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An Unusual Rash in an Infant: Expanding the Differential Diagnosis for Sepsis in an Infant Younger than 3 Months
Get PDFIntroduction: We present a case of Lyme disease in an infant younger than 3 months. Although Maine is a Lyme disease endemic area, infants younger than 1 year rarely present with Lyme disease.
Clinical Findings: The infant was evaluated due to rash and a history of fever and irritability, with a history of tick bite 1 week earlier. Laboratory findings were normal.
Clinical Course: The infant was evaluated for sepsis as recommended for young infants with fever. Because of the presence of erythema migrans rash and negative bacterial cultures, the infant was treated with ceftriaxone parenterally for 7 days and amoxicillin for an additional 7 days. There were no complications after treatment.
Conclusions: Lyme disease in young infants has been rarely reported, with limited evidence about duration and route of treatment. The medical literature describes 3 cases of infant Lyme disease, with treatment durations ranging from several days of parenteral therapy followed by oral therapy to 14 days of parenteral therapy. These infants must be evaluated for typical systemic bacterial infections as well. However, in Lyme disease endemic areas, Lyme disease should also be considered, even in very young infants
Early Disseminated Lyme Disease with Multiple Cranial Neuropathy
Get PDFIntroduction: Lyme disease, caused by the spirochete Borrelia burgdorferi and transmitted by the Ixodes tick, encompasses a variety of symptoms across multiple stages. Early localized Lyme disease may present within 1 month of tick bite with erythema migrans, arthralgias, and fever. Disseminated infection typically occurs 3 to 12 weeks later and can cause neurologic symptoms of dizziness, headache, diplopia, cranial neuropathy, cranial nerve (CN) VII palsy, meningitis, encephalopathy, and cardiac arrhythmia or heart block. Late Lyme disease may arise after months or years and is characteristically associated with monoarticular arthritis. Among patients who have cranial neuropathy in early disseminated Lyme disease, 80% have CN VII involvement, but optic and extraocular neuropathy may occur.
Clinical Findings: We describe a case of a patient in their 60s who presented with erythema migrans, headache, neck pain, and diplopia, and they were found to have right CN VI palsy. A brain magnetic resonance imaging showed diffuse enhancement of the bilateral oculomotor nerves, trigeminal nerves, abducens nerves, and CN IX/X/XI complexes; patchy enhancement of the right facial nerve; and pachymeningeal enhancement.
Clinical Course: Although initial testing for Lyme disease antibodies was negative in serum and cerebrospinal fluid, a repeat serum enzyme-linked immunoabsorbent assay was positive. After a course of intravenous ceftriaxone and methylprednisolone followed by oral doxycycline, their skin lesions, headache, neck pain, and diplopia resolved.
Conclusions: Lyme disease may involve multiple CNs and present with diverse neurologic symptoms, even before seroconversion occurs. Our unique case of neuroborreliosis—which presented as headache followed by diplopia, neck pain, and CN VI palsy, with diffuse CN involvement shown on magnetic resonance imaging—responded well to treatment
Implementation and Evaluation of a Resident Pediatric Complex Care Education Series
Get PDFChildren with medical complexity have significant chronic health problems that affect multiple organ systems and result in functional limitations, high health care need or utilization, and often dependence on medical technology. Addressing their needs requires optimizing care within the medical home and medical neighborhood.https://knowledgeconnection.mainehealth.org/lambrew-retreat-2025/1011/thumbnail.jp
Analysis of Novice and Expert Rater Reliability for a Neonatal Resuscitation Program® Adherence Assessment Tool
Get PDFAn NRP Adherence Assessment Tool used to evaluate efficacy of a telesimulation neonatal resuscitation training program demonstrated strong interrater reliability with both expert and novice raters.https://knowledgeconnection.mainehealth.org/lambrew-retreat-2025/1031/thumbnail.jp
A Case of a Portuguese Man-O-War Envenomation in Southern Rhode Island
No full textWe present the case of a 16-year-old patient who was stung by a Portuguese Man-O-War (Physalia physalis) in southern Rhode Island (RI) while surfing. P. physalis are not typically found in southern RI waters and envenomations are rare. Emergency medical services (EMS) are often the first clinicians to arrive on scene following an injury and are crucial to alleviating the immediate pain and long-term consequences of P. physalis envenomations. RI state decontamination and treatment protocols for P. physalis envenomations differ from national guidelines. Notably, RI EMS protocols recommend dousing the affected area with vinegar, contrary to national EMS protocols and research studies which indicate that the application of vinegar may increase nematocyst discharge. We examine the current literature for the decontamination and treatment of Portuguese Man-O-War envenomation and provide guidance for treatment of envenomated patients
Statewide Needs Assessment of Neonatal Readiness at Delivery Hospitals in Maine
No full textBACKGROUND AND OBJECTIVE: Neonatal mortality is higher in hospitals with low birth rates, and in Maine, two-thirds of birthing hospitals deliver less than 1 baby each day. Our objective was to characterize neonatal readiness at all Maine birthing hospitals and to identify barriers to and resources for improving care. METHODS: We used a descriptive survey in which hospital leaders completed a 226-question survey followed by a virtual site meeting for data quality assurance. The survey we developed assessed hospital demographics and services, personnel, training, leadership, quality improvement, policies, transport/disaster preparedness, equipment, and barriers to and resources for improving neonatal care. The survey was adapted from existing assessments used for leveling of care and pediatric readiness. Data were analyzed using descriptive statistics, stratified by state-designated level of care I-IV. RESULTS: From May 2022 to September 2023, all hospitals (N = 23) completed the survey and interview: 18 level I, 3 level II, 1 level III, and 1 level IV. Only 4 hospitals (17%) have on-site pediatricians and 3 (13%) have on-site obstetricians. All level I/II hospitals have access to specialists via phone consultation, whereas only 30% have telemedicine access to neonatology. A total of 87%, 74%, 61%, and 22% require Neonatal Resuscitation Program certification for physicians, nurses, respiratory therapists, and advanced practice clinicians who staff deliveries, respectively. Site-level qualitative data emphasized the need for additional resources and protected time to plan and implement training. CONCLUSION: Level I/II hospitals need support in accessing critical resources, both physical resources and pathways for accessing neonatal specialists, including appropriate equipment and increasing the availability of teleconsultations. Educational and clinical support is needed to improve neonatal readiness, which may help retain skilled clinicians and ensure quality of care at hospitals open for deliveries
Implementing HeartPal: Design and Early Results of a Specialized Care Delivery Model for Advancing Palliative Care in Advanced Heart Disease Populations
No full textBACKGROUND: Patients with advanced heart disease (AHD) face high symptom burden and complex care decisions with inconsistent access to palliative care (PC). We describe the design, implementation, and early outcomes of HeartPal, a specialty-aligned interprofessional PC service embedded within an AHD program, to inform replication in similar settings. METHODS: Launched in 2019, HeartPal includes a nurse practitioner, social worker, and PC physician delivering longitudinal care across inpatient and outpatient settings. We analyzed registry data from 505 patients referred between 2019-2021, fiscal year (FY) 2024 data, and service operational metrics. RESULTS: Monthly referrals increased from 13.2 to 19.3 patients (+46.2%). Referrals for advanced therapy evaluations decreased from 76/158 (48.1%) to 26/174 (14.9%), while goals-of-care referrals increased from 79/158 (50.0%) to 145/174 (83.3%). Among decedents, referrals within 60 days of death decreased by 47.1%. In-hospital deaths following index admission declined from 24 to 15 (-37.5%), and clinic follow-up increased from 23/142 (16.2%) to 34/158 (21.5%). In FY24, the team completed 837 encounters, generating 2,063 relative value units (RVUs). Billing offset 20% of direct personnel costs. CONCLUSIONS: HeartPal illustrates the feasibility of embedding PC within AHD care pathways, while highlighting the critical need for institutional investment
Progressive Pericardial Effusions (PEF) in Patients With Pulmonary Arterial Hypertension (PAH) Taking Sotatercept-Association With Pre-Existing Pericardial Effusion
No full textPericardial effusion (PEF) in PAH may be a marker of worsening disease or associated with autoimmune conditions. Sotatercept was not initially reported as associated with the development or progression of PEF. We describe PAH patients taking sotatercept who were found to have new or worsening PEF and examine associated comorbidities
Leveraging NSQIPP testicular torsion process measures: Initial survey of the NSQIPP testicular torsion collaborative
No full textBACKGROUND: Testicular torsion is a pediatric emergency that poses a time-sensitive risk to the testicle. Best practices for testicular torsion protocols remain unclear. We convened the Testicular Torsion Collaborative, leveraging National Surgical Quality Improvement Program Pediatric (NSQIPP) Testicular Torsion Process Measure collection to assess factors associated with favorable metrics. METHODS: Data were accrued across 29 participating NSQIPP sites, excluding neonatal and non-urgent cases. Post-processed data available through NSQIPP included site of initial presentation and time stamps for presentation, ultrasound, and operating room entry; number of cases greater than the NSQIPP median for each time stamp; and orchiectomy rate. Hospital level data and torsion-related care processes were collected from each participating site via an electronic survey. RESULTS: From 10/1/2021 to 9/30/22, 1007 testicular torsion patients were included, with 494 (49.1 %) transferred from another institutions. A standardized evaluation protocol was associated with fewer patients exceeding the NSQIPP median from presentation to ultrasound (38.8 % vs 60 %, p = 0.03). Testicular Workup for Ischemia and Suspected Torsion (TWIST) score use was associated with a shorter time frame from presentation to ultrasound (0.7 vs 1.1 h, p = 0.03). Free-standing children\u27s hospitals (p \u3e 0.01) and institutions with an American College of Surgeons Children\u27s Surgery Verification (p = 0.03) also demonstrated improved time to ultrasound. Overall orchiectomy rate was 15.8 % and there were no statistical differences noted across the study variables. CONCLUSIONS: Across a wide spectrum of hospitals within NSQIPP, we demonstrate that certain torsion-related processes and hospital-level factors are associated with faster times to ultrasound. The NSQIPP Testicular Torsion Collaborative will continue to explore interventions to improve testicular torsion care and outcomes
December 17th, 2025: From Words to Impact: Best Practices in Serious Illness Communication
No full texthttps://knowledgeconnection.mainehealth.org/medicine_gr/1055/thumbnail.jp