Effective use of a two-dose regimen of dalbavancin to treat prosthetic joint infections and spinal hardware infections.

PURPOSE: Dalbavancin is an attractive antibiotic for the treatment of Gram-positive musculoskeletal infections given its long half-life and prolonged duration in cortical bones. For certain patient populations compliance with antibiotic regimens can be problematic. Therefore, the purpose of this study was to assess the effectiveness, tolerance, and compliance of treating prosthetic joint and spinal hardware infections with a unique two-dose regimen of dalbavancin. METHODS: Identification of patients that had prosthetic joint infections and spinal hardware infections from January 1, 2017, through December 31, 2021, that had received a two-dose regimen of dalbavancin for these infections was conducted. Patient demographics, infection recurrence, compliance and adverse drug reactions to the two-dose regimen of dalbavancin were recorded. Furthermore, preserved clinical isolates from these infections were assessed for susceptibility to dalbavancin with microbroth dilutions. RESULTS: All patients were fully compliant with the two dose dalbavancin regimen and no patient had any adverse reactions to the two-dose dalbavancin regimen. Thirteen of fifteen patients (85.7%) have not had any recurrence of their infections and all preserved clinical isolates showed susceptibility to dalbavancin. DISCUSSION: The two-dose regimen of dalbavancin is an effective and attractive option in treating prosthetic joint and spinal hardware infections to forgo long term central venous access and ensure compliance. However, the use of rifampin and suppression antibiotics still needs to be considered when treating these infections. Nonetheless this study supports that a two-dose dalbavancin regimen is a viable alternative in certain clinical settings and consideration for a randomized controlled clinical trial should be entertained to prove its non-inferiority to conventional treatments.

Deep Learning Localizes and Identifies Polyps in Real Time With 96% Accuracy in Screening Colonoscopy.

BACKGROUND & AIMS: The benefit of colonoscopy for colorectal cancer prevention depends on the adenoma detection rate (ADR). The ADR should reflect the adenoma prevalence rate, which is estimated to be higher than 50% in the screening-age population. However, the ADR by colonoscopists varies from 7% to 53%. It is estimated that every 1% increase in ADR lowers the risk of interval colorectal cancers by 3%-6%. New strategies are needed to increase the ADR during colonoscopy. We tested the ability of computer-assisted image analysis using convolutional neural networks (CNNs; a deep learning model for image analysis) to improve polyp detection, a surrogate of ADR. METHODS: We designed and trained deep CNNs to detect polyps using a diverse and representative set of 8,641 hand-labeled images from screening colonoscopies collected from more than 2000 patients. We tested the models on 20 colonoscopy videos with a total duration of 5 hours. Expert colonoscopists were asked to identify all polyps in 9 de-identified colonoscopy videos, which were selected from archived video studies, with or without benefit of the CNN overlay. Their findings were compared with those of the CNN using CNN-assisted expert review as the reference. RESULTS: When tested on manually labeled images, the CNN identified polyps with an area under the receiver operating characteristic curve of 0.991 and an accuracy of 96.4%. In the analysis of colonoscopy videos in which 28 polyps were removed, 4 expert reviewers identified 8 additional polyps without CNN assistance that had not been removed and identified an additional 17 polyps with CNN assistance (45 in total). All polyps removed and identified by expert review were detected by the CNN. The CNN had a false-positive rate of 7%. CONCLUSION: In a set of 8,641 colonoscopy images containing 4,088 unique polyps, the CNN identified polyps with a cross-validation accuracy of 96.4% and an area under the receiver operating characteristic curve of 0.991. The CNN system detected and localized polyps well within real-time constraints using an ordinary desktop machine with a contemporary graphics processing unit. This system could increase the ADR and decrease interval colorectal cancers but requires validation in large multicenter trials.

Esophageal cancer in Hispanics: a demographic analysis of the National Cancer Database.

BACKGROUND: Hispanics are the fastest-growing minority and the second largest ethnic group in the United States, accounting for 18% of the national population. The American Cancer Society estimated 18,440 new cases of esophageal cancer (EC) in the United States in 2020. Hispanics are reported to be at high risk of EC. We sought to interrogate the demographic patterns of EC in Hispanics. Secondary objective was to examine evidence of socioeconomic disparities and differential therapy. METHODS: We identified Hispanic vs non-Hispanic patients with EC in the National Cancer Database between 2005 and 2015. Groups were statistically equated through propensity score-matched analysis. RESULTS: A total of 3205 Hispanics (3.8%) were identified among 85,004 patients with EC. We identified significant disparities between Hispanic and non-Hispanic groups. Disparities among Hispanics included higher prevalence of squamous EC, higher likelihood of stage IV cancer diagnosis, younger age, uninsured status, and income< $38,000. Hispanics were less likely to have surgical intervention or any type of treatment when compared to non-Hispanics. Multivariate analysis showed that age, ethnicity, treatment, histology, grade, stage, and Charlson-Deyo scores were independent predictors of survival. Treated Hispanics survived longer than non-Hispanics. CONCLUSION: Despite the lower prevalence of EC, there is a disproportionately higher prevalence of metastatic and untreated cases among Hispanics. This disparity may be explained by Hispanics' limited access to medical care, exacerbated by their socioeconomic and insurance status. Further study is warranted to examine these health disparities among Hispanics.

Are Biodegradable Calcium Sulfate Antibiotic Beads Effective and Safe Adjuvants for Diabetic Foot Osteomyelitis?

INTRODUCTION:  Diabetic foot osteomyelitis (DFO) is a highly morbid condition that commonly affects diabetic patients. Biodegradable calcium-sulfate antibiotic beads (CaSO4) are theoretical adjuvant agents to reduce morbidity in DFO. However, there is a paucity of research on the safety and effectiveness of CaSO4 beads in DFO. Therefore, the purpose of this study was to assess the safety and effectiveness of CaSO4 beads in different DFO locations. METHODS: We conducted a retrospective cohort study between January 1, 2015 and January 1, 2022 of patients with DFO who underwent surgical intervention and adjuvant CaSO4 beads placement. The location of DFO was determined based on the forefoot, midfoot, or hindfoot locations. Outcomes measured were ulcer-free time points of three and six months as well as recurrence of DFO at 12 months. Safety was also evaluated with incidences of acute kidney injury, wound drainage, and hypercalcemia. RESULTS: Forty-five cases were included. Of these, only 9/45 (20%) and 13/45 (29%) were ulcer-free at three months and six months, respectively. DFO recurred in 19/45 (42%) patients. Safety outcomes were significant for wound drainage (62%) and acute kidney injury (9%). Stratifying according to the location of DFO showed no statistically significant difference in outcomes. CONCLUSION: In this cohort study, adjuvant CaSO4 beads showed high rates of ulcer persistence and DFO recurrence. Given the limited benefits seen here and the potential for high rates of wound drainage, the use of adjuvant CaSO4 beads should be used cautiously until a multicenter randomized clinical trial is conducted to definitely evaluate the safety and effectiveness of CaSO4 beads in DFO.

A case of viral meningitis due to Varicella Zoster virus infection in a young adult male.

A 36-year-old male with headaches was empirically treated for herpes simplex virus meningitis; CSF PCR testing later confirmed varicella zoster virus meningitis. Valacyclovir was increased to 2 g QID for remaining duration of therapy with full recovery. This case highlights the importance of comprehensive testing and proper treatment adjustment for rarer etiologies of aseptic meningitis.

More Than Meets the Eye: Infective Endocarditis Presenting as Endogenous Endophthalmitis.

Endogenous endophthalmitis (EE) is a potentially blinding ophthalmological emergency with poor visual prognosis requiring a high index of clinical suspicion to obtain a prompt diagnosis. The main factors associated with poor visual outcomes include the virulence of the causative organism and timing of intervention. Infective endocarditis can present with nonspecific ocular complaints and remains an important risk factor for developing EE. We report an unusual case of EE in a 78-year-old male caused by infective endocarditis secondary to Streptococcus viridans resulting in bioprosthetic aortic valve abscess with dehiscence.

A Rare Case of Double Antibody-Positive Rapidly Progressive Glomerulonephritis: A Therapeutic Challenge.

Crescentic glomerulonephritis, also known as rapidly progressive glomerulonephritis, is a syndrome characterized by progressive and rapid deterioration of renal function over the course of weeks to months. Oliguria, hematuria, azotemia, and hypertension are characteristic features of this condition. Crescentic glomerulonephritis is further classified according to the staining pattern on immunofluorescence. In rare instances, a mixed pattern of injury is encountered as in the case of double antibody-positive rapidly progressive glomerulonephritis (RPGN). This case illustrates the challenge in treatment of double antibody-positive RPGN in an elderly female with no previous renal disease. The patient was found to be positive for anti-GBM antibody and MPO-ANCA. Treatment was initially targeted against MPO-ANCA as the biopsy was most consistent with this process; however, the patient failed to respond to treatment and was subsequently transitioned to oral cyclophosphamide directed against anti-GBM disease. In cases of doubly antibody-positive RPGN with anti-GBM disease and ANCA-associated vasculitis, initial treatment should focus on inducing remission of anti-GBM disease as double antibody-positive disease often presents with the aggressive morbidity and mortality seen in anti-GBM disease, and the chronic risk of relapse seen in ANCA-mediated vasculitis.

Sitagliptin-induced Pancreatitis: Chronic Use Would Not Spare You the Complication.

Medication-induced pancreatitis is an overlooked cause of acute pancreatitis. We present an 81-year-old male patient with acute sharp epigastric pain radiating to his back, who was found to have lipase of more than 30,000 U/L. The patient denied current alcohol use. Abdominal ultrasound and abdominal computed tomography scan revealed no gallstones or biliary duct abnormalities. The patient had been taking sitagliptin for eight years. Supportive treatment with intravenous fluids, pain medications, and early feeding adequately treated his disease. With our case, we aim to increase awareness of sitagliptin-induced pancreatitis, regardless of the duration of use.

Nitrous Oxide-Induced Vitamin B12 Deficiency Resulting in Myelopathy.

Nitrous oxide, primarily used in the medical field and in the food industry, can cause symptoms of euphoria and analgesia. Recreational use of nitrous oxide is rising, as are reports of its adverse effects, including neurologic complaints secondary to an evoked vitamin B12 deficiency. We outline a case of a patient presenting with several neurologic symptoms and found to have myelopathy secondary to vitamin B12 deficiency in the presence of prolonged recreational nitrous oxide use.

Not Your Average Seizure: A Case of N-Methyl-D-Aspartate Receptor Encephalitis and Review of Literature.

Encephalitis is an inflammatory process of the brain that is most commonly related to infectious etiology; nonetheless, autoimmune encephalitis has been an increasingly identified entity that can cause it as well and should be considered. N-methyl-D-aspartate (NMDA) receptor encephalitis is a recently identified process but remains less recognized than autoimmune encephalitis. We report a case of an 18-year old female who initially presented with seizures and later developed behavioral symptoms of agitation, crying, screaming, and emotional lability. Ultimately, she was found to have NMDA receptor encephalitis related to ovarian paraneoplastic teratoma. The patient was treated with anti-epileptics and intravenous immunoglobulin and underwent oophorectomy that lead to her recovery. This case highlights the importance of early recognition of NMDA receptor encephalitis to facilitate appropriate investigations and management.

Endoscopic Ultrasound-Guided Drainage of Intramural Duodenal Abscess Caused by Foreign Body Ingestion.

A 63-year-old man presented with fever and generalized weakness for 2 days. Computed tomography scan showed an intramural duodenal abscess and a linear radiolucent foreign body penetrating the duodenal wall. Endoscopic drainage was performed. Endoscopic ultrasound showed fluid collection in the second portion of the duodenum. The duodenal lumen was punctured with the creation of stoma using a lumen-apposing metal stent and electrocautery system. The stent was deployed, and the drainage of purulent fluid followed. The foreign body was suspected to be a wire brush bristle. The patient received intravenous antibiotics for 14 days. Follow-up images showed the resolution of the abscess.

Mycobacterium fortuitum ventriculoperitoneal shunt infection in an immunocompromised patient: A case report.

We present a case of Mycobacterium fortuitum ventriculoperitoneal shunt infection in a 26-year-old immunocompromised woman. The patient was treated with revision and replacement of her peritoneal shunt and prolonged combination antimicrobial therapy. There are no established guidelines for the treatment of VP shunt infections due to M. fortuitum. We review the literature and provide treatment recommendations.