Predictors of Outcomes in Cerebellar Stroke: A Retrospective Cohort Study From the National Inpatient Sample Data.

Cerebellar strokes have high morbidity and mortality due to bleeding or edema, leading to increased pressure in the posterior fossa. This retrospective cohort study analyzed three outcomes following a cerebellar stroke: in-hospital mortality, length of hospital stay, and total hospitalization costs. It uses data from the National Inpatient Sample (NIS) and aims to identify the predictors of outcomes in cerebellar stroke patients, including 464,324 patients, 18 years of age and older, hospitalized between 2010 and 2015 in US hospitals with cerebellar strokes. In our study, for every decade age increased beyond 59 years, there was a significant increase in mortality; those aged 80+ years had 5.65 odds of mortality (95% CI: 5.32-6.00; P < 0.0001). Significant differences in patient characteristics were observed between patients who survived to discharge and those who did not, including older age (77.4 vs. 70.3 years; P < 0.0001), female sex (58% vs. 52%; P < 0.0001), and being transferred from another healthcare facility (17% vs. 10%; P < 0.0001). Patients admitted directly rather than through the emergency department were more likely to die (29% vs. 16%; P < 0.0001). The mortality rate was lower for blacks (OR: 0.75; P < 0.0001), Hispanics (OR: 0.91; P = 0.005), and Asians (OR: 0.89; P = 0.03), as compared to the white population, for females in comparison to males, and geographically, in all other areas (Midwest, South, and West) in contrast to the Northeast. Cerebellar stroke incidence and high mortality were seen in the traditional stroke belt. Mortality is also affected by the severity of the disease and increases with the Charlson Comorbidity Index (CCI), All Patient Refined Diagnosis Related Groups (APR-DRG) scores, and indirectly by place of receiving care, length of stay (LOS), cost of stay, type of insurance, and emergency department admissions. LOS increased with age, in males in the Northeast, and was less in whites compared to other races. Trend analysis showed a decrease in LOS and costs from 2010 to 2015. Increased costs were seen in non-whites, males, higher household income based on zip code, being covered under Medicaid, transfers, CCI ≥ 5, and discharges in the western US. Median household income based on the patient's zip code was well-balanced between those who lived and those who died (P = 0.091). However, payers were not evenly distributed between the two groups (P < 0.0001 for the overall comparison). A higher proportion of discharges associated with in-hospital mortality were covered under Medicare (70% vs. 65% in the died vs. lived groups, respectively). Fewer discharges were associated with death if they were covered by commercial insurance or paid for out-of-pocket (15% vs. 19% for commercial insurance and 3% vs. 5% for out-of-pocket). In-hospital mortality was associated with a longer length of hospital stay (5.6 days vs. 4.5 days; P < 0.0001) and higher costs ($16,815 vs. $11,859; P < 0.0001). Variables that were significantly associated with lower total costs were older age, having commercial insurance, paying out-of-pocket or other payers, not being admitted through the emergency department, having a lower comorbidity index (CCI = 1-2), and being discharged from a hospital that was small- or medium-sized, located in the Midwest or South, and/or was non-teaching (rural or urban).

Antimalarial prophylaxis failure: Malaria in a returning traveler despite mefloquine prophylaxis.

This case report presents a perplexing case of Plasmodium malariae breakthrough infection despite prophylaxis with appropriate antimalarial prophylactic regimen of mefloquine in a compliant patient. A 78-year-old missionary who travels each year to the African subcontinent for multiple weeks to months, over 25 years, adheres to stringent antimalarial prophylaxis with Mefloquine as prescribed, starting prior to the trip and continuing after the return to the U.S.A. She gave no prior history of malaria during her 25 years of travel to Africa and back. Since she had no prior history of malaria and due to her excellent compliance with antimalarial regiment, despite her presentation which were suggestive of malaria, neither the patient nor her providers recognized the onset of malaria in this case. Infectious diseases physicians approached this case with an open mind, investigated appropriately, requested appropriate tests, found the presence of malarial parasite, identified as P. malariae species thereafter. She was started on antimalarial treatment in a timely fashion and showed an excellent response. This intriguing recovery of malarial parasite and response to treatment despite the patient being on antimalarial prophylaxis raised the possibility of mefloquine failure as an antimalarial prophylactic agent against P. malariae species.

Case report: Hospital-acquired chickenpox in a healthcare setting.

Chickenpox (varicella) is a rare occurrence in healthcare settings in the USA, but can be transmitted to healthcare workers (HCWs) from patients with herpes zoster who, in turn, can potentially transmit it further to unimmunized, immunosuppressed, at-risk, vulnerable patients. It is uncommon due to the inclusion of varicella vaccination in the recommended immunization schedule for children and screening for varicella immunity in HCWs during employment. We present a case report of hospital-acquired chickenpox in a patient who developed the infection during his prolonged hospital stay through a HCW who had contracted chickenpox after exposure to our patient's roommate with herpes zoster. There was no physical contact between the roommates, but both patients had a common HCW as caregiver. The herpes zoster patient was placed in airborne precautions immediately, but the HCW continued to work and have physical contact with our patient. The HCW initially developed chickenpox 18 days after exposure to the patient with herpes zoster, and our patient developed chickenpox 17 days after the HCW. The timeline and two incubation periods, prior to our patient developing chickenpox, indicate transmission of chickenpox in the HCW from exposure to the herpes zoster patient and subsequently to our patient. The case highlights the potential for nosocomial transmission of chickenpox (varicella) to unimmunized HCWs from exposure to patients with herpes zoster and further transmission to unimmunized patients. Verification of the immunization status of HCWs at the time of employment, mandating immunity, furloughing unimmunized staff after exposure to herpes zoster, and postexposure prophylaxis with vaccination or varicella zoster immunoglobulin (Varizig) will minimize the risk of transmission of communicable diseases like chickenpox in healthcare settings. Additionally, establishing patients' immunity, heightened vigilance and early identification of herpes zoster in hospitalized patients, and initiation of appropriate infection control immediately will further prevent such occurrences and improve patient safety.This is a case report of a varicella-unimmunized 31-year-old patient who developed chickenpox during his 80-day-long hospitalization. He had different roommates during his long hospital stay but had no physical contact with them and neither had visitors. On most days, the same HCW rendered care to him and his roommates. One of the patient's roommates was found to have herpes zoster and was immediately moved to a different room with appropriate infection prevention measures. The HCW is presumably unimmunized to varicella and sustained significant exposure to the patient with herpes zoster during routine patient care which involved significant physical contact. The HCW was not furloughed, assessed for immunity, or given postexposure prophylaxis (PEP). The HCW had continued contact with our patient as part of routine care. On day 18, after exposure to the patient with herpes zoster, the HCW developed chickenpox. 17 days thereafter, our patient developed chickenpox. The time interval of chickenpox infection in the HCW after one incubation period after exposure to the patient with herpes zoster followed by a similar infection of chickenpox in our patient after another incubation period suggests the spread of varicella zoster virus (VZV) from the herpes zoster patient to the HCW and further from the HCW to our patient. Assessing the immunity of HCWs to varicella at the time of employment, ensuring only HCWs with immunity take care of herpes zoster and varicella patients, furloughing unimmunized exposed HCWs, offering PEP, and documentation of patients' immunity to varicella at the time of hospital admission could help prevent VZV transmission in hospital settings. This is an attempt to publish this novel case due to its high educational value and relevant learning points.

Subacute Thyroiditis Masking as Fever of Unknown Origin: An Intriguing Case Report.

This study presents a unique case of subacute thyroiditis, which presents as prolonged high-grade fever without any other symptoms except for mild throat pain. A 46-year-old, otherwise healthy male presented with high-grade fever for more than two to three weeks and was found to have hyperthyroidism, with elevated free thyroxine levels (free T4), low thyroid-stimulating hormone (TSH) levels, elevated c-reactive protein (CRP) an inflammatory marker, and heterogeneous bilateral thyroid nodules on imaging studies. His workup was negative for infectious etiology of fever, thus favoring the diagnosis of subacute thyroiditis as the cause of fever of unknown origin (FUO). This case highlights the importance of considering subacute thyroiditis as a potential etiology in patients with FUO and the significance of a comprehensive workup to guide appropriate management.

A Case Report of Cardiac Failure in a Patient on Teduglutide for High-Output Ileostomy Stoma.

A high volume of ileostomy output in patients with extensive bowel resection can be hard to manage. This leads to extensive loss of fluids and electrolytes along with malabsorption. Medications have traditionally controlled it by delaying intestinal transit and decreasing intestinal and gastric secretion using opiates, loperamide, diphenoxylate, omeprazole, somatostatin, and octreotide. However, many patients depend on parenteral nutrition and fluid and electrolyte infusions, even with optimal drug therapy. Despite the best possible care, they may develop renal failure. Teduglutide is a glucagon-like peptide-2 (GLP-2) analog given as a daily subcutaneous injection, and it has been promising in managing short bowel syndrome. It has been effective in decreasing the dependence on parenteral nutrition. However, improving fluid and electrolyte balance can precipitate cardiac failure in some patients, especially those with borderline cardiac functions, hypertension, and thyroid disorders. This usually presents in the first few months of the initiation of teduglutide therapy and may require stopping the medication. We present the case report of an elderly female with a high-output stoma on parenteral nutrition on teduglutide. There was a significant decrease in stoma output, and parenteral nutritional support could be stopped. However, she presented with worsening dyspnea and was diagnosed with cardiac failure with an ejection fraction of 16%-20%. The baseline ejection fraction was 45%, done six months before this. Coronary angiography showed no stenosis in any vessels, and the decline in left ventricular ejection fraction and fluid overload was attributed to teduglutide therapy.

Effect of Electronic Cigarettes on the Gastrointestinal System.

INTRODUCTION: In the United States, the use of electronic cigarettes (EC) has seen an exponential rise with 12.6% of adults using an EC at least once in their lifetime, with use differing by age, sex, and race. The level of nicotine exposure of EC is highly variable with its liquids containing 14.8-87.2 mg/ml of nicotine. Its use has been documented to be associated with adverse effects on the respiratory, nervous, cardiovascular, and gastrointestinal (GI) systems. Common adverse effects on the GI system include xerostomia, oral mucositis, tongue discoloration, gingivitis, gum bleeding, nausea, vomiting, gastric burning, and altered bowel habits. METHODS: A retrospective review of the National Health and Nutrition Examination Survey (NHANES) data from 2015-16 was conducted. Data regarding the use of EC and a history of vomiting and diarrhea over a period of 30 days was analyzed using SAS 9.4 (2013; SAS Institute Inc., Cary, North Carolin, United States). Additionally, data regarding age, gender, and income were also analyzed. A p-value of <0.05 was considered statistically significant. Continuous variables were analyzed using the two-sample t-test, and categorical variables were analyzed using the Chi-Square test. RESULTS: A total of 944 participants were included in the study. Of these, 261 participants (males 62.84%) used EC at least one day and 683 participants (males 54.76%) never used EC, during the preceding 30 days. Amongst EC users (n=261), 10.73% had a stomach or intestinal illness manifesting as vomiting or diarrhea that started during those 30 days compared to 8.64% who never used EC during the same period (n=683). However, the results did not reach statistical significance (p = 0.3208) Conclusion: Conflicting views exist regarding the effects of EC on the GI tract. Our study demonstrated an association between EC consumption and vomiting and diarrhea. The study results are to be viewed by taking into consideration the limitations of a smaller sample, shorter duration, comorbidities, and undefined nicotine content in the EC. Although recent studies have shown no effect of EC on the oral or gut microbiota, our study findings could be attributed to EC-induced alteration of motility or irritation of the GI tract. However, further studies are required to establish a causal relationship and enunciate the mechanism by which EC components affect the GI tract. Careful consideration and diligence about the health effects of ECs are required before it is assumed to be safe as a cigarette substitute or as a means of smoking cessation.

Interns' anticipatory anxiety about cardiopulmonary resuscitation: reducing it while bolstering confidence with psychological skills training.

INTRODUCTION: Dealing with emergencies is a critical responsibility of physicians-in-training. Residents typically lead cardio-pulmonary resuscitation efforts in a teaching hospital. A 'Code Blue' is a situation that is highly challenging, time sensitive and very often highly anxiety-provoking. Recently, there is greater recognition of the need and value of integrating specific psychological performance skills training to better manage the stress of critical situations. In this study, we sought to evaluate the impact of including a psychological skills training program with BLS/ACLS training for performance and confidence optimization and mitigation of anxiety in 1 year residents related to participating in and leading emergency resuscitations. MATERIALS AND METHODS: First-year residents across six specialties underwent traditional BLS/ACLS training with the addition of a 3 h psychological skills training component (Code Calm) as part of their residency orientation. Anxiety and confidence-based questionnaires were used to evaluate the residents' perceptions of code-related stress and confidence to lead resuscitation efforts. RESULTS: Code-related anxiety scores demonstrated a statistically significant decrease post training (p < 0.0001); general confidence scores showed a statistically significant increase post-training (p < 0.001); confidence in leading resuscitation showed a statistically significant increase (p < 0.0001). DISCUSSION: The results of this study demonstrate that BLS/ACLS training can positively influence anxiety and confidence in residents related to their resuscitation skills, especially if combined with psychological skills training. Future studies should evaluate the incremental value of including psychological skills training with BLS/ACLS and its impact on enhancing physical performance skills.

Salt Consumption and Myocardial Infarction: Is Limited Salt Intake Beneficial?

INTRODUCTION: Sodium is an essential mineral that plays a crucial role in the maintenance of normal cellular homeostasis, regulation of fluid and electrolytes, and blood pressure (BP). Due to the presence of sodium in a variety of regularly consumed food products, the deficiency of sodium is extremely unlikely. On the other hand, excess intake of dietary sodium is observed in many populations as it is generally used in most food products. Existing guidelines recommend lowering salt consumption for better cardiovascular health; these dietary sodium intake recommendations are not reassuring as the evolving studies show evidence that there is a higher risk of cardiovascular disease (CVD) with low sodium consumption. The aim of this study was to identify the association between salt consumption and myocardial infarction (MI). METHODS: The National Health and Nutrition Examination Survey (NHANES) data between 2017- 2018 was analyzed to examine the association between sodium intake (use in daily meal preparation) and reported history of MI. Logistic regression was used to assess for significant differences between the groups and calculated odds ratios while adjusting for confounders. RESULTS: A total of 4626 participants were included in the study, with a mean age of 66 ± 11 years in those with a history of MI (n = 212). Amongst these participants, those with salt consumption "Occasionally used" or "Very often used" were less likely to have suffered from MI than those who "Never used" salt in meal preparation. Multivariable logistic regression was performed to control for confounders. "Occasionally used" compared to "Never used" odds ratio was 0.5227 (95% confidence interval (CI); 0.3053-0.9009 p = 0.0184) and "Very often used" compared to "Never used" odds ratio was 0.5033 (95% CI; 0.2892-0.8799 p = 0.0152). CONCLUSION: After adjusting for confounders, the participants that used salt more liberally during meal preparation were less likely to have MI than those who minimally or never used salt in meal preparation.

Factors associated with increased mortality in hospitalized COVID-19 patients.

BACKGROUND: The rapid spread of the coronavirus disease 2019 (COVID-19) epidemic has significantly impacted global health. So far, the evidence regarding the risk factors that predict the outcomes of COVID-19 patients is limited. In this study, we identified several risk factors that are associated with increased mortality in COVID-19 patients. METHODS: We performed a retrospective review of electronic medical records of the patients admitted with an initial diagnosis of COVID-19. We extracted several patient variables (including demographics, lab results, and pre-existing conditions) and examined for their association with increased mortality. RESULTS: Of the 487 people included in the study, 340 survived and 147 expired. Significant differences existed in demographics and underlying comorbidities between the two groups. A higher proportion of patients were age 65 and older (87.76% vs 53.24%, p < 0.001), and were predominantly male (63.27% vs 52.94%, p = 0.0351). Multivariate analysis showed five variables to be the predictors for mortality: age ≥65 [OR = 3.87, 95% CI (2.01, 7.46), p < 0.001], initial presentation with dyspnea [OR = 1.71, 95% CI (1.03, 2.82), p = 0.037], history of cardiomyopathy [OR = 3.33, 95% CI (1.07, 10.41), p < 0.038], positive initial chest imaging findings [OR = 2.24, CI (1.26, 3.97), p = 0.006], and acute kidney injury (AKI) [OR = 3.33 CI (2.10, 5.28), P < 0.001]. CONCLUSION: Identifying COVID-19 patients with these characteristics may help guide the management and improve mortality.

Atypical presentation of an elderly male with autoimmune encephalitis: anti-LG1 limbic encephalitis.

INTRODUCTION: We present a case of an elderly male with anti-LG1 limbic encephalitis involving hypothalamus presenting with acute changes in mental status and persistent hyperthermia. CASE REPORT: A 74-year-old male presented to the hospital with fever and chills. He had also been evaluated by his PCP for changes in his mental status, trouble remembering things, and following directions while driving. A lumbar puncture was performed, and empiric meningitis coverage was initiated. His LP results were not suggestive for any infectious process. An MRI showed bilateral hippocampal edema. As an infectious workup was non-revealing and other causes were ruled out, with the concern for paraneoplastic or autoimmune encephalitis, patient was started on high dose steroids and plasma exchange while results of antibodies for autoimmune and paraneoplastic encephalitis were awaited. After plasmapheresis and a course of steroids, the patient's mental status began to slowly improve. He was discharged from the hospital and on subsequent neurology office visit, his serum autoimmune encephalitis panel returned positive for anti-LGI 1 antibodies. Further management consisted of outpatient rituximab infusion. DISCUSSION: Diagnosis of limbic encephalitis can be challenging and can present with symptoms of limbic dysfunction. A modest index of suspicion of limbic encephalitis should be kept in adults with altered mental changes. Early recognition and initiation of therapy can be crucial in the management of patients with autoimmune encephalitis and can prevent permanent cognitive impairment and damage.

The Role of Interleukin-6 Inhibitors in the Treatment of COVID-19 Infections: A Case Series.

An outbreak of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) infection started in December 2019 in China that resulted in a global health emergency. The World Health Organization later named the disease as coronavirus disease 2019 (COVID-19). Currently, there is no effective treatment available and the data are evolving through continuous clinical trials and ongoing research. Severe infections present with hypoxemic respiratory failure from acute respiratory distress syndrome as one of the major complications. We report two cases of COVID-19 patients who initially presented with moderate to severe symptoms. Later, their clinical course worsened despite ongoing treatment with multiple medications such as hydroxychloroquine and azithromycin until they were started on tocilizumab. Within a short period after they were administered tocilizumab, their oxygen saturation improved and other inflammatory markers such as D-dimer levels, lactate dehydrogenase, and ferritin levels decreased. There is an increase in the amount of research citing the role of various cytokines in the pathophysiology of COVID-19. Targeting the inflammatory mediators in the pathogenesis, especially interleukin-6 pathway inhibitors, would improve overall morbidity and mortality, thus decreasing the burden on healthcare systems.

Metformin Associated Lactic Acidosis in the Intensive Care Unit: A Rare Condition Mimicking Sepsis.

Metformin-associated lactic acidosis (MALA) is a rare but serious complication of metformin use, associated with high mortality. MALA can occur any time a patient on metformin suffers disruption in renal function resulting in the accumulation of metformin. A 63-year-old man with a history of non-insulin-dependent type 2 diabetes mellitus, alcohol abuse, and hypothyroidism was brought to the emergency department with altered mental status, nausea, vomiting, and abdominal pain. He was found to be in respiratory distress, was hypotensive and hypoglycemic (48 mg/dL), and required emergent intubation. Blood work was significant for pH<6.69, undetectable bicarbonate, anion gap 37.2 mEq/L, lactate >12 mmol/L, creatinine 15.95 mg/dL, blood urea nitrogen (BUN) 112 mg/dL, glomerular filtration rate (GFR), 3 ml/min/1.73sqm, and potassium 7 mmol/L. He suffered cardiac arrest, underwent cardiopulmonary resuscitation (CPR), and was admitted to the intensive care unit (ICU) where he required multiple vasopressors, bicarbonate infusion, and bicarbonate pushes. He was started on continuous renal replacement therapy with a high flux membrane. A high dose of pre- and post- filter fluids was used to improve conductive clearance. His pH corrected to normal in less than 24 hours, and hemodialysis was initiated the following day for a total of four days. Head/chest/abdomen/pelvis CT, urine, and blood cultures did not reveal any pathology that would explain lactic acidosis. The patient's dose of metformin was 1 gr twice daily and sitagliptin, 100 mg daily. Blood metformin that had been tested on admission was 29 mcg/ml (therapeutic range, 1-2 mcg/ml). Methanol, ethanol, ethylene glycol, propylene glycol, and isopropanol levels were negative. He had been started on lisinopril 5 mg and amitriptyline 25 mg four weeks prior to admission and had normal creatinine at that time. He was discharged to an acute rehabilitation facility on day seven of hospitalization. MALA generally presents with nausea, vomiting, and fatigue-often mimicking sepsis. It is possible that our patient progressively developed alcoholic ketoacidosis and acute renal failure from dehydration and excessive drinking in the setting of newly started Angiotensin-converting-enzyme (ACE) inhibitor. Recommendations for the optimal treatment of MALA mostly depend on expert opinion and case reports. Treatment is restricted to supportive measures, although hemodialysis may offer a protective effect. Our case demonstrates that even in extreme cases of MALA, prompt and adequate supportive measures can produce a favorable outcome.

Takotsubo Cardiomyopathy in a Nonagenarian With Urosepsis.

Takotsubo cardiomyopathy (TCM) is a rare but reversible myocardial left ventricular (LV) dysfunction, which mimics acute coronary syndrome (ACS) without the presence of significant coronary artery disease (CAD). Emotional stressors may include the death of kin or a life-threatening medical diagnosis whereas physical stressors include infections, endoscopic procedures, exacerbation of asthma, or systemic disorders. A 90-year-old female presented to the ED with nausea, intermittent chest heaviness, and generalized weakness for a duration of three days. Her troponin-I was elevated and an electrocardiogram (EKG) showed T-wave inversions in leads V2-V6 and no ST-segment changes. An echocardiogram (ECHO) revealed an ejection fraction (EF) of 35%-40% with anteroapical hypokinesis. She underwent cardiac catheterization showing nonobstructive CAD. She was diagnosed with pan-sensitive Escherichia coli urosepsis and started on ceftriaxone. She improved clinically and was discharged. A repeat ECHO done a month later showed normal EF. Urosepsis-induced TCM has rarely been reported in the literature. Physicians should have a high index of suspicion of TCM in patients with symptoms mimicking ACS in the presence of a physical stressor like an infection. We report the case of TCM, which resulted from a urinary tract infection (UTI) in an elderly female.

Packed Red Blood Cell Transfusion as a Potential Treatment Option in COVID-19 Patients With Hypoxemic Respiratory Failure: A Case Report.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of coronavirus disease 2019 (COVID-19), an ongoing pandemic that started as an outbreak in China. The clinical picture varies from asymptomatic or mild cases to critically ill patients. Most of the critically ill patients present with hypoxia due to acute respiratory distress syndrome. These patients have a poor prognosis, especially in people with underlying co-morbidities. We present a case report of a 78-year-old male with multiple co-morbidities initially presenting with cardiac arrest and COVID-19 who showed drastic clinical improvement after he was administered a packed red blood cell transfusion. The patient was initially intubated for acute respiratory failure but was extubated on the second day as the patient's respiratory status improved. Although this patient had multiple comorbidities, he did extremely well after he received a packed red blood cell transfusion. Recently, there is some evidence showing the effect of the novel coronavirus on hemoglobin levels. Poor clinical outcomes of critically ill patients are most likely due to the impaired gaseous exchange in the lungs in addition to the decreased oxygen-carrying capacity caused by the destruction of red blood cells. Currently, there is limited evidence available in this area and further research may help in developing effective treatment strategies.

Grit in Medical Education: Differing Perspectives of Residents and Mentors.

Background Increasing concerns about depression and burnout in residents have led to a recent focus on assessing "non-cognitive" traits in residents and residency applicants. One attribute that has received significant attention is grit, defined as trait-level perseverance and passion for long-term goals. With an objective measure available, an important question is under what circumstances of administration is that measure reliable and accurate. The goal of this study was to ascertain whether internal medicine residents and their faculty mentors were congruent in their ratings of resident grit, or if not, how the ratings differed.  Methods Subjects were internal medicine residents (N=42) at a community-based university-affiliated hospital internal medicine residency program. Near the end of the academic year 2019, residents completed the GRIT-S (short form). As each resident is assigned a mentor during their training, each resident's mentor was also asked to complete the GRIT-S based on their view of their mentee.  Results This study failed to find a significant correlation between resident self-ratings of grit and those of their mentors. Conclusions The results of these two studies underscore the difficulty in obtaining accurate assessments of non-cognitive traits. These results further the understanding of the role of grit and raise important questions about how assessments might be used to assure validity. Further areas of inquiry into this potentially important characteristic are suggested.

Opioid antidote induced pulmonary edema and lung injury.

INTRODUCTION: Opioid overdose emergencies are increasing every year, naloxone is the antidote for the treatment of opioid overdose. Naloxone is being dispensed to even lay persons through some programs to prevent opioid overdose deaths. CASE: 23 year old patient presented with naloxone treated opioid overdose complained of chest pain, pink frothy sputum production and shortness of breath. Physical exam showed tachycardia, tachypnea and coarse breath sounds. Imaging of the lungs showed diffuse pulmonary edema. Within an hour after the administration of naloxone patient developed pulmonary edema and lung injury. Patient was managed with non-invasive positive pressure ventilation which improved patient's symptoms in less than 6 hours confirmed by radiological improvement in 24-36 hrs. DISCUSSION: There are no specific observation guidelines post naloxone treatment in opiate overdose patients. We recommend early treatment of naloxone induced pulmonary complications during the observation period with non-invasive positive pressure ventilation to reduce the morbidity.

Prevalence of Cancer in Rheumatoid Arthritis: Epidemiological Study Based on the National Health and Nutrition Examination Survey (NHANES).

Rheumatoid arthritis (RA) is a multi-system autoimmune disease with significant morbidity and healthcare burden. It is an inflammatory condition and has been associated with lymphomas, with or without the presence of immunosuppressive therapy. However, the association of rheumatoid arthritis with other malignancies has been inconsistent. We used the data from a population-based National Health and Nutrition Examination Survey (NHANES) for epidemiological study to evaluate the association between RA and the incidence of cancer. Using the data collected between 2011 and 2014, we were able to determine the incidence of cancer in 11,262 patients. Incidence of cancer was increased in patients with RA with an odds ratio of 1.632 (95% confidence interval [CI]: 1.239-2.151; p=0.0005). Breast cancer (CA) and prostate CA were the most common types of cancer (each diagnosed in 16.22% individuals) and lung CA and lymphomas found in 1.35% of individuals. It is also important to be aware of increased risk and adequately screen patients for malignancies during the course of treatment and follow up of rheumatoid arthritis. Further large prospective studies are required to determine the association of the RA or its treatment and the risk of malignancies.

Extraintestinal Manifestations of Crohn's Disease in the Form of Pulmonary Nodules: A Case Report.

Crohn's disease is a systemic illness with a plethora of extraintestinal manifestations affecting various organs, of which the lungs are relatively rare. Pulmonary involvement may include airway diseases, lung parenchymal diseases, pleural diseases, or drug-related diseases. Tracheobronchial involvement is the most common respiratory presentation, whereas Crohn's disease-related interstitial lung disease is seen less frequently. A 41-year-old woman with a past medical history of Crohn's disease (status-post subtotal colectomy) presented to the hospital for an enlarging ground-glass opacity in her right middle lobe detected on routine computed tomography of the abdomen six months earlier. The opacity had increased in size from 21 x 18 mm to 28 x 18 mm and another ground-glass opacity in the right lower lobe increased in size from 5 mm to 12.4 mm. A robotic right middle lobectomy with lymph node dissection was done and bronchoscopy showed benign nodular lymphoid hyperplasia and a single perivascular epithelioid granuloma. A year later, her relapsing episodes of cough and shortness of breath were managed with prednisone, 20 mg, for a probable pulmonary manifestation of Crohn's disease. A non-contrast computed tomography of the chest showed interval resolution of the right lower lobe ground-glass opacity. A year after that, she presented to the hospital with increasing cough, shortness of breath, and a new right lower lobe ground-glass opacity (14 x 14 mm) on non-contrast computed tomography of the chest and has been managed with steroids with consideration of immunosuppression. In conclusion, pulmonary manifestations of Crohn's disease present in a myriad of varieties and often present confounding diagnostic problems necessitating an extensive work-up. Thus, Crohn's disease should be kept in the differential list in case of unusual clinical symptoms and radiological signs of idiopathic pulmonary presentations. These infrequent, and sometimes life-threatening, extraintestinal manifestations need to be considered when dealing with Crohn's disease to avoid further impairment of health status and alleviate patient symptoms by prompt recognition and treatment.

A Rare Case of Mollaret's Meningitis Complicated by Chronic Intractable Migraine and Papilledema: Case Report and Review of Literature.

Mollaret's meningitis is characterized by recurrent episodes of aseptic meningitis that last two to seven days and resolve spontaneously without any residual neurological deficit or complication. Viruses are the most common cause of aseptic meningitis and herpes simplex virus (HSV) type 2 has been noted as the most commonly associated virus in Mollaret's meningitis. We describe a rare case of a female who had four episodes of meningitis in a five-year period associated with chronic intractable migraine and papilledema attributed to Mollaret's meningitis.

Lactobacillus rhamnosus Bacteremia in an Immunocompromised Renal Transplant Patient.

Conventionally, Lactobacillus species are considered as low virulence organisms and rarely cause infection in immunocompetent individuals. However, it might be an opportunistic infection source in immunocompromised patients and can cause invasive serious infections. To our knowledge, there are only a handful of cases in the literature reporting primary bloodstream infection caused by Lactobacilli spp. in transplant recipients. Here, we report a case of a kidney transplant recipient with Lactobacillus rhamnosus bacteremia.