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    Flood Syndrome in a Patient with Decompensated Liver Cirrhosis: A Case Report
    (2022) Janecki, Julia; Vidal, Natalie; Roy, Joyce; Hapuarachchi, Menalee; Hoang, Long
    Background: Cirrhotic patients with ascites have a 20% risk of umbilical hernia development during the course of their disease due to elevated intra-abdominal pressures. In rare cases, patients with large volume ascites may develop a spontaneous umbilical hernia rupture leading to a sudden rush of ascitic fluid through a skin lesion, a complication known as Flood syndrome. The development of Flood syndrome is often provoked by local trauma or sudden rise in intra-abdominal pressure such as coughing, straining, vomiting, heavy lifting, or large volume ascites. Complications of a ruptured umbilical hernia include bowel incarceration, cellulitis, peritonitis, evisceration of the small bowel, and eventually sepsis. In this case report, we present the unique case of a patient with decompensated liver cirrhosis complicated by Flood syndrome. Case information: We present the case of a 56 year old male with a past medical history of decompensated cirrhosis secondary to alcoholism/chronic Hepatitis C infection complicated by ascites and hepatic encephalopathy, and chronic kidney disease of unknown stage, who presented to the ED with spontaneous leakage of fluid from his umbilical hernia. Emergent paracentesis expelled a total of 12 L milky fluid in a stream from his umbilicus and the patient was medically managed with IV albumin. Peritoneal fluid analysis revealed glucose of 144, WBC of 152, fluid protein of 1.4, and elevated triglycerides of 843, suggesting chylous ascites. A fluid serum ascites albumin gradient (SAAG) of 3 and fluid protein of 1.4 suggested the etiology was primarily cirrhosis complicated by portal hypertension. Following paracentesis, his ascites did not recur. His kidney function declined and he developed hepatorenal syndrome, deeming him a poor candidate for surgical intervention of his umbilical hernia. Conclusions: Flood syndrome is a rare complication of refractory ascites and liver cirrhosis, with a significant morbidity and mortality rate of 30%. Rupture prevention is dependent on the optimal management of underlying ascites with conventional strategies that includes diuretics, regular paracentesis, avoidance of alcohol/non-steroidal inflammatory drugs along with dietary salt and fluid restriction. Due to the complexity of syndrome, surgical treatment is not a well-established procedure and is associated with a mortality rate of up to 30%, especially in patients undergoing emergent hernia repair.
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    Characterization of Echocardiogram, Peritoneal Fluid, and Transjugular Liver Biopsy Assessment in Patients With Noncirrhotic Cardiogenic vs. Nephrogenic Ascites
    (2022) Khwaja, Areeba
    Purpose: Patients with heart failure (HF) may present with cardiogenic ascites in the absence of cirrhosis. Likewise, patients with end-stage renal disease (ERSD) on hemodialysis (HD) may develop nephrogenic ascites in the absence of cirrhosis. In many cases, these patients are assumed to have underlying portal hypertension. However, onset of ascites in ESRD patients on HD could instead be cardiogenic in nature as a result of right-sided HF. Peritoneal fluid analyses, echocardiogram, and transjugular (TJ) liver biopsy with hepatic venous pressure gradient (HVPG) may more accurately define etiology and clinical disease status of noncirrhotic ascites in both these patient cohorts. Methods: A retrospective comparative analysis of two non-cirrhotic cohorts: (1) Patients with HF and ascites (cardiogenic ascites) and (2) Patients with ESRD and ascites was done from 2014 to 2021 at a high-volume academic hospital with a liver transplant program. The identified etiologies of cardiogenic ascites included ischemic, non-ischemic, pulmonary hypertension, and valvular heart disease in patients with histology consistent with passive hepatic congestion and corresponding clinical history/evaluation of HF and ascites. Patients with ESRD on HD who presented with new-onset ascites were also included. Both cohorts were assessed by three measures, including echocardiography, peritoneal fluid analysis, and TJ liver biopsies. Results: Of the 29 non-cirrhotic patients included in analysis, 10 had cardiogenic ascites and 19 had ESRD with ascites. Patients were confirmed to have no cirrhosis by histology; 55% exhibited only minimal hepatic fibrosis (stage < 2). Sinusoidal dilation was present in 21/29 (72%) of patients overall, including 90% in the cardiogenic group and 63% in ESRD (p=NS). On echocardiogram, a larger proportion of patients with cardiogenic ascites had reduced right ventricular systolic function (89% vs. 41%, p=0.04). Peritoneal fluid analysis revealed serum-ascites albumin gradient (SAAG) was higher among those with cardiogenic ascites (1.65, 0.6-2.4) vs. ESRD (0.9, 0.4- 4.0; p=0.005), such that cardiogenic ascites was more likely associated with high SAAG >1.1 (80%) while ESRD was more likely to have low SAAG (79%; p=0.004). Peritoneal fluid protein was higher in ESRD (4.3, 3.0-5.8 g/dL) vs. cardiogenic ascites (3.3, 2.0-4.6 g/dL; p=0.002). TJ hepatic venous pressure gradient (HVPG) was performed in 27/29 (93%) patients. Patients with cardiogenic ascites had significantly elevated free hepatic vein pressure (22, 11-54 mmHg) vs. (12, 2-29 mmHg; p=0.01) and wedged hepatic vein pressure (24, 11-57 mmHg) vs. (14, 3-32 mmHg; p=0.03) compared with ESRD. Conclusion: Although patients with cardiogenic ascites exhibited elevated protein, SAAG, and both free and wedged hepatic vein pressures by TJ assessment compared to the ESRD cohort, evidence of right-sided HF was still present on echocardiogram in multiple patients of the ESRD cohort. Therefore, further characterization of hemodynamic, histologic, and advanced echocardiographic features, especially in a larger cohort size, may help improve our understanding of stratifying the risks of HF severity/prognosis as well as the etiology of nephrogenic ascites and how frequently it actually occurs without any true underlying evidence of HF.
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    Optimizing Chronic Pain Management through Patient Engagement with Health-Related Quality-of-Life Measures: A Randomized Controlled Trial
    (2022) McDonald, Hanna; Yablon, Mckenna; Ngo, Wayne; Garza, Kimberly; Licciardone, John C.
    Purpose Chronic low back pain (CLBP) is a common health issue that requires accessible and cost-effective methods of management. Relevant guidelines in the United States emphasize the use of non-pharmacological and non-opioid treatments as first-line interventions. Additionally, health-related quality of life (HRQOL) has been proposed as an emerging measure of CLBP outcomes that may provide important information not captured by conventional measures such as pain intensity or physical function. Recent studies suggest that eHealth interventions to promote patient self-management may improve health outcomes in patients with chronic pain, including low back pain. The primary aim of this randomized controlled trial was to measure the efficacy of an eHealth intervention for HRQOL outcomes in patients with CLBP. Methods Trial participants were recruited from the PRECISION Pain Research Registry from November 2019 through February 2021. These participants met the NIH definition of CLBP, were between 21-79 years of age, and had HRQOL deficits involving sleep disturbance, pain interference, anxiety, depression, and low energy or fatigue (SPADE cluster derived from the Patient-Reported Outcomes Measurement Information System) as evidenced by a baseline score ≥55. A total of 331 participants were randomized to treatment or wait-list control groups. The treatment group received an eHealth intervention, which consisted of an individualized HRQOL report based on the SPADE cluster and subscale scores and an interpretation guide. Outcomes were assessed 3 months after randomization. The primary outcomes were changes in the SPADE cluster and subscale scores. Secondary outcomes included low back pain intensity measured with a numerical rating scale, and back-related disability measured with the Roland-Morris Disability Questionnaire. Changes over time for each outcome measure reported by participants in each group were compared using the Student's t test for statistical significance and Cohen's d statistic for clinical importance. Positive change scores and d-statistics favored the eHealth intervention group. Results There were no significant differences between the eHealth intervention and wait-list control groups for changes over time in any primary or secondary outcome measure. The mean difference between groups in change scores on the SPADE cluster was 0.15 (95% CI, -0.73 to 1.03) (P=0.73). The d statistic for this difference was 0.04 (95% CI, -0.18 to 0.25). The corresponding d statistics for the SPADE subscales ranged from -0.06 (95% CI, -0.27 to 0.16) for anxiety to 0.11 (95% CI, -0.10 to 0.33) for sleep disturbance. Conclusions The eHealth intervention studied herein did not achieve statistically significant or clinically important improvements in any of the primary or secondary outcome measures. However, almost three-fourths of participants were enrolled after onset of the COVID-19 pandemic and may have had limited access to treatments for low back pain or to facilities or services needed to act on the information or recommendations derived from the HRQOL report. Thus, the validity and generalizability the findings may have been limited by the unforeseen onset and impact of the COVID-19 pandemic shortly after beginning the trial.
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    Chronic Ventral Hernioplasty Mesh Infection with Enterocutaneous Fistulae: Operative Treatment of a 62-Year-Old Female with a History of Extensive Abdominal Surgery
    (2022) Hall, Lendon
    Background: Enterocutaneous fistulae (ECF) are abnormal communications between the small or large bowel and the skin. They arise as complications of abdominal surgery, in this case years after intraperitoneal polypropylene mesh placement during ventral hernia repair. Surgical management of infected hernia mesh entails en bloc removal of the infected mesh with the adjacent fistula tract. Case Information: A 62-year-old Hispanic female presented to the general surgery clinic for evaluation of an ECF in the context of chronic ventral hernia mesh infection. The patient had an extensive abdominal surgical history that included two cesarean sections, hysterectomy, three ventral hernia repairs, a sigmoid colectomy, a laparoscopic adjustable gastric band, and a cholecystectomy. The patient noted a fistula formed two years prior and eventually closed spontaneously. 4-5 months prior, the fistula opened again with pain and pasty discharge requiring dressing changes every 2-3 hours. Upon evaluation in the clinic, the patient had infected intraperitoneal mesh with an enterocutaneous fistula. Given the patient's good nutritional status, en bloc excision of the infected mesh and ECF with small bowel resection and abdominal wall closure was planned and performed. During surgery, mesh was identified and noted to be extending across the abdominal wall and the enterocutaneous fistulae were noted. The small and large bowel were densely adhered. Extensive lysis of adhesions using Metzenbaum scissors was performed. Small bowel that was proximally and distally attached to the mesh was identified. The mesh was bisected at midline to facilitate dissection. The infected mesh along with the ECF were removed. Primary hand-sewn side to side anastomosis was performed to repair the defect. The small bowel anastomosis was brought together by approximating the sides. A two-layer anastomosis was created using Lambert and Connell stitches, and the peritoneal cavity was cleaned and closed. The patient was awakened and taken to the PACU in stable condition. The patient's post-op course was complicated by fascial dehiscence requiring multiple laparotomy reopenings, revision of anastomoses due to perforations, further small and large bowel resections due to non-viability, colostomy, mesh placement to cover the open abdominal defect, and several wound VAC replacements. The patient remained stable and continued to receive wound VAC replacements every three days until she was discharged to a skilled nursing facility several months after the hernia mesh was removed. Discussion: Hernia repair mesh that is placed inside the peritoneal cavity has a propensity to cause catastrophic long-term problems such as the ECF presented in this case. Mesh placement between abdominal wall layers, i.e. retrorectus or preperitoneal placement, has been shown to reduce infection and hernia recurrence rates compared to intraperitoneal placement. Patients need to be made aware of the risks of intraperitoneal mesh placement and surgeons need to be encouraged to take the time to prevent these tragic outcomes by improving the hernia repair technique.
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    Outpatient Intravenous Albumin Decreases Hospitalization and Mortality in Patients with Cirrhosis and Refractory Ascites or Anasarca
    (2022) Edwards, Miki; Gonzalez, Stevan; Gautam, Manjushree; Osborne, Brooke; Modi, Apurva; Ashfaq, Mohammad; Huang, Amy; Asrani, Sumeet; Trotter, James
    Purpose: Albumin improves survival and outcomes associated with complications of cirrhosis including spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, and volume overload. The role of outpatient intravenous albumin infusions in decreasing hospitalizations and mortality in this population has not been well established. Methods: A retrospective electronic medical record review of cirrhotic patients with refractory ascites or anasarca who underwent outpatient intravenous albumin therapy between the years of 2011 and 2015 was performed. All patients received at least one albumin infusion of 25% albumin 50 g which was given independently from albumin received during paracenteses. Patients with transjugular intrahepatic portosystemic shunts (TIPS) were excluded. Laboratory, clinical data, and hospitalizations 3 months before initiation of albumin therapy and longitudinal follow up over 12 months were assessed, including hospitalizations, transplantation and overall survival. Results: 97 patients received at least one outpatient albumin infusion. Patient demographics included median age 62 (range 38-86), 64% male, 86% Caucasian, 36% cryptogenic/nonalcoholic fatty liver disease and 34% chronic hepatitis C. Median Model for End-Stage Liver Disease (MELD) score was 15 (6-29) with 24% MELD >20 and 51% of patients required hospitalizations within 3 months prior to initiation of albumin infusions. 18% of patients received a transplant by 12 months and 69% died during follow up. The median frequency of albumin infusions among patients was one infusion every 3 weeks and 40% received albumin infusions at least once every 2 weeks. Frequency of hospitalizations was decreased at 3 months (p=0.04), 6 months (p=0.04), and 12 months (p=0.08) among patients who had infusions at least every 2 weeks. Competing-risks regression was performed, demonstrating patients who received albumin infusions at least once every 2 weeks during the first 3 months had a lower cumulative incidence of death accounting for liver transplantation as a competing event (p=0.05), independent of sustained virologic response with chronic hepatitis C treatment and MELD score (p = 0.04). Conclusions: Outpatient intravenous albumin infusions decrease incidence of hospitalization and mortality in cirrhotic patients with refractory ascites or anasarca who are not candidates for TIPS placement.
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    Index Pollicization with Subsequent Development of Scaphoid AVN
    (2022) Frangenberg, Alexander; Pipkin, William
    Background: Preiser's disease, or idiopathic scaphoid avascular necrosis (AVN), is a rare ischemic event of the scaphoid occurring in patients with no prior history of wrist injury. Blood flow to the scaphoid originates distally from the radial artery and proximally; thus, many cases of Presier's disease present with proximal pole ischemia. Holt Oram syndrome is an autosomal dominant disease that presents with cardiac and upper appendicular skeletal deformities, namely of carpal and thenar origin. Carpal malformations include scaphoid hypoplasia and bipartite ossification, retention of the os centrale in utero, and the addition of extra carpal bones or other carpal anomalies, while thumb malformations present with triphalangeal, hypoplastic, or absent thumbs. Scaphoid AVN has only ever been reported in patients presenting with Holt Oram syndrome in cases of trauma. Case Information: A 38-year-old female with a history of index finger pollicization in 1983 for congenital thumb agenesis from Holt-Oram syndrome presented to the clinic for evaluation of radial and ulnar sided wrist pain for one year that bothered her daily. She presented with an MRI that demonstrated avascular necrosis of the scaphoid. Physical examination demonstrated intact pollicization of the index finger with well-healed incisions. Pain located to the scaphoid on flexion and extension of the wrist. Exam was positive for snuffbox tenderness. Patient demonstrated adequate range of motion in all digits. The patient elected to proceed with scaphoid excision and four-corner fusion after conservative therapies had been exhausted. After 2 months of short arm immobilization, fusion was demonstrated on X-ray, and the patient was pain-free on exam with adequate composite fist formation. Conclusions: For patients with thumb absence or hypoplasia, index pollicization is considered the ideal treatment, as it positions a functioning finger in place of the lacking thumb. There is no mention in the literature of scaphoid AVN as a long-term complication of index pollicization. Treatment of scaphoid AVN in this patient with index pollicization showed similar outcomes to those treated with isolated scaphoid AVN. To our knowledge, this is the first reported case of scaphoid AVN in a patient with a history of index finger pollicization. In this case, treating scaphoid AVN in the traditional fashion has led to a satisfactory outcome in regards to both pain control and function.
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    Three Pediatric Siblings With CADASIL
    (2022) Russell, Kate; Kurjee, Nehel
    BACKGROUND: Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a congenital small vessel disease of the brain due to NOTCH3 gene mutations. Although adult-onset CADASIL is well documented, more cases are being described within the pediatric population. We describe 3 siblings with NOTCH3 mutations with various symptomatic presentations of early-onset CADASIL and 1 sibling with concurrent moyamoya syndrome. PATIENT PRESENTATIONS: A 19-year-old male who has experienced behavioral dysregulation, hallucinations, and memory loss along with a hyperintense signal abnormality in his temporal lobe. His 15-year-old sister who has the mildest presentation in terms of normal imaging results but experiences severe headaches, anxiety, and depression. And the youngest sibling, a 13-year-old with first reported case of a NOTCH3 mutation associated with moyamoya syndrome and a TREX1 gene mutation of uncertain clinical significance. She had multiple strokes before 5 years of age. CONCLUSION: Our set of siblings share many similarities with other reported pediatric cases of CADASIL, all with NOTCH3 gene mutations and with early onset symptoms that range from abnormalities in the cognitive/behavioral/psychiatric field to neurological deficits, migraines, and strokes. Gene testing and imaging studies in symptomatic children with a family history suggestive of CADASIL might aid in early diagnosis even though there is no effective therapy. We believe that the correlation of clinical presentations and gene mutations together with increased research into the molecular mechanisms underlying CADASIL (and related arteriopathies such as moyamoya syndrome) are critical to the eventual development of targeted therapies.
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    Comparison of dominant and non-dominant knee kinetics in healthy controls versus anterior cruciate ligament reconstruction.
    (2022) Panchal, Olivia; Goto, Shiho; Singleton, Steven; Dietrich, Lindsay; Hannon, Joseph; Garrison, Craig
    Purpose/Hypothesis: To examine the knee joint loading with anterior cruciate ligament reconstruction (ACL-R) of the dominant (ACL-D) or non-dominant (ACL-ND) limb at the time of return to sport (RTS) compared to matched healthy controls (CON). Subjects: A total of 150 athletes volunteered. (ACL: N=75, Age=15.56±1.74yrs, Ht=167.93±9.77cm, Mass=67.22±11.39Kg; CON: N=75, Age=15.52±1.91yrs, Ht=168.84±8.33cm, Mass=63.74±11.61Kg). Participants in the ACL-R group underwent ACL-R with a patellar BTB or hamstring graft and were assessed at time of RTS. All subjects in the CON group were considered healthy with no history of lower extremity injury in 3 months prior to testing and IKDC ≥ 95. Materials/Methods: Lower extremity 3-D joint angles and ground reaction force data were collected using an 8 three-dimensional Motion Capture System and force plates. Participants performed 5 double-leg squats (DLS) at a standardized speed (60 bpm). Peak knee extension moment (KnEXTmm) was calculated during the descent phase. Knee joint energy absorption (KnEA) and knee joint energy absorption contribution (KnEAC) were calculated during the same phase. These variables were normalized to the participant's height and weight and averaged across the middle 3 trials. Finally, peak quadriceps (QUADS) isokinetic strength at 60°/sec was assessed, normalized to body weight, and averaged across 3 trials. Separate ANOVAs were performed to examine difference between groups. Comparisons were made between those with ACL-D and the dominant limb of the CON-D and between those with an ACL-ND and the non-dominant limb of CON-ND. Results: In both the ACL-D and ACL-ND groups, KnEA (ACL-D=-0.04±0.02, CON-D=-0.05±0.02; p=0.016. ACL-ND=-0.04±0.01, CON-ND=-0.05±0.01; p< 0.001) and QUADS (ACL-D=1.36±0.51, CON-D=1.79±0.45; p=0.001. ACL-ND=1.40±0.38, CON-ND=1.69±0.41; p=0.001) were significantly decreased compared to controls. KnEAC (ACL-D, CON-D; p>0.05. ACL-ND=51.73±12.54, CON-ND=60.93±9.83; p< 0.001.) and KnEXT mm (ACL-D, CON-D; p>0.05. ACL-ND=-0.04±0.01, CON-ND=-0.05±0.01; p=0.00.) were significantly decreased in the ACL-ND group compared to CON-ND. Significant differences were not observed for these variables between the ACL-D and CON-D groups (p>0.05). Conclusion: Non-significant difference in KnEAC and KnEXTmm in the ACL-D group indicates these subjects performed DLS task at the level observed in the healthy population. However, the significant difference in KnEA in the ACL-D group indicate an overall lower level of loading on the involved limb. All other variables, regardless of side of injury, the ACL-R groups exhibited significantly decreased kinetic and muscle performance relative to healthy controls indicating that side of dominance had little influence on knee biomechanics during DLS at RTS. Clinical Implication: Clinicians should take into consideration which limb underwent ACL-R when designing rehabilitation programs and be aware of these kinetic deficits at the knee joint and attempt to address these differences prior to time of return to sport.
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    Transverse Myelitis After Johnson & Johnson COVID Vaccine - A Case Report
    (2022) Mathew, Ezek; Williamson, Julie; Johnson, Reign; Mamo, Lois; Mahama-Rodriguez, Alia; Dickerman, Rob
    Introduction: As the novel coronavirus disease of 2019 (COVID) is an ongoing public health issue, many turn to vaccinations as a means of defense. While vaccination is generally safe, reports of rare pathologies subsequent to COVID vaccination exist, especially in the realm of neurological disorders. One such rare complication is tranverse myelitis, which will be the subject of this case report. Patients impacted by transverse myelitis may present with a varied neurological symptom, which may sometimes progress rapidly without treatment. These can include motor, sensory, and/or autonomic dysfunctions stemming from the spinal cord. These dysfunctions typically occur bilaterally at clearly defined sensory levels, and T2 weighted MRI will indicate cord hyperintensity. Case Description: A 56-year-old male patient presented to clinic with a chief complaint of episodic bilateral arm numbness. The patient tested positive for COVID in December of 2020, although recovery was uneventful. In May of 2021, the patient received the Johnson & Johnson COVID vaccine. The symptoms associated with his chief complaint developed approximately two months after receiving the vaccine. Two weeks preceding the patient visit, cervical Magnetic Resonance Imaging (MRI) was performed. Imaging evidenced severe cord edema from C1 to T1-2 with associated cord expansion. At C4-C5, there is a right sided disc protrusion causing moderate spinal stenosis with cord effacement. Additionally, the thecal sac measures 7mm at this level. At the C5-C6 and C6-C7 levels, there is evidence of moderate foraminal stenosis, bilaterally. Radiological evaluation confirmed these findings, while listing possible differentials of transverse myelitis, neuromyelitis optica, or a viral myelitis. Along with recommendation for follow up and referral for contrast MRI, oral corticosteroid treatment was rapidly initiated. One week after treatment, another cervical MRI was performed. The radiology interpretation noted decreased extent of the abnormal enhancing signal within the cervical cord, compatible with resolving transverse myelitis. Over the time course of multiple weeks, symptoms improved. Discussion: While the majority of cases may yield abnormal strength and DTR, transverse myelitis presentations after COVID vaccination may ultimately vary widely, necessitating thorough evaluation. The prognosis of transverse myelitis is rather varied and depends on factors such as rate of symptom progression, quality of nerve conduction, possibility of spinal shock, and speed of treatment initiation. Prompt treatment and management of symptoms may allow for a successful recovery, as in this patient's case.
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    Outcomes Associated with Various Iterations of The Dedicated Orthopaedic Trauma Room
    (2022) Biddle, Kathryn
    Purpose: Scheduling urgent, orthopaedic trauma cases has long been a challenge for health care institutions. Traditionally, these cases are scheduled for an operating room (OR) slot in the middle of the night, by "bumping" elective cases to later in the day, by adding a case on after-hours, or by delaying the case for several days until an OR becomes available. As a solution to the challenges facing traditional scheduling modules, trauma centers around the country have instituted the use of a dedicated orthopaedic trauma room (DOTR). While there are multiple studies analyzing the effects of DOTRs on various outcomes, there is not a centralized review of these studies. This paper will serve as a review of the various models of the DOTR as well as the effect of the DOTR on after-hours procedures, time to surgery (TTS), duration of surgery (DOS), length of stay (LOS), cost, and surgical complications. Methods: An extensive review of the literature was performed through PubMed and Embase. Studies were included in the review if they were published in English, involved clinical research, and reported the use of a dedicated operating room at a regular interval throughout the week, specifically for orthopaedic trauma. 15 studies were found to meet the eligibility criteria. Results: We found a decrease across all studies measuring incidence of after-hours procedures before and after the implementation of a DOTR. Regarding mean TTS after the implementation of a DOTR, 3 out of 11 studies found a statistically significant decrease, 3 out of 11 studies found a statistically significant increase, and 5 out of 11 studies found no significant difference. Regarding mean DOS after the implementation of a DOTR, 2 out of 9 studies found a statistically significant decrease, 1 out of 9 studies found a statistically significant increase, and 6 out of 9 studies found no significant difference. Regarding mean LOS after the implementation of a DOTR, 6 out of 12 studies found a statistically significant decrease, 1 out of 12 studies found a statistically significant increase, and 5 out of 12 studies found no significant difference. Multiple studies reported financial outcomes favoring the DOTR. In addition, multiple studies reported favorable findings after the implementation of a DOTR regarding decreased mortality, unplanned reoperations, and postoperative ICU admission. Conclusions: This review suggests that DOTRs have a significant effect on decreasing the number of after hour procedures, decreasing cost, and decreasing morbidity and mortality of orthopaedic trauma patients. There is variability in the data regarding the effect on time to surgery, duration of surgery, and length of stay.
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    Pleural Effusion as an Unusual Complication in a Woman with Primary Sjögren's Syndrome: A Case Report
    (2022) Healy, Jack; Malik, Rehan
    BACKGROUND: Sjögren's syndrome (SS) is a chronic, systemic, autoimmune condition causing lymphocytic damage to exocrine glands. Immune-mediated dysfunction of the lacrimal and salivary glands leads to the classic symptoms of SS: dry eyes (xeropthalmia) and dry mouth (xerostomia). The combination of these two symptoms is also known as sicca syndrome. Sjögren's Syndrome is classified as either primary (occurring in isolation, without another diagnosed autoimmune condition) or secondary (occurring with a comorbid autoimmune disorder, such as systemic lupus erythematosus or rheumatoid arthritis). In addition to sicca symptoms, patients with Sjögren's Syndrome may have extra-glandular involvement in multiple organ systems. Lung manifestations most frequently involve the airways and interstitium. Inflammation usually spares the serosa (pericardium and pleura), and pleural effusion in this population is rare (< 1% reported incidence). CASE INFORMATION: A 79-year-old female with primary Sjögren's syndrome presented to the ED for chest pain. Her medical history also included COPD, anemia, and atrial fibrillation with previous cardioversion. She described the pain as sudden onset, bilateral, squeezing chest discomfort that awoke her from sleep earlier that morning. Her pain was exacerbated by lying down and inspiration, and non-responsive to over-the-counter analgesics. She endorsed dyspnea and vomiting but denied cough, diaphoresis, or pain radiating to her jaw or back. In the ED, she was tachypneic but otherwise in stable condition. She was admitted for further evaluation and treatment. Workup for ACS, heart failure, COPD exacerbation, pneumonia, pneumothorax, flu, and Covid-19 were negative. CT and X-ray suggested new bilateral pleural effusions with no evidence of embolism. Thoracentesis drained 870 mL of fluid and confirmed the diagnosis. Analysis of the collected sample showed weakly exudative pleural fluid with a protein ratio of 0.58, and cytology negative for malignancy. After eight days of supportive care (IV furosemide and respiratory therapy) she was discharged in stable condition, with evidence of resolving pleural effusion on imaging. CONCLUSIONS: The pulmonary structures typically involved in Sjögren's syndrome are the airways and interstitium, not the pleura. The most commonly seen pulmonary compilations in SS are pneumonitis, bronchiolitis, and bronchiectasis. As such, this case describes an unusual complication of pleural effusion in the setting of primary Sjogren's Syndrome. The mechanism underlying pleural effusion in SS in unknown. One theory suggests that CD4+ T cells may activate B lymphocytes, which produce autoantibodies against lung tissue, causing buildup of fluid in the pleural space.
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    Role of BMI in predicting treatment response to standard dose intranasal esketamine
    (2022) Shah, Dilan; Czysz, Andy
    Purpose: The current work aims to determine the effects of BMI on the response and remission rates of patients treated with standard dosed intranasal esketamine after 8 treatments. Introduction: Major depressive disorder (MDD) is the most common psychiatric illness in the United States and presents with a significant economic, emotional, and healthcare burden. Treatment-resistant depression (TRD), a subset of MDD for which nearly 30% of patients meet criteria, is especially challenging to manage, with most current interventions proving largely unsuccessful at reaching long-term remission. While definitions can vary, failure of two oral antidepressants of adequate dose and duration is the most common definition of TRD. Recently intranasal esketamine was approved as the first mechanistically distinct medication for depression in over 50 years. Proposed mechanisms of esketamine's anti-depressive function include NMDA receptor antagonism and modulation of the mTOR signaling cascade to affect synaptogenesis. Functional imaging also demonstrates esketamine's effect on multiple brain regions, including the medial prefrontal, motor, cingulate, and somatosensory cortex regions as well as subcortical regions. Though there is limited research beyond the recently concluded phase 3 clinical trials, the data and anecdotal evidence thus far have been promising that esketamine can provide a real solution for patients with treatment-resistant depression. Previous studies have been conducted to determine the treatment response in patients with MDD who received weight-based intravenous ketamine. No work exists, to the author's knowledge, investigating how BMI affects the response to standard-dosed intranasal esketamine. Materials and Methods: This study is conducted as a retrospective chart review of more than 40 patients who received treatment with intranasal esketamine at the BL6 clinic at UT Southwestern medical center in Dallas, Texas. Inclusion criteria consisted of patients ages 18 and older, with a primary diagnosis of major depressive disorder with failure of two or more oral antidepressants in the current depressive episode and received intranasal esketamine treatment. All patients were treated with a 56mg starting dose of intranasal esketamine and received treatment at an escalated 86mg dose on a standardized 8-week schedule. Efficacy of treatment was determined by collecting survey data of indexes of depression and suicidality that are integrated into each patient's EPIC Flowsheet. These include the Patient Health Questionnaire (PHQ-9), Quick Inventory of Depression Symptomology Clinical Rating/Self Reporting (QIDS-SR/C), and the Clinical Global Impressions Scale (CGI). Patients were then stratified by body mass index and differences in response to esketamine treatment were delineated. Statistical analyses are underway. Impact: The need to bring real effective treatment to patients suffering from treatment-resistant depression is needed now more than ever, as societal unrest and hardship continue to exacerbate the mental health pandemic. Innovation in care is needed to meet demand and bring more patients to long-term remission. As new treatment options like intranasal esketamine surface, further investigation into the confounding factors of treatment is needed.
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    Hypertension at Home: How Telehealth Can Impact Hypertension Screening
    (2022) Khimani, Faria; Mallory, Brandon; Ojha, Sujata; Wolf, Adam
    Purpose: Telemedicine is a virtual or hybrid platform of delivering healthcare that has grown tremendously over the last decade thanks to technological advancements. Since the start of the COVID-19 pandemic in 2020, preventive care screenings of hypertension, diabetes, hyperlipidemia, and obesity have significantly declined due to hesitations with in-person visits and staffing limitations in clinics and hospitals. That combined with a significant reduction in physical activity might probe one to think about the adverse impacts the pandemic might have in the cardiac health of the average American. Hypertension, defined here as ≥140mmHg systolic or ≥ 90mmHg diastolic, is a very prevalent pathology in our population and can lead to devastating sequelae such as heart attack, stroke, kidney disease, and dementia. Looking specifically at hypertension management, some limitations to screening include lack of an available blood pressure cuff at home and missed follow-up visits with providers leading to non-renewal of anti-hypertensive medications. This investigation aims to retrospectively study how the pandemic impacted the incidence of hypertension in 2020 and understand what role telemedicine played in providing healthcare screenings to patients. We postulate that there is an increased incidence of hypertension in 2020, during the pandemic, compared to 2019, before the pandemic. Methods: Retrospective data was gathered via chart review of an urgent care telemedicine company on patients aged 18-65. 1,000 charts were de-identified, randomized, and stratified by pre-pandemic (July-December 2019) or pandemic (July-December 2020) periods. The incidence of hypertension was calculated per year. The criteria for hypertension included systolic pressure ≥140mmHg or diastolic blood pressure ≥90mmHg. A two-sample t-test with unequal variance was used to confirm significance. Results: Preliminary analysis, comparing 2019 pre-pandemic visits (n=500) with 2020 pandemic visits (n=232) showed a statistically significant increase in incidence of systolic (20% during the pandemic compared with 16% before the pandemic, p< 0.05) and diastolic (36% during the pandemic compared with 26% before the pandemic, p< 0.05) blood pressure readings. Conclusion: Based on the increased number of hypertensive readings during 2020 compared to 2019, we conclude that there is a higher incidence of hypertension during the COVID-19 pandemic. This finding can be explained by multiple factors and requires further investigation. First, the pandemic severely restricted physical activity with jobs being lost or switched to virtual formats, forcing many to stay home. Second, unhealthy diets and increased caloric intake may have led to increased obesity. Lastly, lack of follow-up with physicians may have led to reduced hypertension screenings allowing more patients to have undiagnosed and untreated hypertension. Telemedicine is one avenue that may address these problems. This platform offers convenience in scheduling and attending appointments, therefore including younger populations that are often abandoned in early screenings. It has a wider reach that is not geographically bound and has the potential to reduce healthcare costs. We hope that this study raises further questions regarding the rise in hypertension during the pandemic and ways to increase early detection of preventable conditions.
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    Presentation of a Rare Isolated Soft Tissue Nontuberculous Mycobacterial Infection with MRI Characterization
    (2022) Timmer, Benjamin; Ali, Arkoon; Schultz, Steven
    Background: Nontuberculous mycobacteria (NTM), also known as atypical or environmental mycobacteria, was first described in the early 20th century. Although these bacteria are related to Mycobacterium tuberculosis, they are a distinct group of mycobacteria. Like Mycobacterium tuberculosis, NTM most commonly affects the lungs, however extra-pulmonary infections involving soft tissue, skin, and lymph nodes can also occur. These extra-pulmonary infections are rare and are primarily acquired secondary to skin breaks following trauma, minor surgeries and cosmetic procedures. Due to the rarity of NTM soft tissue infections the diagnosis is challenging and often delayed. Patients who develop NTM infections are typically immunocompromised, as the rate of clinical infection is significantly low. The incidence of skin and soft tissue infections (SSTI) by NTM however has increased threefold over a thirty-year period, which has attracted attention in the medical community. Case Presentation: A 78-year-old male pecan farmer presented with a left lateral knee mass that progressively worsened over a four-year period. He described the initial lesion as a small knot and denied any trauma or skin abrasions to the affected area prior to developing the nodule. The patient had no history of immunodeficiency and he denied pain, redness, or drainage of the nodule. He also denied fevers, chills, night sweats, chronic cough, or unintentional weight-loss. A T2 weighted axial MRI demonstrated a 5.3 x 7.4 cm well circumscribed, sharply marginated, and encapsulated perifascial soft tissue collection with mixed high and low signal that was mildly heterogeneous along the iliotibial fascial band. These imaging manifestations suggested either a soft tissue tumor or an infectious process. After failing conservative treatment with antibiotics, the patient was referred to an orthopedic surgeon for excision of the mass. An encapsulated cyst-like mass was excised circumferentially around the IT band and was sent to pathology. The gross specimen was described as a 3-cm diameter smooth walled cyst that was partially filled with soft material. Cut sections revealed caseating granulomatous inflammation. Special stain was positive for acid-fast bacilli consistent with mycobacteria. The specimen was negative for atypia, neoplasm, fungi, or polarizable crystals. Cultures did not grow any organisms and the TB gold assay and T spot test were negative for tuberculosis. This left a nontuberculous mycobacterial soft tissue infection as the diagnosis of exclusion. Treatment for SSTI NTM includes a multi-drug antibiotic regimen for at least 6 months based on susceptibility testing. Surgical intervention is indicated if antibiotic treatment is not effective. For this patient, surgical resection was the definitive treatment. Conclusion: This case illustrates a unique presentation of a rare isolated chronic NTM soft tissue infection of the lateral knee in a patient with no known history of trauma or immunodeficiency. Knowledge and clinical suspicion of this pathogen along with MRI findings can aid in the accurate and timely diagnosis of NTM soft tissue infections.