An Atypical Presentation of Disseminated CMV in an Immunocompromised Patient

Discussion: We present a case of disseminated CMV manifesting as cutaneous eruptions, viremia, retinitis, and encephalopathy in an immunocompromised patient. This patient was admitted for multifocal pneumonia, but continued to spike fevers and remained encephalopathic even after resolution of the pneumonia. Despite extensive evaluation for other infectious etiologies he failed to improve until he was placed on ganciclovir. Encephalopathy in HIV patients requires evaluation for Toxoplasma, primary CNS lymphoma, progressive multifocal leukoencephalopathy, and also HIV encephalopathy. This patient had never been on anti-retroviral therapy, and imaging was concerning for HIV encephalopathy; however, he had drastic improvement in mentation upon initiating ganciclovir therapy. Disseminated CMV is not uncommon in AIDS patients, but is traditionally associated with visceral organ involvement (retinitis, colitis, meningitis, and hepatitis). Cutaneous manifestations, and encephalopathy are less common presentations. Conclusion: Due to the immunocompromised nature of AIDS patients, there are multiple infectious etiologies that can present with encephalopathy, and cutaneous manifestations. As such, a thorough history, physical exam, and a systematic approach is necessary to identify the cause. Disseminated CMV can present with encephalopathy as well as cutaneous lesions that can be co-infected with HSV 1 and 2. This patient showed dramatic improvement in mentation and skin lesions while being on IV ganciclovir.https://scholarlycommons.henryford.com/merf2019caserpt/1051/thumbnail.jp

Immunosuppressants in Behcet’s disease: a boon or a bane?

Adalimumab is a disease-modifying antirheumatic drug and monoclonal antibody that works by antagonising tumour necrosis factor-alpha prescribed in many rheumatological conditions like Rheumatic arthritis, Ankylosing spondylitis and Behcet’s disease. Serious side effects with this drug include heart and liver failure, nervous and blood disorders, allergic and immune system reactions and opportunistic infections. A 27-year-old female patient, known case of Behcet’s disease presented to the hospital with complaints of fever, cough and breathlessness following administration of Adalimumab, six doses over three months. Chest X-ray and BAL-CBNAAT was suggestive of Tuberculosis. AKT was started and Adalimumab was suspended until patient recover

Confocal Endomicroscopy Characteristics of Different Intraductal Papillary Mucinous Neoplasm Subtypes

Intraductal papillary mucinous neoplasms are classified into gastric, intestinal, pancreatobiliary, and oncocytic subtypes where morphology portends disease prognosis. The study aim was to demonstrate EUS-guided needle-based confocal laser endomicroscopy imaging features of intraductal papillary mucinous neoplasm subtypes. Four subjects, each with a specific intraductal papillary mucinous neoplasm subtype were enrolled. An EUS-guided needle-based confocal laser endomicroscopy miniprobe was utilized for image acquisition. The mean cyst size from the 4 subjects (2 females; mean age = 65.3±12 years) was 36.8±12 mm. All lesions demonstrated mural nodules and focal dilation of the main pancreatic duct. EUS-nCLE demonstrated characteristic finger-like papillae with inner vascular core for all subtypes. The image patterns of the papillae for the gastric, intestinal, and pancreatobiliary subtypes were similar. However, the papillae in the oncocytic subtype were thick and demonstrated a fine scale-like or honeycomb pattern with intraepithelial lumina correlating with histopathology. There was significant overlap in the needle-based confocal laser endomicroscopy findings for the different intraductal papillary mucinous neoplasm subtypes; however, the oncocytic subtype demonstrated distinct patterns. These findings need to be replicated in larger multicenter studies

Assessing Readability of Online Patient Education Materials for Spine Surgery Procedures

Increased patient reliance on Internet-based health information has amplified the need for comprehensible online patient education articles. As suggested by the AMA and NIH, spine fusion articles should be between a 4th and 6th grade readability level to increase patient comprehension, which may contribute to improved postoperative outcomes. Objective: To determine the average readability level of online healthcare education information relating to anterior cervical discectomy and fusion (ACDF) and lumbar fusion procedures. Design: Online Health-Education Resource Qualitative Analysis. Setting: Rush University Medical Center - Department of Orthopaedic Surgery. Methods: Three popular search engines were utilized to access patient education articles for common cervical and lumbar spine procedures. Relevant articles were analyzed for readability using Readability Studio Professional Edition software (Oleander Software, Ltd). Articles were stratified by organization type as follows: General Medical Websites (GMW), Healthcare Network/Academic Institutions (HNAI), and Private Practices (PP). Thirteen common readability tests were performed with the mean grade level for each readability test compared between subgroups using ANOVA analysis. Results: 79 ACDF and 231 lumbar fusion articles were determined to have a mean readability level of 10.7 ± 1.5 and 11.3 ± 1.6, respectively. GMW, HNAI, and PP subgroups had mean readability levels of 10.9 ± 2.9, 10.7 ± 2.8, and 10.7 ± 2.5 for ACDF and 10.9 ± 3.0, 10.8 ± 2.9, and 11.6 ± 2.7 for lumbar fusion articles. Of 310 total articles, only 6 (3 ACDF and 3 lumbar fusion) were written below the 7th grade reading level. Conclusions: Current online literature from medical websites containing information regarding ACDF and lumbar fusion procedures are written at a grade level higher than the suggested guidelines. Therefore, current patient education articles should be revised to accommodate the average readability level in the United States and may result in improved patient comprehension and postoperative outcomes

Novel TCAP mutation c.32C>A causing limb girdle muscular dystrophy 2G

TCAP encoded telethonin is a 19 kDa protein, which plays an important role in anchoring titin in Z disc of the sarcomere and is known to cause LGMD2G, a rare muscle disorder characterised by proximal and distal lower limb weakness, calf hypertrophy and loss of ambulation. A total of 300 individuals with ARLGMD were recruited for this study. Among these we identified 8 clinically well characterised LGMD2G cases from 7 unrelated Dravidian families. Clinical examination revealed predominantly proximo - distal form of weakness, scapular winging, muscle atrophy, calf hypertrophy and foot drop, immunoblot showed either complete absence or severe reduction of telethonin. Genetic analysis revealed a novel nonsense homozygous mutation c.32C>A, p.(Ser11*) in three patients of a consanguineous family and an 8 bp homozygous duplication c.26_33dupAGGTGTCG, p.(Arg12fs31*) in another patient. Both mutations possibly lead to truncated protein or nonsense mediated decay. We could not find any functionally significant TCAP mutation in the remaining 6 samples, except for two other polymorphisms, c.453A>C, p.( = ) and c.-178G>T, which were found in cases and controls. This is the first report from India to demonstrate TCAP association with LGMD2G

The Efficacy of Topical Hydrolyzed Psoralea corylifolia Extract in Treating Postinflammatory Hyperpigmentation

Background: Post-inflammatory hyperpigmentation (PIH) is common following resolution of acne. Purpose: The purpose of this study is to determine the treatment efficacy of Topical Hydrolyzed Psoralea Corylifolia extract (HPCE) on acne-induced PIH and TCA-induced PIH using a previously validated model.1Methods: A prospective, single-blinded, non-randomized study was conducted on 20 subjects with acne-induced PIH. Three acne-induced PIH areas on the face and three 35% TCA-induced PIH areas on the buttocks were analyzed. Subjects received topical HPCE [Unigen] and vehicle cream with instructions on twice daily application on two separate facial and gluteal lesions for 28 days; the third lesion served as a control. Clinical photography and Investigator Global Assessment (IGA) scores for hyperpigmentation were performed on days 0, 28, 35, 42, and 56 for all sites. Degree of improvement was defined as the change in the IGA score for hyperpigmentation between the first and last day of treatment. Results: For facial acne sites, one-way repeated measures ANOVA for degree of improvement as assessed by IGA analysis demonstrated a greater degree of improvement for product sites when compared to vehicle (1.9 times) and control (1.5 times); however, statistical significance was not reached. For TCA-induced PIH sites, there was a statistically significant degree of improvement for product treated sites compared to vehicle (9 times) and control (9 times). For both acne and TCA-induced PIH sites, Pearson correlation coefficient between time and IGA score for hyperpigmentation showed a strong and statistically significant (phttps://scholarlycommons.henryford.com/merf2019clinres/1010/thumbnail.jp

Emerging trends in the recovery of ferrospheres and plerospheres from coal fly ash waste and their emerging applications in environmental cleanup

Coal fly ash (CFA) is a major global problem due to its production in huge volumes. Fly ash has numerous toxic heavy metals; thus, it is considered a hazardous material. However, it also has several value-added minerals like ferrous, alumina, and silica along with other minerals. Fly ash also has several natural micro- to nano-structured materials; for instance, spherical ferrous-rich particles, cenospheres, plerospheres, carbon nanomaterials, and unburned soot. These micron- to nano-sized particles are formed from the molten slag of coal, followed by condensation. Among these particles, plerospheres which are hollow spherical particles, and ferrospheres which are ferrous-rich particles, have potential applications in the environmental cleanup, research, catalytic industries, and glass and ceramics industries. Additionally, these particles could be further surface-functionalized or purified for other applications. Moreover, these particles are widely explored for their potential in the army and other defense systems like lightweight materials and sensing The recovery of such particles from waste fly ash will make the process and remediation technology economically and environmentally friendly. The current review focuses on the various structural and elemental properties of ferrospheres and plerospheres from fly ash. This review also focuses on the emerging applications of both naturally formed materials in CFA

Fine-scale sampling uncovers the complexity of migrations in 5th–6th century Pannonia

As the collapse of the Western Roman Empire accelerated during the 4th and 5th centuries, arriving "barbarian" groups began to establish new communities in the border provinces of the declining (and eventually former) empire. This was a time of significant cultural and political change throughout not only these border regions but Europe as a whole.1,2 To better understand post-Roman community formation in one of these key frontier zones after the collapse of the Hunnic movement, we generated new paleogenomic data for a set of 38 burials from a time series of three 5th century cemeteries3,4,5 at Lake Balaton, Hungary. We utilized a comprehensive sampling approach to characterize these cemeteries along with data from 38 additional burials from a previously published mid-6th century site6 and analyzed them alongside data from over 550 penecontemporaneous individuals.7,8,9,10,11,12,13,14,15,16,17,18,19 The range of genetic diversity in all four of these local burial communities is extensive and wider ranging than penecontemporaneous Europeans sequenced to date. Despite many commonalities in burial customs and demography, we find that there were substantial differences in genetic ancestry between the sites. We detect evidence of northern European gene flow into the Lake Balaton region. Additionally, we observe a statistically significant association between dress artifacts and genetic ancestry among 5th century genetically female burials. Our analysis shows that the formation of early Medieval communities was a multifarious process even at a local level, consisting of genetically heterogeneous groups

Understanding 6th-century barbarian social organization and migration through paleogenomics.

Despite centuries of research, much about the barbarian migrations that took place between the fourth and sixth centuries in Europe remains hotly debated. To better understand this key era that marks the dawn of modern European societies, we obtained ancient genomic DNA from 63 samples from two cemeteries (from Hungary and Northern Italy) that have been previously associated with the Longobards, a barbarian people that ruled large parts of Italy for over 200 years after invading from Pannonia in 568 CE. Our dense cemetery-based sampling revealed that each cemetery was primarily organized around one large pedigree, suggesting that biological relationships played an important role in these early medieval societies. Moreover, we identified genetic structure in each cemetery involving at least two groups with different ancestry that were very distinct in terms of their funerary customs. Finally, our data are consistent with the proposed long-distance migration from Pannonia to Northern Italy.This work was supported by National Science Foundation award #1450606, the Anneliese Maier Research Award of the Alexander von Humboldt Foundation, the Max Planck Society, the German Federal Ministry for Education and Research, the Swedish Riksbankens Jubieleumfond, the Gerard B. Lambert Foundation, the Institute for Advanced Study Director’s Office, and the Italian Ministry for University and Research Department of Excellence Program