Introduction. Aseptic meningitis can occur from different types of infections of which viral etiologies are the most common. Varicella zoster virus (VZV) nowadays is considered a familiar entity of aseptic meningitis. However, it is usually reported in immunocompromised patients. For cases of VZV meningitis that are observed, a rash has been noted before the onset of meningitis or sometimes after it. Clinical Case. We present an uncommon case of VZV meningitis in an 18-year-old immunocompetent male who did not have a rash on presentation and did not develop one during his course either. Cerebrospinal fluid showed lymphocyte-predominant leukocytosis and elevated protein with normal glucose suggestive of aseptic meningitis. Cerebrospinal fluid polymerase chain reaction (CSF PCR) was positive for VZV; cerebrospinal fluid cultures and blood cultures were negative. The patient had complete resolution of symptoms with no complications on intravenous acyclovir therapy and was discharged home on oral valacyclovir therapy. Conclusion. It is important to consider varicella zoster virus as an etiology of aseptic meningitis as clinical presentation can be without a vesicular rash and in immunocompetent patients.

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INTRODUCTION: Gastrointestinal Bleeding (GIB) is one of the most common conditions that lead to an admission to the intensive care unit (ICU). The aim of this study is to determine the risk factors, clinical predictors, and prognostic significance of myocardial ischemia associated with GIB. METHODS: We reviewed our ICU database and electronic medical record of all patients admitted to the ICU with GIB (including upper or lower GIB) between 10/1/05 and 9/30/18. Data aggregated include demographics, hemoglobin (HGB) and troponin (TROP) values, comorbidities and outcome parameters. Patients were categorized as having myocardial ischemia (“ISCH,” including ST elevation myocardial infarction, non-ST elevation myocardial infarction, or demand ischemia), or no ischemia (“NON”). We compared risk factors and clinical characteristics of both groups and created a multivariable logistic regression model to determine the independent association of ISCH with mortality. RESULTS: This investigation includes 403 patients with GIB. 155 of 403 (38.5%) had enzymatic and/or electrocardiographic evidence of ischemia. ISCH were older than NON (78 [66-86] vs. 68 [55-79]; P < 0.0001) with higher rates of cardiac risk factors, including diabetes mellitus (30.3% vs. 20.6%; P = 0.0367), class III or IV cardiac disease (25.8% vs. 5.2%; P < 0.0001), and prior myocardial infarction (20.0% vs. 10.1%; P = 0.0081). ISCH had higher severity of illness: APACHE (acute physiology and chronic health evaluation) III score (62 [50-77] vs. 47 [34-61]; P < 0.0001) and higher rates of mechanical ventilation (18.7% vs. 10.5%; P = 0.029). Minimum HGB values were similar (7.5 [2.0] vs. 7.7 [2.0]; P = 0.2) and maximum TROP were higher (0.21 [0.09-1.90] vs. 0.01 [0.01-0.03]; P < 0.0001). ISCH had longer ICU length of stay (1.7 [1.0-3.2] vs. 1.3 [0.8-2.0] days; P = 0.0001) and higher mortality (20.0% vs. 5.6%; P < 0.0001). Multivariable analysis demonstrated that ISCH was independently associated with higher mortality: Odds ratio (95% confidence interval) 3.23 (1.34-7.78; P = 0.0088). CONCLUSION: Myocardial ischemia occurs frequently in critically ill patients admitted to the ICU with GIB and is identified in this investigation as being an independent risk factor for mortality. Recognition of risk factors and comorbidities associated with cardiac disease in the setting of GIB can identify patients who are at increased risk of cardiovascular stress and could aid in targeting more aggressive treatment, potentially improving outcomes.

INTRODUCTION: Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the United States. Treatment for HCV infection is currently available, curative, and with few associated side effects, increasing the importance of identifying HCV-infected individuals. HCV screening guidelines recommend a 1-time screening for baby boomers (individuals born between 1945 and 1965). Baby boomers have a higher risk for HCV-related morbidity and mortality. As of 2015, less than 13% of this population has undergone screening for HCV infection. This study aims at quantifying the baseline screening rates amongst baby boomers in a medical residents’ community clinic and evaluating the impact of resident-targeted interventions on HCV screening rates. METHODS: A retrospective chart review of baby boomers seen by medical residents between 7/1/17 and 12/31/18 was performed. Patients had to be seen at least once for a physical exam by the medical resident during the study period, and not screened for HCV infection previously. Baseline screening rates were recorded. Interventions were implemented for a period of 4 months. These included an updated electronic medical record (EMR) reminder for screening based on birth year, an EMR HCV risk assessment tool to identify patients need testing before visit, a link to HCV screening indications and guidelines, and small group teaching sessions about testing and linking patients to appropriate posttest care. A second phase of data collection included a chart review of baby boomers seen between 2/1/19 and 5/31/19 and meeting same criteria. A paired comparison t-test is used to analyze results. RESULTS: This investigation includes 502 patients in the first phase and 164 patients in the second phase of data collection. Pre-intervention screening rate was 89/502 (17.7%) compared with 72/164 (43.9%) post-intervention (P value < 0.0001). CONCLUSION: This investigation shows the suboptimal baseline HCV screening rate in baby boomers in a residents’ community clinic. Our post-intervention findings highlight the impact of focused resident-targeted education and the effectiveness of integrating appropriate tools into clinic infrastructure to help improve the rate of screening. Subsequently, this can help identify individuals who are in need for medical attention, potentially reducing complications of HCV infection and providing good value for our health care dollar overall.