INTRODUCTION: Purpura fulminans (PF) is a life-threatening sequalae of a deficiency in serum anticoagulant proteins.PF can be secondary to neonatal, idiopathic, and infection.Our case illustrates PF secondary to an acute infection.CASE PRESENTATION: A 48-year-old female with history of Streptococcus pneumoniae septic arthritis in 2016, and chronic inflammatory demyelinating polyneuropathy presented to the intensive care unit with septic shock and multiorgan failure.She was placed on vasopressors, stress-dosed corticosteroids, and broad-spectrum antibiotics.Later, she developed a progressive generalized non-pruritic petechial purpuric rash.Rapid urine S. pneumoniae antigen was positive and her blood cultures grew S. pneumoniae.Her rash was clinically consistent with purpura fulminans.She was treated on low-dose intravenous immunoglobulins (IVIG) 5 grams daily for 3 days in addition to ceftriaxone and linezolid.Her rash progressed; thus, she was given high-dose IVIG 1.5-2 grams per kilogram for 2 days.She was also on renal replacement therapy due to acute renal failure and anuria.Further workup was done due to recurrent S. pneumoniae infections.Peripheral smear showed schistocytes and Howell-Jolly bodies.ANA was speckled and elevated at 1:320.Complement levels were low with total complement CH50 at 22 and complements C3 and C4 at 54 and 10, respectively.Tests were negative for human immunodeficiency virus, cold hemagglutinins, serum cryoglobulin, aldolase, anti-neutrophil cytoplasmic antibody, myeloperoxidase antibody, and proteinase-3 antibody.Computed tomography of abdomen revealed hypoplastic spleen indicating functional asplenia.Vasopressors were weaned and she finished her two-week course of ceftriaxone.On follow-up she was doing well, and her complement levels returned to normal.DISCUSSION: PF is a serious condition with protein C, protein S, and anti-thrombin III deficiency leading to disseminated dermal and microvasculature ischemia with subsequent tissue necrosis and disseminated intravascular coagulation.PF occurs in 10-20% of patients who present with Neisseria meningitidis or S. pneumoniae bacteremia.There is a higher prevalence of PF in patients with functional asplenia or after a splenectomy.In acute infectious PF, dissemination of the endotoxin produced by the bacteria activates the coagulation cascade leading to widespread thromboses.Initial clinical presentation is petechial rash with progression into frank purpura and eventual gangrenous or hemorrhagic necrosis.Management includes treating the underlying cause.For infectious PF, treatment is antibiotics and toxin suppression with clindamycin or linezolid.IVIG may also be used for antibodies to bacterial toxins.Corticosteroids may also play a role with immunomodulation.CONCLUSIONS: Our case showed the importance of starting appropriate antimicrobials with toxin control early.This is imperative in the setting of S. pneumoniae bacteremia with functional asplenia to decrease the risk of progressing to PF.

Background Post-intensive care syndrome (PICS) affects up to 50% of intensive care unit (ICU) survivors, leading to long-term neurocognitive, psychosocial, and physical impairments. Approximately 80% of COVID-19 pneumonia ICU patients are at elevated risk for developing acute respiratory distress syndrome (ARDS). Survivors of COVID-19 ARDS are at high risk of unanticipated health care utilization postdischarge. This patient group commonly has increased readmission rates, long-term decreased mobility, and poorer outcomes. Most multidisciplinary post-ICU clinics for ICU survivors are in large urban academic medical centers providing in-person consultation. Data are lacking on the feasibility of providing telemedicine post-ICU care for COVID-19 ARDS survivors. Objective We explored the feasibility of instituting a COVID-19 ARDS ICU survivor telemedicine clinic and examined its effect on health care utilization post-hospital discharge. Methods This randomized, unblinded, single-center, parallel-group, exploratory study was conducted at a rural, academic medical center. Study group (SG) participants underwent a telemedicine visit within 14 days of discharge, during which a 6-minute walk test (6MWT), EuroQoL 5-Dimension (EQ-5D) questionnaire, and vital signs logs were reviewed by an intensivist. Additional appointments were arranged as needed based on the outcome of this review and tests. The control group (CG) underwent a telemedicine visit within 6 weeks of discharge and completed the EQ-5D questionnaire; additional care was provided as needed based on findings in this telemedicine visit. Results Both SG (n=20) and CG (n=20) participants had similar baseline characteristics and dropout rate (10%). Among SG participants, 72% (13/18) agreed to pulmonary clinic follow-up, compared with 50% (9/18) of CG participants (P=.31). Unanticipated visits to the emergency department occurred for 11% (2/18) of the SG compared with 6% (1/18) of the CG (>.99). The rate of pain or discomfort was 67% (12/18) in the SG compared with 61% (11/18) in the CG (P=.72). The anxiety or depression rate was 72% (13/18) in the SG versus 61% (11/18; P=.59) in the CG. Participants’ mean self-assessed health rating scores were 73.9 (SD 16.1) in the SG compared with 70.6 (SD 20.9) in the CG (P=.59). Both primary care physicians (PCPs) and participants in the SG perceived the telemedicine clinic as a favorable model for postdischarge critical illness follow-up in an open-ended questionnaire regarding care. Conclusions This exploratory study found no statistically significant results in reducing health care utilization postdischarge and health-related quality of life. However, PCPs and patients perceived telemedicine as a feasible and favorable model for postdischarge care among COVID-19 ICU survivors to facilitate expedited subspecialty assessment, decrease unanticipated postdischarge health care utilization, and reduce PICS. Further investigation is warranted to determine the feasibility of incorporating telemedicine-based post-hospitalization follow-up for all medical ICU survivors that may show improvement in health care utilization in a larger population.

Abstract Introduction Narcolepsy is a common cause of chronic sleepiness, affecting 1 in 2000 people. Despite the frequency of narcolepsy, the average time from the onset of symptoms to diagnosis is 5 to 15 years, and may remain undiagnosed in as many as half of all affected people. The etiology of this problem is largely unknown and usually multifactorial. The prevalence of these sleep disorders is increased in sarcoidosis compared to the general population. We present a case of narcolepsy in a patient with biopsy proven extrapulmonary sarcoidosis. Report of Cases: 42-year-old female has a history of Sjogren’s syndrome (SSA/SSB positive, ANA positive 1:160), antiphospholipid syndrome with past left lower extremity deep venous thrombosis and positive LAC and anticardiolipin antibody, and Raynaud’s syndrome for more than 15 years, asthma, pleurisy, irritable bowel syndrome, GERD, depression, migraine and fibromyalgia. Her primary sleep complaint is excessive daytime sleepiness and nonrestorative sleep requiring frequent napping. She exhibited intermittent hypnagogic hallucinations but denies cataplexy. She has no history of smoking and denies drinking caffeine/alcohol. Has 3-5 isolated awakenings at night otherwise denies insomnia. She had a score of 17 on the Epworth scale. Her in-lab polysomnography demonstrated an AHI of 0/hr, sleep latency of 4.5 minutes and REM latency of 31.5 minutes. No other abnormalities noted. She then underwent a multiple sleep latency test. Sleep was achieved in all the nap trials with a mean sleep latency of 1.2 minutes with three Sudden Onset REM Sleep recorded meeting criteria for narcolepsy. A subsequent PET/CT scan was obtained due to elevated liver enzymes and positive MRI findings, which incidentally showed a 2 mm enhancing focus involving the medial right cerebellar peduncle. She underwent biopsy which showed granulomatous disease consistent with sarcoidosis. Patient is currently successfully treated with methylphenidate for her underlying narcolepsy. Conclusion We present a patient with narcolepsy and multiple underlying autoimmune diseases including biopsy indicating extrapulmonary sarcoidosis. We, furthermore, present radiographic evidence in her brain that may have contributed to her narcolepsy. Support (If Any)

A growth in recreational drug use will lead to a rise in delayed posthypoxic leukoencephalopathy cases. Physicians may inadvertently misdiagnose this rare condition as a primary psychiatric disorder by not maintaining a broad differential diagnosis.

BACKGROUND:Incidence of delayed intracranial hemorrhage (DICH) in patients on warfarin has been controversial. No previous literature has reported the utility of international normalized ratio (INR) in predicting traumatic DICH. OBJECTIVES:Utilizing INR to risk stratify head trauma patients who may be managed without repeat imaging. METHODS:This was a retrospective study at a Level II trauma center. All patients on warfarin with head injuries from March 2014 to December 31, 2017 were included. Each patient underwent an initial head computed tomography scan (HCT) and subsequent repeat HCT 12 h after. Patients presenting > 12 h after head injury received only one HCT. Two blinded neuroradiologists reviewed each case of DICH. Statistical analysis evaluated Glasgow Coma Scale (GCS), Injury Severity Score (ISS), heart rate, systolic blood pressure (SBP), age, and platelet count. RESULTS:There were 395 patients who qualified for the protocol; 238 were female. Average age was 79 years. Seventy-seven percent of patients underwent repeat HCT. Five resulted in DICH (INR 2.6-3.0), three of which might have been present on initial HCT; incidence rate of 0.51-1.27%. One patient required neurosurgical intervention. Among 80 patients with INR < 2, no DICH was identified, resulting in high sensitivity, but with a wide confidence interval; sensitivity of 100% (95% confidence interval [CI] 47.8-100), specificity 21% (95% CI 16.6-28.9). Correlation of factors: ISS (p = 0.039), GCS (p = 0.978), HR (p = 0.601), SBP (p = 0.198), age (p = 0.014), and platelets (p = 0.281). CONCLUSION:No patient with INR < 2 suffered DICH, suggesting that warfarin users presenting with INR < 2 may be managed without repeat HCT. For INR > 2, patients age and injury severity can be used for shared decision-making to discharge home with standard head injury precautions and no repeat HCT.

INTRODUCTION: “Intussusception” is a term initially used by the Scottish surgeon, Dr. John Hunter in 1789 which means invaginating or telescoping. It is caused by any condition that disrupts the normal physiological mechanism of intestinal peristalsis. Intussusception in adults is rare with incidence of 2-3 cases per population of 1000000 annually. The most common cause of intussusception in adults is neoplasms. CASE DESCRIPTION/METHODS: 22-year-old female, with multiple past episodes of abdominal pain and vomiting, presented with one day duration of sudden onset worsening abdominal pain, vomiting and diarrhea. The stools were black but without tarry clots or frank blood. She also had four episodes of non-bilious and non-bloody emesis. Of note, she had more than one year history of extensive marijuana use. Upon presentation, her vitals were unremarkable. Physical exam was pertinent for diffuse abdominal tenderness without guarding or rebound. Initial labs were unremarkable except for an elevated lactic acid level (4.6 Mmol/L). Pregnancy test was negative. Patient received anti-emetics, proton pump inhibitor and IV fluids. She then underwent a CT scan of the abdomen and pelvis which revealed a small bowel intussusception in the left hemiabdomen. She was made NPO and subsequently underwent both upper endoscopy and colonoscopy which were normal. She was treated conservatively with bowel rest, anti-emetics and IV fluids. She gradually improved with resolution of symptoms on day four of hospital stay. Her intussusception had resolved on a follow up small bowel series. She was discharged home with outpatient Gastroenterology follow up. DISCUSSION: There is enough evidence to support that cannabis acts on several segments of the bowel. It has been demonstrated that interaction through inhibition of intrinsic cholinergic mechanisms can result in cannabis-induced inhibition of gastrointestinal motility. Fernández-Atutxa et al. and Olga et al. presented a 3 patient case series and a case report respectively with clinical presentation similar to our patient. These patients were diagnosed with intussusception with no apparent organic cause but had a history of extensive marijuana use. Our case presentation is intended to pay attention to adverse effects of cannabis in light of increasing legalization and increasing therapeutic use of cannabis and its derivatives.

Ninety-two adult twin-pairs were recruited through advertisements in the local media. Twin zygosity was determined by use of the self-report inventory developed by Nichols and Bilbro (1966). The level and lability of subclinical depression were assessed. Mood level was assessed by the Beck Depression Inventory and by the MMPI D, D30, and DR Scales. Mood lability was assessed by daily administrations over a 2-week period of the Depression Adjective Check List (DACL) and the Wessman-Ricks Elation-Depression Mood Scales. Monozygotic twins resembled one another more than dizygotic twins in most measures of both level and lability of mood, which provides modest evidence for a genetic influence on subclinical levels of depression. Implications of these findings for the continuity hypothesis of depression are discussed.

211 open PD were performed.Operations were performed by three surgeons, who perform both open PD and RAPD.Conversion rate each year ranged from 15.4% to 38.9% (p = 0.81).Utilization of RAPD per year increased from 18% in 2009 to 26% for 2012-2013(p= 0.45).There was no statistical difference between tumor size (2 to 2.45cm, p=0.24), percentage of malignant lesions (30.8% to 62.5%, p=0.36), and post-operative pancreatic fistula rate (grade A-C)(30% to 50%, p= 0.28) between the study years.Compared to the open PD cohort, mean estimated blood loss was significantly less (500cc vs. 200cc) (p<0.001).Length of stay (LOS) also had a trend towards significance with average LOS of 11.5 days for the open PD versus 9 days in the RAPD cohort (p=0.06).However, there was a significant decrease in mean LOS for the RAPD cohort, from 10 days in 2009 to 7 days in 2013 (p= 0.03).The rate of BMI increase over time for RAPD was significantly higher compared to open PD cohort (p=0.04)(Figure 1).In comparison between groups in regard to overall surgical site infections, there was no difference between the open PD and RAPD groups (25% vs 28%, p=0.76).However, there was a trend towards a decrease rate of incisional infections in the RAPD group compared to open PD (8% vs 15%, p=0.32).Conclusion: Increasing experience with RAPD has led to higher overall utilization regardless of underlying patient disease.To achieve the maximal benefits of a minimally invasive approach to PD, we have significantly and purposely increased the selection of obese patients.While a larger cohort of RAPD patients is needed, our initial experience suggests that the greatest benefit of RAPD is best utilized in patients with a higher BMI.