A case of cryptococcoma in an immunocompetent man with polysubstance use.

Cryptococcus most commonly affects the pulmonary and central nervous systems in patients who are immunocompromised. It is most likely to present as meningitis. However, it can affect immunocompetent patients in the cerebral parenchyma. Here we describe a rare case of cryptococcoma in an immunocompetent male patient who originally presented with headache and possible seizure-like activity and had IV drug use as a risk factor. Cryptococcomas are a rare manifestation of the disease, and can present due to Cryptococcus gatti. Definite diagnosis is dependent on culture of the organism and treatment includes a long course of anti-fungals.

An interpretable feature-learned model for overall survival classification of High-Grade Gliomas.

PURPOSE: An accurate and well-defined survival prediction of High Grade Gliomas (HGGs) is indispensable because of its high incidence and aggressiveness. Therefore, this paper presents a unified framework for fully automatic overall survival classification and its interpretation. METHODS AND MATERIALS: Initially, a glioma detection model is utilized to detect the tumorous images. A pre-processing module is designed for extracting 2D slices and creating a survival data array for the classification network. Then, the classification pipeline is integrated with two separate pathways: a modality-specific and a modality-concatenated pathway. The modality-specific pathway runs three separate CNNs for extracting rich predictive features from three sub-regions of HGGs (peritumoral edema, enhancing tumor and necrosis) by using three neuro-imaging modalities. In these pathways, the image vectors of the different modalities are also concatenated to the final fusion layer to overcome the loss of lower-level tumor features. Furthermore, to exploit the intra-modality correlations, a modality-concatenated pathway is also added to the classification pipeline. The experiments are conducted on BraTS 2018 and BraTS 2019 benchmarks, demonstrating that the proposed approach performs competitively in classifying HGG patients into three survival groups, namely, short, mid, and long survivors. RESULTS: The proposed approach achieves an overall classification accuracy, sensitivity, and specificity of about 0.998, 0.997, and 0.999, respectively, for the BraTS 2018 dataset, and for BraTS 2019, these values correspond to 1.000, 0.999, and 0.999. CONCLUSIONS: The results indicate that the proposed model achieves the highest values of the evaluation metrics for the overall survival classification of HGG.

Abortion providers in the United States: expanding beyond obstetrics and gynecology.

In the years preceding the Dobbs v Jackson Women's Health Organization (2022) decision, there had been a shift in the demographics of abortion providers. Although most abortion providers were obstetricians-gynecologists, there had been a rapid increase in the number of internal medicine and family medicine physicians and advanced practice clinicians providing abortion care. As discourse about limiting abortion access has gained volume over the past few years, so have the number of legislative restrictions aimed at preventing people from seeking abortions. Among these are laws and policies targeted at reducing the number of providers and clinics providing abortion care, resulting in an absence of training, high case volume, and institutional restrictions. With the overturning of Roe v Wade, the landscape of abortion provision will continue to shift further. Action needs to be taken to expand the types of providers getting trained and providing abortions to ensure access for those seeking abortions.

An atypical presentation of malaria in a 19-year-old woman.

We describe an atypical presentation of malaria in a 19-year-old female who emigrated from Nigeria to the United States one year prior to presentation. Her primary complaint was fever and occipital headache radiating down to the neck. Rapid antigen testing was positive for Plasmodium vivax/ovale and microscopy demonstrated the same. She received treatment with atovaquone-proguanil with improvement in symptoms but was lost to outpatient follow up. This case is unusual in several aspects: the 12-month latency in disease manifestation after her last epidemiologic exposure and the recovery of P. vivax/ovale which is uncommon in Nigeria. Appropriate identification of travel history, clinical presentation and disease epidemiology are necessary to guide pharmacologic treatment.

Socioeconomic Analysis of the Surgical Management of Ectopic Pregnancies: An Analysis of the National Inpatient Sample.

STUDY OBJECTIVE: To identify racial and socioeconomic disparities in the surgical management of ectopic pregnancy. DESIGN: Retrospective study. The National Inpatient Sample was sampled from 2015 to 2017 for inpatient hospitalizations for ectopic pregnancy. Cohorts were identified by surgical treatment type-open procedure vs laparoscopic procedure. Race/ethnicity, primary payer status, and median household income were primary variables of interest. Univariate and multivariable analyses were conducted. SETTING: Nationwide inpatient analysis. PATIENTS: Women presenting for ectopic pregnancy treatment. INTERVENTIONS: Type of surgery. MEASUREMENTS AND MAIN RESULTS: Outcome measures were laparotomy vs laparoscopy for treatment. A total of 18 725 cases were identified, 8325 open and 10 400 laparoscopic. Hispanic women were more likely to receive open procedures as treatment for ectopic pregnancy than White women (odds ratio 1.226, p <.001). Women with private insurance were more likely to receive open procedures than women who used self-pay for treatment (odds ratio 0.809, p <.001). Women of lower median income status, <$60 000, were more likely to receive open procedures than women of the fourth quartile income group. Black women predominantly made up the first quartile income group. When controlling for covariates, Black women were not more likely to receive 1 method of surgical procedure over another. CONCLUSION: Income appears to be related to surgical management of ectopic pregnancy with women of lower median incomes receiving laparotomies over laparoscopic procedures. Equal access to healthcare remains a prudent need in communities of color. Further studies are needed to elucidate surgical decision-making in the management of ectopic pregnancy.

Pediatric Replantation after Traumatic Amputation at the Distal Forearm: Rehabilitation Protocol and Outcomes.

Major limb replantation is a formidable task, especially in the pediatric setting. While meticulous microsurgical technique is required in the operating room, the authors aim to highlight the importance of postoperative rehabilitation therapy for optimal function. We highlight the case of a 12-year-old boy who suffered complete traumatic amputation through the distal left forearm. The limb was successfully replanted with successful restoration of sensation and function with the aid of intensive postoperative occupational therapy. A multidisciplinary team is of paramount importance to maximize function of a replanted upper extremity.

Analysis of the impact of chronic corticosteroid use on free flap reconstruction.

BACKGROUND: Systemic corticosteroids negatively impact wound healing, potentially increasing postoperative wound complication rates. In this study, the authors utilize the American College of Surgeons (ACS) National Surgical Quality Improvement (NSQIP) database to investigate the impact of chronic steroid usage on postoperative complications following microvascular free tissue transfer procedures. METHODS: The ACS NSQIP database was queried for all free flap procedures performed between 2005 and 2016. Patients with a history of chronic steroid use (n = 159) were compared to patients with no history of chronic steroid use (n = 3,405). The two cohorts were compared by univariate analysis, followed by multivariate binary logistic regression for all complications noted to be statistically significant on univariate analysis. RESULTS: Patients treated with systemic corticosteroids were more likely to be smokers, have a history of diabetes, hypertension, bleeding disorders, hypoalbuminemia, anemia, and have a wound infection at time of surgery. There were increased rates of bleeding requiring transfusion (37.7 vs. 27.5% p = .005), overall surgical complications (48.4 vs. 36.7%, p = .003) and overall complication rates (56.0 vs. 42.3%, p = .001) in these patients. On multivariate analysis, chronic steroid use was not associated with increased risk of surgical complications (OR = 2.540, p = .056, 95% CI 0.975-6.622), overall complications (OR = 2.303, p = .086, 95% CI 0.888-5.973), or wound complications. However, chronic steroid usage conferred nearly a four times increased risk for major bleeding complications (OR = 3.995, p = .009, 95% CI 1.415-11.279). CONCLUSION: Chronic corticosteroid use does not increase rates of wound complications, reoperation, or readmission. However, this population may be at increased risk for major bleeding requiring blood transfusion following free flap reconstruction.

The Cost of the "July Effect" in Microsurgery.

The existence of the "July effect," or the idea that the new academic year intrinsically has an increased complication rate is evaluated in microsurgical free tissue transfer procedures. The National Surgical Quality Improvement Program registry was queried for all free flap procedures performed between 2005 and 2016 (n = 3405). Cases were grouped as having occurred in the first academic quarter (Q1: July 1-September 30) or fourth quarter (Q4: April 1-June 30). Demographical data and complications were compared using univariate χ analysis, multivariate logistic regression was used to control for confounding variables, and inpatient stay and operating cost estimates were created. Of a total of 1722 cases, 905 were performed in the first academic quarter and 817 were performed in the fourth academic quarter. There was no significant difference between Q1 and Q4 in readmission rate (P = 0.378) or reoperation rate (P = 0.730). Patients in Q1 had significantly longer operative times (P = 0.001) and length of stay (P = 0.002) compared with those in Q4. In addition, cost of inpatient stay and operating costs associated with each free flap were significantly increased in Q1 compared with Q4 (P = 0.029; P = 0.001). The total cost per quarter for free flaps was also significantly more expensive in Q1 vs Q4, with the highest average difference in cost of $350,010.64 (P = 0.001). Having surgery early in the academic year does not put patients at any increased risk for major complications but is associated with increased operating time, length of stay, and total cost.

The Impact of Metabolic Syndrome on Patients Undergoing Breast Reduction Surgery.

Metabolic syndrome affects 35% of individuals in the USA and has been correlated with increased complications following certain surgical procedures. There has been an increase of 11% in breast reduction procedures from 2016 to 2017 making it the seventh most common reconstructive procedure in the USA. Previous studies have identified an increase in demand for breast reduction among obese patients with BMI ≥ 30 but have not defined the role of metabolic syndrome in surgical outcomes. The authors aim to investigate the impact of metabolic syndrome on 30-day postoperative morbidity and mortality in patients who underwent reduction mammoplasty.

Double Trouble: Massive Unruptured Aortic Aneurysms.

We describe a patient who presented to the emergency department complaining of generalized weakness, dark stools, and urinary retention who was found to have two large abdominal aortic aneurysms (AAA) compressing his bilateral ureters with associated hydronephrosis and renal insufficiency. In elderly male patients presenting with signs of obstructive uropathy, AAA should be considered as a potential cause.

Activating Mutations in PIK3CA Lead to Widespread Modulation of the Tyrosine Phosphoproteome.

The human oncogene PIK3CA is frequently mutated in human cancers. Two hotspot mutations in PIK3CA, E545K and H1047R, have been shown to regulate widespread signaling events downstream of AKT, leading to increased cell proliferation, growth, survival, and motility. We used quantitative mass spectrometry to profile the global phosphotyrosine proteome of isogenic knock-in cell lines containing these activating mutations, where we identified 824 unique phosphopeptides. Although it is well understood that these mutations result in hyperactivation of the serine/threonine kinase AKT, we found a surprisingly widespread modulation of tyrosine phosphorylation levels of proteins in the mutant cells. In the tyrosine kinome alone, 29 tyrosine kinases were altered in their phosphorylation status. Many of the regulated phosphosites that we identified were located in the kinase domain or the canonical activation sites, indicating that these kinases and their downstream signaling pathways were activated. Our study demonstrates that there is frequent and unexpected cross-talk that occurs between tyrosine signaling pathways and serine/threonine signaling pathways activated by the canonical PI3K-AKT axis.

Mirror image artifact mimicking heterotopic pregnancy on transvaginal ultrasound: case series.

Vaginal bleeding in early pregnancy is a common emergency department complaint. Point-of-care ultrasound is a useful tool to evaluate for intrauterine ectopic pregnancy. Emergency physicians performing these studies need to be cognizant of artifacts produced by ultrasound technology, as they can lead to misdiagnosis. We present two cases where mirror-image artifacts initially led to a concern for heterotopic pregnancies but were excluded on further imaging.