A Rare Case of Anti-glycyl transfer RNA (tRNA) Synthetase Antibody-Related Non-specific Interstitial Pneumonia.

This is a case of a 65-year-old female with a past medical history of type 2 diabetes mellitus (DM) and hypothyroidism who presented with a five-day history of shortness of breath, dry cough, and fatigue. Shortness of breath was exertional, and cough was intermittent. She had no exposure to COVID-19 infection. During the presentation, the patient required supplemental oxygen up to 6 liters per minute (L/m) and was tachypneic and tachycardic. Initial computed tomography (CT) of the chest revealed bilateral parenchymal disease compatible with COVID-19 pneumonia, however, the patient's COVID-19 polymerase chain reaction (PCR) test was persistently negative. Despite being treated for COVID-19 pneumonia, the patients' oxygen requirement increased, leading to the requirement of non-invasive positive pressure ventilation (BiPAP - bilevel positive airway pressure). The pulmonologist initiated a workup for possible underlying interstitial lung disease (ILD). Anti-glycyl transfer RNA (anti-EJ) antibody was positive on two occasions. The patient was started on pulse dose steroid and long-term steroid taper. The patient responded very well to the steroid and was later able to wean off the oxygen to room air. High-resolution CT which was done 3 months after the hospital stay revealed features suggestive of non-specific interstitial pneumonia (NSIP). Anti-synthetase syndrome is a rare but treatable etiology of ILD and should always be considered as a differential during workups.

An Unusual Case of Dilated Cardiomyopathy in Wegner's Granulomatosis.

A 33-year-old male presented to the emergency with cough, hemoptysis, and shortness of breath. He was on steroids for suspected Still's disease due to arthralgias and fever prior to presentation to the emergency. He developed sudden hypoxic respiratory failure and required mechanical ventilation. The initial imaging studies of the chest including computed tomography (CT) of the chest showed marked diffuse central and basilar predominant opacities with associated smooth septal thickening. Furthermore, the patient's creatinine, troponin, B-type natriuretic peptide (BNP), rheumatoid factor, and D-dimer were elevated. Vasculitis workup, bronchoscopy, and echocardiogram were performed. The echocardiogram revealed severely decreased left ventricular systolic function with an ejection fraction of 24% with dilated left ventricle. The electrocardiogram did not show any findings of acute ischemia. He was started on pulse dose steroid and dobutamine drip along with intermittent diuresis. The patient was successfully extubated after two days of mechanical ventilation. He was started on cyclophosphamide in the hospital. Dobutamine was discontinued. He was moved to the general medical floor as his oxygenation improved, but later at night, he developed respiratory failure and required a bumetanide drip. The cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) (anti-PR-3 antibody) came back positive with titer >1:40, so Wegner's granulomatosis was diagnosed. He received three sessions of plasmapheresis. The patient's kidney function improved significantly, and the bumetanide drip was transitioned to intravenous pushes. His oxygenation improved significantly with saturations of 92% on room air. The patient was discharged on steroid, Bactrim, and systolic heart failure medications to follow up with rheumatology, nephrology, pulmonology, and cardiology in the office. Due to insurance issues, his outpatient care was delayed significantly. The patient followed up with rheumatology after two months and has been planned for rituximab induction and to continue steroid along with Bactrim. This case is worth reporting because it describes dilated cardiomyopathy (DCM) as a cardiac manifestation of Wegner's granulomatosis. Early cardiac evaluation should be incorporated into the management of the patient suspected of Wegner's granulomatosis.

Prevalence of poor mental health among medical students in Nepal: a cross-sectional study.

BACKGROUND: Poor mental health among medical students is widely acknowledged. Studies on mental health among medical students of Nepal are lacking. Therefore, we conducted a study to determine the prevalence of mental disorders. METHODS: A cross-sectional study was conducted among medical students at KIST Medical College and Teaching Hospital, Nepal from December 2016 to February 2017. Our survey instrument consisted of the Patient Health Questionnaire (PHQ) and questions about socio-demographic factors, smoking, marijuana use, suicidal ideation and thoughts of dropping out of medical school. RESULTS: The prevalence rates were 29.2% (95% CI, 24.4% - 34.3%) depression, 22.4% (95% CI, 18.0% - 26.9%) medium to highly severe somatic symptoms, 4.1% (95% CI, 2.0% - 6.2%) panic syndrome, 5.8% (95% CI, 3.4% - 8.3%) other anxiety syndrome, 5% (95% CI, 2.7% - 7.3%) binge eating disorder and 1.2% (95% CI, 0.0% - 2.3%) bulimia nervosa. Sixteen students [4.7% (95% CI, 2.4% - 6.9%)] seriously considered committing suicide while in medical school. Thirty-four students [9.9% (95% CI, 6.8% - 13.1%)] considered dropping out of medical school within the past month. About 15% (95% CI, 11.1% - 18.6%) of the students reported use of marijuana during medical school. CONCLUSIONS: We found high prevalence of poor mental health among medical students of Nepal. Future studies are required to identify the factors associated with poor mental health.

Use of 90% ethanol to decontaminate stethoscopes in resource limited settings.

BACKGROUND: In developing countries like Nepal, 90% ethanol is cheap and is available in most hospitals. The unavailability of isopropyl alcohol (IPA) in these settings led us to compare the efficacy between 90% ethanol and isopropyl alcohol pads in reducing the bacterial contamination of diaphragm of stethoscope. METHODS: A randomized blinded experimental study was carried out to determine the difference between cleaning stethoscopes with 90% ethanol and IPA. Cultures of diaphragm were taken before and after cleaning with one of the cleaning agent. Colony forming units (CFU) count and organism identification was done by a blinded investigator. CFU before and after cleaning were compared using Wilcoxon signed-rank test. Mann Whitney U test was used to compare the decrease in CFU count between the cleaning agents. RESULTS: About 30% of the stethoscopes harbored potential pathogens. Significant reduction in CFU was observed with both IPA (Wilcoxon signed-rank test, P value <0.001) and 90% ethanol (Wilcoxon signed-rank test, P value <0.001). Comparing median decrease in CFU between cleaning with IPA and with 90% ethanol, no significant difference was found (Mann Whitney U test; U = 1357, P value >0.05). CONCLUSIONS: Both 90% ethanol and IPA are equally effective in decontaminating the diaphragm of stethoscope. Selection of agent should be done on the basis of cost and availability.