Reactive Infectious Mucocutaneous Eruptions (RIME) in COVID-19

Reactive infectious mucocutaneous eruptions (RIME) is a relatively novel terminology describing postinfectious mucocutaneous eruptions that usually affect 2 or more mucosal sites. To our knowledge, we describe the first case of RIME secondary to COVID-19 infection in an elderly 64-year-old immunocompetent male patient. This contrasts with previous case reports that have identified cases of RIME post-COVID-19 infection among the pediatric population and young adults. Our patient had characteristic mucosal involvement and required hospitalization and treatment with systemic steroids. This report also reviews the clinical features, treatment modalities, and outcome of RIME secondary to COVID-19 infection in other published case reports. We emphasize the need for further prospective studies to better elucidate the use of steroids in the management of RIME.

Alcohol-induced Cushing syndrome: report of eight cases and review of the literature

Introduction

Alcohol-induced hypercortisolism (AIH) is underrecognized and may masquerade as neoplastic hypercortisolism [Cushing syndrome (CS)] obscuring its diagnosis.

Objective and methods

In order to characterize AIH, we performed a chart review of eight patients (4 males and 4 females; 2014-2022) referred for evaluation and treatment of neoplastic hypercortisolism - six for inferior petrosal sinus sampling, one due to persistent CS after unilateral adrenalectomy, and one for pituitary surgery for Cushing disease (CD). Five underwent dDAVP stimulation testing.

Results

All eight patients had clinical features of hypercortisolism and plasma ACTH levels within or above the reference interval confirming hypothalamic-pituitary mediation. All had abnormal low-dose dexamethasone suppression test and increased late-night salivary cortisol. Only one had increased urine cortisol excretion. In contrast to CD, the 5 patients tested had blunted or absent ACTH and cortisol responses to desmopressin. Two had adrenal nodules and one had abnormal pituitary imaging. Most patients underreported their alcohol consumption and one denied alcohol use. Elevated blood phosphatidyl ethanol (PEth) was required in one patient to confirm excessive alcohol use. All patients had elevations of liver function tests (LFTs) with AST>ALT.

Conclusion

AIH is an under-appreciated, reversible cause of non-neoplastic hypercortisolism that is indistinguishable from neoplastic CS. Incidental pituitary and adrenal imaging abnormalities as well as under-reporting of alcohol consumption further confound the diagnosis. Measurement of PEth helps to confirm an alcohol use disorder. Elevations of LFTs (AST>ALT) and subnormal ACTH and cortisol responses to dDAVP help to distinguish AIH from neoplastic hypercortisolism.

Teprotumumab-Induced Encephalopathy: A Rare Side Effect of a Novel Therapeutic

INTRODUCTION

Teprotumumab is a novel monoclonal antibody used for treatment of thyroid eye disease (TED). To our knowledge, this is the second reported case of encephalopathy associated with teprotumumab therapy.

CASE PRESENTATION

A 62-year-old White woman with a history of hypertension, Graves' disease, and thyroid eye disease presented with 1 week of intermittent altered mental status following her third teprotumumab infusion. Neurocognitive symptoms resolved following plasma exchange therapy.

DISCUSSION

By using plasma exchange as first-line therapy, our patient had a shorter time course from diagnosis to symptom resolution than was reported in the previously published case.

CONCLUSIONS

Clinicians should consider this diagnosis in patients with encephalopathy after teprotumumab infusion, and our experience suggests plasma exchange is an appropriate initial treatment. Proper counseling of this potential side effect is warranted for patients prior to starting teprotumumab to facilitate earlier detection and treatment.

The Impact of Dynamic Real-Time Feedback on Patient Satisfaction Scores

INTRODUCTION

Providers' communication skills have a significant impact on patients' satisfaction. Improved patients' satisfaction has been positively correlated with various healthcare and financial outcomes. Patients' satisfaction in the inpatient setting is measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. In this study, we evaluated the impact of dynamic real-time feedback to the providers on the HCAHPS scores.

METHODS

This was a randomized study conducted at our 550-bed level-1 tertiary care center. Twenty-six out of 27 hospitalists staffing our 12 medicine teams (including teams containing advanced practice providers (APPs) and house-staff teams) were randomized into intervention and control groups. Our research assistant interviewed 1110 patients over a period of 7 months and asked them the three provider communication-specific questions from the HCAHPS survey. Our intervention was a daily computer-generated email which alerted providers to their performance on HCAHPS questions (proportions of "always" responses) along with the performance of their peers and Medicare benchmarks.

RESULTS

The intervention and control groups were similar with regard to baseline HCAHPS scores and clinical experience. The proportion of "always" responses to the three questions related to provider communication was statistically significantly higher in the intervention group compared to the control group (86% vs 80.5%, p-value 0.00001). It was also noted that the HCAHPS scores were overall lower on the house-staff teams and higher on the teams with APPs.

CONCLUSION

Real-time patients' feedback to inpatient providers with peer comparison via email has a positive impact on the provider-specific HCAHPS scores.

Syphilitic Hepatitis: A Rare Cause of Elevated Liver Function Tests

Syphilitic hepatitis is a rare manifestation of syphilis with an incidence of 0.2-38%. We describe a case of a healthy, immunocompetent male patient with elevated liver function tests (LFTs) who was found to have syphilitic hepatitis. A 28-year-old male with no past medical history presented with abdominal pain for two to three weeks. He also reported diminished appetite, intermittent chills, weight loss, and fatigue. His history was positive for high-risk sexual behavior including multiple partners and absence of using protection. His physical examination was remarkable for right-sided abdominal tenderness and a painless chancre on his penile shaft. His workup revealed elevated aspartate aminotransferase (AST: 169 U/L), alanine transaminase (ALT: 271 U/L), and alkaline phosphatase (ALP: 377 U/L). His abdominal CT scan was unremarkable except for the abdominal and pelvic lymphadenopathy. A thorough serology panel revealed negative hepatitis A, B, C, human immunodeficiency virus (HIV) (including HIV RNA), Epstein-Barr virus (EBV), and cytomegalovirus (CMV). His immunological workup was negative as well. His rapid plasma reagin (RPR) was reactive with positive IgG/IgM treponemal antibodies. He was managed as secondary syphilis and received 2.4 million units of benzathine penicillin. Upon follow-up after one week, he reported a complete resolution of his symptoms, and his LFTs were normalized on a repeat checkup. Given the significant morbidity associated with a missed diagnosis, syphilitic hepatitis should be considered an essential part of the workup for evaluating elevated LFTs in an appropriate clinical setting. This case also highlights the importance of obtaining a comprehensive sexual history and performing a thorough genital examination.

Raoultella ornithinolytica and Klebsiella oxytoca pyogenic liver abscess presenting as chronic cough

Raoultella ornithinolytica is a Gram-negative rod belonging to the Enterobacteriaceae family and closely related to Klebsiella spp. It is commonly present in aquatic environments. Human infections caused by R. ornithinolytica are being increasingly recognized. It has been documented to cause various hospital-acquired infections including but not limited to gastrointestinal, skin, and genitourinary infections. The organism has been particularly associated with invasive procedures and is commonly seen in patients with malignancy, diabetes, chronic kidney disease and immunodeficiency. To our knowledge, we report the first case of pyogenic liver abscess caused by this organism. The patient presented subtly with a chronic, nonresolving cough and was managed successfully by surgical drainage and appropriate antimicrobials.

To Assess Sleep Quality among Pakistani Junior Physicians (House Officers): A Cross-sectional Study

Background:

Sleep deprivation among junior physicians (house officers) is of growing concern. In developed countries, duty hours are now mandated, but in developing countries, junior physicians are highly susceptible to develop sleep impairment due to long working hours, on-call duties and shift work schedule.

Aim:

We undertook the study to assess sleep quality among Pakistani junior physicians.

Subjects and Methods:

A cross-sectional study was conducted at private and public hospitals in Karachi, Pakistan, from June 2012 to January 2013. The study population comprised of junior doctors (house physicians and house surgeons). A consecutive sample of 350 physicians was drawn from the above-mentioned study setting. The subject underwent two validated self-administered questionnaires, that is, Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS).

Results:

A total of 334 physicians completely filled out the questionnaire with a response rate of 95.4% (334/350). Of 334 physicians, 36.8% (123/334) were classified as “poor sleepers” (global PSQI score > 5). Poor sleep quality was associated with female gender (P = 0.01), excessive daytime sleepiness (P < 0.01), lower total sleep time (P < 0.001), increased sleep onset latency (P < 0.001), and increased frequency of sleep disturbances (P < 0.001). Abnormal ESS scores (ESS > 10) were more prevalent among poor sleepers (P < 0.01) signifying increased level of daytime hypersomnolence.

Conclusion:

Sleep quality among Pakistani junior physicians is significantly poor. Efforts must be directed towards proper sleep hygiene education. Regulations regarding duty hour limitations need to be considered.

Pattern of external injuries sustained during bomb blast attacks in Karachi, Pakistan from 2000 to 2007

OBJECTIVE

To evaluate patterns of external injury resulting from bomb blasts in Karachi, and compare the injury profile resulting from explosions in open versus semi-confined blast environments.

METHODS

The retrospective, cross-sectional study was conducted in Karachi and comprised relevant data from January 2000 to October 2007. Casualty medical records and medico-legal certificates of the victims presented to three large public-sector hospitals were evaluated using a self-designed proforma. SPSS 17 was used for statistical analysis.

RESULTS

Of the 1146 victims, data of 481(42%) represented the final study sample. Of these, 306(63.6%) were injured in open spaces and 175(36.4%) in semi-confined spaces. Of the 896 recorded injuries, lacerations were encountered as external injury in 427(47.7%) cases, followed by penetrating wounds in 137(15.3%). Lower and upper extremities were injured in 348(38.8%) and 170(19%) victims respectively. Open and semi-confined blast environments produced specific injury pattern and profile (p<0.001).

CONCLUSIONS

External injuries sustained during bomb blast attacks in Karachi demonstrated specific injury patterns and profiles. Further studies are required to account for internal injuries and classification of injuries based on standardised scoring systems.

Effect of diabetes mellitus on sleep quality

Diabetes mellitus (DM) is a highly prevalent condition affecting about 347 million people worldwide. In addition to its numerous clinical implications, DM also exerts a negative effect on patient’s sleep quality. Impaired sleep quality disrupts the adequate glycemic control regarded as corner stone in DM management and also lead to many deleterious effects causing a profound impact on health related quality of life. This article outlines various factors leading to impaired sleep quality among diabetics and delineates how individual factor influences sleep. The article also discusses potential interventions and lifestyle changes to promote healthy sleep among diabetics.

Sleep quality among medical students of Karachi, Pakistan

OBJECTIVE

To characterise sleep quality and assess degree of daytime sleepiness among medical students of Karachi.

METHODS

The cross-sectional study was conducted between August and December 2013 and subjects were recruited from five haphazardly selected medical colleges in Karachi. A convenience sample of medical students underwent two validated self-administered questionnaires i.e. Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale. SPSS 17 was used for statistical analysis.

RESULTS

Of the 650 students approached, 504(77.5%) subjects completely filled out the questionnaires. Of them, 300(59.5%) were females and 204(40.5%) were males. Overall mean age was 20±1.4 years. Of them, 199(39.5%) were classified as "Poor Sleepers". Poor sleep quality was associated with female gender (p <0.05), excessive daytime sleepiness (p <0.05), total hours slept (p <0.001) and sleep disturbances (p <0.001). Bed-timing analysis showed 365(72%) students went to bed after midnight.

CONCLUSIONS

Sleep quality among Pakistani medical students was significantly poor. Efforts must be directed towards proper sleep hygiene education.

Influence of Hispanic ethnicity in prevalence of diabetes mellitus in sleep apnea and relationship to sleep phase

INTRODUCTION

Recent studies have shown a strong association between insulin resistance, diabetes mellitus, and obstructive sleep apnea (OSA). This association has not been previously reported in the Hispanic population. The objective of this study was to study the prevalence of diabetes in a cohort of Hispanic patients with OSA in comparison with a white cohort.

METHOD

We performed a retrospective chart review of 103 Hispanic patients and 69 white patients with OSA. All patients had undergone full-night baseline polysomnography. We excluded charts of patients who underwent split-night studies and those who did not have rapid eye movement (REM) sleep.

RESULTS

Both groups were well matched in terms of age, gender distribution, and body mass index. The prevalence of self-reported diabetes in Hispanic patients with OSA was 42.71% compared with 24.28% of whites (P = 0.005). A REM apnea hypopnea index (AHI) of > 20 was significantly associated with an increased prevalence of diabetes in the Hispanic population; this association was not seen in the white population.

CONCLUSION

There was a very high prevalence of diabetes in an unselected cohort of Hispanic patients with OSA compared with white patients.