United States

Introduction
Emergent endovascular abdominal aortic aneurysm repair (EVAR) in ruptured or symptomatic patients is often performed in patients with sub-optimal aortic anatomy. Our aim was to assess outcomes of emergent EVAR in patients with various neck morphologies.

Methods
Using the Vascular Quality Initiative, we conducted a retrospective review of patients who underwent EVAR from 2003-2023. We categorized patients by urgency (elective, symptomatic, ruptured) and neck morphology (short/narrow, short/wide, long/narrow, long/wide), excluding patients with incomplete data. Neck length under 15mm was short; neck diameter over 28mm was wide. Primary outcomes were Type 1A endoleaks and conversion to open repair. Secondary outcomes were AAA sac diameter change and short- and long-term mortality. Multivariable logistic regression was used to assess the relationship between neck group (long/narrow as reference group) and each primary outcome, controlling for demographic factors and presence of type 1B endoleak for each urgency setting separately. 

Results
78,239 patients underwent EVAR: 66,313 (84.76%) elective, 7,055 (9.02%) symptomatic, 4,871 (6.2%) ruptured. 30,912 patients had data on urgency and neck anatomy. Average age was 73 years. 81.4% were male.
In multivariable analysis, symptomatic patients with short/wide (OR3.43 p=0.0016) and short/narrow (OR2.75 p&lt;0.0001) necks had increased odds of Type 1A endoleak; in ruptures, short/narrow necks (OR3.32 p=0.0002) had higher odds. Conversion to open repair was higher in rupture (2.91%) than symptomatic (0.5%) and elective (0.3%). Conversion was not significantly associated with neck group in any setting. 
Symptomatic patients had a median decrease of 6mm in sac diameter (range -89 to +46mm) at median follow up of 413 days. At median follow-up of 403 days, patients with ruptured aneurysms had a median sac diameter decrease of 11mm (range -107 to +62mm). There was no significant difference in sac diameter change between neck groups (p&gt;0.05).
Patients with ruptures and short/narrow necks had lowest survival probability while those with long/narrow necks had highest survival probability at one year (63.75 vs 74.86%, respectively; p&lt;.0001).

Conclusion
Neck morphology remains an important factor in outcomes of EVAR performed in emergent settings. In symptomatic and ruptured aneurysms undergoing EVAR, short/narrow necks performed the worst with increased rates of Type 1A endoleaks and decreased survival.

AMA Research Challenge 2024 

Impact of Neck Morphology on Outcomes of Emergent Endovascular Aneurysm Repair

Introduction
Emergent endovascular abdominal aortic aneurysm repair (EVAR) in ruptured or symptomatic patients is often performed in patients with sub-optimal aortic anatomy. Our aim was to assess outcomes of emergent EVAR in patients with various neck morphologies.

Methods
Using the Vascular Quality Initiative, we conducted a retrospective review of patients who underwent EVAR from 2003-2023. We categorized patients by urgency (elective, symptomatic, ruptured) and neck morphology (short/narrow, short/wide, long/narrow, long/wide), excluding patients with incomplete data. Neck length under 15mm was short; neck diameter over 28mm was wide. Primary outcomes were Type 1A endoleaks and conversion to open repair. Secondary outcomes were AAA sac diameter change and short- and long-term mortality. Multivariable logistic regression was used to assess the relationship between neck group (long/narrow as reference group) and each primary outcome, controlling for demographic factors and presence of type 1B endoleak for each urgency setting separately. 

Results
78,239 patients underwent EVAR: 66,313 (84.76%) elective, 7,055 (9.02%) symptomatic, 4,871 (6.2%) ruptured. 30,912 patients had data on urgency and neck anatomy. Average age was 73 years. 81.4% were male.
In multivariable analysis, symptomatic patients with short/wide (OR3.43 p=0.0016) and short/narrow (OR2.75 p<0.0001) necks had increased odds of Type 1A endoleak; in ruptures, short/narrow necks (OR3.32 p=0.0002) had higher odds. Conversion to open repair was higher in rupture (2.91%) than symptomatic (0.5%) and elective (0.3%). Conversion was not significantly associated with neck group in any setting. 
Symptomatic patients had a median decrease of 6mm in sac diameter (range -89 to +46mm) at median follow up of 413 days. At median follow-up of 403 days, patients with ruptured aneurysms had a median sac diameter decrease of 11mm (range -107 to +62mm). There was no significant difference in sac diameter change between neck groups (p>0.05).
Patients with ruptures and short/narrow necks had lowest survival probability while those with long/narrow necks had highest survival probability at one year (63.75 vs 74.86%, respectively; p<.0001).

Conclusion
Neck morphology remains an important factor in outcomes of EVAR performed in emergent settings. In symptomatic and ruptured aneurysms undergoing EVAR, short/narrow necks performed the worst with increased rates of Type 1A endoleaks and decreased survival.

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The opioid epidemic has adversely affected neonates and children; but the scope and mechanisms of these affects are not well understood. Failure to understand the impact of prenatal opioid exposure on long term adverse health outcomes could lead to gaps in care for this population. The purpose of this study is to investigate the association of prenatal opioid exposure with the development of adverse respiratory health outcomes, both acute and chronic. We propose that prenatal exposure leads to increased odds of development of childhood asthma, respiratory distress, apnea, and bronchiolitis. This is a retrospective cohort study using the PearlDiver Mariner database and a simple match design. Records from preterm and full-term infants exposed to opioids in utero are analyzed separately for the development of adverse health outcomes. Our preliminary results indicate that opioid exposure in utero results in preterm birth. In full-term infant births, opioid exposure leads to increased odds for developing respiratory distress (OR = 7.54), bronchiolitis (OR = 4.12) and apnea (OR = 1.58). Lastly, diagnoses for adverse respiratory outcomes were earlier in full-term opioid exposed infants than in their unexposed controls. The significance of this study is that it will encourage closer monitoring of full-term infants who are exposed to opioids in utero for specific respiratory outcomes and provide conceptual grounding for future mechanistic studies.



Prenatal opioid exposure impacts respiratory outcomes within the first 5 years of life

Recurrent Mucosal Melanoma: Clinical Complexities and Socioeconomic Barriers
Ishita Gupta Kaushal, Arshdeep Singh, Le Yen Ly Nguyen, Pragti Garg, Raziullah Riaz, Ajaybir Singh Buttar, Chandan Sona Bevara,Youngsang You, Ansa Ali, Onkardeep Kaur, Aparna Malireddi, Ratesh Khillan MD

Background
Mucosal melanoma of the oral cavity (MMO) constitutes less than 1% of all melanomas. The majority of MMO occur in upper alveolus and hard palate (70%) followed by lower alveolus. The etiology, risk factors and pathogenesis for MMO are poorly understood. Patients with MMO can present with bleeding, local discoloration, facial pain, ulceration, with localized swelling being the most common. Due to the diversity of initial symptoms and histological pleomorphism, immunohistochemical staining is crucial to confirm the diagnosis. Mucosal melanoma (MM) has a very poor prognosis and most patients develop incurable metastatic disease, irrespective of surgical excision.
Due to poor prognosis, staging starts from T3 for lesions confined to mucosa and adjacent soft tissue and T4 for moderately advanced and very advanced lesions, as recommended in 8th edition of AJCC. For tumors limited to mucosa, NCCN recommends postoperative radiotherapy within 6 weeks of resection with consideration for systemic therapy.
In this study, we present a unique case of a 64-year-old Hispanic female with multiple recurrences of MMO.

Case presentation
A 64-year-old Hispanic female presented to our clinic with a possible recurrence of malignant melanoma of hard palate. It started as an irregularly shaped discoloration of gums and the hard palate. She underwent 3 surgical resections in her home country. Adjuvant chemo and radiotherapy were recommended, which proved to be financially challenging.
On presentation to our clinic, she had a tender bluish patch approximately 1 cm in diameter with ulcers on hard palate and a soft bluish bumpy left upper gum lesion approximately 1 cm in diameter, which bled on touching. Following the punch biopsies and various radiographic studies, left maxillectomy was done, the pathology report and immunohistochemistry of which confirmed stage ypT3N0 residual malignant melanoma. Again, patient could not undergo adjuvant chemo and radiotherapy due to financial constraints.

Discussion
Due to the condition’s rarity, rapid progression, and hence delayed diagnosis and poor prognosis, it is essential to complete the treatment regimen, which includes surgical resection followed by chemo and radiotherapy. This case shows the inequitable distribution of medical resources in patients with low socioeconomic status. The lack of medical insurance can hinder patient care in basic cancer treatment like surgery and radiotherapy. This issue is of even greater relevance in the treatment of cancer which is rapidly debilitating and fatal. Even in instances of potentially curable cancers, socioeconomic status, lack of available therapies and cultural stereotypes can impede treatment.

Recurrent Mucosal Melanoma: Clinical Complexities and Socioeconomic Barriers

Background:
Dog bites are a well-known mode of transmission for Capnocytophaga canimorsus. However, patients rarely present with meningitis. The few reported individuals experience high fevers and have concerning rates of neurological sequelae upon recovery. Common risk factors include a compromised immune system, alcoholism, and animal exposure. Although most patients recover with sufficient antibiotic treatment, the selected course varies widely. Here, we present an unusual case of brain infarction and subarachnoid hemorrhage in addition to Capnocytophaga canimorsus meningitis.

Case Presentation:
A 74-year-old man with history of seizures, hypertension, and smoking presented to our hospital with a one-day history of malaise and after being found unresponsive by his wife. Upon arrival to the hospital, he was found to have seizures, a high fever of 39.1°C, and hypoxemia requiring 4 L of oxygen via nasal cannula. The patient received levetiracetam, ceftriaxone, and vancomycin. Lumbar puncture was performed and yielded cloudy cerebrospinal fluid (CSF) with a WBC count of 1185 cells/mm3 (98% polymorphonuclears), glucose of 9 mg/dL, and protein of 417 mg/dL. Gram stain revealed gram-negative bacilli, and the culture showed Capnocytophaga canimorsus susceptible to ceftriaxone (MIC 0.25), with low MICs for ciprofloxacin, meropenem, and penicillin. Brain MRI showed multiple embolic infarcts and subarachnoid hemorrhage. Transthoracic echocardiogram showed no vegetations. The patient was treated with 4 weeks of intravenous ceftriaxone and clinical follow up showed clinical improvement after antibiotic treatment.

Discussion:
In the case presented, this individual required longer antibiotic treatment than the reported median of 15 days. Of the three prior reported cases with acute brain infarction during infection, two had lingering neurological issues and also required bilateral lower extremity amputation. A hyperinflammatory state, vasospasm, and activation of the coagulation cascade have all been hypothesized to contribute to the association between bacterial meningitis and cerebral infarction. This known complication in meningitis has severe repercussions for the long-term recovery of patients. Prompt recognition and treatment is vital to limb salvage and optimal neurological recovery.

A rare case of Capnocytophaga canimorsus meningitis with acute cerebral infarct and subarachnoid hemorrhage

Introduction:
Klebsiella pneumoniae is a well-described etiology of pyogenic liver abscess (PLA) in patients from Southeast Asia, but rarely outside of that region. We present a rare case of Klebsiella PLA in Eastern Long Island in a patient with no travel history to Southeast Asia.

Case Presentation:
A 71-year-old Puerto Rican male with PMH diabetes, hepatitis C s/p treatment presented with dull, non-radiating right lower quadrant pain associated with non-bloody non-bilious vomiting and intermittent fevers for 2 weeks. He denied other previous gastric or hepatobiliary disease or malignancy, abdominal trauma/surgeries, alcohol use, IV drug use, history of pancreatitis or liver transplant, PPI use, or any travel history in the last 15 years. On examination, T 102.8°F, BP 126/86, HR 96, RR 27, SpO2 99% on RA; he had tenderness in the right lower quadrant. Labs showed normal WBC and hepatic function, and mildly elevated alkaline phosphatase at 142. CT abdomen/pelvis with oral and IV contrast showed a liver mass (Figure 1). Subsequent MRI abdomen with and without IV contrast (Figure 2) demonstrated a 6.1 x 6.9 x 6.9 cm posterior right hepatic lobe abscess. He was admitted for sepsis secondary to liver abscess and started on broad-spectrum antibiotics. The abscess was drained and fluid culture subsequently grew Klebsiella pneumoniae. The patient improved clinically during the remainder of the hospitalization and was discharged on four weeks of oral levofloxacin.

Discussion:
Pyogenic liver abscesses (PLA) are pus-filled masses that can develop after hematogenous spread from an intraabdominal infection, bacteremia, or nearby liver injury. The incidence of pyogenic liver abscess is about 2.3 cases per 100,000 people and has been well-described in Southeast Asia – especially in Taiwan. Klebsiella pneumoniae PLA has been reported in Taiwan since the 1980’s with more than 900 cases identified, as compared to only 50 cases in Western countries from the 1990’s to early 2000s. In another extensive literature review, only 93 cases were found in the United States from 1949 to 2016. 80% of PLA cases found Klebsiella pneumoniae as the predominant bacteria, as compared to non-Eastern Asian countries, where E. coli and Streptococcus species predominate. Risk factors include diabetes, history of hepatobiliary infection or colorectal cancer, abdominal trauma or surgeries. Clinical features include fever, right upper abdominal, nausea and vomiting. Labs may show leukocytosis, hyperbilirubinemia, elevated ALP/ AST. MRI with IV contrast is the most sensitive study. Treatment involves drainage and antibiotic therapy, with good prognosis.

Conclusion:
Clinicians should keep rare etiologies in mind for patients who present with liver abscesses.


But I Never Went to Southeast Asia! A Rare Case of Klebsiella penumoniae Pyogenic Liver Abscess in Eastern Long Island

Fournier's gangrene (FG) is an uncommon and life-threatening necrotizing fasciitis affecting the perineum and genital region. This condition typically involves polymicrobial infection of the deep soft tissues and fascial planes. FG occurs more frequently in diabetic patients due to impaired immune function, hyperglycemia, microvascular complications, peripheral neuropathy, or genital and urinary infections. In this case, it is observed that it can also develop in a non-diabetic individual, presenting a considerable diagnostic and treatment challenge.

Fournier’s Gangrene in a Non-Diabetic Female Presenting with Severe Hypoglycemia: A Case Report

Introduction
Early administration of intramuscular epinephrine can be life-saving in the acute management of anaphylaxis. Rarely, intracranial hemorrhage (ICH) can occur after epinephrine use due to rapid elevations in blood pressure. We report a rare case of a man who developed ICH following epinephrine injection for acute anaphylaxis.
Case Description
A 70-year-old man with end-stage renal disease on dialysis, hypertension, and diabetes presented to the emergency department with a 1-month history of left ear pain. He had no prior history of anaphylaxis, intracranial hemorrhage, stroke, or allergies. Initial vital signs showed blood pressure of 203/87 mmHg. Physical exam revealed left edematous ear canal and mastoid tenderness, with no focal neurologic deficits. Suspected mastoid infection prompted a CT temporal bone scan with contrast, which was consistent with otomastoiditis and showed no evidence of intracranial hemorrhage or other intracranial pathology. Empiric antibiotic treatment was given with cefepime and vancomycin. Within 10 minutes of initiating vancomycin infusion, he developed shortness of breath and tongue/facial swelling, with blood pressure 152/116 mmHg. The patient then rapidly decompensated, developing altered mental status, bradycardia (30 bpm), hypoxia (40% O2 on pulse oximetry), and minimally palpable pulse. Anaphylaxis was suspected, and 0.3 mg intramuscular epinephrine, diphenhydramine, and dexamethasone were given. A repeat BP 5 minutes later showed hypertension up to 261/102 mmHg. Due to altered mental status and for airway protection, an emergent surgical airway was established with subsequent blood pressure 114/108 mmHg twenty minutes after sedation and ventilation with tracheostomy tube. Patient was subsequently admitted to the intensive care unit. Four days later, MRI brain with/without contrast for evaluation of osteomyelitis showed incidental bilateral intraventricular hemorrhage and acute pontine hemorrhages, confirmed stable by subsequent CT six hours later. Patient had no neurologic deficits and was discharged to a rehabilitation facility 35 days later with a tracheostomy collar.
Discussion
First-line treatment of anaphylactic shock is administration of epinephrine; however, adverse events can occur. Epinephrine can cause short term elevations in systolic blood pressure. Factors that can cause precipitation of intracranial hemorrhage include platelet dysfunction in the setting of chronic kidney disease with dialysis and hypertensive urgency. Physicians should be aware of ICH as a rare cerebrovascular complication of epinephrine injection in the setting of anaphylaxis, particularly in elderly patients with hypertension and high bleeding risk.

Intracranial Hemorrhage Following Epinephrine Injection for Anaphylactic Shock: A Rare Complication 



Abstract Title:
Navigating Anaplasmosis: A Case Report Highlighting Diagnosis and Treatment
Background:
Human Granulocytic Anaplasmosis caused by Anaplasma phagocytophilum is an emerging concern in the United States, spread by Ixodes scapularis and Ixodes pacificus in the Northeastern and Midwestern regions and in the Western regions, respectively. Tick-borne infections are increasingly reported during the summer months, especially in Pennsylvania. Lyme disease remains the most reported tick-borne illness in the state. Anaplasmosis presents unique challenges due to its nonspecific clinical manifestations and potential to mimic other tick-borne diseases. Preventing tick bites prevents the spread of infections.
Case Presentation:
The case of a 68-year-old male patient highlights the critical importance of recognizing and diagnosing anaplasmosis promptly. He presented to the ED with sudden onset high-grade fevers at 103°F, chills, abdominal pain with nausea and vomiting, and generalized weakness. His heart rate was 105/min and BP was 146/87 mm Hg. Fever panel was negative. With alarming findings such as profound thrombocytopenia (platelets decreasing from 102 K/mcL to 56 K/mcL within a day), transaminitis, and elevated CRP levels at 322.1 mg/dL, admission for suspected sepsis of unclear origin was necessitated. Empirical treatment with IV Doxycycline, Atovaquone, and Azithromycin was initiated to cover potential tick-borne infections. Radiological investigations, including CT scans and echocardiography, were unremarkable, further complicating the diagnostic process. The patient's history of living in wooded areas, owning dogs, and previous deer rearing raised suspicion for a tick-borne illness, despite no recollection of a recent tick bite. Definitive diagnosis was achieved through a tick-borne PCR panel, which confirmed Anaplasma phagocytophilum infection. This gram-negative intracellular bacterium selectively infects neutrophils, leading to the characteristic intracytoplasmic inclusions known as morulae, observed on peripheral blood smear. Given the patient's old age, he was at increased risk for severe complications such as systemic inflammatory response syndrome and multiorgan failure. Following a five-day course of IV Doxycycline, the patient's clinical status improved with resolution of fever and thrombocytopenia. He was discharged on oral Doxycycline and Atovaquone, emphasizing the importance of timely intervention and appropriate antimicrobial therapy in managing anaplasmosis.
Discussion:
This case underscores the challenges in diagnosing tick-borne illnesses, particularly in non-endemic regions with limited awareness. Heightened clinical suspicion due to drastic thrombocytopenia, prompt empirical treatment, and utilization of specific diagnostic tools such as NAAT/Tick-borne PCR panels are crucial in achieving favorable patient outcomes. Early recognition of clinically compatible symptoms associated with thrombocytopenia remains paramount in combating the rising incidence of tick-borne infections across the United States.



Navigating Anaplasmosis: A Case Report Highlighting Diagnosis and Treatment

Background 

Patients with Limb Girdle Muscular Dystrophy (LGMD) and other RYR1 variants present unique challenges to the anesthesiologist because of muscle weakness and potential for malignant hyperthermia (MH). We describe the anesthetic management of a patient with LGMD and a potentially difficult airway. 

Case Presentation 

A 55-year-old male with LGMD and no prior exposure to anesthesia presented for resection of colon cancer. The patient’s LGMD predominantly affected his shoulders. Pre-anesthesia examination and routine blood tests were within normal limits. While LGMD is not associated with difficult airways, there was concern for one because of the patient’s small mouth opening and beak-shaped mouth and jaw. Thus, an awake-fiberoptic intubation was performed and the airway was secured with a 7.0 mm endotracheal tube. The anesthesia team took precautions for MH and used a new anesthesia machine to avoid triggers. In the operating room, the patient was positioned at 45 degrees and semi-reclined. Maintenance of anesthesia was achieved with total intravenous anesthesia (TIVA) with propofol, dexmedetomidine, fentanyl, and paralysis with rocuronium. The patient was managed conservatively in the postoperative period and extubated without incident the following day. 

Discussion 

Literature on safe anesthetic management of LGMD is limited. In this case report, we highlight the successful use of TIVA in avoiding MH triggers, and the use of awake-fiberoptic intubation as an effective technique for securing a difficult airway in a patient with LGMD. 
Inhaled anesthetics and succinylcholine are contraindicated in LGMD patients because of an increased risk of developing MH, rhabdomyolysis, and hyperkalemia [1]. Using TIVA avoids the triggers of MH while maintaining appropriate anesthetic depth. Interval measurement of lactate and CK are also important in monitoring for development of MH. Dantrolene should be readily available for suspected MH. 
LGMD increases the risk of respiratory compromise under anesthesia, particularly since muscle relaxants can further exacerbate existing respiratory weakness. Awake-fiberoptic intubation requires thorough pre-anesthesia airway assessment and planning, preserves spontaneous ventilation, and mitigates the risk of respiratory decompensation associated with muscle relaxation, allowing for a controlled and gradual approach to securing the airway. In this case, a thorough airway assessment revealed potential challenges (limited mouth opening, and beak-shaped mouth and jaw) that could have complicated conventional intubation. Anticipation of potential airway challenges and advanced planning for an awake-fiberoptic intubation ensured a safe intubation and successful anesthetic for this patient.

Anesthetic Challenges of a Patient with Limb Girdle Muscular Dystrophy

Although uncommon, the loss of artificial valve components during surgery has been documented in the literature. If a valve fracture occurs intraoperatively, parts of the valve can either remain within the heart cavities or migrate distally into the thoracoabdominal aorta or aortic bifurcation. When the disc fragments, it may be found in the iliac, femoral, or even popliteal arteries. Historically, computed tomography (CT) scans have proven more effective in locating these fragments compared to plain radiography, angiography, and ultrasound.

Missing Aortic Valve Leaflet in Double Valve Replacement Surgery

Background
Pacemaker implantation is routine in modern day medicine, with nearly one million performed annually worldwide, and 200,000 in the United States alone. Despite being so commonplace, cardiac device implant can be associated with serious complications which require awareness for prevention and appropriate treatment. We present an unusual case of pneumomediastinum, pneumopericardium and contralateral pneumothorax following pacemaker implantation.

Case Presentation
A 71-year-old male with a history of coronary artery disease requiring multiple stents, ischemic cardiomyopathy causing heart failure with mildly reduced ejection fraction (40-45%), abdominal aortic aneurysm requiring endovascular aorta repair, hypertension, type II diabetes, and atrial fibrillation presented to the hospital after a significant conversion pause was noted by event monitoring. He subsequently underwent dual chamber pacemaker placement via the left subclavian vein with creation of a left chest wall pocket; insertion of the ventricular lead in the left bundle branch area was noted to be challenging requiring multiple attempts. However, the dual chamber pacemaker implantation was otherwise routine without immediate complications. Proper lead position was confirmed via fluoroscopy.

The patient was admitted overnight for observation. The following morning, routine chest x-ray discovered a right apical pneumothorax and pneumomediastinum. Subsequent CT chest revealed moderate-volume right pneumothorax and pneumopericardium, with the atrial lead extending into the right pleural space. The right atrial lead tip bored through the atrium into the lungs, creating a channel leading to communication between lung parenchyma, pleural space and the pericardium. The surgery service subsequently placed a right-sided chest tube. Imaging the next day demonstrated resolution of pneumothorax and pneumopericardium. The chest tube was removed the following morning, with the patient remaining asymptomatic throughout his post-procedural recovery. Due to concern for potential dislodgement or further extension of the right atrial lead into the right pleural space, it was successfully extracted prior to discharge. 

Discussion
This case represents an unusual mechanism of pneumothorax after pacemaker implant, which typically occurs due to inadvertent lung puncture ipsilateral with vascular access. Patients with pneumothorax and pneumopericardium may initially present asymptomatically, then later develop symptoms days later including pleuritic chest pain and shortness of breath. Findings may not be readily apparent on chest x-ray depending on burden of air and may require lead removal or repositioning. Clinicians must maintain a high index of suspicion when thoroughly analyzing post-procedural images.

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Impact of Neck Morphology on Outcomes of Emergent Endovascular Aneurysm Repair

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