Thoracic Erector Spinae Plane Catheter as a Bridge to Patient-Controlled Thoracic Epidural Analgesia in Unilateral Lung Transplantation.

Erector spinae plane (ESP) blocks may be an acceptable alternative to thoracic epidural analgesia during the postoperative period in lung transplant patients. In this case report, we describe the use of an ESP block to manage acute postoperative pain in a unilateral lung transplant, although it was inferior to the thoracic epidural, which was eventually placed.

Diagnosing Lemierre's Syndrome as the Cause of Multifocal Pneumonia During the COVID-19 Pandemic.

A 21-year-old male with no past medical history presented with a sore throat, cough, and shortness of breath after attending a party days earlier. He was initially treated for community-acquired pneumonia, but subsequently developed a new oxygen requirement. CT imaging of the chest showed multifocal airspace disease, concerning for COVID-19. Testing for SARS-CoV-2 was negative by RT-PCR and antibody testing. Blood cultures subsequently grew Streptococcus anginosus. A CT scan of his neck demonstrated a right peritonsillar abscess and right internal-jugular thrombus, consistent with Lemierre's syndrome. He underwent incision and drainage of the peritonsillar abscess and completed 4 weeks of IV antibiotics, which improved his symptoms. It is important to recognize that the differential diagnosis of multifocal pneumonia is broad and includes Lemierre's syndrome. The COVID-19 pandemic presents challenges with regards to anchoring bias for multifocal pneumonia.

Splenomegaly, Non-Traumatic Splenic Rupture, and Pancytopenia in Patient with Human Granulocytic Anaplasmosis.

BACKGROUND: Splenic rupture is a well-described complication of babesiosis but is rarely associated with anaplasmosis. CASE PRESENTATION: We report a case of a 37-year-old man with no significant past medical history who presented with malaise, myalgias, arthralgias and severe left upper quadrant pain. He was found to have splenic rupture secondary to infection by Anaplasma phagocytophilum. He reported a single tick bite the week prior to onset of his symptoms. On presentation, he was found to have left upper quadrant abdominal tenderness, pancytopenia, and splenomegaly with evidence of splenic rupture and hemoperitoneum on contrasted computed tomography. Blood smear did not demonstrate intraerythrocytic parasites or morulae. His hemoperitoneum was treated conservatively and he was empirically treated for babesiosis. Diagnosis was confirmed by a positive serum PCR for Anaplasma phagocytophilum. CONCLUSIONS: This case study adds to the small number of prior case reports and provides evidence for anaplasmosis-associated splenic rupture.

Lessons Learned from a Rhode Island Academic Out-Patient Lyme and Tick-Borne Disease Clinic.

Although the prevalence of Lyme and tick-borne diseases (TBDs) continues to rise, there is conflicting information regarding the best approach to management. The Lifespan Lyme Disease Clinic (LDC) is an academic out- patient clinic for Lyme and other TBDs. A chart review of 218 new patients between March and November 2018 was conducted. Symptoms most commonly reported included fatigue (66.5%), joint pain (58.2%), cognitive difficulty (32.1%), and headaches (27.9%). Most (87.1%) patients had received TBD-directed antibiotic treatment prior to their first appointment. Of the 136 patients who had experienced more than 6 months of symptoms attributed to Lyme, 55.1% had positive two-tiered serologies. Many patients characterized themselves as having "chronic Lyme" or had a diagnosis of "post-treatment Lyme disease syndrome," a condition for which there is no clear consensus on pathophysiology or treatment. Outlined here are some lessons learned and practical approaches used by LDC physicians in caring for this patient population.

Remdesivir Use Compared With Supportive Care in Hospitalized Patients With Severe COVID-19: A Single-Center Experience.

BACKGROUND: The US Food and Drug Administration issued an Emergency Use Authorization for remdesivir use in patients with severe COVID-19. METHODS: We utilized data from 2 quaternary acute care hospitals. The outcomes of interest were the impact of remdesivir on in-hospital death by day 28 and time to recovery, clinical improvement, and discharge. We utilized Cox proportional hazards models and stratified log-rank tests. RESULTS: Two hundred twenty-four patients were included in the study. The median age was 59 years; 67.0% were male; 17/125 patients (13.6%) who received supportive care and 7/99 patients (7.1%) who received remdesivir died. The unadjusted risk for 28-day in-hospital death was lower for patients who received remdesivir compared with patients who received supportive care (hazard ratio [HR], 0.42; 95% CI, 0.16-1.08). Although this trend remained the same after adjusting for age, sex, race, and oxygen requirements on admission (adjusted HR [aHR], 0.49; 95% CI, 0.19-1.28), as well as chronic comorbidities and use of corticosteroids (aHR, 0.44; 95% CI, 0.16-1.23), it did not reach statistical significance. The use of remdesivir was not associated with an increased risk of acute kidney injury (AKI) or liver test abnormalities. Although not statistically significant, the rate ratios for time to recovery, clinical improvement, and discharge were higher in women and black or African American patients. CONCLUSIONS: Patients on remdesivir had lower, albeit not significant, all-cause in-hospital mortality, and the use of remdesivir did not increase the risk for AKI. Promising signals from this study need to be confirmed by future placebo-controlled randomized clinical trials.

SARS-CoV-2 and HIV coinfection: clinical experience from Rhode Island, United States.

INTRODUCTION: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has infected >6 million people worldwide since December 2019. Global reports of HIV/SARS-CoV-2 coinfection are limited. To better understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on persons with HIV and improve their care, we present an outpatient and inpatient clinical experience of HIV/SARS-CoV-2 coinfection from Rhode Island, US. METHODS: We describe outpatient and inpatient preparedness for the COVID-19 pandemic, and present a case series of all known patients with HIV/SARS-CoV-2 coinfection at The Miriam Hospital and Rhode Island Hospital, and The Miriam Hospital Infectious Diseases and Immunology Center, in Providence, Rhode Island, US. RESULTS AND DISCUSSION: The Infectious Diseases and Immunology Center rapidly prepared for outpatient and inpatient care of persons with HIV and SARS-CoV-2. Between 30 March and 20 May 2020, 27 patients with HIV were diagnosed with SARS-CoV-2. Twenty were male, six female and one transgender female; average age was 49 years; 13/27 were Hispanic and 6/27 were African American. All had HIV viral load <200 copies/mL and were on antiretroviral therapy with CD4 count range 87 to 1441 cells/µL. Twenty-six of the 27 had common COVID-19 symptoms for one to twenty-eight days and most had other co-morbidities and/or risk factors. Nine of the 27 were hospitalized for one to thirteen days; of those, three lived in a nursing home, six received remdesivir through a clinical trial or emergency use authorization and tolerated it well; eight recovered and one died. Overall, 17% of known Center people had HIV/SARS-CoV-2 coinfection, whereas the comparable state-wide prevalence was 9%. CONCLUSIONS: We highlight challenges of outpatient and inpatient HIV care in the setting of the COVID-19 pandemic and present the largest detailed case series to date from the United States on HIV/SARS-CoV-2 coinfection, adding to limited global reports. The aggregated clinical findings suggest that the clinical presentation and outcomes of COVID-19 appear consistent with those without HIV. Whether SARS-CoV-2 infection is more frequent among persons with HIV remains to be determined. More data are needed as we develop our understanding of how HIV and antiretroviral therapy are affected by or have an impact on this pandemic.

Babesiosis-associated Splenic Rupture: Case Series From a Hyperendemic Region.

BACKGROUND: Spontaneous splenic rupture is an increasingly reported complication of babesiosis and has been described as a severe complication. METHODS: We performed a retrospective chart review in a high-prevalence area to identify 7 cases of babesiosis-related splenic rupture between 2014 and 2016. RESULTS: Splenic rupture occurred in approximately 1% of babesiosis cases. Compared to cases without splenic rupture, these patients were younger (by >10 years), healthier (most with ≤1 comorbidity), had a lower degree of parasitemia (<10%), and were less likely to have end-organ dysfunction other than their splenic involvement. CONCLUSIONS: Younger, healthier patients may be more prone to develop splenic rupture, as splenic histiocytes engage in more robust erythrophagocytosis, leading to pathological mechanical strain and rupture.

Atypical Localization of Malignant Plasma Cells in Non-Viable Cell Area on Flow Cytometry Light-Scatter Dot Plot.

BACKGROUND Multi-parameter (multicolor) flow cytometric study of the bone marrow aspirate is a very useful tool for diagnosis of plasma cell dyscrasia and for evaluation of post-therapy bone marrow for minimal residual disease. CASE REPORT We present a case of a 50-year-old man with multiple myeloma, whose plasma cells on a bone marrow aspirate flow cytometric study showed atypical placement on a light-scatter dot plot, both on forward and side scatter. The bone marrow aspirate sample was 33 hours and 11 minutes old, and the light-scatter dot plot demonstrated that plasma cells, detected by their expression of CD138, CD38, and CD56, occupied an area otherwise characteristic for dead cells and cell detritus. Expressions of CD138 and CD56 were dim (down-regulated). CONCLUSIONS Morphologically atypical plasma cells with irregular nuclear contours/polylobated nuclei from non-fresh samples can present with atypical localization in the area of dead cells. Our study of the multiple myeloma patient with normal localization of plasma cells on a light-scatter dot plot showed a fraction of plasma cells in the dead cell area with dim expression of CD138 and CD56, suggesting that plasma cells may deteriorate (age) rather rapidly, losing surface markers even in less than 24-hour-old specimens. We suggest that the non-viable cell/dead cell area should be checked for expression of CD138 so as not to miss plasma cell dyscrasia, especially if the specimen was run 24 hours after bone marrow sampling.

First confirmed case of Powassan neuroinvasive disease in Rhode Island.

The Powassan Virus is the arthropod-borne vector responsible for Powassan neuroinvasive disease. The virus was first isolated in 1958 and has been responsible for approximately 100 cases of neuroinvasive disease. Rates of infection have been on the rise over the past decade with numerous states reporting their first confirmed case; New Jersey, New Hampshire and Connecticut all reported their first case within the last five years. We present here the first confirmed case of Powassan neuroinvasive disease in the nearby state of Rhode Island. A previously healthy 81-year-old female with known tick exposure presented with fever, altered sensorium, seizures and focal neurological deficits. After an extensive work-up that was largely unrevealing Powassan encephalitis was suspected. The diagnosis was confirmed with serological testing consisting of Powassan IgM enzyme-linked immunosorbent assay and Powassan plaque reduction neutralization testing. The case study provides evidence for the increasing spread of Powassan neuroinvasive disease and reinforces the importance of requesting focused testing for Powassan Virus in patients from an endemic area with a clinically compatible syndrome.

Group A streptococcus acute otitis media progressing to neuroinvasive disease in adults.

Acute otitis media affects 700 million people each year with children being disproportionately affected relative to adults. Group A streptococcus is a pathogen implicated in a broad array of human pathology. It is, however, a rare cause of acute otitis media and neuroinvasive disease in older adults with only 2-3 cases occurring per year in the United States. We describe two such cases from a single institution in Rhode Island in 2017. The clinical presentation, neuroimaging and management are reviewed. The mechanism of intracranial spread may have involved dehiscence of the bony tegmen of the roof of the middle ear cavity.

Coping styles moderate the relationships between exposure to community violence and work-related outcomes.

The purpose of this study was to identify coping strategies used by employees exposed to community violence and their relationships to work-related outcomes. In study 1, Mexican Maquiladora employees who experienced community violence reported their coping strategies. Results identified 3 strategies: social, solitary, and maladaptive coping. In study 2, another sample completed measures of violence exposure, strain, coping, and turnover intention. Supervisors provided performance evaluations. Community violence predicted the use of all 3 strategies. Social coping lessened the effects of community violence on turnover while maladaptive strategies predicted increased psychological strain. Results indicate that workers use a variety of coping strategies in response to community violence that both lessen and magnify the effects of violence exposure and impact their psychological strain, turnover intention, and job performance. (PsycINFO Database Record

Does knowledge of coronary artery calcium affect cardiovascular risk perception, likelihood of taking action, and health-promoting behavior change?

BACKGROUND: Evidence indicates that a healthy lifestyle can reduce cardiovascular disease risk, yet many people engage in unhealthy behaviors. New technologies such as coronary artery calcium (CAC) screening detect atherosclerosis before clinical disease is manifested. Knowledge of an abnormal finding could provide the "teachable moment" to enhance motivation for change. OBJECTIVE: The aim of this study was to examine how knowledge of CAC score affects risk perception, likelihood of taking action, and health-promoting behavior change in persons at high risk for cardiovascular disease. METHODS: This study used a descriptive prospective design with 174 high-risk adults (≥3 major risk factors) recruited at a radiology center offering CAC scans. Baseline self-report surveys using the Perception of Risk of Heart Disease Scale, the Benefits and Barriers Scale, the Quality of Life Index, and the Health-Promoting Lifestyle Profile II were completed immediately after a screening CAC scan but before results were known. Follow-up occurred 3 months later using mailed packets. RESULTS: Participants' mean age was 58 years; 62% were men, 89% were white, and most were well educated. There was no significant change in risk perception scores over time or between groups, except for a positive interaction in the moderate-risk group (CAC scores of 101-400) (P = .004). Quality of life remained unchanged. Health-promoting behavior changes increased in all groups over time (P < .001). McNemar χ² analysis indicated that risk reduction medication use increased in all groups, with a significant increase in statin (P < .001) and aspirin (P < .001) intake. Predictors of behavior change were perceived barriers (ß = -.41; P < .001) and quality of life (ß = .44; P < .001). CONCLUSIONS: Knowledge of CAC score does impact risk perception for some at-risk groups. This knowledge does enhance motivation for behavior change. Knowledge of CAC score does not impact quality of life. It is hoped that through improved understanding of the effect of CAC scoring on behavior change, nurses can better assist patients to modify behaviors during teachable moments.

Independently movable multielectrode array to record multiple fast-spiking neurons in the cerebral cortex during cognition.

A multiple microelectrode carrier system is described that allows each of 16 microelectrodes in a high-density array to be manipulated in the brain independently by remote control during a cognitive task. Descriptions of the carrier system, advancing techniques, and microelectrode design are presented that allow high-fidelity, extracellular recordings of multiple cerebral cortex neurons with high signal-to-noise ratio and day-to-day repeatability. The motivation for the new carrier system was to provide a method to target multi-microelectrode recordings to a distinct population of fast-spiking neurons in the cerebral cortex during a behavioral task to assess their involvement in selective attention. Recent work using intracellular recording in vitro and single-neuron extracellular recordings in vivo has demonstrated that subpopulations of cortical interneurons can be identified on the basis of their action potential waveform and response to sensory input, and that such interneurons play a fundamental role in generating cortical rhythmicity associated with vigilant wakefulness. A new behavioral paradigm is presented, based on Pavlov's and Kamin's classic work on compound conditioning, that permits the electrophysiological patterns of selective attention among neuronal ensembles to be distinguished from those of sensation without attention in a primary sensory cortex. Our approach of multiple, individually guided cerebral cortical recordings in behaving rats during a complex cognitive task is beginning to provide new support for the role of fast cerebral rhythms in selective attention.