Fibrosing mediastinitis: an unusual cause of pulmonary symptoms.

Fibrosing mediastinitis (FM), also known as granulomatous or sclerosing mediastinitis, is an uncommon but serious cause of chest symptoms. Due to an infectious or inflammatory challenge, production of collagen occurs in the confined space of the mediastinum. Collagen formation leads to compression of vital structures, resulting in cough, chest pain and dyspnea. The majority of cases of FM occur as a result of prior exposure to Histoplasma capsulatum. The following is a case of a previously healthy young woman who presented with a 3-month history of cough, chest pain and trouble breathing, and was subsequently found to have fibrosing mediastinitis. Fibrosing mediastinitis should be considered in the differential diagnosis of cough, chest pain and dyspnea, primarily when findings such as increased venous pressure are present on physical exam and hilar abnormalities are seen on chest radiograph. Clinical presentation, diagnosis and management of fibrosing mediastinitis are discussed.

Design and methods of a multi-site randomized controlled trial of an integrated care model of long-acting injectable buprenorphine with infectious disease treatment among persons hospitalized with infections and opioid use disorder.

BACKGROUND: Hospitalization with co-occurring opioid use disorder (OUD) and infections presents a critical time to intervene to improve outcomes for these intertwined epidemics that are typically managed separately. A surge in life-threatening infectious diseases associated with injection drug use, including bacterial and fungal infections, HIV, and HCV accounts for substantial healthcare utilization, morbidity, and mortality. Infectious Disease (ID) specialists manage severe infections that require hospitalization and are a logical resource to engage patients in medication treatment for OUD (MOUD). An injectable long-acting monthly formulation of buprenorphine (LAB) has a potential advantage for initiating MOUD within hospital settings and bridging to treatment after discharge. METHODS: A randomized multi-site trial tests a new model of care (ID/LAB) in which OUD and infections are managed by ID specialists and hospitalists using LAB coupled with referrals to community resources for long-term MOUD. A sample of 200 adults admitted to three U.S. hospitals for OUD and infections are randomly assigned 1:1 to ID/LAB or treatment as usual (TAU). The primary outcome measure is the proportion of patients enrolled in effective MOUD at 12 weeks after randomization. Secondary outcomes include relapse to opioid use, adherence to infectious disease treatment, infection morbidity and mortality, and drug overdose. RESULTS: We describe the design, procedures, statistical analysis, and early implementation issues of this randomized trial. CONCLUSIONS: Study findings will provide insight into the feasibility and effectiveness of integrated treatment of OUD and serious infections and have the potential to reduce morbidity and mortality in this vulnerable population.

Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations.

Open fractures are often associated with high-energy trauma and have an increased risk of infection because of surrounding soft-tissue damage and the introduction of environmental contaminants that may communicate with the fracture site. The Gustilo-Anderson classification of open fractures has been used to guide prophylactic antibiotic therapy because different types of open fracture have been shown to have varying rates of surgical site infections with different combinations of pathogens. Prophylactic treatment with various classes of antibiotics, including penicillins and cephalosporins, aminoglycosides, and fluoroquinolones, has evolved over the past half century. More recently, broader spectrum agents including monobactams and glycopeptides have been used for additional coverage. Duration of antibiotic therapy remains variable between institutions, and antibiotic choice is not standardized. Coverage for nosocomial and multidrug-resistant organisms is an ongoing area of clinical research.

Septic Arthritis of the Hip and Enterocutaneous Fistula Formation After Hip Arthroscopy: A Case Report of Psoas Abscess Misdiagnosed as Labral Pathology.

CASE: We describe a case of septic hip arthritis and enterocutaneous fistula formation caused by the seeding of a hip joint during hip arthroscopy performed in the setting of a psoas abscess. Treatment consisted of multiple debridements and femoral head resection with subsequent total hip arthroplasty. CONCLUSIONS: This case highlights the importance of a thorough history, physical examination, and assessment of available imaging before proceeding to surgery, even when the procedure is one considered to have minimal risks, such as arthroscopy.

Early Postoperative Infection Following Open Reduction Internal Fixation Repair of Closed Malleolar Fractures.

BACKGROUND: Early postoperative infection (EPI) following hardware placement in patients with malleolar fractures is a serious complication. Identifying factors that place patients at risk for early infection may help target interventions to prevent infections. METHODS: Data for the study included all adult patients who underwent operative management for closed malleolar fracture from 2006 to 2013 in the National Surgical Quality Improvement Program database. Characteristics of patients with and without EPI were compared using univariate tests. Logistic regression was used to perform a multivariable analysis of risk factors for EPI while controlling for covariates. Length of stay was analyzed using a generalized linear model. RESULTS: The analysis sample included 7054 patients, of whom 116 developed EPI. Patients with EPI were slightly older on average, more likely to have diabetes, and had higher anesthesia class. Multivariable analysis identified several risk factors for EPI, including diabetes (odds ratio [OR] = 2.6; 95% CI = 1.5-4.5; P < .0001), American Society of Anaesthesiology (ASA) class 3+ (OR = 2.3; 95% CI = 1.03-5.0; P = .04), unclean surgery (OR = 2.4; 95% CI = 1.3-4.2; P < .0001), and inpatient location (OR 1.7, 1.1-2.7; P = .01). After controlling for other factors, EPI was not significantly associated with a longer hospital stay (0.2 days, P = .55). CONCLUSION: In the 30 days after hardware placement for malleolar fracture, infection occurs with increased frequency in older patients, diabetics, those with higher anesthesia class, and in the setting of unclean surgery and inpatient operative location. Patients with the identified risk factors should be followed closely for development of infection. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.