Bezlotoxumab use as adjunctive therapy with the third fecal microbiota transplant in refractory recurrent Clostridium difficile colitis; a case report and concise literature review.

Clostridium difficile is the most commonly reported pathogen to cause nosocomial infections in the United States with a high burden affecting morbidity, mortality and healthcare expenditure. The use of Fecal Microbiota Transplantation (FMT) is one of the current standard therapies for recurrent C. difficile infection (CDIr). One emerging promising approach is the use of monoclonal antibodies that bind to and neutralize C. difficile toxins such as Bezlotoxumab. We present the first case report on combining the third FMT with bezlotoxumab after the failure of standard-of-care antibiotics and two trials of FMT alone, with subsequent success in preventing the recurrence of refractory CDI for 12 weeks following treatment. This case highlights the need for further studies and guidelines to recommend the best combination among different treatment options and modalities.

Effect of the duration of protease inhibitor therapy in HIV-infected individuals on the severity of obstructive sleep apnea.

BACKGROUND: Protease inhibitors (PIs) are a vital part of the antiretroviral therapy. Long-term use of PIs may cause lipodystrophy, a clinical syndrome characterized by peripheral lipoatrophy and central fat accumulation, which may increase the risk of developing obstructive sleep apnea (OSA) in HIV-infected patients. We hypothesize that a longer duration of PIs' use might be associated with increasing severity of OSA in HIV-infected patients. MATERIALS AND METHODS: This was a retrospective cohort study of HIV-infected patients who were treated with PIs, who presented with symptoms suggestive of OSA, and underwent nocturnal polysomnography. The primary objective of the study is to evaluate the association between the duration of PIs' use and the severity of OSA. The duration of PIs' use measured in months was recorded for each patient. The primary outcome of interest was the apnea-hypopnea index (AHI) obtained at the time of the sleep study. Data were analyzed using univariate and multivariate linear regression between AHIs with PIs' use as well as other predictors. RESULTS: A total of 54 patients diagnosed with HIV and OSA were included in the study cohort for the analysis. Sleep study body mass index (BMI; P = 0.042) and change in BMI (ΔBMI; P = 0.027) were the only statistically significant independent predictors of AHI. The association between AHI and PIs' use duration was found to be nonlinear and nonsignificant. Gender differences evaluation suggested possible duration-related effect relationship between PIs and OSA severity among HIV-infected men exposed to PIs within a 66-month duration. CONCLUSION: We did not observe a significant association between PIs' use duration and the severity of OSA.

Mediastinal extragonadal seminoma presenting as severe back pain in a young male.

Back pain is a common complaint in the outpatient setting. The etiology is most often benign but it can be a serious, even life-threatening problem. This report describes a 33-year-old Caucasian male who presented with severe upper back pain for three weeks that did not respond to symptomatic outpatient treatment. Imaging studies revealed a mediastinal mass and lymphadenopathy with superior vena cava and tracheal compression. Pathology showed a poorly-differentiated malignant neoplasm consistent with seminoma. No evidence of primary testicular tumor was found. His atypical presentation of back pain was thus consistent with an extragonadal seminoma in the mediastinum.

The prognostic effect of brain natriuretic peptide levels on outcomes of hospitalized patients with COVID-19.

Natriuretic peptides are biomarkers of myocardial stress and are frequently elevated among patients with severe respiratory illnesses, typically in the absence of elevated cardiac-filling pressures or clinical heart failure. Elevation of brain natriuretic peptide (BNP) or NT-proBNP is associated with worse outcomes among patients with Acute Respiratory Distress Syndrome (ARDS). We conducted a retrospective cohort study based on a comprehensive review of Electronic Medical Records (EMRs) of patients with Coronavirus Disease 2019 (COVID-19) to evaluate whether BNP on admission has prognostic value on mortality and hospital length of stay (LOS) among patients admitted with confirmed COVID-19 along with the inclusion of additional prognostic variables. Overall, 146 patients were included after analyzing 230 patients' EMR and excluding potential confounding factors for abnormal BNP. Our statistical analysis did not show a statistically significant association between BNP level and mortality rate (P = 0.722) or ICU LOS ( P = 0.741). A remarkable secondary outcome to our study was that impaired renal function (GFR<60) on admission was significantly associated with an increased mortality rate (P = 0.026) and an increased ICU LOS (P = 0.022). Although various studies have presented the predictive role of pro-BNP among patients with respiratory distress in the past years, our study did not find BNP to be an accurate predictive and prognostic factor among patients with COVID-19 in our study population. Renal impairment and high Acute Physiology and Chronic Health Evaluation (APACHE) II scores on admission, on the other hand, have demonstrated to be strong predictors for COVID-19 morbidity and mortality. This study could represent an introduction to more prominent multicenter studies to evaluate additional prognostic factors and minimize the ordering of nonspecific testing.

The Prognostic Effect of Serum Albumin Level on Outcomes of Hospitalized COVID-19 Patients.

As SARS-CoV-2 continues to spread across the globe and significantly impacts health-care systems and strains resources, identifying prognostic factors to predict clinical outcome remains essential. We conducted a retrospective cohort study to further explore the prognostic value of serum hypoalbuminemia and other factors in hospitalized COVID-19 patients. The primary endpoint was defined as the risk of in-hospital mortality. 300 patients were included in the analysis, with 56% being male and a mean (±SD) age of 61.5 ± 15.3 years. The mean (±SD) albumin was 2.86 ± 0.5 g/dL. Our analysis showed that patients with in-hospital mortality had lower albumin levels than patients without in-hospital mortality (2.6 ± 0.49 vs. 2.9 ± 0.48 g/dL, respectively, with P value = <0.001). A multivariant logistic regression analysis was subsequently conducted, and after adjustment, the serum albumin level remained a strong predictor of the primary outcome. Based on the data gathered, we were able to create a model predictive of mortality in this patient group based on the serum albumin level and other pertinent factors. In this model, with all other variables remaining constant, each one-unit increase in albumin is estimated to reduce the odds of mortality by 73%. Our results strengthen the current available data on the prognostic value of serum albumin in COVID-19 patients and provide a model to predict in-hospital mortality.

Back pain and mental retardation.

UNLABELLED: A 25-year-old African-American male with mental retardation was brought to the hospital by his caregiver with a chief complaint of low back pain for four months, complicated by recent anorexia and weight loss. Lumbar spine x-ray showed spondylosis at L2-L3 with normal sacroiliac joints, hip and femur; MRI showed a fracture of the L2 vertebral body. Consequently he underwent L2 anterior corpectomy with bone graft replacement and fusion. Spinal surgical biopsy revealed large cell neuroendocrine carcinoma with immunostaining studies suggesting lung origin. A chest CT scan showed a large solid mass in the mediastinum. CONCLUSION: We are reporting a unique case of large cell neuroendocrine carcinoma (LCNEC) of the lung in a nonsmoking young male which presented as low back pain to emphasize the importance of taking symptoms of patients with mental retardation seriously to avoid diagnostic delay.

Giant-neglected facial Marjolin's ulcer associated with perioperative blood loss anemia.

Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in humans after basal cell carcinoma. Marjolin's ulcer is a form of cutaneous malignancy, and mostly represents cSCC, arising from chronic burns and wounds. We describe an interesting case of giant-neglected facial Marjolin's ulcer identified as cSCC associated with perioperative blood loss anemia. We also highlight its staging workup and the treatment options provided.

Evaluating the efficacy of best practice alerts to improve Clostridium difficile early detection in hospital settings: A 6-month interim analysis of the 2-year prospective study.

INTRODUCTION: Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness with high burden on the health-care system. DESIGN: Observational, retrospective, prospective, pre- and post-intervention study on the incidence and prevalence rates of CDIs. The primary outcome is the healthcare-onset CDIs (HO-CDIs) incidence rate and proportion. METHODS: Best practice alerts (BPAs) for CDI were developed in electronic medical records and released on July 13, 2016. When high-risk patients for CDI are identified, BPAs are triggered requiring nurses to order contact isolation and stool studies followed by other subsequent BPAs encouraging providers to de-escalate antibiotics and order probiotics. Data on admission count, patient-days, CDIs categories prevalence, and incidence rates were collected for the 24-month preintervention and will be collected for the 24-month postintervention period. RESULTS: An interim analysis comparing the data from the first 6-month postintervention period with the average 6-month data of the preintervention period showed that short-term BPAs use is associated with significant increase in the overall CDI infection rate (71.47 vs. 38.38, P < 0.0001), incidence rate (53.81 vs. 28.76, P < 0.0001), overall prevalence rate (1.86 vs. 1.32, P = 0.001), and admission prevalence rate (1.10 vs. 0.70, P < 0.0001). Despite the observed overall shift from HO toward CO; no statistically significant difference in the HO-CDI event number and proportion was detected (28 [21.4%] vs. 22 [29.1%], P = 0.094). CONCLUSION: Short-term BPAs use is associated with significant increase in the overall CDI incidence and prevalence along with a non-statistically significant decline in HO-CDI proportion. Final analysis with full sample size is essential to provide a better picture about the long-term effect.