Quality Improvement Project.

BACKGROUND: A key strategy to eliminate tuberculosis (TB) in the United States is to increase latent tuberculosis infection (LTBI) screening, testing, and treatment among non-US-born Asian populations. PURPOSE: The purpose was to increase LTBI screening, testing, and treatment at a community clinic. METHODS: Retrospective baseline LTBI data were retrieved through electronic medical record review. Interventions included adoption of standardized TB risk assessment, training providers to use shorter LTBI treatment regimens, and use of a care coordinator. Chart abstraction to examine outcomes was conducted postintervention at 4 months. RESULTS: In 2017, only 3 patients (7%) with LTBI were started on treatment. At 4 months postintervention, 28 (72%) patients with LTBI were started on treatment, of which 27 (96%) were placed on 3- to 4-month regimens. CONCLUSIONS: Training for providers and changes to clinic workflow, including use of a care coordinator, can help increase LTBI screening, testing, and treatment in community clinics.

Beyond the usual suspects: methanogenic communities in eastern North American peatlands are also influenced by nickel and copper concentrations.

Peatlands both accumulate carbon and release methane, but their broad range in environmental conditions means that the diversity of microorganisms responsible for carbon cycling is still uncertain. Here, we describe a community analysis of methanogenic archaea responsible for methane production in 17 peatlands from 36 to 53 N latitude across the eastern half of North America, including three metal-contaminated sites. Methanogenic community structure was analysed through Illumina amplicon sequencing of the mcrA gene. Whether metal-contaminated sites were included or not, metal concentrations in peat were a primary driver of methanogenic community composition, particularly nickel, a trace element required in the F430 cofactor in methyl-coenzyme M reductase that is also toxic at high concentrations. Copper was also a strong predictor, likely due to inhibition at toxic levels and/or to cooccurrence with nickel, since copper enzymes are not known to be present in anaerobic archaea. The methanogenic groups Methanocellales and Methanosarcinales were prevalent in peatlands with low nickel concentrations, while Methanomicrobiales and Methanomassiliicoccales were abundant in peatlands with higher nickel concentrations. Results suggest that peat-associated trace metals are predictors of methanogenic communities in peatlands.

How to Simplify the Evaluation of Newly Introduced Chemotherapeutic Interventions in Myeloma.

When the bortezomib [PS341], adriamycin and dexamethasone (PAD) regimen was first evaluated, the response rate in untreated patients was much superior to that elicited by conventional chemotherapeutic agents. We demonstrated the efficacy of PAD in relapsed or refractory patients by comparing the response rate obtained in 53 patients who received vincristine, adriamycin and dexamethasone (VAD) or equivalent regimen as induction therapy, using a comparative design in which each patient acted as their own control. Whereas 25 patients had a positive response to VAD, 37 patients had a response to PAD ≤ partial remission (PR) (p = 0.023). Using the more stringent response level of very good PR (VGPR) the results favored the PAD regimen very significantly (p = 0.006) (McNemars test). Similar results were seen using paired M-protein levels from individual patient comparisons. As the PAD regimen was subsequently adopted as the re-induction therapy in the British Society for Blood and Marrow Transplantation/United Kingdom Myeloma Forum Myeloma X (Intensive) trial, now concluded, we have retrospectively analyzed the findings from both studies. Comparison of response rates and adverse effects of patients having had previous autologous transplantation (Cohort 1) with the corresponding data from Myeloma X showed close correlation. These findings provide evidence that rapid results may be obtained in the evaluation of newly introduced, and potentially highly effective, anti-tumour agents by direct comparison to the response to the immediately preceding standard regimen, particularly in relatively resistant tumours.

Comparing public policies impacting prescribing and medication management in primary care in two Canadian provinces.

The challenges of polypharmacy and inappropriate prescribing are recognized internationally. This study synthesizes and compares the policies related to these issues introduced in Canada's two most populous provinces - Ontario and Quebec - over the first two decades of the 21st century. Drawing on policy documents and consultations with experts, we found that while medication management to address polypharmacy and inappropriate prescribing has not been an explicit and consistent policy target in either province, some policy changes sought to directly or indirectly impact medication management. These changes include the introduction of primary care teams that include pharmacists, the introduction of a medication review performed by pharmacists (in Ontario), increased emphasis on quality improvement with some attention to potentially inappropriate medications (specifically opioids in Ontario), and investments in information technology to improve communication across providers and move toward electronic prescribing to improve medication safety and appropriateness. Despite growing evidence of the problem of polypharmacy and inappropriate prescribing, there has been limited policy attention targeting these problems directly, and policy changes with potential to improve prescribing and medication management may not have been fully realized. Further research to evaluate the impact of these changes on provider behaviours, and on patient outcomes, warrants attention.

The effect of breastfeeding on postpartum fructosamine and HbA1c values after normal pregnancy.

INTRODUCTION: Breastfeeding can lower postpartum oral glucose tolerance test results by 5%. Similar data do not exist regarding fructosamine and HbA1c. The primary outcome was to determine if breastfeeding would lower fructosamine values by 5%. METHODS: At the 4-8 week postpartum visit, women with uncomplicated pregnancies were given a questionnaire and had blood drawn for fructosamine and HbA1c. RESULTS: Breastfeeding (n = 22) and non-breastfeeding women (n = 28) were demographically similar, including postpartum weight loss. The respective values among breastfeeding and non-breastfeeding women were: fructosamine 2.20 versus 2.21 mmol/L; HbA1c 5.2% versus 5.2%. Only two of the seven women with an HbA1c of 5.7% or more had an abnormal fructosamine. CONCLUSION: After uncomplicated pregnancies, breastfeeding was not associated with lower levels of postpartum fructosamine or HbA1c. Future research to improve screening for persistent postpartum dysglycemia in high-risk populations can utilize these tests without concern that results will be confounded by breastfeeding.

Osteochondral Fresh Allograft Transfer to Address Osteochondral Defect of the First Metatarsal Head in Early Hallux Limitus.

Osteochondral fresh allograft transfer of the first metatarsal can be an accepted surgical management option for early stages of hallux limitus. This study consisted of evaluating clinical outcomes with patients who underwent this procedure. Thirteen (N=13) patients were included in this study, 10 (76.9%) were female and 3 (23.1%) were male. The mean age was 52.2 (range, 27-61) years and the mean body mass index was 25.3 (range, 33.8-19.4) kg/m2. Intraoperative evaluation of osteochondral defects of the first metatarsal demonstrated a mean diameter size of 8.2 mm. Ten (76.9%) patients had a concomitant cheilectomy procedure performed. The mean follow-up was 41.0 (range, 3.5-89.1) months. American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire and patient satisfaction survey were completed. The mean AOFAS Hallux Metatarsophalangeal-Interphalangeal score, which was determined postoperatively, was 71.2 (range, 55-85) of 100. Four (30.8%) patients with overall scores below 60 (range, 55-59) reported moderate daily pain at the first metatarsophalangeal joint. Mean AOFAS pain score was 26.9 (range, 20-30) of 40. Mean AOFAS function score was 30.8 (range, 24-35) of 45. Mean AOFAS alignment score was 13.4 (range, 8-15) of 15. There was statistical significance in mean AOFAS total score when comparing hallux limitus grade 1 versus grade 2, as well as when comparing grade 1 versus grade 3, p < .05. There was no significance in mean AOFAS total score when comparing number of plugs used, body mass index, and size of defect. However, an overall improvement in preoperative symptoms and patient satisfaction was documented and therefore osteochondral fresh allograft transfer can be considered a reasonable option in treating defects found at the first metatarsal head.

Prevalence of abnormalities in electrocardiogram conduction in dialysis patients: a comparative study / Prevalência de anormalidades de condução no eletrocardiograma de pacientes em diálise: um estudo comparativo

ABSTRACT Background: The electrocardiogram (ECG) can aid in identification of chronic kidney disease (CKD) patients at high risk for cardiovascular diseases. Cohort studies describe ECG abnormalities in patients on hemodialysis (HD), but we did not find data comparing ECG abnormalities among patients with normal kidney function or peritoneal dialysis (PD) to those on hemodialysis. We hypothesized that ECG conduction abnormalities would be more common, and cardiac conduction interval times longer, among patients on hemodialysis vs. those on peritoneal dialysis and CKD 1 or 2. Methods: Retrospective review of adult inpatients' charts, comparing those with billing codes for "Hemodialysis" vs. inpatients without those charges, and an outpatient peritoneal dialysis cohort. Patients with CKD 3 or 4 were excluded. Results: One hundred and sixty-seven charts were reviewed. ECG conduction intervals were consistently and statistically longer among hemodialysis patients (n=88) vs. peritoneal dialysis (n=22) and CKD stage 1 and 2 (n=57): PR (175±35 vs 160±44 vs 157±22 msec) (p=0.009), QRS (115±32 vs. 111±31 vs 91±18 msec) (p=0.001), QT (411±71 vs. 403±46 vs 374±55 msec) (p=0.006), QTc (487±49 vs. 464±38 vs 452±52 msec) (p=0.0001). The only significantly different conduction abnormality was prevalence of left bundle branch block: 13.6% among HD patients, 5% in PD, and 2% in CKD 1 and 2 (p=0.03). Conclusion: To our knowledge, this is the first study to report that ECG conduction intervals are significantly longer as one progresses from CKD Stage 1 and 2, to PD, to HD. These and other data support the need for future research to utilize ECG conduction times to identify dialysis patients who could potentially benefit from proactive cardiac evaluations and risk reduction.

RESUMO Introdução: O eletrocardiograma (ECG) pode auxiliar na identificação de pacientes com doença renal crônica (DRC) e alto risco para doenças cardiovasculares. Estudos de coorte descrevem anormalidades no ECG de pacientes em hemodiálise (HD), mas não encontramos dados comparando anormalidades no ECG entre pacientes com função renal normal ou aqueles em diálise peritoneal (DP), com aqueles em hemodiálise. Nossa hipótese foi de que as anormalidades de condução no ECG seriam mais comuns, e o intervalo de condução cardíaca seria mais longo entre os pacientes em hemodiálise comparados àqueles em diálise peritoneal e DRC 1 ou 2. Métodos: revisão retrospectiva dos prontuários de pacientes adultos internados, comparando aqueles com códigos de cobrança para "Hemodiálise" versus pacientes internados sem esses encargos, e uma coorte de pacientes em diálise peritoneal ambulatorial. Pacientes com DRC 3 ou 4 foram excluídos. Resultados: Cento e sessenta e sete prontuários foram revisados. Os intervalos de condução no ECG foram consistente- e estatisticamente mais longos entre os pacientes em hemodiálise (n = 88) vs. em diálise peritoneal (n = 22) e DRC estágios 1 e 2 (n = 57): PR (175 ± 35 vs 160 ± 44 vs 157 ± 22 msec) (p = 0,009); QRS (115 ± 32 vs. 111 ± 31 vs 91 ± 18 ms) (p = 0,001); QT (411 ± 71 vs. 403 ± 46 vs 374 ± 55 ms) (p = 0,006 ), QTc (487 ± 49 vs. 464 ± 38 vs 452 ± 52 ms) (p = 0,0001). A única anormalidade de condução significativamente diferente foi a prevalência de bloqueio do ramo esquerdo: 13,6% nos pacientes em HD, 5% em DP e 2% na DRC 1 e 2 (p = 0,03). Conclusão: Pelo que sabemos, este é o primeiro estudo a relatar que os intervalos de condução no ECG são significativamente maiores à medida que se progride das DRC Estágios 1 e 2, para DP, e para HD. Esses e outros dados corroboram a necessidade de estudos futuros para utilizar os tempos de condução no ECG para identificar pacientes em diálise que poderiam se beneficiar de avaliações cardíacas proativas e assim redução de risco.

Non-completion of latent tuberculosis infection treatment among Vietnamese immigrants in Southern California: A retrospective study.

OBJECTIVES: To examine socio-demographic and health-related factors associated with latent tuberculosis infection (LTBI) treatment refusal, non-initiation, and non-completion among a cohort of Vietnamese immigrants. DESIGN: This is a retrospective cohort study in which LTBI charts were reviewed at a public health clinic in Orange County, California between January 2010 and August 2011. SAMPLE: Altogether, 474 patient charts with documented LTBI treatment were reviewed for patients who met the inclusion criteria. MEASUREMENTS: Univariate and multivariate analyses were used to identify socio-demographic and health-related factors associated with LTBI treatment refusal, non-initiation, and non-completion. RESULTS: Of the 474 charts reviewed, 171(36.1%) patients refused LTBI treatment and 21(6.9%) accepted but did not initiate. Of the 282 that started treatment, 62 (22.0%) did not complete the regimen prescribed. The primary barrier documented for treatment refusal and non-completion was concern about medication side effects. Other barriers to treatment non-completion include transportation issues and conflicts with travel plans or work schedules. CONCLUSIONS: Community and public health nurses working with the Vietnamese immigrant population can play a vital role in improving patients' LTBI treatment acceptance, initiation, and completion. A proactive approach to addressing barriers and potential medication side effects can improve overall treatment success.

Prevalence of abnormalities in electrocardiogram conduction in dialysis patients: a comparative study.

BACKGROUND: The electrocardiogram (ECG) can aid in identification of chronic kidney disease (CKD) patients at high risk for cardiovascular diseases. Cohort studies describe ECG abnormalities in patients on hemodialysis (HD), but we did not find data comparing ECG abnormalities among patients with normal kidney function or peritoneal dialysis (PD) to those on hemodialysis. We hypothesized that ECG conduction abnormalities would be more common, and cardiac conduction interval times longer, among patients on hemodialysis vs. those on peritoneal dialysis and CKD 1 or 2. METHODS: Retrospective review of adult inpatients' charts, comparing those with billing codes for "Hemodialysis" vs. inpatients without those charges, and an outpatient peritoneal dialysis cohort. Patients with CKD 3 or 4 were excluded. RESULTS: One hundred and sixty-seven charts were reviewed. ECG conduction intervals were consistently and statistically longer among hemodialysis patients (n=88) vs. peritoneal dialysis (n=22) and CKD stage 1 and 2 (n=57): PR (175±35 vs 160±44 vs 157±22 msec) (p=0.009), QRS (115±32 vs. 111±31 vs 91±18 msec) (p=0.001), QT (411±71 vs. 403±46 vs 374±55 msec) (p=0.006), QTc (487±49 vs. 464±38 vs 452±52 msec) (p=0.0001). The only significantly different conduction abnormality was prevalence of left bundle branch block: 13.6% among HD patients, 5% in PD, and 2% in CKD 1 and 2 (p=0.03). CONCLUSION: To our knowledge, this is the first study to report that ECG conduction intervals are significantly longer as one progresses from CKD Stage 1 and 2, to PD, to HD. These and other data support the need for future research to utilize ECG conduction times to identify dialysis patients who could potentially benefit from proactive cardiac evaluations and risk reduction.

Iatrogenic Cushing's Syndrome Following Intra-Articular Triamcinolone Injection in an HIV-Infected Patient on Cobicistat Presenting as a Pulmonary Embolism: Case Report and Literature Review.

BACKGROUND: Iatrogenic Cushing's syndrome (ICS) typically develops after long-term exposure to corticosteroids, but it can occur after a single dose in patients treated with cobicistat or ritonavir for HIV. We present a patient who developed ICS due to the interaction between cobicistat and triamcinolone, a review of the literature, and what to our knowledge is the first case of ICS presenting as a pulmonary embolism. CASE PRESENTATION: A 55-year old male with a past medical history of human immunodeficiency virus, undetectable for 15 years and currently on elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, received 2 intra-articular injections of triamcinolone one month apart for a Baker's cyst in his right knee. He used nasal fluticasone for 9 days in-between the injections. After his second knee injection, he developed easy bruising and friable skin. Over the coming months, he experienced weight gain and Cushingoid facies. Four months after the knee injections he developed a pulmonary embolism and deep vein thrombosis treated with warfarin. The Cushingoid facies prompted an evaluation and diagnosis of ICS along with hypothalamic pituitary adrenal axis suppression. CONCLUSION: This case demonstrates the need to monitor patients on pharmacological boosters with any exposure to corticosteroids, whether it be injected, inhaled, topical, oral or intravenous, as it can lead to profound adrenal suppression and ICS.

Tolosa-Hunt Syndrome: A Non-Classical Presentation of a Rare Cause of Unilateral Headache and Painful Ophthalmoplegia.

Tolosa-Hunt syndrome is a rare condition involving the orbital and retro-orbital space. The typical symptoms are orbital pain, swelling, headache, palsies of the cranial nerves, and sensory loss in the distribution of the trigeminal nerve. Tolosa-Hunt syndrome relapses and remits with episodes separated by months to years. It is a diagnosis of exclusion after ruling out other causes of painful ophthalmoplegia and is treated with high-dose steroids. We present a case of a 43-year-old woman with a history of recurrent headaches and vision disturbances for the past 4 years presenting with worsening left-eye pain that radiated to the back of her head, swelling around the left eye, double vision, and a unilateral left-sided headache. Visual acuity was decreased in the left eye compared to the right and the patient reported left-eye pain when at extreme medial and lateral gaze. Erythrocyte sedimentation rate (ESR) was found to be elevated with all other laboratory testing within normal limits. Computed tomography (CT) scan of the orbits was unremarkable. Ophthalmology excluded other differential diagnoses and she was treated with intravenous methylprednisolone with significant improvement of symptoms. The triad of one or more episodes of unilateral orbital pain, paresis of one or more of the cranial nerves, and granulomas by magnetic resonance imaging (MRI) or biopsy is 95-100% sensitive at diagnosing the syndrome; however, our patient did not present with the "classic" triad. Initial treatment of Tolosa-Hunt is with high-dose steroids which as in our case lead to rapid and significant improvement of symptoms.

Peatland Microbial Community Composition Is Driven by a Natural Climate Gradient.

Peatlands are important players in climate change-biosphere feedbacks via long-term net carbon (C) accumulation in soil organic matter and as potential net C sources including the potent greenhouse gas methane (CH4). Interactions of climate, site-hydrology, plant community, and groundwater chemical factors influence peatland development and functioning, including C dioxide (CO2) and CH4 fluxes, but the role of microbial community composition is not well understood. To assess microbial functional and taxonomic dissimilarities, we used high throughput sequencing of the small subunit ribosomal DNA (SSU rDNA) to determine bacterial and archaeal community composition in soils from twenty North American peatlands. Targeted DNA metabarcoding showed that although Proteobacteria, Acidobacteria, and Actinobacteria were the dominant phyla on average, intermediate and rich fens hosted greater diversity and taxonomic richness, as well as an array of candidate phyla when compared with acidic and nutrient-poor poor fens and bogs. Moreover, pH was revealed to be the strongest predictor of microbial community structure across sites. Predictive metagenome content (PICRUSt) showed increases in specific genes, such as purine/pyrimidine and amino-acid metabolism in mid-latitude peatlands from 38 to 45° N, suggesting a shift toward utilization of microbial biomass over utilization of initial plant biomass in these microbial communities. Overall, there appears to be noticeable differences in community structure between peatland classes, as well as differences in microbial metabolic activity between latitudes. These findings are in line with a predicted increase in the decomposition and accelerated C turnover, and suggest that peatlands north of 37° latitude may be particularly vulnerable to climate change.

Capsule Endoscopy Transit Time to Duodenum: Relation to Patient Demographics.

Background Anesthesia guidelines recommend fasting for at least two hours to minimize aspiration risk related to endoscopic procedures, and the American Society for Gastrointestinal Endoscopy (ASGE) states that the final oral preparation liquid can be administered three to eight hours before the procedure. We have observed the cancellation of endoscopy procedures if liquids were consumed within four, six, or eight hours of the start time. Objectively, documenting gastric transit time via a review of pill endoscopy data could address clinician concerns, prevent delays in patient care, and improve the rate at which our clinicians practice within national guidelines. The objective was to utilize capsule endoscopy data from our center to report the relationship between patient factors that could affect gastric transit time (GTT) and small bowel transit time (SBTT) such as chronic kidney disease (CKD), diabetes mellitus (DM), nutritional status, and obesity. Methods This retrospective review obtained data on adult pill endoscopy (PillCam™ SB 3) (Medtronic, Minneapolis MN) studies on in- and outpatients. Past medical history and laboratory data were abstracted from electronic medical records. Mean GTT and SBTT are reported in minutes + standard deviation (SD) and times were compared accounting for conditions that could prolong transit, such as diabetes mellitus or chronic kidney disease (CKD). Results One hundred and sixty-three records reviewed. Four patients were excluded as the pill did not pass out of the stomach. The mean age was 66 years, 57% were female, and 26% were evaluated for gastrointestinal (GI) bleeding. The mean GTT for all patients (n = 159) was 35 + 49 with a median of 19 minutes. There were no statistically significant differences in GTT between the following subgroups: CKD0 (n = 100) 40 + 58 versus CKD5 (n = 11) 35 + 39, albumin > 3.0 (n = 123) 37 + 53 versus albumin < 3.0 (n = 36) 27 + 30, diabetes mellitus (DM) (n = 40) 51 + 71 vs. non-DM (n = 119) 42 + 79, body mass index (BMI) > 30, or aspirin use. The SBTT results in all patients (n = 124) was 238 + 88 minutes. Similarly, there was no relation between SBTT and albumin, any CKD, CKD0 versus CKD5, DM status, or BMI. The patients with the capsule stuck in the stomach did not have any other clinical history to explain this occurrence. Conclusions This analysis of objective data regarding pill endoscopy found that the mean GTT was 44 minutes, and it was < 60 minutes for 85% of the cohort. Patient factors were not associated with longer transit times, and this is the first report to document PillCam times in relation to CKD. These data support recommendations that endoscopic procedures, in accordance with anesthesia and ASGE guidelines, can be safely conducted in the majority of patients within 60 minutes of ingesting liquids.