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Pericardial Conundrum: Unmasking Tuberculosis as the Culprit
No full textBACKGROUND: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the lungs but can involve other organs, termed extrapulmonary tuberculosis. Tuberculous pericarditis (TBP) is a rare form, representing approximately 1% of tuberculosis-related autopsies and 4% of acute pericarditis cases in developed countries.
CASE SUMMARY: A 29-year-old healthy Indian man presented with fever, night sweats, and weight loss. Imaging revealed a large pericardial effusion with tamponade physiology. He underwent pericardiocentesis and a surgical pericardial window, with biopsy confirming M. tuberculosis. He was treated with rifampin, isoniazid, pyrazinamide, and ethambutol therapy, colchicine, and a steroid taper, resulting in clinical improvement.
DISCUSSION: TBP is rare in developed regions and presents diagnostic challenges because of nonspecific symptoms and delayed culture results. Early recognition and intervention are critical to prevent progression to constrictive pericarditis and improve outcomes.
TAKE-HOME MESSAGE: A high index of suspicion for TBP is essential in patients with pericardial effusion to enable timely diagnosis and intervention, optimizing clinical outcomes
Virtually-delivered prenatal yoga to prevent postpartum depression (PRYD) in women with a history of depression: Protocol for an exploratory pilot randomized controlled trial
No full textPostpartum depression affects approximately 13 % of women in the United States and contributes to adverse maternal and infant health outcomes. While a range of effective treatment approaches are available, there are substantial barriers to receiving care for postpartum depression. Preventive interventions during pregnancy to reduce the risk of postpartum depression may mitigate some of the barriers experienced in the postpartum period, and approaches that help manage stress and improve wellness are needed. Prenatal yoga, which has a range of physical and mental health benefits and has been shown to improve depressive symptoms in pregnancy, may be a feasible and acceptable alternative to traditional mental health treatment. However, additional research is needed to increase the accessibility of prenatal yoga for high-risk populations and determine whether it can be effectively implemented in healthcare settings to reduce postpartum depression risk. The PRY-D Study is an exploratory pilot randomized controlled trial that optimizes a mindful prenatal yoga intervention to prevent postpartum depression for pregnant patients at high risk of postpartum depression and examines feasibility, acceptability, satisfaction and preliminary effectiveness of the intervention. Results from this pilot randomized controlled trial enrolling a total of 48 pregnant patients at a large healthcare system will inform the development of a future fully powered hybrid type 2 effectiveness-implementation trial. Clinical Trial Registration Number: NCT06004232
Impact of Individualized Versus Weight-Based Pain Protocols on Patient Satisfaction for Patients With Sickle Cell Disease Experiencing a Vaso-Occlusive Episode
No full textINTRODUCTION: National guidelines for the acute management of sickle cell disease vaso-occlusive episodes recommend the use of a patient-specific or a weight-based protocol. The authors compared patient satisfaction with pain management between those randomized to receive either a patient-specific or weight-based pain protocol in the COMPARE-VOE randomized control trial.
METHODS: Participants with sickle cell disease were pre-enrolled and patient satisfaction with pain management was assessed at the time of discharge from the 6 participating emergency departments. Patients were randomized to receive a patient-specific or weight-based pain protocol. The authors compared continuous variables between the patient-specific and weight-based protocols with the 2-sample t test and categorical variables by the chi-square test.
RESULTS: The authors enrolled 104 participants. Compared with satisfaction with pain management on previous ED visits, more participants in the patient-specific protocol group than the weight-based group (57.1% vs 31.8%; P = .02) were satisfied with pain management. Most who were discharged home (91.2%) felt their pain was sufficiently relieved to be discharged home.
DISCUSSION: These findings support evidence-based guidelines to manage vaso-occlusive episodes in emergency departments. Patient-specific protocols can be implemented by partnering with local sickle cell disease providers to make protocols available in the emergency department
Hemophagocytic Lymphohistiocytosis After Treatment With Checkpoint Inhibitor Therapy
No full textHemophagocytic lymphohistiocytosis (HLH) is a rare hematological syndrome presenting with massive, dysregulated cytokine release that can result in multiple organ failure and is associated with a high risk of mortality. Based on the recent North American consortium recommendations, it has been suggested to categorize HLH into two entities, HLH syndrome and HLH disease. HLH disease encompasses multiple subgroups, including familial HLH (F-HLH), HLH-associated immune compromise (IC-HLH) and HLH observed after immune activating therapies. The diagnosis can be quite challenging, and the pathophysiology leading to HLH disease has yet to be fully elucidated. Much less is known about HLH that occurs due to treatment with immunotherapy such as immune checkpoint inhibitors (ICIs). Herein, the authors report a case of a 71-year-old man who was treated with a combination of nivolumab and ipilimumab for bladder cancer. He later presented with mental status changes and pancytopenia, ultimately meeting the diagnostic criteria for HLH syndrome
Clinical and Genomic Characterization of Recalcitrant Enterococcal Bacteremia: A Multicenter Prospective Cohort Study (VENOUS)
No full textBACKGROUND: Patients with recalcitrant enterococcal bloodstream infections are at greater risk of adverse outcomes. We identified patients in the 2016-2022 Vancomycin-Resistant Enterococcal Bacteremia Outcomes Study (VENOUS) cohort experiencing recalcitrant bloodstream infections for further clinical and genomic characterization.
METHODS: Bacteremia episodes were considered persistent if there was a lack of clearance on day four while receiving ≥ 48 hours of active therapy and recurrent if there was clearance during hospitalization with a subsequent positive culture (collectively, recalcitrant bacteremia). A matched comparison group of non-recalcitrant bacteremia patients was chosen in a 2:1 control:case ratio. Isolates were subjected to short- and long-read whole-genome sequencing. Hybrid assemblies were created using a custom pipeline.
FINDINGS: A total of 46 recalcitrant infections from 41 patients were identified. Patients with persistent bacteremia were more often admitted to the ICU upon admission relative to controls. E. faecalis strains causing persistent infections had a significantly higher proportion of genes associated with carbohydrate utilization relative to controls. Representation of functional groups associated with mutated genes was disparate between E. faecium and E. faecalis index and persistent isolates, suggesting species-specific adaptation.
DISCUSSION: Enterococcal isolates causing recalcitrant bacteremia were genomically diverse, indicating that strain-specific signatures are not drivers of persistence. However, comparisons of index vs. persistent isolates revealed that E. faecium may be genetically pre-adapted to cause persistent infection, and site-specific structural variation during infection suggests the role of differential gene expression in adaptation and persistence. This data lays groundwork for future studies to define signatures of enterococcal adaptation during bacteremia
Patients with cystic fibrosis do not have an increased risk of adverse events after endoscopic retrograde cholangiopancreatography: a propensity-matched analysis
No full textBACKGROUND: Cystic fibrosis (CF) is a common life-limiting genetic disease often associated with hepatobiliary complications. Endoscopic retrograde cholangiopancreatography (ERCP), though valuable, carries procedural risks. We assessed the safety of ERCP in CF patients using real-world data.
METHODS: A retrospective cohort study using the TriNetX database (2010-2024) identified adults (≥ 18 years) with CF who underwent ERCP. Propensity-score matching adjusted for confounders, including age, sex, race, and hospitalization history. The primary outcome was post-ERCP pancreatitis (PEP); secondary outcomes included bleeding and infection. Subgroup analysis evaluated outcomes in patients with choledocholithiasis.
RESULTS: Among 534 matched CF patients (mean age 44.6 years; 48.3% female), rates of PEP (8.3% vs. 4.9%, adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 0.937-3.315; P=0.075), bleeding (3.1% vs. 2.1%, aOR 1.52, 95%CI 0.674-3.409; P=0.31), and infection (3.7% vs. 2.4%, aOR 1.55, 95%CI 0.638-3.785; P=0.33) were not significantly different compared to non-CF controls. Subgroup analysis of choledocholithiasis patients similarly showed no significant differences.
CONCLUSIONS: ERCP in CF patients demonstrated comparable adverse event rates to non-CF controls. These findings support the procedural safety of ERCP in this population, though further prospective studies are needed to validate these results and clarify risk by indication
Reduction of inflammatory biomarkers underlies extracellular vesicle mediated functional recovery in an aged monkey model of cortical injury
No full textCortical injury results in inflammation and cell death that can cause disability, especially in the aged population. Previous studies from our group have demonstrated the efficacy of bone marrow mesenchymal stromal cell derived extracellular vesicles (MSC-EVs) as a therapeutic to mitigate damage and enhance recovery in our aged monkey model of cortical injury. In the first 3-5 weeks following injury to the hand representation of the primary motor cortex, monkeys treated intravenously with MSC-EVs exhibited a more rapid and complete recovery of fine motor grasp compared to vehicle-treated monkeys. However, whether recovery and treatment are associated with temporal changes in peripheral or central biomarkers of inflammation remain unknown. The current study used the highly sensitive Olink(®) Proximity Extension Assay to assess inflammatory protein biomarkers in blood and CSF across a 6-week recovery period in aged female monkeys. MSC-EV treatment promoted a sustained downregulation of pro-inflammatory proteins in plasma across the entire recovery period, and a transient downregulation of anti-inflammatory proteins at 2 weeks post-injury. Functional annotation and pathway analyses showed that the plasma proteins downregulated with MSC-EV treatment were associated with the suppression of pro-inflammatory signaling. Further, immunolabeling of perilesional brain tissue harvested 6-weeks post injury showed an increase in homeostatic microglial phenotypes with MSC-EV treatment. Downregulation of inflammatory markers in plasma and brain tissue were positively correlated with improved functional recovery. These data suggest that MSC-EVs facilitate recovery of function after brain injury, in part, via sustained suppression of both peripheral and central pro-inflammatory signaling across recovery
Ultra-early postoperative ambulation in spine surgery: a Michigan Spine Surgery Improvement Collaborative study
No full textOBJECTIVE: Previous studies have demonstrated the benefit of early ambulation in patients who have undergone elective spine surgery. However, there are limited data on how early patients can feasibly move about in the postoperative period and whether there is further benefit in an ultra-early postoperative ambulation time frame. Current Michigan protocols aim for 80% of all patients ambulating within 8 hours of surgery end time. The goal of this retrospective study was to determine whether patients who ambulate within 4 hours of surgery have any greater benefit than those who ambulate 4-8 hours after surgery.
METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried for patients who had undergone elective spine surgery between January 2020 and May 2024. Patients were categorized into two groups based on the time to ambulation: \u3c 4 hours postoperatively (ultra-early) and 4-8 hours postoperatively. Patients who had 4 or more levels altered, a durotomy, or CSF leakage were excluded from analysis. Primary outcomes were the presence of any complication and hospital length of stay. Secondary outcomes included patient-reported outcomes. A multivariate analysis was conducted to adjust for potential confounders.
RESULTS: A total of 21,725 patients were included in the study. Compared to the ultra-early cohort, the patients who ambulated 4-8 hours postoperatively were more likely to have complications (RR 1.14, 95% CI 1.04-1.26, p = 0.005), more likely to be readmitted after surgery (RR 1.18, 95% CI 1.03-1.35, p = 0.020), less likely to be discharged to home (RR 0.99, 95% CI 0.98-1.00, p = 0.005), and less likely to reach a minimal clinically important difference in back pain 1 year after surgery (RR 0.96, 95% CI 0.93-0.99, p = 0.022). The ultra-early ambulation cohort had a 0.47-day shorter length of stay (95% CI 0.34-0.6, p \u3c 0.001) relative to the 4- to 8-hour cohort.
CONCLUSIONS: Ambulating patients in an ultra-early manner, that is, \u3c 4 hours after spine surgery, is feasible and demonstrates a potential benefit in the outcomes of elective spine surgery. The benefits appear to be a lower risk of complications and lower likelihood of readmission
Incidental diagnosis of gallbladder carcinoma during or after routine cholecystectomy: A retrospective study with emphasis on clinicopathologic findings
No full textBACKGROUND: Cholecystectomy is a common surgical procedure routinely performed for patients with benign gallbladder disease. The most common indications for cholecystectomy are acute or chronic cholecystitis with or without cholelithiasis. However, in rare instances, incidental findings ranging from benign to malignant conditions are encountered, of which gallbladder adenocarcinoma is an aggressive and fatal disease.
AIM: To determine the prevalence of all incidental diagnoses in routinely performed cholecystectomy specimens, with a particular emphasis on adenocarcinoma, and to characterize the clinicopathological characteristics of malignant postoperative specimens.
METHODS: The electronic medical record and institutional pathology database were searched for analyses done on gallbladder specimens from patients who had a routine cholecystectomy for benign gallbladder disease during the study period (February 2000 to February 2023). A total of 30678 cholecystectomies performed across the study period were included for analysis. Patients who had preoperative findings or radiological results concerning malignancy were excluded. The demographic and clinical data including patient age and gender, preoperative diagnosis, radiographic results at time of diagnosis, gross and morphologic features of gallbladder specimens, and pathologic staging parameters according to the American Joint Committee on Cancer were recorded.
RESULTS: Of the 30678 cholecystectomy specimens received by the Department of Pathology from patients with who had cholecystectomy for putative benign gallbladder disease during the study period, 42 (0.14%) were determined to be incidental gallbladder adenocarcinoma and 1 was adenocarcinoma in situ. There were 2 benign incidental diagnoses, including 9 patients (0.02%) with accessory/ectopic liver lobe, and 3 with paraganglioma.
CONCLUSION: Thorough histopathological examination of routine gallbladder specimens is important to provide an early diagnosis of unexpected gallbladder cancer to ensure that patients receive timely care when the disease is treatable
Project #068: Thinking Like an Infection Prevention Expert: Creating an Automated Report to Aid Frontline Staff in the Reduction of Clostridioides difficile Infections
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