Recognition and Treatment of Wounds in Persons Using Xylazine: A Case Report From New Haven, Connecticut.

BACKGROUND: Xylazine is an α 2 -adrenergic agonist that is commonly used as a veterinary tranquilizer and is increasingly present in the unregulated US drug supply since at least 2019. There are many suspected clinical complications of xylazine use, including unusual skin wounds, atypical overdose presentations, and possible dependence and withdrawal syndromes. However, there are few reports of cutaneous manifestations of xylazine in patients who inject drugs that can guide diagnosis and management in patients with confirmed xylazine toxicology. CASE SUMMARY: We present the cases of 3 stably housed patients in Connecticut with opioid use disorder and intravenous use of fentanyl who presented with atypical, chronic wounds at the site of injection drug use. Xylazine toxicology sent on all 3 patients was positive. All patients were seen by wound care and dermatology, and 1 patient was followed by infectious diseases. Wound care management strategies are discussed as well as harm reduction strategies. For all patients, the dose of their medication for opioid use disorder was increased to decrease frequency of drug use given concern that patients were exposed to a drug supply containing xylazine. CLINICAL SIGNIFICANCE: This case report presents wound characteristics that raise the index of suspicion for xylazine-involved injection wounds and might assist in their diagnosis and management. There is urgent need for more reporting of such cases as well as rigorous research to understand the potential impact of xylazine on people who use drugs. Multidisciplinary best practices should be established.

Comparison of the weight of conventionally heat-processed hollow and solid obturators and 3D printed hollow obturators.

STATEMENT OF PROBLEM: The weight of larger obturators places increased stress on the supportive teeth and bearing tissue and allows gravity to act as a dislodging factor affecting the stability and retention of the prosthesis. However, whether conventionally processed and 3-dimensionally (3D) printed hollow obturators have similar reduced weights compared with solid obturators is unclear. PURPOSE: The purpose of this in vitro study was to evaluate the weight difference between conventionally heat-processed complete denture obturators with and without hollowing and 3D printed obturators with a hollow bulb. MATERIAL AND METHODS: Obturators were fabricated as conventionally heat-processed solid obturators, conventionally heat-processed with a hollow obturator bulb, and 3D printed with a hollow obturator bulb. Nine obturator prostheses were fabricated for each type of Aramany Class I, Class II, and Class III defect. The weights of each of the 27 obturator prostheses were measured, and a statistical analysis was performed with exact versions of the Kruskal-Wallis test or Wilcoxon Rank Sum test (α=.05). RESULTS: Conventionally heat-processed solid obturators were significantly heavier than the conventionally heat-processed hollow (P<.001) or the 3D printed hollow obturators (P<.001). No significant difference (P=.222) was found between the conventionally heat-processed hollow and 3D printed hollow obturators. The decrease in weight was proportional to the size of the defect with the Aramany Class I defect having the largest differences in weight between the different fabrication methods, followed by Class II, and then Class III with a much smaller defect. CONCLUSIONS: Additive manufacturing could be a suitable alternative to conventional techniques for the fabrication of a closed hollow obturator because of the comparable weights.

Lymphocytic Choriomeningitis Virus in Person Living with HIV, Connecticut, USA, 2021.

Lymphocytic choriomeningitis virus is an underreported cause of miscarriage and neurologic disease. Surveillance remains challenging because of nonspecific symptomatology, inconsistent case reporting, and difficulties with diagnostic testing. We describe a case of acute lymphocytic choriomeningitis virus disease in a person living with HIV in Connecticut, USA, identified by using quantitative reverse transcription PCR.

Building an Infectious Disease Diversity, Equity, and Antiracism (ID2EA) Curriculum: A Single Center's Experience and Reflections.

In response to longstanding healthcare inequities unmasked by the Coronavirus Disease 2019 pandemic, the infectious diseases (ID) section at the Yale School of Medicine designed and implemented a pilot curriculum integrating Infectious Disease Diversity, Equity, and Antiracism (ID2EA) into ID educational training and measured program outcomes. We herein describe a mixed-methods assessment of section members on whether the ID2EA curriculum affected their beliefs and behaviors regarding racism and healthcare inequities. Participants rated the curriculum as useful (92% averaging across sessions) and effective in achieving stated learning objectives (89% averaging across sessions), including fostering understanding of how inequities and racism are linked to health disparities and identifying strategies to effectively deal with racism and inequities. Despite limitations in response rates and assessment of longer-term behavioral change, this work demonstrates that training in diversity, equity, and antiracism can be successfully integrated into ID physicians' educational activities and affect physicians' perspectives on these topics.

Incidence, Risk Factors, and Subsequent Complications of Postoperative Hematomas Requiring Reoperation After Primary Total Hip Arthroplasty.

Background: Studies analyzing the incidence and clinical implications of postoperative hematomas after total hip arthroplasty (THA) remain limited. The purpose of the present study was to use the National Surgical Quality Improvement Program (NSQIP) dataset to determine rates, risk factors, and subsequent complications of postoperative hematomas requiring reoperation after primary THA. Methods: Study population included patients who underwent primary THA (CPT code: 27130) from 2012-2016 recorded in NSQIP. Patients who developed a hematoma requiring reoperation in the 30-day postoperative period were identified. Multivariate regressions were created to identify patient characteristics, operative variables, and subsequent complications that were associated with a postoperative hematoma requiring reoperation. Results: Among the 149,026 patients who underwent primary THA, 180 (0.12%) developed a postoperative hematoma requiring reoperation. Risk factors included body mass index (BMI) ≥ 35 (relative risk [RR]: 1.83, P = .011), American Society of Anesthesiologists (ASA) class ≥3 (RR: 2.11, P < .001), and history of bleeding disorder (RR: 2.71, P < .001). Associated intraoperative characteristics were an operative time ≥100 minutes (RR: 2.03, P < .001) and use of general anesthesia (RR: 1.41, P = .028). Patients developing a hematoma requiring reoperation were at higher risk of subsequent deep wound infection (RR: 21.57, P < .001), sepsis (RR: 4.3, P = .012), and pneumonia (RR: 3.69, P = .023). Conclusions: Surgical evacuation for a postoperative hematoma was performed in about 1 in 833 cases of primary THA. Several nonmodifiable and modifiable risk factors were identified. Given the 21.6 times increased risk of subsequent deep wound infection, select, at-risk patients may benefit from closer monitoring for signs of infection.

Prosthetic Joint Infections of the Hip and Knee Among the Elderly: A Retrospective Study.

BACKGROUND: As the population ages and demand for total joint arthroplasty increases, rates of periprosthetic joint infection are expected to increase in the geriatric population. Studies comparing prevalence of risk factors, etiology, management, and mortality of prosthetic joint infection in older patients are lacking. METHODS: We compared clinical characteristics, management, and mortality of patients <75 vs ≥75 years of age with first prosthetic joint infection of the hip or knee admitted to a tertiary medical center between September 2017 and December 2019. RESULTS: Ninety-eight patients (<75 years of age [n = 63]; ≥75 years of age (n = 35) were studied. Groups were similar in terms of etiology, culture-directed therapy, antibiotic suppression, and length of stay. There was no difference in surgical management, performed in almost 97% of cases in both groups. Arrhythmia and heart failure were more prevalent in those aged ≥75 years. Readmission related to prosthetic joint infection occurred less often in older individuals (P = .005). Deaths within 1 year of diagnosis were rare (n = 4; 4.1%), occurring in older patients and resulting mostly from sepsis. CONCLUSION: In our single-center study, patients with first prosthetic joint infection had similar management, regardless of age. We identified cardiac history as one of the host factors for prosthetic joint infection most seen in patients ≥75 years of age. Although deaths were rare, 1-year mortality was higher in patients aged ≥75. Prospective, multicenter studies are needed to explore risk factors and management strategies of prosthetic joint infection among elderly populations.

Orbital Exenteration and Brachytherapy for the Treatment of Pediatric, Fusion-positive, Recurrent Rhabdomyosarcoma.

A 20-month-old boy presented with biopsy-proven recurrent alveolar rhabdomyosarcoma without metastasis. He was previously treated with multiagent chemotherapy and external beam irradiation showing a complete response. Upon relapse, he was treated with chemotherapy, orbital exenteration, and brachytherapy. Customized, intraoperative brachytherapy has potential to limit the sequelae associated with radiation adjuvant therapy.

Unnecessary Routine Use of Mycobacterial Cultures in Patients With Periprosthetic Joint Infections.

Accurate diagnosis ensures appropriate therapy of periprosthetic joint infection (PJI). Since mycobacterial PJI is rare, routine testing is inappropriate. We reviewed hip and knee PJI at our institution over 28 months. Mycobacterial cultures were routinely sent with rare positivity. Mycobacterial cultures should be sent only when there is clinical suspicion.

The Need for Multidisciplinary Hospital Teams for Injection Drug Use-related Infective Endocarditis.

Injection drug use-related infective endocarditis (IDU-IE) is a complex disease with increasing incidence. Although universally recognized that IDU-IE requires antibiotics and often requires cardiac surgery, most patients do not receive addiction treatment which substantially increases their risk of recurrent IDU-IE from drug use recurrence. Accordingly, a multidisciplinary approach integrating addiction treatment may benefit patients with IDU-IE. We describe the format and structure of a team called the Multidisciplinary Endocarditis Evaluation Team (MEET) whose purpose is to optimize, formalize, and standardize the care of patients with IDUIE. Given the complexity of IDU-IE, MEET is comprised of addiction medicine, anesthesia, cardiology, cardiac surgery, infectious disease, case management, nursing, and social work. MEET strived to be acceptable to patients and families to support their preferences and values. MEET focused treatment of IDU-IE on the patient's medical and surgical needs with attention to the patients' underlying substance use disorder as an essential component.

Provider Satisfaction With Infectious Diseases Telemedicine Consults for Hospitalized Patients During the Coronavirus Disease 2019 (COVID-19) Pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, our institution transitioned infectious diseases (ID) consultations on hospitalized patients to telemedicine. We evaluated satisfaction with telemedicine among referring providers and ID consultants. Respondents were satisfied with telemedicine consults for hospitalized patients, although there were significant differences in perceptions of quality and timeliness between consultants and referring providers.

Intravenous (IV) cefazolin with oral probenecid: A novel daily regimen for the management of Methicillin Sensitive Staphylococcus aureus (MSSA) bacteremia in a patient with renal dysfunction.

A 78 year old man developed a methicillin sensitive Staphylococcus aureus (MSSA) post-operative wound infection following an elective L2-L4 laminectomy. He was treated with surgical debridement which was to be followed by a planned 6 weeks course of cefazolin. However, two weeks post debridement, a follow-up MRI revealed an L3-L5 epidural abscess, septic arthritis and vertebral osteomyelitis prompting repeat surgical debridement. No purulence was noted, and operative cultures were negative for growth. His hospital course was complicated by acute kidney injury and a renal biopsy reveled crescentic glomerulonephritis consistent with post infectious glomerulonephritis. He was treated with daptomycin, followed by oral linezolid. Five months after his original laminectomy, he developed purulent drainage from his back wound. Blood cultures grew MSSA and a repeat aspirate done by interventional radiology also grew MSSA. He improved with nafcillin and was transitioned to telavancin on discharge to facilitate once daily treatment. While on telavancin he developed increasing back pain and fever. Therefore, the regimen was changed to IV cefazolin and oral probenecid for five weeks followed by oral cephalexin to complete a total of 12 weeks of therapy. There is no evidence of disease recurrence one year after completion of therapy. IV cefazolin with oral probenecid may represent a once daily IV treatment option for patients with MSSA bacteremia and kidney disease.

Electronic Health Record-Assisted Reflex Urine Culture Testing Improves Emergency Department Diagnostic Efficiency.

The authors evaluated the effectiveness of an electronic health record (EHR)-based reflex urine culture testing algorithm on urine test utilization and diagnostic yield in the emergency department (ED). The study implemented a reflex urine culture order with EHR decision support. The primary outcome was the number of urine culture orders per 100 ED visits. The secondary outcome was the diagnostic yield of urine cultures. After the intervention, the mean number of urine cultures ordered was 5.95 fewer per 100 ED visits (9.3 vs 15.2), and there was a decrease in normal, or negative, cultures by 2.42 per 100 ED visits. There also was a statistically significant decrease in urine culture utilization and an increase in the positive proportion of cultures. Simple EHR clinical decision-support tools along with reflex urine culture testing can significantly reduce the number of urine cultures performed while improving diagnostic yield in the ED.

Rehabilitation of a patient after a total maxillectomy with a 2-piece magnetically retained obturator: A clinical report.

After ablative surgery, especially a total maxillectomy, an obturator is commonly used as a method of reconstruction. However, the loss of a palatal denture-bearing area and vestibular retentive undercuts leaves an anatomically deficient base on which to construct the definitive prosthesis. As a result, retention and stability is compromised. A solution to the retention problem is to construct an obturator that engages undercuts and scar bands. Engagement of all undercuts can lead to a prosthesis that is too cumbersome and difficult to insert, especially in a patient with scars after radiation. In this article, a technique for creating a 2-piece magnetic obturator that engages the nasal scar band is described.

Three-dimensional printed definitive cast for a silicone obturator prosthesis: A clinical report.

For patients with head and neck cancer requiring a maxillectomy, obturator prostheses help with quality of life. These patients routinely require adjuvant oncologic treatments with significant adverse effects. Treatment sequelae can leave patients with difficulty speaking and swallowing, reduced salivary function, reduction in maximal incisal opening, and at risk of osteoradionecrosis. A 55-year-old African-American woman presented with significant trismus and reduction in maximal incisal opening after treatment for squamous cell carcinoma of the left maxillary sinus. She had received a left total maxillectomy with adjuvant chemotherapy and radiation treatments. With her reduced opening, she was no longer able to insert her interim obturator prosthesis, which caused difficulty speaking and nasal regurgitation. A cone beam computed tomography scan was made of the patient's maxillectomy defect. From the Digital Imaging and Communications in Medicine file, a definitive cast was 3-dimensionally printed to fabricate a flexible silicone obturator prosthesis. This treatment has allowed the patient to return to a functional quality of life and could help other patients in similar situations.

Fabrication of a custom brachytherapy appliance.

This article reviews the prosthodontic and laboratory steps in the fabrication of a custom brachytherapy appliance. This technique is described through the treatment of a patient with recurrent orbital rhabdomyosarcoma. After a non-eyelid-sparing orbital exenteration of a 7-year-old boy, an impression of the orbital defect was captured to fabricate a custom brachytherapy appliance with mock catheters. One week later, the prosthesis was placed in the orbit, and the device was loaded with radiation catheters to deliver targeted radiation. The prosthesis was secured with Velcro straps fitted into slots made in the prosthesis and wrapped around the back of the patient's head. Brachytherapy appliances have been used to provide effective therapy for patients receiving care at Memorial Sloan Kettering Cancer Center.

Lyme periprosthetic joint infection in total knee arthroplasty.

Lyme arthritis, caused by the spirochete Borrelia burgdorferi sensu stricto, is a common tick-borne illness in New England and the upper Midwest. Most often, the disease affects the knee and has typically been reported as a cause of native joint infection. There has been only 1 case of Lyme periprosthetic joint infection (associated with a total knee arthroplasty) reported in the literature, and to our knowledge, no other reported cases of Lyme periprosthetic joint infections exist. In this article, we report on 2 patients diagnosed with prosthetic joint infections who were subsequently found to have Lyme prosthetic joint infections, with B burgdorferi as the infectious organism. We discuss the medical and surgical management of these patients.

Restoration of Facial Form and Lip Competence in a Patient with a Midfacial Defect.

Squamous cell carcinoma (SCC) of the head and neck can be treated with a combination of modalities. There is an esthetic and functional compromise with midfacial defects secondary to ablative surgery and adjuvant therapies for SCC. Osteoradionecrosis, tissue contracture, and trismus, are all negative side effects of treatment and can impact a patient's function and possibly their nutrition. In this report, we describe a procedure for fabrication of a prosthesis that provides cosmetic improvement and labial competence to maintain caloric intake.

Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease - United States.

The term "chronic Lyme disease" is used by some health care providers as a diagnosis for various constitutional, musculoskeletal, and neuropsychiatric symptoms (1,2). Patients with a diagnosis of chronic Lyme disease have been provided a wide range of medications as treatment, including long courses of intravenous (IV) antibiotics (3,4). Studies have not shown that such treatments lead to substantial long-term improvement for patients, and they can be harmful (1,5). This report describes cases of septic shock, osteomyelitis, Clostridium difficile colitis, and paraspinal abscess resulting from treatments for chronic Lyme disease. Patients, clinicians, and public health practitioners should be aware that treatments for chronic Lyme disease can carry serious risks.

Cytomegalovirus appendicitis in an immunocompetent host.

Cytomegalovirus (CMV) is a common viral pathogen. Asymptomatic infection or a mononucleosis syndrome are the most common manifestations in otherwise healthy individuals. End-organ disease is rare in immunocompetent individuals. Here, we describe a case of CMV appendicitis in a patient without an immune-compromising condition.

Use of Orbital Conformer to Improve Speech in Patients with Confluent Maxillectomy and Orbital Defects.

The basic objective in prosthetic restoration of confluent maxillary and orbital defects is to achieve a comfortable, cosmetically acceptable prosthesis that restores speech, deglutition, and mastication. It is a challenging task complicated by the size and shape of the defects. The maxillary obturator prosthesis often satisfies the objective of adequate deglutition; however, orbital defects that are not obturated in the medial, septal, or posterior walls allow air to escape, negatively impacting phonation. This article describes a technique to achieve favorable prosthetic rehabilitation in a patient with a maxillectomy and ipsilateral orbital exenteration. The prosthetic components include maxillary obturator, orbital conformer, and orbital prosthesis connected using rigid magnetic attachments.