Gunshot-related nerve injuries of the upper extremities: clinical, electromyographic, and ultrasound features in 22 patients

Objectives

Gunshot wounds of the upper extremities may cause permanent neurovascular injuries, leading to significant morbidity, chronic pain, functional loss, and disability. While there are many reports on the incidence and intraoperative findings in gunshot-related nerve injuries (GSNI) sustained during wars, there is a paucity of details pertaining to GSNI of the upper extremities in civilians. The goal of this paper is to provide the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in 22 patients with GSNI of the upper extremities.

Methods

This is a retrospective study of patients referred for EDX studies to evaluate the presence of nerve injury after sustaining GSWs to the upper extremities. All patients underwent EDX studies, and 16 patients had US evaluations. Numerous metrics were documented including presenting symptoms, neurological abnormalities, EDX findings, and US features.

Results

The forearm was the most frequent location of injury (8 [36%] patients). The ulnar nerve was the most common injured nerve (10 [45%] patients), followed by the brachial plexus (7 [32%] patients). All patients complained of muscle weakness; the most frequently affected muscles were the first dorsal interosseous (FDI) (14 [64%] patients) and abductor pollicis brevis (APB) (11 [50%] patients). Muscle atrophy was noted in 19 (86%) patients, 15 of whom had atrophy of the FDI. Axonotmesis was the type of nerve injury in all patients based on EDX studies. Of the 16 patients who underwent US studies, a neuroma in continuity was noted in 4 (25%) patients and neurotmesis in 1 (6.2%) patient. Eleven (69%) patients had enlarged and/or hypoechoic nerves.

Conclusions

Axonotmesis of the ulnar nerve was the most common finding among patients sustaining gunshot injuries to the upper extremities. EDX and US studies provide valuable insight into the underlying pathophysiology and guidance for management of patients with GSNI of the upper extremities.

Genomic characterization of vulvar squamous cell carcinoma reveals differential gene expression based on clinical outcome

OBJECTIVE

The greatest challenge in the management of vulvar squamous cell carcinoma (VSCC) is treatment of recurrent disease where options for surgery and radiation have been exhausted, or treatment of disease where distant metastasis is present. Identification of mutations differentially expressed between tumor from patients who died of aggressive disease and tumor from patients with an indolent course could reveal novel prognostic indicators and guide development of therapeutic drugs.

METHODS

From 202 consecutive patients with VSCC, patients who recurred and died of disease (group A) were identified and matched by age, tumor size, depth of invasion and nodal status with those whose disease did not recur (group B). Tumors from 21 patients were subjected to whole exome sequencing of DNA and RNA, immunohistochemistry (IHC) antibodies of PD-L1 and P16, and in-situ hybridization (ISH) for high-risk HPV.

RESULTS

Analysis of DNA and RNA revealed six genes that were strongly differentially expressed between group A and B: TGM3, ACVR2A, ROS1, NFEL2, CCND1 and BCL6. Clinically relevant DNA mutations were significantly greater in group A versus B: 7 vs 2.3 mutations per patient. The most common genomic alterations were mutations in TP53 and the promoter region of TERT. Other common genomic events include alterations of FAT1, CDKN2A, PIK3CA, CCND1, and LRP1B. All samples were MSI stable and tumor mutational burden (TMB) was similar in groups A and B. Most VSCC specimens (81%) were positive for PD-L1.

CONCLUSIONS

ACVR2A and TGM3 are significantly under-expressed in tumors with poor outcome, suggesting they may play a role in tumor suppression. Clinical outcome of VSCC appears independent of MSI, TMB, or PD-L1 status.

Impact of Occupations and Hobbies on the Severity of Carpal Tunnel Syndrome: An Electrodiagnostic Perspective

OBJECTIVE

This study describes the clinical and electrodiagnostic (EDX) findings as well as occupations and hobbies in 613 patients diagnosed with carpal tunnel syndrome (CTS).

METHODS

Patients with moderate, moderately severe, or severe CTS based on EDX criteria were included.

RESULTS

The most common occupations included workers in offices, construction/maintenance, and assembly lines. The occupation severity scores were greatest in garment workers, musicians, and landscapers. Regardless of occupation, patient age and occupation duration were significantly correlated ( P < 0.001). Gardeners had the highest average severity score of the hobbies, followed by painters, those who sew, and individuals who perform house chores.

CONCLUSIONS

Physicians should be aware of particular occupations and hobbies associated with a greater risk of severe CTS and offer modifications to their patients' work duties and hobbies to minimize the likelihood of developing severe CTS.

Etiology of spastic foot drop among 16 patients undergoing electrodiagnostic studies: patient series

BACKGROUND

Differentiating foot drop due to upper motor neuron (UMN) lesions from that due to lower motor neuron lesions is crucial to avoid unnecessary surgery or surgery at the wrong location. Electrodiagnostic (EDX) studies are useful in evaluating patients with spastic foot drop (SFD).

OBSERVATIONS

Among 16 patients with SFD, the cause was cervical myelopathy in 5 patients (31%), cerebrovascular accident in 3 (18%), hereditary spastic paraplegia in 2 (12%), multiple sclerosis in 2 (12%), chronic cerebral small vessel disease in 2 (12%), intracranial meningioma in 1 (6%), and diffuse brain injury in 1 (6%). Twelve patients (75%) had weakness of a single leg, whereas 2 others (12%) had bilateral weakness. Eleven patients (69%) had difficulty walking. The deep tendon reflexes of the legs were hyperactive in 15 patients (94%), with an extensor plantar response in 9 patients (56%). Twelve patients (75%) had normal motor and sensory conduction, 11 of whom had no denervation changes of the legs.

LESSONS

This study is intended to raise awareness among surgeons about the clinical features of SFD. EDX studies are valuable in ruling out peripheral causes of foot drop, which encourages diagnostic investigation into a UMN source for the foot drop.

Impact of Dyslexia and Health Literacy on Racial and Gender Disparity in the Incarcerated Population

Dyslexia is the most common learning disability and involves difficulty in reading, writing, and spelling in your native language despite at least average intelligence. A disproportionate share of incarcerated individuals have both dyslexia and are African American. Behavior manifestations associated with dyslexia often lead to life choices resulting in incarceration. Dyslexia is rarely considered as playing a role in unemployment, drug misuse, and incarceration. Dyslexia screening upon prison admission permits identification of individuals with dyslexia and allows for specialized reading classes to boost self-esteem and develop a skill set that is desirable in the workforce upon release. Dyslexia should be recognized as a social determinant of health whose early recognition and intervention may engender self-confidence in those affected and encourage them to be positively engaged in society.

Iatrogenic median and ulnar nerve injuries during carpal tunnel release: clinical, electrodiagnostic, and ultrasound features in 12 patients. Patient series

BACKGROUND

Nerve injuries during carpal tunnel release (CTR) are rare. Electrodiagnostic (EDX) and ultrasound (US) studies may be helpful in evaluating iatrogenic nerve injuries during CTR.

OBSERVATIONS

Nine patients sustained a median nerve injury, and 3 patients experienced ulnar nerve damage. Decreased sensation occurred in 11 patients, and dysesthesia occurred in 1 patient. Abductor pollicis brevis (APB) weakness occurred in all patients with median nerve injury. Of the 9 patients with median nerve injury, the compound muscle action potentials (CMAPs) of the APB and sensory nerve action potentials (SNAPs) of the 2nd or 3rd digit were not recordable in 6 and 5 patients, respectively. Of the 3 patients sustaining ulnar nerve injuries, the CMAPs of the abductor digiti minimi (ADM) and SNAPs of the 5th digit were not recordable in 1 patient; 2 patients showed prolonged latency and decreased amplitude of CMAPs/SNAPs. US studies of 8 patients with a median nerve injury showed a neuroma within the carpal tunnel. One patient underwent surgical repair urgently, and 6 did so after variable intervals.

LESSONS

Surgeons should be cognizant of nerve injuries during CTR. EDX and US studies are useful in evaluating iatrogenic nerve injuries during CTR.

Using a Harm Reduction Approach to Treat Inpatients With Substance Use Disorders

OBJECTIVE

This study investigated harm reduction (HR) strategies at our institution to decrease the number of patients with a substance use disorder (SUD) who left against medical advice (AMA).

BACKGROUND

HR is a public health strategy used for adult substance use problems for whom abstinence is not feasible.

METHODS

An HR program was established at 1 institution to enhance the care of hospitalized patients with a SUD.

RESULTS

Of the 1780 unique visits for patients with a diagnosis of SUD, 311 patients (17.5%) left our hospital AMA or eloped. The average length of stay for all patients evaluated by the HR team was 6.6 days compared with 4.0 days for those who left AMA. Patients with >1 hospital stay accounted for 22% of our population but represented 34% of the patients who left AMA.

CONCLUSIONS

This study reports the approaches implemented to reduce the AMA rate of patients with a SUD and to promote patient-enhanced care.

Differences in Clinical Characteristics Between Prepubescent and Postpubescent Males With Testicular Torsion

Testicular torsion represents a pediatric surgical emergency. In this 6-year study with 140 patients, prepubescent (<13 years) and postpubescent (≥13 years) males with testicular torsion were identified. Prepubescent boys had a longer symptom duration (P = .016) and underwent more orchiectomies (P = .005) compared with postpubescent boys. The risk of orchiectomy decreased by 15% per 1-year increase in age (P = .002). Boys who underwent an orchiectomy had a longer symptom duration (P < .001), were younger (P = .002), had scrotal swelling (P = .001), scrotal erythema (P < .001), higher degrees of torsion (P = .036), and more left-sided surgeries (P = .014) compared with those who had an orchiopexy. Postpubescent boys were 63% less likely to receive an orchiectomy versus an orchiopexy compared with prepubescent boys. Pediatricians should be cognizant of the age discrepancies between prepubescent and postpubescent males with testicular torsion and educate parents about the importance of urgent evaluation in the Emergency Department to reduce the likelihood of an orchiectomy.

Etiological study of superficial radial nerve neuropathy: series of 34 patients

Objectives

Superficial radial nerve (SRN) neuropathy is a rare focal neuropathy leading to pain and paresthesia of the dorsolateral aspect of the hand. Reported causes include trauma, extrinsic compression, or it may be idiopathic. We describe the clinical and electrodiagnostic (EDX) features of 34 patients with SRN neuropathy of varied etiology.

Methods

This is a retrospective study of patients with upper limb neuropathy referred for EDX studies who were found to have SRN neuropathy based on clinical and EDX findings. Twelve patients also had ultrasound (US) evaluations.

Results

Decreased pinprick sensation was noted in the distribution of the SRN in 31 (91%) patients, and a positive Tinel's sign was observed in 9 (26%). Sensory nerve action potentials (SNAPs) were not recordable in 11 (32%) patients. Of the patients who had a recordable SNAP, the latency was delayed, and the amplitude was decreased in all cases. Of the 12 patients who underwent US studies, 6 (50%) had an increased cross-sectional area of the SRN at or immediately proximal to the site of injury/compression. A cyst was located adjacent to the SRN in 2 patients. The most common cause of SRN neuropathy was trauma in 19 (56%) patients, of which 15 were iatrogenic. A compressive etiology was identified in 6 patients (18%). No specific etiology was detected in 10 patients (29%).

Conclusion

This study is aimed at raising the awareness among surgeons about the clinical features and varied causes of SRN neuropathy; such knowledge may potentially lessen iatrogenic causes of injury.

Surgical Technologist Apprentice Program: An Innovative Approach to Improve Staffing

Along with surgeons, anesthesia professionals, and RN circulators, surgical technologists are essential members of the perioperative team. Despite a partnership with a local community college that offered a surgical technologist degree program, Norton Healthcare in Louisville, Kentucky, continued to experience a shortage of surgical technologists. To meet demands, the clinical educators at the facility developed an in-house Surgical Technologist Apprentice Program (STAP). The STAP consists of six weeks of didactic learning and hands-on training in an OR simulation laboratory, followed by a six-month preceptorship in the OR. This program has proven invaluable, particularly as the COVID-19 pandemic increased the need for personnel who are not only skilled in the OR but also can provide essential frontline patient care when needed. Together, the STAP and the college partnership offer a career-building opportunity for those in entry-level positions who may not otherwise be able to afford to train for this specialized role.

Surge in testicular torsion in pediatric patients during the COVID-19 pandemic

BACKGROUND

Testicular torsion is a pediatric surgical emergency, and prompt diagnosis and treatment is imperative. During the COVID-19 pandemic, pediatric patients with symptoms of testicular torsion may be reluctant to seek medical care which increases the likelihood of delayed presentation and the need for an orchiectomy. This observational study sought to determine whether there was a higher number of testicular torsion cases during COVID-19.

METHODS

As the first patient with COVID-19 was admitted to our facility on March 6, 2020, we identified male children ages 1-18 years with testicular torsion between March 1-December 31, 2020 (during COVID-19) compared to the same time period between 2015 and 2019 (prior to COVID-19). All patients were evaluated at our Institution's Emergency Department by a pediatric urologist.

RESULTS

There were 38 cases of testicular torsion between March 1-December 31, 2020 compared to 15.8 cases on average during the same 10-month period between 2015 and 2019 (a total of 79 cases). There was a statistically significant increase in testicular torsion cases during the COVID-19 pandemic compared to equivalent time periods in 2015-2019 (38 vs. 15.8, p = 0.05). Patients with testicular torsion during the COVID-19 pandemic were younger, had a longer duration of symptoms, and had a higher number of orchiectomies (although not statistically significant).

CONCLUSION

During the COVID-19 pandemic, an escalation in testicular torsion cases was observed. Timely assessment, diagnosis, and surgery are crucial to prevent testicular loss and potential infertility in the future. Further evaluation is needed to elucidate the surge in testicular torsion and possible mechanisms.

Caring for behaviorally challenging patients in nonpsychiatric settings

This article discusses a pilot study on the use of a behavior support plan to safely address patients who exhibit disruptive behaviors in the ED and nonpsychiatric medical settings while respecting their autonomy.

Multifocal intradural extramedullary ependymoma, MYCN amplified: illustrative case

BACKGROUND

Ependymomas are the most frequent tumors of the adult spinal cord, representing 1.9% of all central nervous system tumors and 60% of spinal cord tumors. Spinal ependymomas are usually solitary, intramedullary lesions. While intradural extramedullary (IDEM) ependymomas are infrequent, multifocal IDEM ependymomas are exceptionally rare.

OBSERVATIONS

The authors reported the first case in the literature of a patient diagnosed with multifocal IDEM ependymomas who was treated with tumor resection and brain and spinal radiotherapy. The patient presented with a 10-day history of bilateral leg numbness extending to the umbilicus and gait instability. Magnetic resonance imaging (MRI) studies revealed multiple enhancing nodular nodules throughout the entire spinal canal. Brain MRI revealed no abnormal lesions. A World Health Organization grade II ependymoma was confirmed histologically. At 31 months postoperatively, the patient remained clinically asymptomatic. Although cervical and thoracic MRI revealed stable intradural nodules and several areas of leptomeningeal enhancement, no malignant cells were seen in the cerebrospinal fluid (CSF). He underwent genetic testing to determine the appropriate chemotherapeutic agent if activation of the tumor should arise.

LESSONS

Because complete resection of multifocal IDEM ependymomas is not feasible, continued monitoring with brain and spine MRI is warranted to detect potential tumor dissemination in the CSF.

Role of electromyography and ultrasonography in the diagnosis of double crush lumbar radiculopathy and common fibular injury: illustrative cases

BACKGROUND

Double crush syndrome consists of two compression sites along a peripheral nerve and is rare in the lower extremities. Electrodiagnostic and ultrasound (US) studies may be helpful in evaluating foot drop involving overlapping pathologies.

OBSERVATIONS

Case 1 involved a man who presented with left dorsiflexor weakness and left foot numbness. Electromyography (EMG) revealed a left common fibular nerve entrapment neuropathy and left L5 radiculopathy. US and magnetic resonance imaging (MRI) revealed a large cystic lesion of the left common fibular nerve treated by cyst removal. The left foot drop persisted postoperatively. Lumbar computed tomography myelography revealed severe left foraminal stenosis at L5–S1. Multilevel lumbar laminectomies and facetectomies with an L5–S1 fusion were performed. Within 1 month postoperatively, the left foot drop had improved. Case 2 involved a man who developed a right foot drop caused by right lumbar foraminal stenosis at L4–5 and L5–S1. EMG and US of the right common fibular neuropathy showed large fascicles involving the right common fibular nerve. MRI revealed a hyperintense signal of the right common fibular nerve. Spontaneous improvement occurred within 6 months without surgery.

LESSONS

Spine surgeons should recognize double crush in the lower extremities. EMG and US are valuable in detecting peripheral nerve abnormalities, especially in cases with overlapping lumbar pathology.

Single low-dose targeted bevacizumab infusion in adult patients with steroid-refractory radiation necrosis of the brain: a phase II open-label prospective clinical trial

OBJECTIVE

There is an unmet need for safe and rapidly effective therapies for refractory brain radiation necrosis (RN). The aim of this prospective single-arm phase II trial was to evaluate the safety and efficacy of a single low-dose targeted bevacizumab infusion after blood-brain barrier disruption (BBBD) in adult patients with steroid-refractory brain RN.

METHODS

Ten adults with steroid-refractory, imaging-confirmed brain RN were enrolled between November 2016 and January 2018 and followed for 12 months after treatment. Bevacizumab 2.5 mg/kg was administered as a one-time targeted intra-arterial infusion immediately after BBBD. Primary outcomes included safety and > 25% decrease in lesion volume. Images were analyzed by a board-certified neuroradiologist blinded to pretrial diagnosis and treatment status. Secondary outcomes included changes in headache, steroid use, and functional status and absence of neurocognitive sequelae. Comparisons were analyzed using the Fisher exact test, Mann-Whitney U-test, linear mixed models, Wilcoxon signed-rank test, and repeated-measures 1-way ANOVA.

RESULTS

Ten adults (mean ± SD [range] age 35 ± 15 [22–62] years) participated in this study. No patients died or exhibited serious adverse effects of systemic bevacizumab. At 3 months, 80% (95% CI 44%–98%) and 90% (95% CI 56%–100%) of patients demonstrated > 25% decrease in RN and vasogenic edema volume, respectively. At 12 months, RN volume decreased by 74% (median [range] 76% [53%–96%], p = 0.012), edema volume decreased by 50% (median [range] 70% [−11% to 83%], p = 0.086), and headache decreased by 84% (median [range] 92% [58%–100%], p = 0.022) among the 8 patients without RN recurrence. Only 1 (10%) patient was steroid dependent at the end of the trial. Scores on 12 of 16 (75%) neurocognitive indices increased, thereby supporting a pattern of cerebral white matter recovery. Two (20%) patients exhibited RN recurrence that required further treatment at 10 and 11 months, respectively, after bevacizumab infusion.

CONCLUSIONS

For the first time, to the authors’ knowledge, the authors demonstrated that a single low-dose targeted bevacizumab infusion resulted in durable clinical and imaging improvements in 80% of patients at 12 months after treatment without adverse events attributed to bevacizumab alone. These findings highlight that targeted bevacizumab may be an efficient one-time treatment for adults with brain RN. Further confirmation with a randomized controlled trial is needed to compare the intra-arterial approach with the conventional multicycle intravenous regimen.

Clinical trial registration no.: NCT02819479 (ClinicalTrials.gov)

Testicular Torsion in Patients With Intellectual and Developmental Disabilities

Patients with intellectual/developmental disabilities are at risk of delayed diagnosis of testicular torsion due to their inability to effectively communicate their symptoms. We identified males ages 1 to 18 years with testicular torsion between January 1, 2015 and December 31, 2020, focusing on patients with intellectual and/or developmental disabilities. Of the 140 patients with testicular torsion, 5 (3.6%) patients exhibited intellectual/developmental disabilities with an inability to effectively verbalize testicular/groin/scrotal pain. The patients with intellectual/developmental disabilities underwent more orchiectomies (5/5, 100%, P = .009) and had a longer duration of symptoms (median = 48 hours, P = .047) compared to those without intellectual/developmental disabilities (51/135, 38% and median = 9 hours, respectively) (51/134, 38%) (P = .038). Parents and other caregivers of males with intellectual/developmental disabilities who are unable to adequately verbalize their testicular/groin/scrotal pain should be cognizant of the signs and symptoms associated with testicular torsion, perform a genitalia examination, and seek an immediate evaluation to diagnose and treat this urgent condition.

Hypertrophy of the tensor fascia lata: A pseudotumor due to lumbar radiculopathy

Background

Pseudotumor of the tensor fascia lata (TFL) consists of a rare, benign soft tissue mass/hypertrophy of the TFL that appears on the anterolateral aspect of the proximal thigh. Notably, this condition often mimics a malignant tumor and may be misdiagnosed as a sarcoma.

Case Description

A 45-year-old male presented with left hip/groin pain, swelling, and a painful mass on the anterolateral aspect of the left hip/thigh. The symptoms had started 3 months ago following an L1-S1 lumbar laminectomy/fusion. The initial diagnosis was hip disease, and the patient underwent a left MR arthrogram. When this study demonstrated a tear of the left anterosuperior acetabular labrum plus an increased alpha angle causing femoroacetabular impingement, the patient then underwent a left hip arthroscopy. However, as he continued to complain of the hip mass, he was referred to an orthopedic oncologist whose presumptive diagnosis favored a sarcoma. Nevertheless, the pelvic MRI scan and ultrasound (US) confirmed the diagnosis of hypertrophy of the left TFL (US left 33.4 mm vs. right 14.4 mm). The patient was first treated with 50 units of locally injected botulinum. As there was no symptomatic relief, the plan was to repeat the injection within the next few months.

Conclusion

Hypertrophy of TFL may mimic a neoplasm such as a sarcoma and contributes to what appears to be a lumbar radiculopathy. However, MR and US imaging should readily identify TFL and rule out malignant lesions such as sarcomas.

Varied Presentation and Importance of MR Neurography of the Common Fibular Nerve in Slimmer's Paralysis

Slimmer's paralysis refers to a common fibular nerve palsy caused by significant and rapid weight loss. This condition usually results from entrapment of the common fibular nerve due to loss of the fat pad surrounding the fibular head. Several etiologies of common fibular nerve palsy have been proposed, including trauma, surgical complications, improperly fitted casts or braces, tumors and cysts, metabolic syndromes, and positional factors. We present 5 cases of slimmer's paralysis in patients who had lost 32–57 kg in approximately 1 year. In 2 cases, MR neurogram of the knee demonstrated abnormalities of the common fibular nerve at the fibular head. Two patients underwent a common fibular nerve decompression at the fibular head and attained improved gait and sensorimotor function. Weight loss, diabetes mellitus, and immobilization may have contributed to slimmer's paralysis in 1 case. Awareness of slimmer's paralysis in patients who have lost a significant amount of weight in a short period of time is imperative to detect and treat a fibular nerve neuropathy that may ensue.

Strategies to Enhance Comprehension in the Healthcare Setting for Patients With Dyslexia

Dyslexia involves extreme difficulty with reading, writing, and spelling in your native language despite at least average intelligence. Health literacy refers to the ability to read, understand, and use health information to make appropriate health decisions. Dyslexia is rarely mentioned as a contributing factor to health literacy. Medical providers should be more aware of the special needs of dyslexic patients and implement interventions to allow them to successfully navigate the healthcare environment.

Acute carpal tunnel syndrome: Clinical, electromyographic, and ultrasound features in 25 patients

BACKGROUND

The acute presentation of carpal tunnel syndrome (CTS) is rare. When symptoms start acutely with no obvious causes, ultrasound (US) imaging may provide clues to the etiology.

OBJECTIVE

This study describes the clinical, electromyographic, and US findings in 25 patients presenting with acute CTS (ACTS).

METHODS

In this analysis, of the patients referred for electrodiagnostic confirmation of CTS over the past decade, 25 had an acute onset of symptoms. All patients underwent EMG/NCV and US of the median nerve at the carpal tunnel and forearm.

RESULTS

Of the 25 cases with ACTS, 5 (20%) had bilateral involvement leading to the total hands studied to 30. In 14 (56%) patients, an inciting event was identified as a possible cause of ACTS. In 11 (44%) patients without an antecedent event, 7 (64%) had a persistent median artery (PMA) detected by US. Electrodiagnostic studies showed prolonged distal motor latency with normal motor conduction velocity proximal to the carpal tunnel in 24 (80%) of 30 hands, 6 (20%) hands showed absent compound muscle action potentials over the abductor pollicis brevis (APB), and 22 (73%) hands had absent sensory potentials. Denervation changes were seen in the APB in 13 (43%) hands, and motor unit potentials were absent in 6 (20%) hands. Sixteen (64%) patients underwent a carpal tunnel release for severe symptoms.

CONCLUSION

CTS may present acutely without a clinically identifiable cause. US complements electrodiagnostic studies and is particularly useful when electrodiagnostic tests are non-diagnostic (due to absent compound muscle and sensory action potentials). US may also provide clues to the underlying cause.

The impact of COVID-19 on patient safety attendant use

ABSTRACT

Patient safety attendants (PSAs) provide constant direct observation to patients who have cognitive impairments or thoughts. Some estimates report that an acute care hospital in the United States may spend more than $1 million annually on PSAs, an expenditure often not reimbursed. With no national defined standards to regulate or monitor PSA use, this study sought to determine the impact of COVID-19 on a PSA reduction program in a large Midwestern healthcare system.

Impact of Screening for Sexual Trauma in a Gynecologic Oncology Setting

OBJECTIVES

Sexual trauma poses a significant concern and is associated with heightened stress, negative health repercussions, and adverse economic effects. A history of abuse may increase a woman's risk of developing cancer, in particular cervical cancer. We analyzed the impact of screening for sexual abuse in a gynecologic oncology population.

METHODS

Patients were screened for sexual trauma in a gynecologic oncology clinic over 5 and a half years (April 1, 2011, to September 30, 2016) in this cohort study. The screening questions were selected by behavioral oncology physicians and integrated into the gynecologic history component of the new patient assessment. Patients who screened positive for a history of sexual abuse or intimate partner violence were offered a behavioral oncology referral. Providers were also questioned about the effect of screening on their practice.

RESULTS

Of the 1,423 consecutive patients screened for sexual trauma, a total of 164 patients (12%) disclosed a history of sexual abuse. Of the 133 patients who specified their age at the sexual trauma, the majority (107 [80%]) responded that they were a young child or early teen. Most patients (92%) declined counseling. Among individuals presenting with cancer, the distribution of cancer type was statistically different between those patients with and without a sexual trauma history (p = 0.0001).

CONCLUSION

Screening for sexual trauma in a gynecologic oncologic population serves as a valuable opportunity to uncover a history of abuse that may increase a woman's susceptibility to cancer. This study demonstrates that screening for sexual abuse in a gynecologic oncology setting may be integrated into new patient interviews with minimal disruption. Identification of an undisclosed sexual trauma history allows for an opportunity to offer counseling and minimize the emotional distress that may be precipitated by treatment and exams.

A-82 Neurocognitive Improvement after Intra-Arterial Bevacizumab for Steroid-Refractory Radiation Necrosis of the Brain

Objective

Evaluate neurocognitive change after single low-dose targeted intra-arterial (IA) bevacizumab in patients with brain radiation necrosis.

Methods

Phase II, single-arm, prospective trial. 10 adults underwent targeted 2.5 mg/kg IA bevacizumab. Neurocognitive indices (Neuropsychological Assessment Battery® and Wechsler Test of Adult Reading) were measured at baseline and 12-months to document performance in 5 domains: Attention, Language, Learning and Memory, Visuospatial, and Executive Function. Clinical indices also quantified. Data (mean ± SD, 95% confidence interval [CI], Cohen’s d) were analyzed using paired t tests. Null hypothesis rejected for p &lt; 0.05.

Results

At baseline, Numbers-&-Letters Speed T-score (38.2 ± 10.7) indicated decreased processing speed consistent with sub-cortical pattern of illness. All other baseline neurocognitive indices were within normalized means (image). 12-months post-treatment, Numbers-&-Letters Errors T-score increased by 6.0 ± 4.9 [95%CI 1.9,10.1] (t = 3.464, d = 1.225, p = 0.010). List-Learning List-Long-Delayed-Recall T-score increased by 9.0 ± 5.6 [95% CI 4.3,13.7] (t = 4.520, d = 1.598, p = 0.003) and Design-Construction T-score increased by 3.5 ± 4.1 [95%CI 0.04,7.0] (t = 2.391, d = 0.845, p = 0.048). Volume of radiation necrosis decreased by 74.4 ± 14.7% (t = −3.308, d = 1.169, p = 0.013). Headache decreased by 84.4 ± 18.2% (t = −3.495, d = 1.236, p = 0.010). 0/10 died or exhibited AEs attributed to bevacizumab. 2/10 patients experienced radiation necrosis recurrence at months 10 and 11, respectively.

Conclusions

Single low-dose intra-arterial targeted bevacizumab led to durable neuropsychological performance increase in memory retrieval and visuospatial ability consistent with improvement in sub-cortical function. To our knowledge this is the first prospective report of this novel approach in adults. Clinical improvements mirrored neuropsychologic improvements. Randomized trials are needed comparing targeted low-dose IA bevacizumab to multi-cycle IV bevacizumab at higher doses to determine which is best alternative in brain radiation necrosis.

Urological Evidence of Tick Bites in Children

ABSTRACT

Ticks pose a serious threat to individuals of all ages owing to numerous physical illnesses including chills, aches, and a rash. Tick-borne illnesses range from a mild fever that may be treated at home to a severe disease necessitating hospitalization. Children are at an increased risk of tick bites owing to to their exposure to tick-infested areas during the summer. We report 2 cases of boys aged 3 and 8 years who sustained tick bites to the hemiscrotum and penis. Overnight hospitalization and a course of antibiotics were mandatory. In the first case, the child experienced significant scrotal cellulitis with erythema and edema extending to the suprapubic area with induration of the right anterior scrotum at the site of the tick bite. A scrotal ultrasound demonstrated swelling of the scrotal wall. In the second case, considerable swelling and induration of the distal penis and glans, pruritis of the left groin and penis, and an erythematous rash over the entire anterior pelvis were observed. A high index of suspicion is warranted because a tick bite may present as penile edema. Pediatric emergency physicians should be aware of the risks associated with tick bites and accurately diagnose and initiate treatment to prevent morbidity and mortality.

Immune-Related Meningoencephalitis following Nivolumab in Metastatic Renal Cell Carcinoma

While immunotherapy with nivolumab is promising for patients with renal cell carcinoma (RCC), overactivation of the immune system can lead to serious side effects. Immune-related meningoencephalitis without a viral or microbial etiology is a rare complication that may occur in patients treated with checkpoint inhibitors (CPI). Herein, we report a 66-year-old man who underwent a partial nephrectomy which revealed a papillary RCC with clear cell component. Three years later, an abdomen and pelvic CT revealed metastatic lesions in the left psoas muscle and in the left 12th rib. The patient was treated with pazopanib which was discontinued after 2 weeks due to significant hepatic and renal toxicity. He subsequently started sunitinib. Two months later, a chest, abdomen, and pelvic CT demonstrated progressive metastatic RCC in the retroperitoneal mass of the left psoas muscle and paraspinal musculature as well as a left renal mass. The patient was treated with 7 cycles of the CPI nivolumab. He was subsequently hospitalized for 3 weeks after experiencing bilateral lower extremity weakness, lethargy, several falls, hyperthermia, confusion, and gait abnormalities. A CSF analysis demonstrated a lymphocyte pleocytosis with elevated protein and no bacterial or viral growth. The patient was treated with high-dose steroids after which his symptoms resolved. Chest, abdomen, and pelvic CT scans over the next 3 years revealed no evidence of metastatic disease, reflecting a progression-free survival of 40 months. We highlight the unique case of a patient with metastatic RCC who experienced immune-related meningoencephalitis following immunotherapy with nivolumab. Medical oncologists should be alert to the potential development of immune-related encephalitis in patients treated with nivolumab and should promptly diagnose and treat this concerning condition. The excellent oncologic outcome of this case emphasizes the need for continued aggressive measures for management of CNS toxicity resulting from CPI therapy.

Venipuncture-Related Median Nerve Palsy Disguised as Intraoperative Brachial Plexus Injury

Iatrogenic peripheral nerve injuries may result from transection, stretch, compression, injections, ligature, heat, anticoagulant use, and radiation. Iatrogenic median nerve palsy has been reported rarely. We report a case of a woman who underwent craniectomy for treatment of trigeminal neuralgia. Intraoperatively, a transient decline in the amplitude of the left upper extremity somatosensory evoked potentials (SSEPs) was noted. This finding was presumed to be due to the traction on the brachial plexus as it improved with repositioning. Immediately upon waking from anesthesia, the patient experienced sensorimotor deficits in the left median nerve distribution. Ecchymoses from venipuncture were observed in this area. Electrodiagnostic studies confirmed a left median nerve neuropathy localized in the antebrachial area. Neurosurgeons and neurologists should be alert to potential iatrogenic median nerve palsy following vascular access at the antebrachial region. Vascular access could be performed under the ultrasound guidance when a patient is under anesthesia or unable to give sensory feedback. Furthermore, placing an additional recording electrode over the proximal upper arm during intraoperative SSEP monitoring aids in distinguishing between brachial plexus and peripheral nerve injuries.

Decline in Physical Restraint Use Following Implementation of Institutional Guidelines

OBJECTIVE

To investigate the strategies implemented at our institution to reduce medical restraint use.

BACKGROUND

Restraints have been utilized to prevent agitation, self-extubations, and falls, although they are often associated with negative repercussions for nurses and patients.

METHODS

The restraint data at our institution were compared with the National Database of Nursing Quality Indicators (NDNQI) benchmark. We also described the measures taken to improve restraint documentation.

RESULTS

The number of patients in medical restraints, medical restraint hours, medical restraints/patient-days, and deaths in restraints at our institution all significantly decreased (P < 0.00001). There were 27 self-extubations of restrained patients compared with 11 self-extubations of nonrestrained patients. The percentage of inpatients with restraints in critical care and step-down areas declined and remained below the NDNQI benchmark.

CONCLUSIONS

This study reports the processes implemented to reduce restraint use through enhanced communication and increased documentation. Further exploration into factors that may attain a restraint-free environment is warranted.

Differentiation of vascular claudication due to bilateral common iliac artery stenosis versus neurogenic claudication with spinal stenosis

Background:

Differentiating between neurogenic and vascular claudication may be difficult. Vascular claudication due to aortic and iliac artery occlusions may present as low back, hip, and buttock pain while walking short distances. These findings are often very similar to those seen for neurogenic claudication attributed to lumbar stenosis.

Case Description:

A 68-year-old female presented with low back, right hip, and groin pain while walking short distances. She had previously undergone lumbar and cardiac surgery. Now, with negative repeated lumbar studies, the CT angiogram (CTA) revealed a dense calcified plaque in the right common iliac artery resulting in 90% stenosis at its origin and <50% stenosis of the left common iliac artery. Once bilateral common iliac artery kissing stents were placed, the patient’s symptoms resolved.

Conclusion:

Spine surgeons should be aware that vascular and neurogenic claudication may mimic each other. Obtaining MR studies of the lumbar spine and EMG/NCV, along with the appropriate vascular studies (CTAs), help differentiate between the two, and result in the appropriate operative choices.

Iatrogenic neurological injury after radiofrequency ablation and epidural steroid injections: illustrative cases

BACKGROUND

Neck pain is often chronic and disabling. Cervical facet joint injections and epidural steroid injections are frequently used to manage chronic neck pain and cervicogenic headaches. While minimal side effects are commonly associated with these treatments, severe complications are exceedingly rare.

OBSERVATIONS

The authors report 4 cases of iatrogenic neurological injury after radiofrequency ablation (RFA) and epidural steroid injections. One patient experienced left shoulder, scapular, and arm pain with left arm and hand weakness that developed immediately after RFA for chronic neck pain. Electromyography/nerve conduction velocity (EMG/NCV) studies confirmed denervation changes in the left C8–T1 distribution. Three patients complained of numbness and weakness of the hands immediately after an interlaminar cervical epidural block. One of these patients underwent EMG/NCV that confirmed denervation changes occurring in the left C8–T1 distribution.

LESSONS

Spine surgeons and pain management specialists should be aware of neurological injuries that may occur after cervical RFA and epidural steroid injections, especially after a multilevel cervical procedure and with severe cervical spinal stenosis. EMG/NCV studies plays an important role in detecting and localizing neurological injury and in differentiating from conditions that mimic cervical root injuries, including brachial plexus trauma due to positioning and Parsonage-Turner syndrome.

Intradural, extramedullary hemangioblastoma at the level of the conus medullaris: illustrative case

BACKGROUND

Hemangioblastomas are rare, slow-growing, and highly vascularized tumors that typically occur in the cerebellum and spinal cord. The cervical and thoracic regions are the most common spinal sites, and the tumors are usually intramedullary.

OBSERVATIONS

The authors report the case of a man whose chest computed tomography performed for managing coronavirus disease 2019 incidentally revealed an enhancing area in the spinal canal at T12–L1. The patient reported low back pain as well as leg numbness and tingling. Magnetic resonance imaging of the lumbar region with and without gadolinium contrast demonstrated an intradural, extramedullary lesion with displacement of the conus medullaris. The differential diagnosis included a schwannoma and myxopapillary ependymoma. Bilateral T12–L1 laminectomies were performed with resection of the mass. The general pathologist rendered the frozen section diagnosis of a spindle cell neoplasm, suggesting the differential diagnosis of schwannoma or myxopapillary ependymoma. Immunohistochemistry was positive for inhibin, GFAP, reticulin, CD31, SOX-10, S100, and EMA. A World Health Organization grade 1 hemangioblastoma was confirmed.

LESSONS

Spinal surgeons should be cognizant of the presenting symptoms and differential diagnosis of hemangioblastomas at the level of the conus medullaris, especially when the tumor is diagnosed incidentally. Additional investigations should be performed to determine whether von Hippel-Lindau syndrome is associated with the hemangioblastoma, as this combination portends a different clinical presentation, multiple tumor locations, and tumor recurrence following resection.

Reduction in Schedule II opioid prescribing by primary care -providers, orthopedic and general surgeons, and pain -management specialists following the implementation of a State House Bill and an Institutional Controlled Substance Task Force

OBJECTIVE

Prescription opioid misuse represents a social and economic challenge in the United States. We evaluated Schedule II opioid prescribing practices by primary care providers (PCPs), orthopedic and general surgeons, and pain management specialists.

DESIGN

Prospective evaluation of prescribing practices of PCPs, orthopedic and general surgeons, and pain management specialists over 5 years (October 1, 2014-September 30, 2019) in an outpatient setting.

METHODS

An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards at our institution.

RESULTS

There were significantly more PCPs, orthopedic and general surgeons, and pain management specialists with a significantly increased number who prescribed Schedule II opioids, whereas there was a simultaneous significant decline in the average number of Schedule II opioid prescriptions per provider, Schedule II opioid pills prescribed per provider, and Schedule II opioid pills prescribed per patient by providers. The average number of Schedule II opioid prescriptions with a quantity >90 and Opana/Oxycontin prescriptions per PCP, orthopedic surgeon, and pain management specialist significantly decreased. The total morphine milligram equivalent (MME)/day of Schedule II opioids ordered by PCPs, orthopedic and general surgeons, and pain management specialists significantly declined. The ages of the providers remained consistent throughout the study.

CONCLUSIONS

This study reports the implementation of federal and state regulations and institutional evidence-based guidelines into primary care and medical specialty practices to reduce the number of Schedule II opioids prescribed. Further research is warranted to determine alternative therapies to Schedule II opioids that may alleviate a patient's pain without initiating or exacerbating a potentially lethal opioid addiction.

Unique Presentation and Diagnostic Challenges in Metastatic Cerebral Angiosarcoma: Case Report

BACKGROUND AND IMPORTANCE

Angiosarcoma is a malignant endothelial tumor arising from vascular or lymphatic tissue. Metastatic cerebral angiosarcoma has been rarely reported and is associated with a poor prognosis.

CLINICAL PRESENTATION

We report a 22-yr-old man who presented with a complex partial seizure. Contrasted brain magnetic resonance imaging (MRI) revealed 3 enhancing masses of the left frontal-parietal junction, right occipital lobe, and right caudate nucleus. Computed tomography (CT) of the chest, abdomen, and pelvis and a cardiac MRI revealed no evidence of primary tumor. Immunohistochemistry following biopsy was positive for the ETS transcription factor ERG, CD31, FLI-1, and FosB, confirming angiosarcoma. CT/positron emission tomography (PET) scan showed skeletal metastases in the left iliac bone, sacrum, and T6 vertebral body. The patient underwent resection of the 2 cortical masses, stereotactic radiosurgery to the intracranial lesions as well as to his oligometastases, and was treated with 9 cycles of paclitaxel and bevacizumab. Brain MRI and CT/PET body imaging after cycle 9 revealed no tumor recurrence or progression. The progression-free and overall survival following the diagnosis of brain metastases was 27 mo.

CONCLUSION

Neurosurgeons should be aware of the unique presentation and diagnostic challenges in metastatic cerebral angiosarcoma, particularly in cases when the primary tumor site is unknown. Furthermore, combined surgery, ablative radiation, and targeted systemic and biological therapy can result in prolonged survival even in patients with metastases.

Thromboembolic events in metastatic testicular cancer treated with cisplatin-based chemotherapy

BACKGROUND

Testicular germ cell tumor (TGCT) is the most curable solid tumor and most common cancer among men 18-39 years. While cisplatin-based chemotherapy has significantly lengthened the survival of patients with TGCT, it is associated with a high rate of thromboembolic events (TEE).

AIM

To summarize our single-center experience highlighting patients who were diagnosed with TGCT and received platinum-based chemotherapy, with special attention to those patients who suffered a TEE.

METHODS

A retrospective analysis of the medical records and imaging studies of 68 consecutive individuals who were diagnosed with TGCT and received platinum-based chemotherapy at our Institution in a metropolitan community between January 1, 2014 and December 31, 2019.

RESULTS

A total of 19 (28%) patients experienced a TEE following orchiectomy which occurred during chemotherapy in 13 (68%) of these patients. Patients with a higher pathologic stage (stage III) were significantly (P = 0.023) more likely to experience a TEE compared to patients who had a lower stage. Additionally, patients who were treated with 3 cycles of bleomycine, etoposide, and cisplatin and 1 cycle of etoposide and cisplatin or 4 cycles of etoposide and cisplatin were significantly 5 (P = 0.02) times more likely to experience a TEE compared to patients who were treated with only 3 cycles of bleomycine, etoposide, and cisplatin.

CONCLUSION

Due to numerous factors that predispose to a TEE such as large retroperitoneal disease, higher clinical stage, greater number of chemotherapy cycle, central venous catheter, cigarette smoking, and possible cannabis use, high-risk ambulatory patients with TGCT treated with cisplatin-based chemotherapy may benefit from prophylactic anticoagulation. Randomized studies to evaluate the safety and efficacy of prophylactic anticoagulants are warranted in this young patient population generally devoid of medical co-morbidities.

Person-in-the-barrel syndrome following cervical spine surgery: illustrative case

BACKGROUND

Person-in-the-barrel syndrome is characterized by bilateral brachial diplegia, intact cranial nerves, and preserved lower-extremity strength. Most cases are due to bilateral supratentorial brain lesions at the border zone of the anterior and middle cerebral artery vascular territories. This condition has been observed with spinal pathology, primarily involving vascular dissection and thromboembolism.

OBSERVATIONS

The authors’ case is the first in the literature to highlight person-in-the-barrel syndrome immediately following cervical spine surgery. Weakness of the deltoids, biceps, infraspinatus, and brachioradialis was observed bilaterally postoperatively. Electromyograph (EMG)-nerve conduction velocity (NCV) studies revealed a cervical radiculopathy involving C5 and C6 bilaterally with denervation of the deltoids, biceps, and brachioradialis. Within 8 months of cervical spine surgery, the patient regained improvement of the bilateral brachial diplegia.

LESSONS

EMG/NCV studies play a valuable role in detecting cervical radiculopathy after cervical spine surgery in patients with bilateral brachial diplegia. The authors postulate that this condition may have occurred following neck hyperextension during cervical cage placement, increasing the foraminal stenosis at C4–5 and C5–6 and worsening the C5 and C6 radiculopathy. Spinal surgeons should be cognizant of person-in-the-barrel syndrome that may ensue following cervical spine surgery and promptly identify and treat this condition to offer the best prognosis for a favorable patient outcome.

Useless hand syndrome: Diagnostic role of electromyography and nerve conduction studies

BACKGROUND

Useless hand syndrome (UHS) refers to clumsiness of complex finger movements and loss of manual dexterity due to cervical cord lesions, often associated with multiple sclerosis (MS). This condition may represent the first demyelinating event in MS or may occur in a patient with pre-existing MS.

METHODS

We report 3 patients with UHS, 2 of whom had not been previously diagnosed with MS. The history and physical examinations, EMG/NCV studies of the arms, and radiological findings are presented.

RESULTS

Presenting symptoms in all 3 cases included paresthesia and difficulty with manual dexterity which led the family physician to refer these patients to a hand surgeon. Pre-EMG neurological examination detected myriad abnormalities such as loss of position sense, two-point discrimination, stereognosis, graphesthesia, and difficulty performing rapid alternating movements. EMG/NCV findings were normal in 2 cases and, in the third case, showed abnormalities which did not explain the clinical picture and pointed to involvement of the central somatosensory pathways. Cervical MRIs revealed demyelinating lesions in all patients.

CONCLUSION

Patients with acute onset of sensory disturbance and clumsy hands are often first referred for EMG/NCV studies. Absence of significant abnormalities may suggest central somatosensory pathway dysfunction and should alert to the possibility of UHS and underlying MS.

Role of PTHrP nuclear localization and carboxyl terminus sequences in postnatal spinal cord development

Parathyroid hormone-related peptide (PTHrP) acts under physiological conditions to regulate normal development of several tissues and organs. The role of PTHrP in spinal cord development has not been characterized. Pthrp knock in (Pthrp KI) mice were genetically modified to produce PTHrP in which there is a deficiency of the nuclear localization sequence (NLS) and C-terminus. Using this genetically modified mouse model, we have characterized its effect on spinal cord development early postnatally. The spinal cords from Pthrp KI mice displayed a significant reduction in its length, weight, and cross-sectional area compared to wild-type controls. Histologically, there was a decreased development of neurons and glial cells that caused decreased cell proliferation and increased apoptosis. The neural stem cells (NSCs) cultures also revealed decreased cell proliferation and differentiation and increased apoptosis. The proposed mechanism of delayed spinal cord development in Pthrp KI mice may be due to alteration in associated pathways in regulation of cell-division cycles and apoptosis. There was significant downregulation of Bmi-1 and upregulation of cyclin-dependent kinase inhibitors p27, p21, and p16 in Pthrp KI animals. We conclude that NLS and C-terminus peptide segments of PTHrP play an important role in inhibiting cell apoptosis and stimulation of cellular proliferation necessary for normal spinal cord development.

Multidisciplinary approach to enhancing provider well-being in a metropolitan medical group in the United States

BACKGROUND

Physician burnout refers to depersonalization, emotional exhaustion, and a sense of lower personal accomplishment. Affecting approximately 50% of physicians in the United States, physician burnout negatively impacts both the physician and patient. Over a 3-year-period, this prospective study evaluated the multidisciplinary approach to decreasing provider burnout and improving provider well-being in our metropolitan community.

METHODS

A multidisciplinary Well-Being Task Force was established at our Institution in 2017 to assess the myriad factors that may play a role in provider burnout and offer solutions to mitigate the stressors that may lead to decreased provider well-being. Four multifaceted strategies were implemented: (1) provider engagement & growth; (2) workflow/office efficiencies; (3) relationship building; and (4) communication. Providers at our Institution took the Mayo Clinic's well-being index survey on 3 occasions over 3 years. Their scores were compared to those of providers nationally at baseline and at 1 and 2 years after implementing organizational and individualized techniques to enhance provider well-being. Lower well-being index scores reflected better well-being.

RESULTS

The average overall well-being index scores of our Institution's providers decreased from 1.76 at baseline to 1.32 2 years later compared to an increase in well-being index scores of physicians nationally (1.73 to 1.85). Both male and female providers' average well-being index scores at our Institution decreased over the 3 years of this study, from 1.72 to 1.58 for males and 1.78 to 1.21 for females, while physicians' scores nationally increased for both genders. The average well-being index scores were highest for providers at our Institution who graduated from medical school less than 5 years earlier (2.0) and who graduated 15-24 years earlier (2.3), whereas the average lowest scores were observed in providers who graduated ≥25 years earlier (1.37). Obstetricians/gynecologists and internal medicine physicians had the highest average well-being index scores (2.48 and 2.4, respectively) compared to other medical specialties. The turnover rate of our Institution's providers was 5.6% in 2017 and 3.9% in 2019, reflecting a 30% decrease.

CONCLUSION

This study serves as a model to reduce provider burnout and enhance well-being through both organizational and individual interventions.

Spontaneous Regression of Delayed Pulmonary and Mediastinal Metastases from Clear Cell Renal Cell Carcinoma

Renal cell carcinoma (RCC) is often metastatic at diagnosis. Conventional therapies such as chemotherapy, radiotherapy, and hormonal therapy have generally proven ineffective in the treatment of RCC. The abscopal effect, specifically, the ability of localized radiation to trigger systemic antitumor effects, has been reported to lead to regression of non-irradiated distant tumor lesions. Herein, we report 3 patients with non-metastatic clear cell RCC (CCRCC) who underwent a nephrectomy and experienced metachronous pulmonary/mediastinal metastases confirmed as CCRCC. No patients underwent radiation post-nephrectomy or pulmonary metastasectomy. The mean duration was 7.24 weeks from the last negative chest CT prior to the nephrectomy and 96.2 weeks post-nephrectomy. All patients achieved durable complete response by RECIST criteria, with a mean follow-up duration of 115 months. Our case series represents the largest in the literature of patients who underwent a nephrectomy for CCRCC with no pre-existing pulmonary/mediastinal metastatic disease confirmed by chest CT, did not undergo radiotherapy, and developed significantly delayed CCRCC pulmonary/mediastinal metastases. We highlight the spontaneous regression of delayed metastatic disease and the role of immune responses in curtailing the growth of pulmonary metastasis in CCRCC.

Delayed Presentation of Urethral Valves: A Diagnosis That Should Be Suspected Despite a Normal Prenatal Ultrasound

Background. Congenital urethral obstruction occurs most frequently as a result of urethral valves. The diagnosis is usually confirmed pre- or neonatally. Though not ideal, delayed diagnosis can occur in childhood, adolescence, or adulthood. Despite a normal prenatal ultrasound, there may still be a delayed diagnosis of urethral valves. Methods. We present 4 patients with delayed diagnosis of posterior urethral valves (PUV) and 1 patient with delayed diagnosis of anterior urethral valves (AUV) who were evaluated by a pediatric urologist at our Institution. We determined the age and symptoms at presentation, physical examination, micturating cystourethrogram (MCU) findings prior to the valve ablation, renal function before and after valve ablation, type of valve ablation, and urine culture and sensitivity. The urological courses following urethral valve ablation including urodynamic study findings are described. Results. The median age at presentation was 33 months. All 5 patients presented with decreased urine output and urinary retention. All 5 patients underwent a MCU that demonstrated bladder trabeculations (3 cases), vesicoureteral reflux (3 cases), and bladder diverticula (2 cases). A urethral valve ablation was performed in all cases. Four patients underwent a renal function panel prior to this procedure, and their serum BUN/creatinine levels decreased 1 day postoperatively. Conclusion. Pediatricians should consider urethral valves as causing urethral obstruction although the prenatal ultrasound may be normal. Early diagnosis and prompt treatment of urethral valves may mitigate the potentially devastating morbidities such as renal failure, congestive heart failure, and respiratory distress that may ensue.

Challenges in the Prenatal Diagnosis of Cloaca

Background:

Cloaca is a common excretory channel for the genital, urinary, and gastrointestinal tracts. It is considered a severe anorectal malformation caused by failed partitioning of the genital, rectal, and urinary tracts.

Methods:

We report 5 infants with cloaca at birth who were identified prenatally by one or more of the following on prenatal ultrasound (US): ambiguous genitalia, a cystic pelvic/abdominal mass, hydronephrosis, ascites, a single umbilical artery, and oligohydramnios.

Results:

A cystic pelvic/abdominal mass and ambiguous genitalia were each observed in 3 cases by prenatal US. Ambiguous genitalia was observed in all 5 neonates at birth. There were 2 twin pregnancies (dichorionic/diamniotic and monochorionic/monoamniotic), with only 1 twin in a set affected with cloaca.

Conclusion:

Pediatricians should be alert to the prenatal US findings that may raise suspicion of a persistent cloaca to improve both prenatal counseling and family preparation.

Platelet-Activating Factor Deteriorates Lysophosphatidylcholine-Induced Demyelination Via Its Receptor-Dependent and -Independent Effects

Accumulating evidence suggests that platelet-activating factor (PAF) increases the inflammatory response in demyelinating diseases such as multiple sclerosis. However, PAF receptor (PAFR) antagonists do not show therapeutic efficacy for MS, and its underlying mechanisms remain poorly understood. In the present study, we investigated the effects of PAF on an ex vivo demyelination cerebellar model following lysophosphatidylcholine (LPC, 0.5 mg/mL) application using wild-type and PAFR conventional knockout (PAFR-KO) mice. Demyelination was induced in cerebellar slices that were cultured with LPC for 18 h. Exogenous PAF (1 μM) acting on cerebellar slices alone did not cause demyelination but increased the severity of LPC-induced demyelination in both wild-type and PAFR-KO mice. LPC inhibited the expression of PAF-AH, MBP, TNF-α, and TGF-β1 but facilitated the expression of IL-1β and IL-6 in wild-type preparations. Of note, exogenous PAF stimulated microglial activation in both wild-type and PAFR-KO mice. The subsequent inflammatory cytokines TNFα, IL-1β, and IL-6 as well as the anti-inflammatory cytokine TGF-β1 demonstrated a diverse transcriptional profile with or without LPC treatment. PAF promoted TNF-α expression and suppressed TGF-β1 expression indiscriminately in wild-type and knockout slices; however, transcription of IL-1β and IL-6 was not significantly affected in both slices. The syntheses of IL-1β and IL-6 were significantly increased in LPC-induced demyelination preparations without PAF but showed a redundancy in PAF-treated wild-type and knockout slices. These data suggest that PAF can play a detrimental role in LPC-induced demyelination probably due to a redundant response of PAFR-dependent and PAFR-independent effects on inflammatory cytokines.

Personalized chemotherapy in clear cell adenocarcinoma of the urethra: A case report

BACKGROUND

Clear cell adenocarcinoma of the urethra is a rare type of aggressive cancer with a poor prognosis. Clear cell carcinoma of the urethra represents less than 0.02% of all malignancies in women. Adenocarcinomas account for 10% of female urethral carcinomas, of which 40% are the clear cell variant. Determining the presence or absence of certain mutations through genetic testing may predict whether a patient with cancer may benefit from a particular chemotherapy regimen.

CASE SUMMARY

A 40-year-old woman presented with a 3-year history of slow urinary flow and a 3-mo history of urinary urgency and frequency as well as gross hematuria. An abdominal and pelvic computed tomography scan demonstrated enlarged lymph nodes in the abdomen and pelvis. A biopsy of a left inguinal lymph node microscopically confirmed a metastatic adenocarcinoma of the urethra. Specialized genetic testing determined personalized chemotherapy. She was treated successfully with a non-platinum-based chemotherapy consisting of paclitaxel and bevacizumab. Following 3 cycles of paclitaxel and bevacizumab, she attained significant clinical improvement, and response by FDG-Positron emission tomography (PET) imaging showed a definite improvement in size and metabolic activity. She achieved complete response after 6 cycles of therapy by PET scan. The patient concluded 11 cycles of paclitaxel and bevacizumab, and a subsequent PET scan confirmed progression of metastatic disease. The patient was then treated with two cycles of doxorubicin after which a PET scan revealed a mixed response to the treatment.

CONCLUSION

We report the first case of a patient with metastatic clear cell adenocarcinoma of the urethra who underwent personalized chemotherapy after testing for cancer gene alterations. Our unique case represents the safe and effective use of non-platinum-based chemotherapy in clear cell adenocarcinoma of the urethra.

Multidisciplinary approach to low-dose CT screening for lung cancer in a metropolitan community

BACKGROUND

Lung cancer is the primary cause of cancer death in men and women in the USA, led by Kentucky. In 2015, the Centers for Medicare and Medicaid Services initiated annual lung cancer screening with a low-dose computed tomography (LDCT) scan. This observational cohort study evaluated the multidisciplinary approach to this screening in our metropolitan community.

METHODS

We present the prospective findings of patients who underwent a screening lung LDCT scan over a 2-year period at our institution in Kentucky. Patients who fulfilled the screening criteria were identified during an office visit with their primary care provider.

RESULTS

Of the 4170 patients who underwent a screening lung LDCT scan, a total of 838 (20.9%) patients had nodules >4 mm. Of the 70 patients diagnosed with lung cancer, Stage 1 non-small cell lung cancer was most commonly detected [38 cases (54.3%)]. A follow-up lung LDCT scan (n = 897), pulmonary function test (n = 157), positron emission tomography scan (n = 12) and a lung biopsy (n = 53) were performed for certain individuals who had anomalies observed on the screening lung LDCT scan. A total of 42% of patients enrolled in group tobacco cessation classes quit smoking.

CONCLUSIONS

This study provides a unique perspective of a lung LDCT scan screening program driven by primary care providers in a state plagued by cigarette smoking and lung cancer deaths and offers a valuable message into the prevention, high-risk screening and diagnosis of lung cancer.

Bilateral aniridia and congenital ureteral valve: Role of genetic testing

Background

Congenital aniridia involves total or partial hypoplasia of the iris and is due to a deficiency in PAX6 gene expression. WAGR syndrome is comprised of Wilms tumor, aniridia, genitourinary abnormalities, and intellectual disability. Numerous genitourinary pathologies may be associated with WAGR syndrome, necessitating an evaluation of the genitourinary anatomy. The WT1 is vital for the development of kidneys, ovaries in females, and testes in males. WT1 gene mutations result in a WT1 protein with a decreased ability to bind to DNA, leading to uncontrolled growth, and cell division in the kidney which permits the development of Wilms tumor. A congenital ureteral valve is an exceedingly rare cause of obstructive uropathy.

Results

A renal and bladder ultrasound demonstrated a renal cyst. A voiding cystourethrogram revealed grade 3 vesicoureteral reflux, and a MAG3 renal scan showed ureteropelvic junction obstruction and hydronephrosis. A ureteral stent was inserted at 3 months of age after which the renal cyst resolved. The patient was urinary tract infection‐free at 27 months of age. Genetic testing confirmed a heterozygous alteration in PAX6 (c.495delG, p.Thr166Leufs*41) and no abnormalities of WT1, excluding WAGR syndrome.

Conclusion

The genitourinary risks potentially associated with aniridia necessitate prompt genetic analysis to evaluate for WAGR syndrome.

Scrotal Ultrasound Is Not Routinely Indicated in the Management of Cryptorchidism, Retractile Testes, and Hydrocele in Children

Cryptorchidism, or undescended testes, is the most common congenital genitourinary anomaly. A failure or delay of treatment may result in reduced fertility or an increased risk of testicular cancer. The American Urological Association (AUA) recommends that a scrotal ultrasound (SUS) not be performed in the preoperative management of cryptorchidism. This study investigated how likely pediatricians were to perform SUS despite the AUA guidelines. We retrospectively studied 243 patients referred to a single pediatric urology practice for clinically diagnosed testis pathology including undescended testis, hydrocele, and retractile testis over a 4-year period (January 1, 2015, to December 30, 2018). A total of 72 patients (29.6%) underwent a SUS ordered by their pediatrician prior to the pediatric urology visit. Pediatricians should be aware that SUS performed prior to pediatric urological evaluation does not alter management and is associated with a significant financial cost in patients with cryptorchidism or hydrocele.

Standardized warfarin monitoring decreases adverse drug reactions

Background

While warfarin is the most commonly prescribed medication to prevent thromboembolic disorders, the risk of adverse drug reactions (ADR) poses a serious concern. This prospective study evaluated how primary care providers (PCP) and cardiologists at our Institution managed patients treated with warfarin with the goal of decreasing the number of warfarin ADRs.

Methods

A multidisciplinary anticoagulation task force was established at our Institution in 2014 to standardize warfarin monitoring and management. Between 2013 and 2017, we analyzed patients who were prescribed warfarin by their PCP or cardiologist upon hospital discharge and in the ambulatory setting to determine the international normalized ratio (INR) within 5, 10, and 30 days after discharge, time in therapeutic range (TTR), number of severe warfarin ADRs, and total and average cost reduction of all severe warfarin ADRs to determine whether there was an organizational cost savings following the implementation of standardized warfarin care.

Results

The warfarin ADR rate significantly decreased over the 5-year period, from 3.8 to 0.98% (p < 0.0001). The proportion of warfarin prescriptions out of all anticoagulants significantly decreased, from 72.2 to 42.1% (p < 0.001). The proportion of individuals who received an INR at 5, 10, and 30 days after hospital discharge compared to the total number of patients prescribed warfarin significantly increased (p < 0.001). The total cost of severe warfarin ADRs decreased by 57.6% between 2013 and 2017.

Conclusions

This study serves as a model to reduce the number of severe warfarin ADRs by the following tactics: (1) educating PCPs and cardiologists about evidence-based guidelines for warfarin management, (2) increasing the use of our Institution’s electronic warfarin module, and (3) enhancing patient compliance with obtaining INR.

Dynamic response of microglia/macrophage polarization following demyelination in mice

BACKGROUND

The glial response in multiple sclerosis (MS), especially for recruitment and differentiation of oligodendrocyte progenitor cells (OPCs), predicts the success of remyelination of MS plaques and return of function. As a central player in neuroinflammation, activation and polarization of microglia/macrophages (M/M) that modulate the inflammatory niche and cytokine components in demyelination lesions may impact the OPC response and progression of demyelination and remyelination. However, the dynamic behaviors of M/M and OPCs during demyelination and spontaneous remyelination are poorly understood, and the complex role of neuroinflammation in the demyelination-remyelination process is not well known. In this study, we utilized two focal demyelination models with different dynamic patterns of M/M to investigate the correlation between M/M polarization and the demyelination-remyelination process.

METHODS

The temporal and spatial features of M/M activation/polarization and OPC response in two focal demyelination models induced by lysolecithin (LPC) and lipopolysaccharide (LPS) were examined in mice. Detailed discrimination of morphology, sensorimotor function, diffusion tensor imaging (DTI), inflammation-relevant cytokines, and glial responses between these two models were analyzed at different phases.

RESULTS

The results show that LPC and LPS induced distinctive temporal and spatial lesion patterns. LPS produced diffuse demyelination lesions, with a delayed peak of demyelination and functional decline compared to LPC. Oligodendrocytes, astrocytes, and M/M were scattered throughout the LPS-induced demyelination lesions but were distributed in a layer-like pattern throughout the LPC-induced lesion. The specific M/M polarization was tightly correlated to the lesion pattern associated with balance beam function.

CONCLUSIONS

This study elaborated on the spatial and temporal features of neuroinflammation mediators and glial response during the demyelination-remyelination processes in two focal demyelination models. Specific M/M polarization is highly correlated to the demyelination-remyelination process probably via modulations of the inflammatory niche, cytokine components, and OPC response. These findings not only provide a basis for understanding the complex and dynamic glial phenotypes and behaviors but also reveal potential targets to promote/inhibit certain M/M phenotypes at the appropriate time for efficient remyelination.

Decline in primary care providers' prescribing of Schedule II opioids following the implementation of federal and state guidelines

OBJECTIVE

Prescription opioid misuse represents a social and economic dilemma in the United States. The authors evaluated primary care providers' (PCPs) prescribing of Schedule II opioids at our institution in Kentucky.

DESIGN

Prospective evaluation of PCPs' prescribing practices over a 3-year period (October 1, 2014 to September 30, 2017) in an outpatient setting.

METHODS

An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards. Special attention focused on Schedule II opioid prescriptions with a quantity > 90, Opana/Oxycontin, and morphine equivalent daily dosage.

RESULTS

A statistically significant increase in the total number of PCPs and PCPs who prescribed Schedule II opioids was observed, while there was a concurrent significant decrease in the average number of Schedule II opioid pills prescribed per PCP, Schedule II opioid prescriptions per PCP, Schedule II opioid pills prescribed per patient by PCPs, Schedule II opioid prescriptions with a quantity > 90 per PCP, and Opana/Oxycontin prescriptions per PCP. A statistically significant decline in the average morphine equivalent daily dosage of Schedule II opioids per PCP was noted.

CONCLUSIONS

This study reports the benefit of incorporating federal and state regulations and institutional evidence-based guidelines into primary care practice to decrease the number of Schedule II opioids prescribed. Further preventive measures include selecting alternative treatments to opioids and reducing the rates of opioid nonmedical use and overdose while maintaining access to prescription opioids when indicated.