Neuromyelitis Optica Spectrum Disorder Management in the Setting of Chronic Hepatitis B and Latent Tuberculosis: A Case Report.

Neuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory autoimmune disorder of the central nervous system, with optic neuritis and transverse myelitis as its most common presentations. Although immunomodulatory treatment options for NMOSD have expanded, preventing reactivation of latent infections in patients can be both a therapeutic challenge and a special consideration for the neurohospitalist in an inpatient setting. We present a challenging case of a NMOSD patient who presented to the emergency department with worsening weakness and numbness in the setting of an NMOSD pseudo-relapse, later found to have untreated latent tuberculosis (TB) and chronic hepatitis B (HBV). She was briefly treated with high-dose IV methylprednisolone, which was stopped after her symptoms and imaging became more consistent with a pseudo-relapse. After confirmation that neither HBV nor TB had reactivated, the patient was discharged on isoniazid and entecavir. A month later, the patient's symptoms were stable, and she was started on inebilizumab for relapse prevention of NMOSD. This case report is the first to highlight the therapeutic complexities of managing NMOSD that requires immunosuppression in the setting of preventing reactivation of both TB and HBV.

The Effect of Race and Socioeconomic Status on Hospitalized Patients with COVID-19 Infection.

Background: There have been varying impacts of COVID-19 on racial, ethnic, and socioeconomic communities in the US. Recent literature suggests that Black Americans have the highest unadjusted and adjusted mortality rates from COVID-19, while White Americans have the lowest unadjusted and adjusted rates. However, the role of socioeconomic status and comorbidities in these disparities in health outcomes from COVID-19 are unclear. Thus, the purpose of this study is to evaluate how socioeconomic status and race impact COVID-19 outcomes in patients hospitalized with COVID-19 in a large health care system in the Mid-Atlantic region. Material and methods: We retrospectively analyzed the association of COVID-19 outcomes and race, ethnicity, and socioeconomic status using electronic medical records and the REDCap database from the time period of March 5, 2020 to June 3, 2020. The outcomes evaluated were intubation, ICU admission, and discharge destination. Multivariate logistic regression analysis was then performed to examine whether race and socioeconomic status were independent risk factors of mortality controlling for age, Charlson comorbidity index (CCI), and comorbidities. Results: Race was not found to be an independent predictor for COVID-19 inpatient mortality. Race was found to be an independent risk factor for ICU admission with odds of ICU admission for Black patients to be 1.5 times higher (odds ratio (OR) 1.4 1.07 to 2.04) compared to Non-Black/Non-White (72.4% identifying as Hispanic) but no difference between Black and White races. Race was found not to be an independent risk factor for intubation nor was race an independent risk factor for increased length of ICU LOS, hospital LOS or intubation days. Socioeconomic status was not an independent risk factor for inpatient mortality although high income groups were significantly less likely to be admitted to the ICU compared to middle income patients. Conclusion: Our cohort of patients in a large mid-Atlantic health system showed that there was no statistically significant difference between race or socioeconomic status and COVID-19 related inpatient mortality. However, Black patients and individuals in the lower to middle socioeconomic group had a higher rate of COVID-19 hospitalizations when accounting for age, sex, and comorbidities. With ongoing vaccination efforts, equitable administration of resources should focus on disproportionately affected populations.

Erratum: Basivertebral Nerve Ablation.

[This corrects the article DOI: 10.1055/s-0042-1745794.].

Intercostal Cryoneurolysis.

Chest wall pain affects many patients following chest surgery, fractures, or malignancies, and can be very difficult to manage with normal pharmacologic agents. Intercostal ablation provides one alternative treatment modality for patients suffering from intercostal pain. Intercostal cryoneurolysis involves using extreme cold to cause Wallerian degeneration of the targeted intercostal nerve. This article reviews the patient selection, technique, and complications in the utilization of intercostal neurolysis in the treatment of intractable chest pain.

Basivertebral Nerve Ablation.

Low back pain is one of the most prevalent musculoskeletal ailments in the United States. Intraosseous radiofrequency ablation of the basivertebral nerve is an effective and durable therapy for low back pain and can be offered to patients who have chronic low back pain of greater than 6 months of duration, failure to respond to noninvasive therapies for 6 months, with either Modic Type I or Type II changes at L3-S1. This article reviews the anatomy and physiology, patient selection, technique, and evidence regarding basivertebral nerve ablation.

Bladder cancer cells shift rapidly and spontaneously to cisplatin-resistant oxidative phosphorylation that is trackable in real time.

Genetic mutations have long been recognized as drivers of cancer drug resistance, but recent work has defined additional non-genetic mechanisms of plasticity, wherein cancer cells assume a drug resistant phenotype marked by altered epigenetic and transcriptional states. Currently, little is known about the real-time, dynamic nature of this phenotypic shift. Using a bladder cancer model of nongenetic plasticity, we discovered that rapid transition to drug resistance entails upregulation of mitochondrial gene expression and a corresponding metabolic shift towards the tricarboxylic acid cycle and oxidative phosphorylation. Based on this distinction, we were able to track cancer cell metabolic profiles in real time using fluorescence lifetime microscopy (FLIM). We observed single cells transitioning spontaneously to an oxidative phosphorylation state over hours to days, a trend that intensified with exposure to cisplatin chemotherapy. Conversely, pharmacological inhibition of oxidative phosphorylation significantly reversed the FLIM metabolic signature and reduced cisplatin resistance. These rapid, spontaneous metabolic shifts offer a new means of tracking nongenetic cancer plasticity and forestalling the emergence of drug resistance.

Risks Factors Associated With Major Lower Extremity Amputation After Vertical Contour Calcanectomy.

The primary aim of the study is to determine risks for major lower extremity amputation after undergoing Vertical Contour Calcanectomy. Subanalysis was performed comparing patients who underwent Vertical Contour Calcanectomy who were fully ambulatory to those who were partially or nonambulatory postoperatively. Within the cohort of 63 patients included in the Vertical Contour Calcanectomy 85.71% (54/63) of patients had diabetes mellitus, 53.97% (34/63) had peripheral arterial disease, and 19.05% (12/63) had Charcot Neuroarthropathy. Multivariate logistic regression, found that (1) patients that underwent primary closure at the time of the Vertical Contour Calcanectomy, were 79.9% more likely (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96) to have limb salvage and that (2) female patients were 85.4% less likely compared to male patients (OR 0.15; 95% CI 0.02-0.99) to undergo major lower extremity amputation. Patients with coronary artery disease were 5.2 times more likely (OR 5.18; 95% CI 1.120-23.94) and patients that were nonambulatory preoperatively, were 10.3 times more likely (OR 10.28; 95% CI 1.60-66.26), to be partially or nonambulatory after Vertical Contour Calcanectomy. Primary closure at time of Vertical Contour Calcanectomy significantly decreases the risk of major lower extremity amputation, and diminished preoperative ambulatory status as well as coronary artery disease makes it less likely that patients return to full ambulation after Vertical Contour Calcanectomy.

Community and Hospital Acquired Pneumonia.

Community-acquired pneumonia is the most common cause of death among infectious diseases, and responsible for millions of hospitalizations annually. Pneumonia may be classified based on how it is acquired, etiology, and clinical presentation. Chest radiographs are the gold standard for initial imaging evaluation and chest computed tomography plays an important role in diagnostic problem-solving and evaluation of complicated and treatment-resistant pneumonia. Follow-up imaging with chest radiographs or computed tomography post-illness resolution may be used to identify treatment-resistant inflammation or unidentified underlying malignancies.

Early Clinical, Functional, and Mortality Outcomes for Heel Ulcers Treated With a Vertical Contour Calcanectomy.

Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N = 51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state.

Current status of liquid biopsies for the detection and management of prostate cancer.

In recent years, new therapeutic options have become available for prostate cancer (PC) patients, generating an urgent need for better biomarkers to guide the choice of therapy and monitor treatment response. Liquid biopsies, including circulating tumor cells (CTCs), circulating nucleic acids, and exosomes, have been developed as minimally invasive assays allowing oncologists to monitor PC patients with real-time cellular or molecular information. While CTC counts remain the most extensively validated prognostic biomarker to monitor treatment response, recent advances demonstrate that CTC morphology and androgen receptor characterization can provide additional information to guide the choice of treatment. Characterization of cell-free DNA (cfDNA) is another rapidly emerging field with novel technologies capable of monitoring the evolution of treatment relevant alterations such as those in DNA damage repair genes for poly (ADP-ribose) polymerase (PARP) inhibition. In addition, several new liquid biopsy fields are emerging, including the characterization of heterogeneity, CTC RNA sequencing, the culture and xenografting of CTCs, and the characterization of extracellular vesicles (EVs) and circulating microRNAs. This review describes the clinical utilization of liquid biopsies in the management of PC patients and emerging liquid biopsy technologies with the potential to advance personalized cancer therapy.