Intussusception in the Setting of an Ulcerative Colitis Flare

Intussusception is an extraordinary cause of acute abdomen in adults and has been defined as the telescoping of a bowel segment into the lumen of an adjacent segment. A 43-year-old female presented to our hospital\u27s emergency department (ED) with 10+ episodes of bloody diarrhea per day, left-sided abdominal pain, and the inability to tolerate oral intake for one month. She was initially diagnosed with ulcerative colitis (UC) ten years ago and is currently on mesalamine oral and enema therapy. She presented to our gastroenterology clinic two weeks after the beginning of her flare and was started on prednisone 40 mg daily. This did not improve her symptoms, and she presented to the ED two weeks later. She underwent a computed tomography (CT) abdomen/pelvis which revealed intussusception in the left hemiabdomen with no definite lead point measuring 5.6 cm in the craniocaudal dimension with pneumatosis and no evidence of bowel obstruction. There were no other significant laboratory abnormalities. Acute care surgery was consulted and suggested obtaining a CT enterography for further evaluation which showed spontaneous resolution of intussusception with no evidence of pneumatosis, portal venous gas, or intraperitoneal free air. She reports that following oral contrast intake, she felt movement and relaxation in her abdomen with substantial pain relief. Infectious workup was negative, and therapy was initiated with intravenous steroids. In conclusion, intussusception has been very rarely reported in patients with UC with the most common treatment being surgical resection. However, conservative management in the absence of bowel obstruction can be attempted

Nonuremic Calciphylaxis Precipitated by COVID-19 Infection

Calciphylaxis is a rare dermatologic condition that is primarily associated with end-stage renal disease (ESRD). Nonuremic calciphylaxis has been reported in patients with autoimmune disorders such as systemic lupus erythematosus and other hypercoagulable states such as anti-phospholipid syndrome. New research throughout the COVID-19 pandemic has shown an increased inflammatory and coagulopathic complication of COVID-19. We present a case of a patient with nonuremic calciphylaxis following treatment for severe COVID-19 and no known cause of hypercoagulability. A 40-year-old Caucasian female with a history of recent COVID-19 infection requiring hospitalization, hypertension, alcohol abuse, anxiety, and one prior spontaneous miscarriage presented to the hospital with bilateral lower extremity wounds. The wounds were seen to have necrosis and eschar formation, as well as blackened mottled skin, and were extremely painful to the patient. The initial lesions were on the anterior thighs bilaterally and spread laterally and to the lower back. Initial autoimmune workup was non-specific, and biopsy confirmed calciphylaxis. Calciphylaxis is a known dermatologic disease that has high mortality and morbidity, but it is usually associated with ESRD. Some cases have been reported for autoimmune or hypercoagulable states. The disease presents with non-healing, painful skin ulcers that are at a high risk of infection and have poor healing. The case presented shows biopsy-confirmed calciphylaxis in the absence of known etiologies, and we hypothesize that it is due to COVID-19 or COVID-19 aggravating an underlying but unidentified hypercoagulable condition

NSTEMI Progressing to STEMI in a Healthy Young Female

Introduction: Spontaneous Coronary Artery Dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) in healthy individuals. There are no risk stratification tools for the prevention of SCAD and no clear guidelines for acute management. The use of traditional ACS therapies, including antiplatelets agents, anti-thrombotics, beta-blockers, and statins, remains controversial.Clinical Case: A 40-year-old female with hypertension and distant history of postpartum pre-eclampsia presented with sudden onset, substernal chest pain radiating to her left arm and jaw. Her pain began while cooking and was associated with dizziness, fatigue and diaphoresis. In the Emergency Department, she was given sublingual nitrogen and aspirin 325mg with immediate improvement in her symptoms. An EKG demonstrated normal sinus rhythm with T-wave inversion in V1-V5. Troponin-I levels were initially normal at 40 ng/L (ref range:/L), elevating to a peak of 22,620 ng/L after 12 hours. She was treated with unfractionated heparin, clopidogrel 300mg, atorvastatin 80mg, and aspirin 81mg for the management of NSTEMI and admitted to the telemetry unit. Left heart catheterization revealed an ejection fraction of 55-60% with apical hypokinesis, and 95% obstruction of the mid LAD with diffuse tapering to the distal segment consistent with Type 2 SCAD. TIMI-2 flow was maintained, and her symptoms had resolved so no additional intravascular imaging or percutaneous intervention was performed. Unfractionated heparin was stopped and atorvastatin was discontinued given her 10-year ASCVD risk of less-than 7.5%, and no evidence of atherosclerotic epicardial coronary artery disease. Four hours post-catheterization she experienced recurrent chest pain while resting in bed. Repeat EKG demonstrated new ST-segment elevations in leads V2 through V5 consistent with STEMI. Troponin-I levels rose to 5270 ng/L after previously down-trending to 4920 ng/L. Repeat catheterization was deferred given known diagnosis of SCAD and prompt resolution of chest pain with further medical management. Unfractionated heparin was not restarted given concern for worsening intraluminal hematoma. Serial EKGs demonstrated resolution of ST segment elevations. She did not experience any additional episodes of chest pain and remained hemodynamically stable for the rest of her hospital stay. She was discharged home on hospital day 5 on metoprolol tartrate 25mg twice a day, aspirin 8mg daily, and 1 year of clopidogrel 75mg daily. Repeat catheterization 51 days after discharge demonstrated 50% obstruction of LAD with improved appearance of SCAD lesion. Discussion: This is a case of a young woman with NSTEMI progressing to STEMI due to Type 2 SCAD. The risks of catheter-induced progression of luminal dissection versus progression of intramural hematoma with unfractionated heparin must be considered based on the angiographic appearance of the affected artery and the patient’s clinical course. Although there are no societal guidelines for the acute management of SCAD, expert consensus has found a role for dual-antiplatelet and beta-blocker therapy in minimizing major adverse cardiac events post-SCAD. More investigation is needed, however, on the use of standard ACS therapies and risk prediction tools for the occurrence and recurrence of SCAD.https://scholarlycommons.henryford.com/merf2019caserpt/1129/thumbnail.jp

Delaying escalation of care for a COVID-19 patient

Background: Since being reported on December 31st 2019, COVID-19 has become a pandemic. In Detroit, there are 1075 cases and 23 deaths, as of March 28th, 2020. Rapid identification of the disease is vital as preliminary reports show that multiple ED and clinic visits are associated with worse outcomes, likely due to delayed treatment. Our report describes the course of a COVID-19 patient who required multiple visits prior to diagnosis, and rapidly deteriorated.Case Report: A 63-year old African American man presented to his PCP with sore throat, cough, and body aches. Patient endorsed symptoms for 4 days, no sick contacts, and flu swab was negative. Patient was diagnosed with a viral syndrome and prescribed rest and symptomatic care. The following day he went to the ED with worsening symptoms and hypotension and was sent home. The next day, patient went for a CXR, where he developed SOB. Due to his distress and presence of bilateral pneumonia, he was sent to the ED rule out COVID. At the ED, patient endorsed a fever, SOB, and chills. Patient’s past medical history included asthma, hypertension, and diabetes. On exam, he was febrile but hemodynamically stable. Patient was ill-appearing, with decreased breath sounds on the left. Labs showed leukopenia, lymphopenia, and an AKI. COVID testing was sent. Patient was admitted, with airborne plus precautions, and antibiotics were started.On hospital day 3, patient became persistently febrile and hypoxic. ABG was done which showed a PaO2 of 55.9. Due to worsening respiratory status, patient was intubated and transferred to the MICU. CXR was repeated and showed worsening airspace opacities bilaterally, and small pleural effusions. COVID test came back positive and treatment began with Hydroxychloroquine, and use of remdesivir pending. On hospitalization day 7, patient received remdesivir and tocilizumab, with hopes that reduced systemic inflammation would lead to improvement of his ARDS. Overnight, patient was hypotensive and nonresponsive to fluids. Levophed was begun, and vent settings were increased. On days 9 and 10, due to worsening hypoxia and inability to follow commands, patient was paralyzed to allow for more time to improve inflammation. Patient was placed on max vent settings, and his PaO2 sat was 57. CXR was repeated due to worsening vent requirements and showed no change. Subsequently, patient became tachycardic in the 120s, and hypotensive to the 80s. D-dimer was elevated, and patient desaturated when turned or repositioned. On day 11, patient was found to be hyperkalemic. Nephrology was consulted and determined the hyperkalemia was due to hemolysis secondary to DIC, but the patient was not a candidate for ultrafiltration or intermittent dialysis. Due to absence of clinical improvement, patient was transferred to comfort care, and expired.Discussion: Our report elucidates the importance of rapid identification of a patient with COVID. Our patient had a standard presentation with cough, fever, body aches and sore throat, indicating that the possibility of COVID as the cause for the patient’s presentation should have been considered. During a pandemic it is vital to practice with a high of index of suspicion. The importance of prompt identification of the illness becomes even more salient considering that current treatment approach is primarily symptomatic management, due to lack of clinically effective curative treatments. It may seem overly simplified, but the sooner a patient is able to receive these services, the more likely they are to recover. While our patient had multiple risk factors for deterioration due to COVID, such as HTN, and T2DM, our patient had two opportunities for escalation of care and identification of his underlying pathology that could have improved his prognosis. Further, our report is in line with preliminary findings that African Americans and patientshttps://scholarlycommons.henryford.com/merf2020caserpt/1103/thumbnail.jp

Severe COVID 19 Case with Atypical Presentation

Introduction: COVID-19 was brought to the attention of the WHO on December 31st, 2019 and classified a global pandemic on March 11th. As of March 26th, there were 2,856 cases and 60 deaths in Michigan, with 851 cases and 15 deaths in Detroit. Efforts to characterize risk factors for severe disease may improve clinical outcomes and inform resource allocation. Better understanding of the epidemiological and clinical characteristics of COVID-19 are essential to slowing transmission and treating patients. Below we detail the clinical features of a COVID-19 positive patient seen in early March, 2020. Case Report: An 80-year-old female presented to the ED with fevers. She endorsed worsening fevers, watery diarrhea, abdominal pain, and myalgias of one week. She was lethargic and presyncopal for one day prior to presentation. She endorsed contact with sick members at home and denied travel history. Her past medical history was significant for resected colon cancer, T2DM, COPD, HTN, and CAD. She was a former smoker. On exam she was febrile and had lower abdominal tenderness. Her labs showed lymphopenia, thrombocytopenia, and mild hyponatremia. Influenza swab, viral panel, and legionella urine antigen were negative, prompting COVID-19 testing. Chest x-ray showed diffuse reticular opacities. Antibiotics were started and she was admitted on hospital day 2. She developed dyspnea, rales, and increasing oxygen demand through her hospitalization. COVID-19 testing resulted positive by day 4. Infectious disease recommended ribavirin and lopinavir-ritonavir. Her son was informed, and all contacts were advised to isolate for two weeks. On days 5 and 6 she improved clinically, though was not discharged due to concern she would not abide by self-isolation recommendations. Overnight, she had increasing oxygen demand and repeat chest x-ray revealed worsening infiltrates. She was intubated and transferred to the MICU on day 7. Inflammatory markers including LDH, CRP, procalcitonin, lactate, anion gap, aPTT, INR, and D-dimer were elevated. ABG revealed low PaO2 and low pH. Her IL-6 and fibrinogen levels were normal. She continued to decompensate with concern for septic shock, and had worsening bradycardia and hypotension, unresponsive to three vasopressors. On day 7, she expired. Discussion: Our report of a COVID-19 patient that ended in their mortality provides important lessons for providers. The transmission mode was local spread, reflecting high transmissibility among family groups. Fevers are reliably present over the illness course, though seen in under half on presentation. Fatigue is common and was observed in our patient. Cough is common, though was absent here. Diarrhea is an uncommon presenting symptom, reducing initial clinical suspicion and potentially delaying diagnosis. Other characteristics seen in our patient reflect a growing body of evidence supporting high rate of morbidity and mortality in patients with COVID-19. Such populations, including critically ill elderly population, require ICU level care, with marked lymphopenia on admission labs, and elevated inflammatory markers across their hospitalization. Also, investigative treatments including Lopinavir-ritonavir, ribavirin, hydroxychloroquine, and azithromycin have yet to demonstrate clinical efficacy in large randomized controlled trials.https://scholarlycommons.henryford.com/merf2020caserpt/1105/thumbnail.jp

Necrotizing Cavitary Lung Mass in Patient with AIDS: A Rare Manifestation of PCP

Introduction: Pulmonary infections in immunocompromised hosts encompass a wide differential diagnosis. Of the possible etiologies, Pneumocystis jirovecii presents as a rare cause of necrotizing cavitary pneumonia, particularly in patients with advanced HIV and AIDS. We present the case of a cavitating lung lesion in a patient with AIDS, as an example of this rare atypical manifestation of Pneumocystis, hoping to increase clinical awareness and assist in prompt diagnosis and management. Case: A 50-year-old male patient presented with progressively worsening cough productive of green blood-tinged sputum of 2-week duration, associated with pleuritic chest pain, night sweats, and diarrhea. Past medical history was significant for AIDS due to HIV-1 with CD-4 count 73/mm3 not on antiretroviral therapy. He was admitted to an outside hospital two months prior for similar symptoms, and chest x-ray at that time demonstrated no acute process (figure 1). On presentation he was tachycardic, tachypneic, and afebrile. Oxygen saturation was 98-100% on room air. Physical examination revealed inspiratory crackles on right upper lung field auscultation with associated dullness to percussion, tenderness in the epigastrium and right upper quadrant of the abdomen, and oral thrush. CXR demonstrated diffuse airspace opacification throughout the right upper lobe (RUL), with internal lucent areas consistent with cavitation (figure 2). A follow-up chest computed tomography (CT) with intravenous contrast demonstrated cavitation of the RUL, with cystic spaces and air fluid levels (figure 3,4). Sputum culture was grossly contaminated with oropharyngeal flora. Three consecutive acid-fast bacilli (AFB) sputum smears were initially negative. Pneumocystis qualitative PCR was positive, with B-D glucan assay (Fungitell) of 239 pg/mL (ref range: \u3c60 pg/mL). Histoplasma urine antigen was negative. Cryptococcus serum testing was negative. A bronchoscopy with bronchoalveolar lavage (BAL) demonstrated findings consistent with necrotizing cavitary pneumonia. Pneumocystis was again identified on qualitative PCR. Anaerobic and aerobic culture, AFB culture, Nocardia, Legionella, and fungal culture were negative. No malignant cells were visualized. After 4 weeks of incubation, the AFB culture from sputum sampling on admission demonstrated Mycobacterium avium complex (MAC) growth in 1 of 3 samples consistent with contamination.Discussion: This case highlights the complexity of cavitary pulmonary lesion diagnosis in a patient with AIDS. The diagnosis of Pneumocystis pneumonia (PCP) was made through sputum and BAL qualitative PCR testing, with fungitell assay testing. The atypical radiographic presentation necessitated exclusion of alternate diagnoses. The possibility of superimposed anaerobic infection was not entirely ruled out, however the location of cavitation with multiple negative cultures on sputum and BAL sampling made this less likely.Conclusion: Pneumocystis jirovecii can present as a necrotizing cavitary pneumonia, and increased awareness regarding this atypical and rare presentation is critical for accurate diagnosis and prompt management.https://scholarlycommons.henryford.com/merf2019caserpt/1045/thumbnail.jp

Inappropriate statin therapy according to ASCVD risk: Can we do better?

Background: Statin therapy targeted at reducing 10-year risk of ASCVD has become a cornerstone of preventative health in the outpatient setting. Appropriate statin prescription can lead to improved morbidity and mortality as outlined by current American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Methods: In this empiric observational study performed in August 2018, we calculated the 10-year ASCVD risk for patients visiting the Henry Ford Hospital Academic Internal Medicine Clinic between January and December 2017, and compared the ACC/AHA guideline recommended statin intensity with the one currently prescribed. Our aim was to assess appropriateness of statin therapy based on ASCVD risk calculation and ACC/AHA guidelines. Results: Of the 2994 patients assessed, approximately 1548 patients were prescribed an inappropriate intensity of statin based on 10-year ASCVD risk calculation (p \u3c 0.001). For female patients, the odds of appropriate statin dose prescription increased by approximately 81.9% (odds ratio 1-1.819) when compared to male patients (95% CI 1.559-2.124). For black patients, the odds of appropriate statin prescription decreased by 32.2% (odds ratio 1-0.678) when compared to white patients (95% CI 0.532-0.864). Approximately 1245 patients currently taking high-intensity statin did not qualify for one as compared to 484 patients (p \u3c 0.001). Conclusion: Calculation of 10-year ASCVD risk is an integral part of guiding statin prescription and preventative health therapy in the outpatient setting, However, an increasing percentage of patients are not managed adequately according to ACC/AHA guidelines. Race, gender, and income disparities appear to be major factors influencing appropriateness of statin prescription. This demonstrates a major opportunity for potential intervention to improve statin prescription and patient health outcomes.https://scholarlycommons.henryford.com/merf2019hcd/1000/thumbnail.jp

COVID-19 Presenting with Neurological Symptoms

Introduction: Healthcare officials of Wuhan City in China became aware of several pneumonia cases with an unknown etiology in December 2019. A novel coronavirus, SARS-CoV-2, was identified as cause of the disease named Coronavirus disease-19 (COVID-19). SARS-CoV-2 enters cells through a receptor found on pneumocytes, and there is also evidence this receptor is located on neurons and glial cells. Recently, the neurological manifestations of COVID-19 have been described. However, to our knowledge, there are currently no known cases of COVID-19 presenting as cerebellar dysfunction and essential tremor, which we describe here. Case: A 77-year-old obese man with a past medical history of hypertension and essential tremor presented with decreased mentation, episodes of blank staring, bradykinesia, and worsening bilateral hand tremors. He also reported shortness of breath with a cough productive of clear sputum. Physical exam was within normal limits except for tachypnea requiring 4 liters of oxygen, a bilateral essential tremor and dysmetria. All labs were within normal limits. A chest x-ray suggested multifocal pneumonia. A Computed Tomography (CT) scan demonstrated scattered ground glass opacities and multi-lobar pneumonia, while a CT scan of the head was negative. Treatment was initiated for community acquired pneumonia with azithromycin and ceftriaxone. Upon admission, the patient continued to be orientated only to person and place. Subsequent laboratory investigation demonstrated elevated ferritin (1,200 ng/mL), Lactate Dehydrogenase (613 IU/L), C-Reactive Protein (13.2 mg/dL), and low procalcitonin ( Discussion: The respiratory systems – cough, sputum production, and dyspnea – and imaging findings of COVID-19 are well described.7–11 The presented case is unique because, while the patient did display the established symptoms of COVID-19, he also had encephalopathy, bilateral essential tremor, and cerebellar dysfunction. Neurological imaging was negative, and patients with these symptoms would traditionally receive further investigation. Patients with neurological dysfunction secondary to COVID-19 can demonstrate some significant findings on magnetic resonance imaging (MRI) such as enhancement in the leptomeningeal region and bilateral frontotemporal hypoperfusion on perfusion imaging.5However, because of his concomitant respiratory symptoms, and in context of the ongoing COVID-19 pandemic, our patient did not receive further neurological imaging as there was a high index of suspicion. The central and peripheral nervous system manifestations of COVID-19 are documented, but this case demonstrates that COVID-19 can result in cerebellar dysfunction as well. Conclusion: COVID-19 is caused by SARS-CoV-2, a virus that enters host cells via a receptor primarily found on pneumocytes but also neurons and glial cells. As such, the most common presenting symptoms are respiratory. Here we present a case of a patient presenting with neurological dysfunction in addition to the established respiratory symptoms. Highlights: Our patient presented with encephalopathy, worsened essential tremor, and cerebellar dysfunction, which is an unusual presentation of COVID-19.-In an ongoing pandemic, it is important to have a high index of suspicion, even when patients present with atypical symptoms -It is unclear at this time if hydroxychloroquine and azithromycin should be the treatment of choice for COVID-19, but the regimen was successful in this patient.https://scholarlycommons.henryford.com/merf2020caserpt/1049/thumbnail.jp

Impact of COVID-19 Infection on 24 Patients with Sickle Cell Disease One Center Urban Experience, Detroit, MI, USA

The city of Detroit has a large population of individuals with sickle cell disease, and hospitals in Detroit have seen some of the highest numbers of cases of coronavirus disease-19 (COVID-19) in 2020. The purpose of this study was to examine the pathophysiological characteristics of COVID-19 in patients with sickle cell disease or trait to determine whether these patients have unique manifestations that might require special consideration. This retrospective analysis included 24 patients with confirmed COVID-19 and sickle cell disease or trait who were seen at the Henry Ford Hospital, Detroit, MI, USA, between March 1 and April 15 2020. Of the 24 patients, 18 (75.0%) had heterozygous sickle cell trait, one (4.0%) was a double heterozygote for Hb S (HBB: c.20A\u3eT)/β(+)-thalassemia (β(+)-thal), four had sickle cell anemia (β(S)/β(S)) and one (4.0%) had Hb S/Hb C (HBB: c.19G\u3eA) disease. A total of 13 (54.0%) patients required hospitalization. All four patients with sickle cell anemia, developed acute pain crisis. We observed one patient who developed acute pulmonary embolism and no patients developed other sickle cell associated complications. Additionally, three (13.0%) patients required packed red blood cell transfusion without the need of exchange transfusion, and one patient required admission to the intensive care unit (ICU), mechanical ventilation and subsequently died. Patients with sickle cell disease or trait and laboratory-confirmed COVID-19 had a generally mild, or unremarkable, course of disease, with lower chances of intubation, ICU admission and death, but with a slightly longer hospitalization

Pandemic Emergency Department Triage Screening: Symptoms Increase Sensitivity

INTRODUCTION: In the weeks following the January 20, 2020, announcement of the first confirmed case of COVID-19 in the United States, valuable data was published on the clinical characteristics, including the most common presenting symptoms of individuals affected with the disease. One study in Wuhan, China, identified fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%) as common symptoms. A second study in Washington State identified shortness of breath as an initial symptom in 76% of patients. This case highlights the importance of rapid incorporation of updated data on the symptomatology of diseases into triage screening questionnaires during pandemics. CASE REPORT: Days after the World Health Organization’s March 11, 2020 declaration of a pandemic, a 37-year-old female presented to our Emergency Department (ED) with a 4-day history of cough, shortness of breath, myalgias, and fever. In triage, the patient was asked if she had traveled outside of the United States and if she had close contact with any person that had laboratory-confirmed COVID-19, for which she answered no. While waiting to be evaluated, the patient spent approximately 40 minutes in triage and an ED hallway before the possibility of COVID-19 was considered. At that point, airborne isolation precautions were ordered. Upon further questioning, the patient revealed she had taken a public bus trip to Florida, 6 days prior. She stated that several passengers on the bus were complaining of flu-like symptoms and were coughing. Upon arrival in Florida, the patient began developing a cough. As her symptoms progressed she also developed headache, nausea, and diarrhea, prompting her to return to Detroit to seek medical attention. The patient had multiple chronic health conditions, including hypertension, insulin-dependent type 2 diabetes, and obesity with a BMI of 48. The patient was subsequently admitted and was later confirmed to be positive for COVID-19. DISCUSSION: Historically, beta-coronaviruses have high rates of transmissibility in healthcare settings. A review of a 2014 MERS outbreak in Saudi Arabia classified 43.5% of all cases as nosocomial infections, while other outbreaks in Saudi Arabia in 2013 and South Korea in 2015 linked 100% to healthcare settings. Studies of the 2002-2003 SARS outbreak found that 21% of all cases occurred in healthcare workers and that the admission of a single index patient in one hospital led to a disastrous superspreading that infected 76 individuals. Data for COVID-19 is still limited, but one series in Wuhan, China presumed that 29% of hospitalized patients with COVID-19 pneumonia acquired the disease in a healthcare setting. It is important to maximize the utility of any tool that has the potential to reduce exposure of a contagious disease to healthcare workers and hospital patrons. Containment and isolation practices are significantly less effective during pandemics that have asymptomatic carriers and lengthy pre-symptomatic states, hence we should not lose opportunities to immediately isolate individuals who are showing symptoms. Another important consideration is that all SARS superspreaders were symptomatic. This case highlights the importance of rapid incorporation of updated data on the symptomatology of a disease into triage screening questionnaires in the setting of an evolving pandemic. This patient presented to our emergency department with a constellation of symptoms that were associated with COVID-19. She had close contact with individuals with the same symptoms while traveling. However, the triage screening questions utilized were not sensitive enough. Shortly after this incident, our institution modified the questionnaire to include specific symptoms associated with the disease, including fever, cough, shortness of breath, and myalgias, which would have potentially identified this patient earlier and expedited the placement of isolation orders.https://scholarlycommons.henryford.com/merf2020caserpt/1115/thumbnail.jp