Comparison of Pediatric Acute Appendicitis Before and During the COVID-19 Pandemic in New York City.

Background: Acute appendicitis (AA) is the most common abdominal surgical emergency in children and adolescents. In the year immediately following the declaration of the coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO), there was a precipitous decline in emergency department (ED) visits especially for surgical conditions and infectious diseases. Fear of exposure to severe acute respiratory coronavirus 2 infection resulted in delay in presentation and time to surgery, and a shift toward more conservative management. Objective: Our goal was to compare the incidence and severity of AA before and during the COVID-19 pandemic. Methods: Patients aged 2-18 years admitted with the diagnosis of AA to Flushing Hospital Medical Center or Jamaica Hospital Medical Center in Queens, New York, were selected for chart review. Data extracted from electronic health records included demographics, clinical findings, imaging studies, and operative and pathological findings. We calculated the Alvarado score (AS) for incidence and the American Association for the Surgery of Trauma (AAST) grade for severity. We compared patients admitted between March 1, 2018-February 29, 2020 (pre-pandemic) to patients admitted between March 1, 2020-February 28, 2021 (pandemic). We then compared pre-pandemic and pandemic groups to determine differences in pediatric AA incidence and severity. Results: Of 239 patients diagnosed with AA, 184 (77%) were in the pre-pandemic group and 55 (23%) in the pandemic group. Incidence (number per year) of AA declined by 40%. The pandemic group had significantly greater overall AS of ≥7, indicating increased likelihood to require surgery, (P = 0.04) and higher AAST grade demonstrating increased severity (P = 0.02). Conclusion: There was a decline in the number of AA cases seen in our pediatric EDs and admitted during the first year of the pandemic. Clinicians need to be aware of increased severity of AA at time of presentation during public health emergencies such as a pandemic, possibly due to modified patient behavior.

An Infected, Noncoronary, Bare Metal Stent Presenting as a Right Groin Abscess.

Bare metal stent infections complicating peripheral endovascular stenting are rare but can be associated with devastating morbidities. The current standard of care necessitates explantation and extra-anatomical bypass of the affected limb. We report the case of a patient presenting with a right groin abscess with draining sinuses secondary to an infected common femoral and right external iliac artery bare metal stent. In addition, a portion of the stent was explanted into the subcutaneous tissues instead of where it was placed intravascularly one year prior. The patient was not an ideal candidate for explantation and bypass due to significant medical comorbidities and underwent local debridement and long-term antibiotic management instead. His postoperative course was uncomplicated, and he had a successful outcome with management utilizing antibiotics and debridement. We aim to highlight the importance of recognizing bare metal stent infections along with their deceptive cutaneous manifestations in order to prevent the development of significant morbidity and mortality.

A Case of Necrotizing Fasciitis Mimicking a Burn in an Elderly Patient.

Necrotizing fasciitis travels along the fascial plane and surrounding soft tissue, leading to ischemia and necrosis. Fournier's gangrene is a type of necrotizing fasciitis invading the deep and superficial planes of the perineal/genital region. It is rapidly progressive in nature and may have life-threatening consequences. Fournier's often exhibits a misleading clinical presentation and can be mistaken for other conditions, such as hematoma, phlebitis, cellulitis, or septic arthritis. Since the ramifications of delayed diagnosis can be clinically significant, recognition of potential mimics is important to prevent morbidity or mortality. We report a case of Fournier's gangrene mimicking a second-degree burn, an exceedingly rare presentation.

Apnea in a Two-Week-Old Infant Infected with SARS-CoV-2 and Influenza B.

Paucity of data exists on presenting symptoms and outcomes in infants with COVID-19. Reports of coinfection with COVID-19 and influenza B are sparse in the literature. Coinfection was uncovered during evaluation of neonatal apnea. Apnea has been reported in infants with SARS-CoV-2 infection, though it is rare. We describe a 2-week-old healthy term infant presenting with apnea and coinfection. The infant had a mild clinical course and complete recovery.

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle.

BACKGROUND: Reduction in the incidence of surgical site infection (SSI) serves as a measure of patient safety and quality improvement. Cesarean birth (CB) accounts for 31.9% of all childbirths in the United States. However, our understanding of SSI prevention bundles predominantly stems from gynecological and colorectal surgeries. This study aimed to determine the efficacy of a standardized perioperative bundle designed to reduce SSI in CBs. METHODS: All CB patients at Flushing Hospital Medical Center from 2017 to 2019 were included in a retrospective analysis. Patients were divided into three groups based on the timing of intervention: prebundle/control, transition, and postbundle. Baseline demographics and clinical characteristics were summarized using descriptive statistics. Multiple logistic regression was performed to determine the association between bundle group and SSI, considering variables different between groups at baseline (P < 0.10). RESULTS: Two thousand eight hundred and seventy-five CBs were performed: 1086 in prebundle, 812 in transition, and 977 in postbundle phase. In the prebundle phase, 25 CBs (2.3%) were complicated by SSIs; in the transition phase, 10 (1.2%) had SSIs; and in the postbundle phase, 7 (0.7%; P = 0.009) had SSIs. In a logistic regression model, only use of the CB bundle (OR 0.26 [95% CI 0.07-0.94]; P = 0.04), rupture of membranes (0.29 [0.09-0.87]; P = 0.03), and operating room time (1.02 [1.01-1.04]; P = 0.01) were significant in prediction of SSI. SSI postbundle was significantly reduced from prebundle (0.04). CONCLUSIONS: Thus, introduction of a hospital-wide perioperative bundle significantly reduced SSI rates, and should be developed as a mainstay of CB surgical care.

Oxygen Indications and Utilization in a Diverse, Urban Community Setting.

PURPOSE: Long-term oxygen therapy (LTOT) is widely used to treat chronic obstructive pulmonary disease (COPD) and other conditions with severe hypoxemia, imposing a large financial burden on the American health care system. METHODS: To better understand oxygen prescription and its use in a multiethnic community hospital, we completed a prospective, observational study with a survey design in our multicultural population to better recognize patient understanding of oxygen indications and utilization. RESULTS: The survey was conducted at three outpatient pulmonary clinics. Among the 94 respondents (42% men and 58% women; age 71.8 ± 13 yr), 64% were current or former smokers. Sixty-one percent had primary diagnoses other than COPD, most commonly interstitial lung disease and congestive heart failure. One-third used oxygen for <12 hr daily. Oxygen use was variable among those to whom it was prescribed. Thirty-two percent of patients described themselves as noncompliant with their prescribed therapy due to poor equipment ergonomics, burdensome machine weight, and negative self-image and social stigma when using oxygen. CONCLUSIONS: Chronic obstructive pulmonary disease represented <50% of LTOT patients who were surveyed. Our data suggest that more structured prescribing practices and patient education should be studied if compliance is to be increased.

Alcohol and Drug Abuse Resource Utilization in the ICU.

Alcohol and drug abuse continue to be major causes of morbidity and mortality and have significant social and economic ramifications. Studies have shown that for every $1 spent on substance use disorder treatment, $4 are saved on healthcare costs. Characterizing the healthcare resource utilization of these patients may shed light on the burden of disease and opportunities for intervention. A retrospective chart review of all patients admitted to the ICU between July 1, 2017 and December 31, 2017 was completed. Variables regarding demographic and clinical characteristics as well as healthcare resource utilization were collected. Of 737 admissions to the ICU, 158 (21%) were due to acute or chronic complications of alcohol or drug abuse. Even though alcohol and drug users were significantly younger (average age 50 years) than the general ICU cohort (average age 66 years), resource utilization was similar between these patients. The median length of stay in the ICU was similar. The number of patients transferred to in-patient rehab was low (8%), and all of those were due to comorbid psychiatric illness. The total hospital charges for the alcohol and drug abuse cohort was over 7 million dollars for the 6 months observed. A significant number of patients had at least one ER visit (49%) during the previous year, and most of these had numerous visits. ICU resource utilization by patients with acute and chronic sequelae of drug or alcohol abuse disorders continues to be high. These patients utilize resources at rates similar to an older group with other disease processes. Patients are unlikely to receive intervention for their disorder unless they have a comorbid psychiatric illness. Patients admitted to the ICU with alcohol or drug-related illness were frequently seen in the ER or were admitted to the hospital in the year prior to ICU admission, providing opportunities for intervention.

Nonresolving pneumonia in the setting of malignancy.

PURPOSE OF REVIEW: This article reviews recent literature and experience in the diagnosis of nonresolving and slowly resolving pneumonia as it pertains to malignancy. RECENT FINDINGS: Malignancy must be considered as an important cause of pneumonia that resolves slowly or has incomplete resolution. Airway obstruction is more common than malignant infiltration as a cause of pneumonia that does not resolve appropriately. Infection due to resistant or unusual organisms must also be considered in the differential diagnosis. SUMMARY: Nonresolving pneumonia remains an important clinical challenge. Bronchoscopic evaluation in conjunction with computed tomography and PET scanning is still the most important technique for diagnosis.

Coexistent Pseudogout and Mycobacterium avium-intracellulare Septic Arthritis in a Patient with HIV and ESRD.

Pseudogout is a crystal-induced arthropathy characterized by the deposition of calcium pyrophosphate dihydrate (CPPD) crystals in synovial fluid, menisci, or articular cartilage. Although not very common, this entity can be seen in patients with chronic kidney disease (CKD). Septic arthritis due to Mycobacterium avium-intracellulare (MAI) is a rare entity that can affect immunocompromised patients such as those with acquired immunodeficiency syndrome (AIDS) or those who are on immunosuppressive drugs. Here, we describe a 51-year-old female who presented with fever, right knee pain, swelling, warmth, and decreased range of motion for several days. The initial assessment was consistent with pseudogout, with negative bacterial and fungal cultures. However, due to high white blood cell (WBC) count in the synovial fluid analysis, she was empirically started on intravenous (IV) vancomycin and piperacillin-tazobactam and discharged on IV vancomycin and cefepime, while acid-fast bacilli (AFB) culture was still in process. Seventeen days later, AFB culture grew Mycobacterium avium-intracellulare (MAI), and she was readmitted for relevant management. This case illustrates that septic arthritis due to MAI should be considered in the differential diagnosis of septic arthritis in immunocompromised patients.

A rare case of mucinous adenocarcinoma of the colon presenting as ileoileal intussusception in an adult.

Intussusception is the cause of around 1% of all bowel obstructions in adults. Unlike in children, where intussusception is most often idiopathic in nature, cases in adults usually have an identifiable etiology, most commonly malignancy. Symptoms are usually non-specific, but timely identification and management is crucial due to high rates of carcinoma as the lead point of intussusception. Here we present a rare case of mucinous adenocarcinoma of the colon that presented as ileoileal intussusception. Diagnostic and treatment issues are also discussed.

An illustrative case of subcutaneous panniculitis-like T-cell lymphoma.

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a very rare form of skin lymphoma that is localized primarily to the subcutaneous adipose tissue without palpable involvement of the lymph nodes. Diagnosis of SPTCL is a challenge, especially during its early phases when symptoms mimic other, more common conditions, such as benign panniculitis, eczema, dermatitis, psoriasis and cellulitis. Clinical and systemic features are nonspecific and can include fever, chills, and weight loss. Further complicating diagnosis is the high number of false negatives provided by biopsy. Here we present a case of SPTCL that illustrates the full course of the disease, from presentation and multiple misdiagnoses to correct disease recognition and successful treatment. A review of the challenges of diagnosis is provided with recommendations for more accurate and timely recognition of SPTCL.

Medial temporal structures and memory functions in adolescents with heavy cannabis use.

Converging lines of evidence suggest an adverse effect of heavy cannabis use on adolescent brain development, particularly on the hippocampus. In this preliminary study, we compared hippocampal morphology in 14 "treatment-seeking" adolescents (aged 18-20) with a history of prior heavy cannabis use (5.8 joints/day) after an average of 6.7 months of drug abstinence, and 14 demographically matched normal controls. Participants underwent a high-resolution 3D MRI as well as cognitive testing including the California Verbal Learning Test (CVLT). Heavy-cannabis users showed significantly smaller volumes of the right (p < 0.04) and left (p < 0.02) hippocampus, but no significant differences in the amygdala region compared to controls. In controls, larger hippocampus volumes were observed to be significantly correlated with higher CVLT verbal learning and memory scores, but these relationships were not observed in cannabis users. In cannabis users, a smaller right hippocampus volume was correlated with a higher amount of cannabis use (r = -0.57, p < 0.03). These data support a hypothesis that heavy cannabis use may have an adverse effect on hippocampus development. These findings, after an average 6.7 month of supervised abstinence, lend support to a theory that cannabis use may impart long-term structural and functional damage. Alternatively, the observed hippocampal volumetric abnormalities may represent a risk factor for cannabis dependence. These data have potential significance for understanding the observed relationship between early cannabis exposure during adolescence and subsequent development of adult psychopathology reported in the literature for schizophrenia and related psychotic disorders.

Effects of shoulder dystocia training on the incidence of brachial plexus injury.

OBJECTIVE: We sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI). STUDY DESIGN: After implementing training for maternity staff, the incidence of OBPI was compared between pretraining and posttraining periods using both univariate and multivariate analyses in deliveries complicated by shoulder dystocia. RESULTS: The overall incidence of OBPI in vaginal deliveries decreased from 0.40% pretraining to 0.14% posttraining (P < .01). OBPI after shoulder dystocia dropped from 30% to 10.67% posttraining (P < .01). Maternal body mass index (P < .01) and neonatal weight (P = .02) decreased and head-to-body delivery interval increased in the posttraining period (P = .03). Only shoulder dystocia training remained associated with reduced OBPI (P = .02) after logistic regression analysis. OBPI remained less in the posttraining period (P = .01), even after excluding all neonates with birthweights >2 SD above the mean. CONCLUSION: Shoulder dystocia training was associated with a lower incidence of OBPI and the incidence of OBPI in births complicated by shoulder dystocia.

Candida parapsilosis meningitis associated with shunt infection in an adult male.

Candida parapsilosis is a very rare cause of meningitis. Though several cases have now been reported in neonates and children, only one has been described in an adult. We report on a 55-year-old male that was admitted due to altered mental status. He had recent sinus drainage and polypectomy, craniotomy with drainage of brain abscess, and ventriculo-peritoneal shunt placement. On admission, imaging studies showed no evidence of shunt dysfunction but did reveal extensive white matter decreased attenuation. Microscopic examination of the first 10 daily cerebrospinal fluid (CSF) cultures revealed yeast. Flucytosine and liposomal amphotericin B were started and externalization of shunt was performed on day 3. On day 8, CSF culture from admission grew C. parapsilosis; fluconazole was added. On day 10, daily CSF still showed yeast and cultures consistently grew C. parapsilosis. Shunt was removed and bilateral ventriculostomy drains were inserted. CSF after procedure as well as at follow-up examinations throughout his 3-month hospitalization were negative for yeast. Extended treatment with flucytosine and fluconazole was initiated. At 8-month follow-up, successful treatment of C. parapsilosis infection without recurrence was confirmed. This case underscores the need for suspicion of C. parapsilosis as a cause of meningitis after invasive surgeries in adults.

Defense mechanisms and suicide risk in major depression.

Past suicide attempt has been consistently reported to be the best predictor of future suicide attempt. The need to identify predictors that can be targets of therapy is of great importance. Coping styles and defense mechanisms have now been linked to suicide in numerous reports. In this study, we expand on past research by exploring differences in defense mechanism use between three groups: 1) without current suicide ideation/attempt; 2) with current suicide ideation/no attempt; and 3) with current suicide attempt. We also explored the contribution of covariates, such as symptom severity and past attempt. Seventy-five adult patients who were within 48 hours of hospital admission for current major depressive episode were recruited. Clinical interview was conducted to verify diagnosis and assess symptom severity. Patients completed the Defense Style Questionnaire within 48 hours of admission based on their current thoughts and beliefs. Logistic regressions were used to determine the best predictors of current suicide status. Consistently, the use of more image-distorting mechanisms was the best predictor of current suicide attempt. Symptom severity and past attempt were not significant predictors after controlling for influence of defense styles. Decreased use of image-distorting mechanisms in adult patients with major depressive disorder should be considered as a distinct target of therapy.

Delayed-onset heparin-induced thrombocytopenia type-2 during fondiparinux (Arixtra) therapy.

Heparin is the most commonly used anticoagulant drug for prevention and treatment of thromboembolic diseases. Heparin-induced thrombocytopenia (HIT) is a well-known and potentially fatal side-effect of heparin therapy. HIT type 1 (HIT-1) is transient and relatively common; it usually develops within 1-7 days of initial heparin exposure. Type 2 HIT (HIT-2) is more severe and is associated with thrombocytopenia and thrombosis. HIT-2 usually develops 5 or more days after initial heparin exposure. It is an immune-mediated disorder that is presumably caused by development of platelet activating antibody against platelet factor 4 (PF4)/heparin complex. Fondaparinux (Arixtra) is a fast-acting selective inhibitor of factor Xa believed to be non-reactive to HIT sera and therefore may be used as prophylaxis for thrombosis in patients with a history of HIT-1 or HIT-2. Development of HIT-2 in patients currently taking fondaparinux prophylaxis is rare. Here we present a fatal case of delayed-onset HIT-2 (1 year after heparin exposure) manifesting while on fondaparinux prophylaxis.

A rare case of uterine leiomyosarcoma metastasis to the duodenum.

Uterine leiomyosarcoma (ULMS) is an uncommon malignant tumor that accounts for less than one-third of uterine sarcomas and approximately 1% of uterine malignancies. Cases of local and distant ULMS metastasis have been widely reported, especially to the lungs. There have been very few cases, however, of ULMS metastasis to the upper gastrointestinal (GI) tract published in the peer-reviewed literature. Here we describe a case of biopsy-proven ULMS metastasis to the first part of the duodenum, representing the third reported case of its kind. Theories regarding presentation, treatment, clinical course, and outcome of patients with ULMS metastasis to the duodenum are presented.

Fibrinolysis treatment for loculated parapneumonic pleural effusion secondary to right lower lobe pneumonia.

The administration of fibrinolytic agents in the pleural cavity is an alternative treatment for the management of loculated empyemas in patients who are poor candidates for surgery and/or do not respond to more standard treatments (e.g., chest tube placement, pleurodesis). Unfortunately, in practice it is not frequently offered as an alternative treatment approach. Here we present the case of a 79-year-old male with right lower lobe pneumonia complicated by a parapneumonic pleural effusion that showed minimal improvement after chest tube placement and broad-spectrum antibiotic treatment. Intrapleural tissue plasminogen activator (tPA) was administered daily for three consecutive days, which resulted in the breakdown of intrapleural loculations and facilitation of drainage, followed by significant clinical and radiologic improvement. tPA was successful in the treatment of parapneumonic pleural effusions in a patient who was not a candidatefor surgical intervention and who failed to respond to standard treatments.

Herpetic and candidal infections of the esophagus in an elderly male.

We present the unique case of an eighty-nine-year-old male without any immunodeficiency state or taking immunosuppressive medication and who did not have conditions affecting clearance of the esophageal lumen who was diagnosed with simultaneous herpetic esophagitis and candidal duodenitis.