A Rare Case of Shock in a Patient with Non-Severe Range Babesiosis

Babesiosis is a tickborne illness caused by microscopic parasites that infect red blood cells. Infections present on a spectrum from asymptomatic to severe, life-threatening presentations. However, life-threatening disease is more typically seen in patients who are asplenic, immunocompromised, or with hepatic/renal disease. We present an unusual case of babesiosis where an immunocompetent patient with age as the only risk factor, became extremely ill with relatively low parasite burden and no co-infection with other tickborne illnesses. A 73-year-old man with essential hypertension and remote prior Lyme disease infection presented to the hospital in late Spring due to acute mental status change after being found acting erratically by police. Upon presentation, he was hypotensive to 70/40 mmHg, tachycardic, and unable to follow commands. Blood parasite smear was positive for Babesia species with 2.2% parasitemia. Ehrlichia, Anaplasma and Lyme IgM species testing was negative. The patient required treatment of septic shock with norepinephrine. Along with azithromycin and atovaquone, he ultimately underwent three exchange transfusions due to significant hemolytic anemia. This led to dramatic improvement in his mental status and he was discharged with 10 additional days of antibiotics. Babesia infections present heterogeneously ranging from asymptomatic to life-threatening presentations with hypotension, hemolysis, thrombocytopenia, DIC, organ failure, and even death, especially in patients with risk factors. Our patient had a critical presentation without an immunocompromised state, no prior splenectomy, lack of liver/renal abnormalities, and relatively low parasitemia. Additionally, exchange transfusion can be considered with hemolysis despite non-severe range parasitemia

New Onset Dyspnea in a Patient with Pacemaker, What Does the ECG Tracing Show?

Dual chamber pacemakers are programmed to allow for AV synchrony. Whenever a patient with a dual chamber pacemaker with underlying sinus rhythm presents with AV dissociation, the lack of AV synchrony should be questioned. The authors present a case of new onset dyspnea diagnosed as pacemaker syndrome. The diagnosis was initially delayed due to underlying ventricular paced rhythm as misidentified as normal pacemaker behavior. A 69-year-old female with a past medical history of 2:1 atrioventricular block status post dual-chamber pacemaker implant presented with complaints of new onset shortness of breath and dyspnea. The ECG showed a ventricular rate of 66 beats per minute. Pacing spikes were prior to each QRS complex indicating ventricular-paced rhythm with left bundle branch morphology. There were p waves from sinus origin which were completely dissociated from the ventricular paced rhythm. Overall, there was ventricular paced rhythm with underlying AV dissociation. This was initially suspected to be normal pacemaker behavior as there was appropriate ventricular pacing and ventricular capture. Review of the tracing noted AV dissociation, which would be unusual in a patient with underlying sinus rhythm and dual chamber device. Device interrogation noted that device was at end of life and atrial lead was powered down to allow for ventricular pacing. It is important to always question the lack of AV synchrony if patients have dual chamber pacemaker as lack of AV synchrony can cause pacemaker syndrome

The Philadelphia surgery conference: a value analysis of a hands-on surgical skill-building event.

Context: Limited opportunities exist to practice technical skills and to be exposed to various surgical specialties during preclinical medical education. Objectives: To assess the value of workshop-based educational opportunities to medical students during preclinical training. Methods: One hundred and 75 medical and physician assistant students from 10 medical schools attended the 2019 Philadelphia Surgery Conference. All students received STOP THE BLEED® bleeding control training and participated in four workshops, chosen from a list of 23, that demonstrated a variety of surgical skills. Data collection was accomplished using both a pre- and postconference survey to assess changes in confidence of personal capabilities, knowledge base, and opinions regarding preclinical medical training. Results: Preconference survey results indicated low baseline confidence in personal surgical skills (mean [SD], 1.9 [1.0], on a Likert scale of 1-5), and knowledge of various surgical specialties (2.7 [1.0]). Students highly valued skill-building experiences (mean [SD], 4.2 [1.1]) and face-to-face interactions with resident and attending physicians (4.4 [0.9]). Postconference survey analysis demonstrated increased confidence in surgical ability by 52.6% (mean [SD], 2.9 [1.0]; p\u3c0.001) and knowledge base by 34.6% (3.5 [0.8]; p\u3c0.001). Value scores increased for both preclinical surgical skill-building opportunities (mean [SD], 4.4 [0.9]; p=0.014) and interactions with resident and attending physicians (4.7 [0.6]; p=0.002). Conclusions: The Philadelphia Surgery Conference provided a highly valuable experience to participating students, increasing confidence in personal knowledge base and surgical skills while facilitating a collaboration between students and resident and attending physicians from various surgical specialties

Transitions to food democracy through multilevel governance

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Treatment with a corticotrophin releasing factor 2 receptor agonist modulates skeletal muscle mass and force production in aged and chronically ill animals

<p>Abstract</p> <p>Background</p> <p>Muscle weakness is associated with a variety of chronic disorders such as emphysema (EMP) and congestive heart failure (CHF) as well as aging. Therapies to treat muscle weakness associated with chronic disease or aging are lacking. Corticotrophin releasing factor 2 receptor (CRF2R) agonists have been shown to maintain skeletal muscle mass and force production in a variety of acute conditions that lead to skeletal muscle wasting.</p> <p>Hypothesis</p> <p>We hypothesize that treating animals with a CRF2R agonist will maintain skeletal muscle mass and force production in animals with chronic disease and in aged animals.</p> <p>Methods</p> <p>We utilized animal models of aging, CHF and EMP to evaluate the potential of CRF2R agonist treatment to maintain skeletal muscle mass and force production in aged animals and animals with CHF and EMP.</p> <p>Results</p> <p>In aged rats, we demonstrate that treatment with a CRF2R agonist for up to 3 months results in greater extensor digitorum longus (EDL) force production, EDL mass, soleus mass and soleus force production compared to age matched untreated animals. In the hamster EMP model, we demonstrate that treatment with a CRF2R agonist for up to 5 months results in greater EDL force production in EMP hamsters when compared to vehicle treated EMP hamsters and greater EDL mass and force in normal hamsters when compared to vehicle treated normal hamsters. In the rat CHF model, we demonstrate that treatment with a CRF2R agonist for up to 3 months results in greater EDL and soleus muscle mass and force production in CHF rats and normal rats when compared to the corresponding vehicle treated animals.</p> <p>Conclusions</p> <p>These data demonstrate that the underlying physiological conditions associated with chronic diseases such as CHF and emphysema in addition to aging do not reduce the potential of CRF2R agonists to maintain skeletal muscle mass and force production.</p