Translation: The University of Toledo Journal of Medical Sciences

A Rare Case of Post-Radiation Angiosarcoma with Pleural Metastasis

2024-07-31T14:28:59+00:00

Soft tissue sarcomas (STS) represent 1% of all malignancies in adults. Angiosarcomas are an uncommon subtype of vascular or lymphatic origin, compromising 2% of STS. We present a rare case of secondary angiosarcoma of the breast. Following treatment for invasive ductal carcinoma and subsequent diagnosis of radiation-induced angiosarcoma two years prior, a 77-year-old female presented with dyspnea and bilateral pleural effusions. Diagnostic thoracentesis demonstrated findings consistent with metastatic angiosarcoma. Angiosarcoma of the breast is exceptionally rare among soft tissue neoplasms and is typically associated with a poor prognosis.

Development of Sepsis in a Patient Admitted to the Detox Unit for Opioid Abuse: A Case Report

2024-04-15T16:18:18+00:00

Patients with opioid or benzodiazepine use disorder will often check themselves into a detox unit to combat withdrawal symptoms. These symptoms can include tachycardia, diaphoresis, and gastrointestinal upset. Unfortunately, these symptoms often mask the symptoms of other serious conditions, such as sepsis. The development of sepsis is observed in patients with substance use disorder, specifically those who abuse IV drugs. If unaddressed, this can progress to septic shock, a condition associated with significant mortality due to end organ damage and hemodynamic decompensation. This case presents a patient admitted to the detox unit for opiate use who had been admitted several times within the last year. She was treated for withdrawal symptoms for two days before it was discovered that she was septic. This case highlights the importance of recognizing acute conditions such as sepsis in the context of experiencing symptoms secondary to opioid withdrawal in patients admitted for substance detox.

Campylobacter bacteremia with psoas abscess: Case Report and review of the literature

2024-10-30T14:05:00+00:00

Infection with Campylobacter fetus can result in bacteremia and disseminated endovascular infection or extraintestinal infections such as osteomyelitis, septic arthritis, or meningoencephalitis. We present a case of a 36-year-old man with HIV who developed bacteremia and a left psoas muscle abscess after an acute episode of gastroenteritis due to C. fetus. The gastroenteritis appeared to resolve rapidly, but weakness, fatigue, and back pain started the following week. Magnetic resonance imaging of the lumbar spine revealed a left psoas abscess. The patient was treated with ertapenem for four weeks and had a resolution of back pain at the three-month follow-up visit but was then lost to follow-up. This case highlights the importance of accurate initial identification and treatment of systemic campylobacteriosis in immunocompromised hosts and the potential for dissemination.

Necrotizing Skin and Soft Tissue Infection Mimicking Cutaneous Metastasis in Lung Cancer

2024-08-09T13:38:07+00:00

Cutaneous metastases occur in 0.7–9% of cancer patients, most commonly from lung cancer in men. When present in lung cancer (1–12% of cases), they indicate poor prognosis with a mean survival of 5–6 months. More often, necrotizing skin and soft tissue infections (NSSTIs) are seen, though they can be diagnostically challenging and can result in delays in treatment. We present a 61-year-old man with newly diagnosed non-small cell lung cancer (NSCLC) and a two-week history of a necrotic abscess on his chest. Following incision and drainage of an 8 x 8 cm cavity, his condition worsened. CT revealed a spiculated lung mass extending into the chest wall, raising concern for cutaneous metastasis. However, cultures grew Streptococcus constellatus and Actinomyces odontolyticus; blood cultures also revealed S. constellatus. With further investigation into the patient’s history, it was discovered that the patient had poor dentition and recent full dental extraction. With targeted antibiotics, he improved and was discharged. This case highlights the importance of having high suspicion for commonly encountered microorganisms in the appropriate setting. Given the risk of rapid decompensation, patients suspected of having NSSTI should be evaluated for evidence of both local complications, hematogenous spread, and initiation of timely treatment, including source control and appropriate antimicrobial therapy.

Gangrenous Laparoscopic Cholecystectomy With Compound Complications Leading to Multiple Hospitalizations:

2023-03-21T15:35:56+00:00

Laparoscopic cholecystectomy is a common procedure in general surgery but can lead to complications, ranging from minor bile leaks to more rare and serious complications. In this article, we present a complex case involving a biloma resulting from injury to the accessory bile duct during laparoscopic cholecystectomy. This rare complication was further complicated by a residual phlegmon turned abscess, subacute-subcapsular hematoma, and persistent bile duct leak. To our knowledge, no other case with this combination of complications has been reported. We aim to describe the case and discuss preventive measures that can be taken to reduce the incidence of these complications. This case highlights the importance of careful surgical technique and postoperative monitoring in preventing complications after laparoscopic cholecystectomy.

Buprenorphine Induced Respiratory Depression: A Case Report

2025-12-10T15:18:17+00:00

Due to buprenorphine’s low maximum effect on respiratory depression because it is a partial agonist at the mu opioid receptor, it is generally considered a safe medication for treating opioid drug dependence. However, in combination with benzodiazepines or other comorbidities, it has been shown that buprenorphine can result in serious respiratory depression. We present the case of a 64-year-old female with a history of type 2 diabetes mellitus, asthma, obstructive sleep apnea, hepatitis C, hyperlipidemia, and hepatic steatosis who presented to the detox unit for alcohol and cocaine dependence and withdrawal. Although her initial presentation was for alcohol and cocaine withdrawal, her medical history was significant for opioid use disorder with multiple prior admissions to the detox unit. In consideration of this, buprenorphine therapy was initiated as part of her opioid dependence treatment. However, when given the standard dosage of buprenorphine, she was found to be sleeping upright in her chair three hours later with reduced O2 saturation. The patient received 1.2 mg of Narcan and had to be intubated because of buprenorphine induced respiratory depression. This case illustrates the potential effects of buprenorphine on respiration status.

Streptococcus pneumoniae Septic Arthritis in a Vaccinated Host: Case Report

2026-05-04T11:39:36+00:00

Streptococcus pneumoniae septic arthritis is an uncommon infection, rarely encountered in the US since the introduction of pneumococcal vaccination. We present a case of S. pneumoniae septic arthritis in a patient with HIV from a serotype not covered by pneumococcal vaccines: the patient had previously received PPV-23 and PCV-13 pneumococcal vaccination in addition to PCV-20 pneumococcal vaccination a year before presentation. This case highlights the importance of S. pneumoniae as a pathogen in people with HIV regardless of vaccination status, and the potential for pneumococcal disease from serotypes not covered in the currently available vaccines (serotype replacement).

Incidental Finding of Incomplete Cor Triatriatum Dextrum During 2nd Trimester of Pregnancy

2024-05-29T14:10:05+00:00

Background:

Cor triatriatum sinistrum is a type of congenital heart defect that occurs due to the left atrium being divided into two chambers by a fibromuscular septum. An even rarer subsection of this is cor triatriatum dextrum, in which the fibromuscular septum fully divides the right atrium.

Case presentation:

We present a patient with intermittent palpitations, chest pressure, and lightheadedness without syncope related to her cor triatriatum dextrum exacerbated by her pregnancy status. Without any prior history of congenital heart defects or pertinent family history, this seemingly health female prior to her pregnancy likely revealed and exacerbated her symptoms and lead to the diagnosis.

Conclusions:

Treatment in the setting of an asymptomatic presentation of a pregnant patient with history of cor triatriatum remains unclear. Many physicians elect close follow up to monitor for development of symptoms. In symptomatic cases, rate control, thromboembolic prophylaxis, and hemodynamic stabilization are mainstays of treatment. This unique presentation in a rare patient population furthers literature and gives a perspective on pregnancy and structural heart disease like cor triatriatum.

Measuring the inflammatory response in viral infections with an eye towards MIS-C

2024-08-07T14:57:37+00:00

Multisystem Inflammatory Syndrome in Children (MIS-C) caused by a recent SARS CoV2 infection in a child, led to broad screening of acutely ill children for widespread inflammation and systemic disease due to need for early diagnosis and therapeutic intervention. This broad laboratory screening to rule-out MIS-C also inadvertently captured the patients who were found to have seasonal viral upper respiratory infections. Thus, this screening provided a unique opportunity to study the inflammatory response to some of the common viral infections. We performed a retrospective chart review for all patients under 18 who presented to the ER or were admitted to the hospital with a positive test for either 1) Viral URI, 2) Acute COVID-19, or 3) positive SARS CoV2 IgG, suggesting previous COVID-19 infection; between March 2020-October 2022. We reviewed 6628 patient encounters with 5312 encounters meeting inclusion criteria.

Here we report that patients who had COVID IgG without other infection identified, most frequently showed widespread inflammation, as indicated by 56.7% of patients with 4 or more positive MIS-C criteria suggesting a diagnosis of MIS-C. One patient had a peak of 15 positive MIS-C criteria. Several seasonal viruses showed multisystem inflammatory responses in limited patients with the most frequent occurring in adenovirus (7.6% >= 4 criteria), and peaks of 9 or 10 criteria in sporadic patients for three seasonal viruses (adenovirus, rhinovirus/enterovirus, and parainfluenza viruses). Acute SARS CoV2 demonstrated elevated inflammatory states similar to seasonal cold viruses with a limited number of patients (4.3%) with >= 4 positive criteria markers of MIS-C, and a peak of 9 criteria. The most significant and largest differences between groups were observed in COVID IgG positive patients in comparison to each of the other viral groups followed by adenovirus compared to 5 out of 6 remaining viral pathogens.

Carbon Monoxide Exposure in Nepalese Workers at Mount Everest Base Camp

2023-10-08T22:46:59+00:00

Carbon monoxide (CO) is an often encountered but undetected toxin that can produce devastating adverse health effects. Sources of CO are commonplace, such as stoves or generators. While clinical effects of short-term exposure are well studied, effects of long-term, low-level exposure remain under characterized. We hypothesized that long-term, low-level exposure to CO may be prevalent at Everest Base Camp (EBC). Cooking stoves in poorly ventilated tents may provide a source for this long-term CO exposure at Mount Everest Base Camp (EBC). Our study intended to monitor carbon monoxide levels in this setting via non-invasive SpCO testing, and survey associated symptoms to determine what significance of carbon monoxide exposure, if any, was present.

Detection of Ventilator-Associated Events Among Adults: Comparing a Naïve Bayes Classifier and Logistic Regression

2024-09-11T14:30:05+00:00

A Naïve Bayes classifier was used to identify mechanically ventilated patients at risk for ventilator-associated events (VAEs). VAEs, which can lead to ventilator-associated pneumonia (VAP), are considered preventable and have therefore been extensively studied. Data were gathered from May 2013 to August 2016 from hospital surveillance records and matched 1:1 with non-VAE cases using age, sex, unit while intubated, use of vasopressors, and total ventilator days. The dataset was split 7:3 to create samples for training and testing. From the training set, the classifier calculated the conditional probabilities for each factor in the model. After the proposed model was trained, it was validated against the testing data sample. The model demonstrated an overall accuracy of 83.0% (95% CI; 74.8% – 89.5%) and was able to correctly classify 80.4% of VAEs (sensitivity) and 85.7% of non-VAEs (specificity). The PPV and NPV were 81.4% and 84.9%, respectively. The AUC was 0.831 (95% CI; 0.751 – 0.911) and the MCC was 0.662. This study indicates that a Naïve Bayes classifier can be used to classify mechanically ventilated patients at risk for VAEs with moderate accuracy. The model could be used to screen for VAEs at the time of intubation and to strengthen manual surveillance. Further research is needed to validate the model in terms of prognostic and diagnostic use for hospitals and clinical settings with different patient characteristics.

Consequences of the COVID-19 Pandemic for Health Profession Students: Perceptions about Academic Program Responsiveness and Mental Health Outcomes

2026-02-23T13:03:25+00:00

Introduction: Given the likelihood of future disease outbreaks, there is a need to examine the mental health consequences of the COVID-19 pandemic for health profession students and the extent to which health profession program responses to the pandemic influenced student mental health.

Objectives: This study uses data from two cohorts (Cohort 1: N=257; Cohort 2: N=177) of health profession students during the COVID-19 pandemic (11/2020-3/2021 and 5/2021-1/2022) to examine and compare student mental health during these time frames and determine associations between students’ perceptions of their programs’ response to the pandemic and mental health outcomes.

Methods: Participants completed self-report measures assessing mental health outcomes (depression, anxiety, COVID-19 obsessive thoughts, sleep disturbance, academic stress) and perceptions of their program’s response to the pandemic.

Results: Few between-cohort differences in mental health outcomes were found. In both cohorts, depression and anxiety symptoms, COVID-19 obsessive thoughts, and sleep disturbance were higher than those observed in the general population. Across both cohorts, the perception that their academic program had taken adequate steps to protect students’ mental health was significantly negatively associated with all mental health outcomes.

Conclusion: Findings highlight the importance of visible and accessible mental health services that can mitigate the psychological burden of pandemics for health profession students.

Transfer of patients with psychiatric illness

2025-04-15T20:06:43+00:00

The transfer of a patient with psychiatric illness from a general medical hospital to an extended care facility (ECF) can involve challenges and pitfalls. Planning should begin with the patient’s admission to the hospital. Comprehensive communication among staff members and also between staff and the patient/family is critical. Errors in diagnoses and medications pose particular risks during the process of transfer. It is essential that the ECF selected for the patient be prepared to provide treatment not just for the patient’s physical needs but also their psychiatric symptoms. Many ECFs do not have enough staff and/or consultants who are prepared to treat psychiatric problems. Once the patient has been established in the ECF, it is important that any changes in their psychiatric symptoms be included in their chart so that their diagnosis is current. The use of electronic medical records may contribute to errors in diagnosis when old, inaccurate information is retained through the inappropriate use of “cut and paste” tools. The purpose of this article is to identify these challenges and offer solutions for hospital staff, (e.g., integrated care providers, hospitalists), pre-transfer and ECF staff after transfer.

Impact of Mode of Transportation On EMS-call-to-PCI Time and Door-to-Balloon Time in STEMI Patients: A Systemic Review and Meta-Analysis of 35,057 Patients

2025-05-28T14:14:46+00:00

Introduction: Emergency revascularization with primary percutaneous coronary intervention (PCI), has been established to improve clinical outcomes for patients with acute coronary syndromes (ACS) and healthcare facilities allot and utilize resources to minimize delays to PCI and reduce door to balloon time. To our knowledge, this is the first meta-analysis that evaluates the data from these research studies collectively. The present meta-analysis focused on evaluating modalities for emergency transport systems and their impact on the outcomes of patients with STEMI.

Methods: We performed a comprehensive literature search for published studies indexed in PubMed, Embase, and Web of Science. This meta-analysis included a total of nine studies that met our inclusion criteria and had a total of 35,057 patients. All studies were observational in nature. Our primary outcomes of interest were the door to balloon time and EMS call to PCI time. Secondary outcomes evaluated were time from arrival at non-PCI facility to PCI within 90 minutes and within 120 minutes.

Results: The major findings for STEMI patients transported by air using helicopter compared with those transported by ground ambulance were as follows: first, EMS call to PCI was shorter in air transportation compared to ground transportation (mean difference -26.28; 95% CI -28.03- -24.52; P<0.001; I2=100%). Second, air transportation had a shorter time from door to balloon (mean difference -1.52; 95% CI -2.10 - -0.93; P<0.001; I2=12%). Third, when comparing air to ground transfer from non-PCI to PCI-capable facilities within the guideline recommended time windows of 90 minutes and 120 minutes for STEMI patients, transfer via air transportation was less likely to achieve the target timeline (within 90 minutes: OR 0.21; 95% CI, 0.05- 0.86; P=0.03; I2=52%; within 120 minutes: OR 0.63; 95% CI 0.59- 0.67; P<0.001; I2=64%).

Conclusion: Data included in this meta analysis show that air transport reduces EMS call to PCI time and door to balloon time for STEMI patients. However, for secondary transfer (from a non-PCI center to a PCI-capable center) air transportation was not superior for achieving guideline-recommended goal times. These results may have implications on transport protocols for STEMI patients. Mode of transportation should be individualized based on the distance from the PCI capable center, patient condition and the local environmental condition. Although thrombolytic therapy was mentioned in the introduction, it was not evaluated in this meta-analysis and remains an important consideration in remote or resource-limited settings.

Integration of Clinical Pharmacy into PA Education

2025-01-23T15:26:06+00:00

Introduction

This study integrated a Clinical Pharmacist (CP) into Physician Assistant (PA) student clinical learning and evaluated the outcomes pertaining to pharmacological knowledge and clinical acumen. Literature supports the interprofessional collaboration of pharmacists and PA students within the didactic phase of learning, but this relationship has not yet been evaluated in clinical year.

Methods

Two cohorts from a single institution were asked to voluntarily participate in this study, n=58. Participation consisted of surveys before and after clinical experiences. Students rotating within Family Medicine were randomly selected to the institution clinic where they were scheduled one half-day with the primary care CP.

Results

Utilizing repeated measures MANCOVA analysis for all student participants before and after their clinical year, there was an increased understanding of chronic disease management, common medication dosing, common drug interactions, and the role of a CP (Fs[1, 16] = 4.40, ps < .05). Students who rotated with the CP reported even greater understanding of prior authorization submissions and when to refer or consult with a CP. These students also highly valued learning from a CP during their clinical rotations.

Discussion

We found evidence that incorporating CPs in the clinical curriculum is valued by PA students and associated with their self-reporting of greater understanding of pharmacological knowledge and how to work with CPs. This study is limited by the small sample size, length, and assessment of perceived increased knowledge, however, demonstrates promise that small amounts of dedicated learning with a CP can positively influence pharmacological learning.