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Cerebrovascular accident (CVA) is one of the leading causes of death in the United States. Von Willebrand factor plays an important role in platelet activation and adhesion. It remains unclear whether Von Willebrand disease (vWD) is associated with a decreased risk of developing CVA. The study aimed to compare the relative risk (RR) of CVA in patients with and without vWD. We queried the National Inpatient Sample from 2009 to 2014 for discharge data and records for vWD and CVA using International Classification of Diseases, Ninth-Revision codes. The unadjusted and adjusted RR of CVA in patients with and without vWD were estimated using log-binomial model. Descriptive measures including means, medians, standard deviations, and range were presented based on normality test of continuous data. The prevalence of CVA was lower in patients with vWD than in those without vWD (1.31% vs 2.04%), with a RR of 0.64 (95% confidence interval (CI): 0.60–0.68). After adjusting for common CVA risk factors, the RR remained lower in vWD patients: 0.81 (95% CI: 0.76–0.86). vWD is associated with a lower RR of developing CVA. This suggests that deficiency of Von Willebrand factor is potentially protective against the development of CVA. To the best of our knowledge, this is the first study in humans to compare the RR of CVA in patients with and without vWD. Future studies are needed to explore causal relationships and therapeutic benefits.

Introduction:Heart failure (HF) remains a significant cause of morbidity and mortality in the United States (US). Approximately 6.2 million adults in the United Status have HF and results in an estimated 13.4% of deaths annually. While the development of HF is linked to a variety of risk factors, the incidence and prevalence of methamphetamine-associated HF (HF-Meth) is rising secondary to the methamphetamine epidemic that is plaguing America. This study aims to compare the characteristics and outcomes of HF-Meth with other forms of HF.Methods:The discharge data of the National Inpatient Sample (NIS) from 2009 to 2014 were analyzed and records for HF hospitalization were identified using all ICD-9 codes for HF. These were further stratified based on meth use with the ICD-9 codes (304.40, 305.7, 969.72). We compared frequency of in-hospital mortality,incidence of cardiac arrhythmias, sudden cardiac death (SCD), rates of unemployment, and homelessness between patients with and without ICD-9 codes indicative of meth use. Percentage and chi-square-based P-values were reported.Results:Out of the 25,209,723 sampling weight-adjusted patients with ICD-9 codes indicative of HF, 58,359 (0.23%) had ICD codes indicative of Meth use. Relative to other patients with HF, HF-Meth experienced a lower in-hospital mortality rate (2.9 vs 5.0%, p <0.001), had a higher incidence of cardiac arrhythmias (7.1 vs 5.9%, p <0.001) and SCD (2.6 vs 1.8%, p <0.001), a higher rate of unemployment (0.49 vs 0.03%, p <0.001) and homelessness (6.1 vs 0.2%, p <0.001). In addition, HF-Meth was associated with a higher rate of alcohol abuse (21.1 vs 2.9%, p <0.001), cigarette smoking (73.8 vs 28.2%, p<0.001) and essential hypertension (43.8 vs 40.3%, p <0.001). Diabetes and hyperlipidemia were more prevalent in patients with other forms of HF (29.3 vs 43.44%, p <0.001 and 0.26 vs 0.45%, p <0.001 respectively).Conclusions:Patients with HF-Meth had a higher rate of cardiac arrhythmias, SCD, unemployment and homelessness. Additionally, they had a lower in-hospital mortality when compared with those not associated with meth use.

Introduction:Von Willebrand factor (vWF) is essential in platelet adhesion and aggregation. High concentration of vWF is associated with cerebrovascular accidents (CVA); however, it is yet unclear if its deficiency could protect against CVA. This study aims to compare the prevalence and relative risk (RR) of CVA in patients with and without vWD.Methods:Discharge data of the National Inpatient Sample (NIS) from 2009 to 2014 were analyzed and records for vWD and CVA were identified using ICD-9 codes. Log-binomial model was used to estimate the RR of CVA in patients with and without vWD after adjustment for CVA risk factors.Results:A total of 224,475,443 weight adjusted hospital discharge sample of patients, including 82,809 patients with vWD, were identified. The prevalence of CVA was lower in patients with vWD than those without vWD (1.31% vs 2.04%), with a RR of 0.64 (95% CI: 0.60-0.68) (table 1). Adjusted RR for CVA risk factors was 0.71 (95% CI: 0.67-0.76) (table 2).Conclusion:Patients with vWD showed a lower risk of developing CVA when compared to those without vWD, this lower RR persisted after controlling for other CVA risk factors. These findings suggest that vWD could be protective against CVA, and vWF might be a potential therapeutic target that requires further investigation in individuals at high risk of developing CVA.

Association of thymoma with myasthenia gravis, pure red cell aplasia, and aplastic anemia is well documented. However, thymoma complicated by acquired amegakaryocytic thrombocytopenia (AAMT) is rarely reported. Here, we present a case of a 60-year-old male with past medical history of recurrent invasive thymoma who presented with cough and blood in sputum. He was found to have severe normocytic normochromic anemia and thrombocytopenia that did not improve with intravenous steroids or multiple transfusions of red cells and platelets. Subsequent bone marrow biopsy showed severely depleted megakaryocytes and erythroid precursor cells with relative myeloid hyperplasia suggestive of amegakaryocytic thrombocytopenia and red cell aplasia. He was started on oral cyclosporine but subsequently developed leukopenia and refused any further treatment or diagnostic procedures and left the hospital against medical advice. AAMT, thus, may be a very early presentation of impending aplastic anemia, and treating physicians need to be aware of this entity.

Lyme disease is a multisystem infection caused by the spirochete Borrelia burgdorferi sensu stricto that manifests with characteristic symptoms in patients. Patients are identified based on their clinical symptoms and then diagnosed through enzyme-linked immunosorbent assay (ELISA), Western blot, and blood culture techniques. Here, we present the case of a 75-year-old, Northeast suburban resident complaining of unstable gait, high fevers, malaise, myalgia, and confusion. This patient’s symptoms were nonspecific, and his lab titers and blood cultures were repeatedly negative during his stay. It was only late in the course of his treatment that blood titers and cerebrospinal fluid analysis were positive for Lyme IgG and IgM. He was treated with intravenous doxycycline and prescribed oral doxycycline on discharge, resulting in a full recovery. We express the need for physicians to consider Lyme disease in endemic patients presenting with nonspecific systemic signs.

Introduction. Acquired thrombotic thrombocytopenic purpura (TTP) has been associated with different autoimmune disorders. However, its association with pernicious anemia is rarely reported. Case Report. A 46-year-old male presented with blood in sputum and urine for one day. The vitals were stable. The physical examination was significant for icterus. Lab tests’ results revealed leukocytosis, macrocytic anemia, severe thrombocytopenia, renal dysfunction, and unconjugated hyperbilirubinemia. He had an elevated LDH, low haptoglobin levels with many schistocytes, nucleated RBCs, and reticulocytes on peripheral smear. Low ADAMTS13 activity (<10%) with elevated ADAMTS13 antibody clinched the diagnosis of severe acquired TTP, and plasmapheresis was started. There was an initial improvement in his hematological markers, which were however not sustained on discontinuation of plasmapheresis. For his refractory TTP, he was resumed on daily plasmapheresis and Rituximab was started. Furthermore, the initial serum Vitamin B12 and reticulocyte index were low in the presence of anti-intrinsic factor antibody. So with the concomitant diagnosis of pernicious anemia, Vitamin B12 was supplemented. The rest of the immunological workups were negative. Subsequently, his symptoms resolved and his hematological parameters improved. Discussion. While pernicious anemia can masquerade as TTP, an actual association between the two can also occur and needs further evaluation and characterization.

ABSTRACTNewcastle disease virus (NDV) avirulent strain LaSota was used to coexpress gp160 Env and p55 Gag from a single vector to enhance both Env-specific and Gag-specific immune responses. The optimal transcription position for both Env and Gag genes in the NDV genome was determined by generating recombinant NDV (rNDV)-Env-Gag (gp160 located between the P and M genes and Gag between the HN and L genes), rNDV-Gag-Env (Gag located between the P and M genes and gp160 between the HN and L genes), rNDV-Env/Gag (gp160 followed by Gag located between the P and M genes), and rNDV-Gag/Env (Gag followed by gp160 located between the P and M genes). All the recombinant viruses replicated at levels similar to those seen with parental NDV in embryonated chicken eggs and in chicken fibroblast cells. Both gp160 and Gag proteins were expressed at high levels in cell culture, with gp160 found to be incorporated into the envelope of NDV. The Gag and Env proteins expressed by all the recombinants except rNDV-Env-Gag self-assembled into human immunodeficiency virus type 1 (HIV-1) virus-like particles (VLPs). Immunization of guinea pigs by the intranasal route with these rNDVs produced long-lasting Env- and Gag-specific humoral immune responses. The Env-specific humoral and mucosal immune responses and Gag-specific humoral immune responses were higher in rNDV-Gag/Env and rNDV-Env/Gag than in the other recombinants. rNDV-Gag/Env and rNDV-Env/Gag were also more efficient in inducing cellular as well as protective immune responses to challenge with vaccinia viruses expressing HIV-1 Env and Gag in mice. These results suggest that vaccination with a single rNDV coexpressing Env and Gag represents a promising strategy to enhance immunogenicity and protective efficacy against HIV.IMPORTANCEA safe and effective vaccine that can induce both systemic and mucosal immune responses is needed to control HIV-1. In this study, we showed that coexpression of Env and Gag proteins of HIV-1 performed using a single Newcastle disease virus (NDV) vector led to the formation of HIV-1 virus-like particles (VLPs). Immunization of guinea pigs with recombinant NDVs (rNDVs) elicited potent long-lasting systemic and mucosal immune responses to HIV. Additionally, the rNDVs were efficient in inducing cellular immune responses to HIV and protective immunity to challenge with vaccinia viruses expressing HIV Env and Gag in mice. These results suggest that the use of a single NDV expressing Env and Gag proteins simultaneously is a novel strategy to develop a safe and effective vaccine against HIV.

Lung cancer is one of the most common cancers in America. Frequent sites of metastasis include the Hilar lymph nodes, adrenal glands, liver, brain, and bone. The following case report is of a primary lung cancer with metastases to the breast and skin. Case. A 48-year-old African American male with a past medical history of poorly differentiated left breast cancer status after modified radical mastectomy (MRM), chronic obstructive pulmonary disease, and smoking (20 pack-years) presents to the ER with progressive shortness of breath on exertion, upper back pain, and weight loss for 2 months in duration. On physical examination he is found to have a MRM scar on his left breast and a left periumbilical cutaneous mass. Chest X-ray and chest CT reveal a right upper lobe mass and biopsies from the breast, lung, and the periumbilical mass indicate a poorly differentiated carcinoma of unclear etiology; all tumor markers are negative. The patient is male and a chronic smoker; therefore the diagnosis is made as lung carcinoma with metastases to the breast and skin. Conclusion. A high index of suspicion for cutaneous metastases should be cast when investigating cutaneous pathologies in patients at risk for primary lung malignancy.

We describe a previously healthy young man who presented with headaches, diplopia with right lateral gaze palsy, dysphagia, and hoarseness over a 2-month period. Magnetic resonance imaging of the brain revealed a small enhancing mass at the prepontine cistern and chest CT showed a left mediastinal mass. Mediastinoscopy and lymph node biopsy were performed. DNA probe and culture of the biopsy specimen were confirmed to be Mycobacterium tuberculosis complex. Resolution of neurologic symptoms was noted after 6 weeks, in addition to regression of brain stem and mediastinal lesions after 12 weeks of antituberculous therapy.