Baylor Scott & White All Saints Medical Center

Cryptococcal meningoencephalitis (CM) is an infection of the brain and spinal cord caused by Cryptococcus species, an opportunistic fungus. Immunocompetent patients who present with subtle or nonspecific symptoms may experience a delayed diagnosis of CM. We present a case of a 25-year-old immunocompetent woman who arrived with severe headache, fever, and mild meningeal symptoms. Initial infectious and imaging studies were unrevealing, and lumbar puncture revealed an elevated opening pressure with normal cerebrospinal fluid indices. Despite lacking conventional risk factors, she was found to have a positive Cryptococcus antigen in serum on two repeated tests. Her workup did not identify an underlying immunodeficiency. A later careful re-evaluation of the history revealed that she had exposure to backyard poultry. She improved gradually with antifungal therapy and was discharged on long-term fluconazole. This case illustrates the diagnostic complexity of CM in patients without overt immunosuppression and emphasizes the importance of considering fungal meningitis in the differential diagnosis of persistent or atypical headaches. Increased awareness of these presentations is critical, as timely recognition and early antifungal treatment remain essential to reducing morbidity and preventing neurologic complications.

Nucleoside analogue (NA) prophylaxis is given indefinitely after liver transplantation for chronic hepatitis B. We evaluated whether antiviral therapy can be discontinued after vaccination with the immune adjuvanted HepB-CpG vaccine. Two groups of liver recipients discontinued NA when anti-HBs levels were >100mIU/mL. Group 1 had previously received 3 doses of vaccine and were given periodic vaccine boosters to maintain this anti-HBs level. Group 2 participated in a 48-week protocol where the same 3-dose series was followed by 1 or 2 boosters based on anti-HBs level at week 20. HBV recurrence was considered to be the reappearance of both HBsAg and HBV DNA by conventional methods of detection. Selected sera in both groups were analyzed for pregenomic (pg) RNA and HBsAg by an ultrasensitive qualitative assay. Twenty liver recipients taking NA prophylaxis were included, 5 in group 1 and 15 in group 2. Most were over age 60 and were transplanted more than 10 years previously. Fifteen (75%) were withdrawn from NA after vaccination, 4 in group 1 and 11 in group 2. Fourteen (93%) remained free of recurrence during a median period of 41.3 months (group 1) and 12 months (group 2). Transient recurrence occurred in a group 1 participant found to have pregenomic RNA 18 months earlier. Another group 1 individual failed vaccination but was found to be pregenomic RNA and HBsAg positive in all samples. One group 2 participant was HBsAg positive at baseline by the ultrasensitive assay and subsequently developed mild self-limiting viremia after NA discontinuation. Discontinuation of NA is frequently possible after HepB-CpG vaccination. Long-term protection is sustainable with periodic boosters. New biomarkers for HBV allow earlier detection of underlying viral transcription and may promote better understanding of vaccine failure.

Placenta accreta spectrum disorder is a condition that is rare but is becoming more common due to the increase in cesarean rates. Placenta accreta spectrum disorder is known to have high morbidity and mortality rates due to its increased risk of hemorrhage. These surgical cases are complex and need to have a robust multidisciplinary team to decrease the risk of potential complications. Due to the complexity of this diagnosis, the plan of care must involve coordination of several specialties and roles as well as ensuring the patient has adequate education and explanation regarding the plan of care. A placenta accreta spectrum disorder navigator was implemented to ensure optimal communication, equipment and team readiness, and a standardized approach to planning for patients with this diagnosis. An anonymous survey was sent to team members following placenta accreta spectrum disorder cases to evaluate their experiences, comparing results from before and after the implementation of the nurse navigator role. The survey included responses from 11 team members in pre implementation and 21 post implementations. Post-implementation data showed improvements in communication, role clarity, and teamwork. Reviewing pre- and post-survey data, along with feedback from discussions and debriefs, revealed that implementing a placenta accreta spectrum disorder navigator improved communication and team efficiency. Data showed enhancements in provider experiences and a reduction in action items from debriefs.

Abstract 26-74% of microplastics are derived from tire rubber and is a large contributor to environmental pollution. While infrastructure contributes to environmental pollution, it equally contributes to pathogenesis of pulmonary disease. Industry workers, particularly in tire manufacturing plants, are susceptible to pulmonary fibrosis and interstitial lung disease (ILD), with studies showing almost half of ILD cases secondary to microplastics. This case highlights the effect of exposure in industry workers over time. A 63-year-old gentleman with remote history of smoking presented to the emergency department with worsening shortness of breath. He was diagnosed to have chronic obstructive pulmonary disease exacerbation, imaging revealed interstitial pattern. He was treated with steroids and with improvement in symptoms. High resolution computed tomography showed evidence of interstitial lung disease. Further questioning revealed that patient reported a 20+ year history of working in a tire shop with exposure to buffed tire dust and autoshop particulates without proper protection. Patient had multiple outpatient visits for 10 years due to recurrent sinusitis. Imaging in the past demonstrated atypical lung disease, which was attributed to chronic sinobronchitis. Pulmonary function test prior to admission demonstrated obstructive disease. While signs of ILD were noted for over 6 years, due to confounding factors, there was delay in further evaluation. He was discharged on 6L oxygen. He presented again to the ED for worsening dyspnea and acute on chronic hypoxia. During this admission, he was unable to be weaned off high flow nasal cannula and discharged to long term acute care for aggressive physical therapy and oxygen management. He was intubated at the facility and returned due to inability to wean from ventilator. He subsequently passed after family decided on compassionate extubation. Talc is commonly used in the tire industry; however, exposure to this substance can cause granuloma formation and subsequent ILD. Our patient was working in the tire industry for more than 20 years with recurrent symptoms of inflammatory processes. Based on imaging, his disease process started in the upper lobe and progressed diffusely throughout the parenchyma. The pathogenesis of microplastics resulting in ILD is not well understood, but is becoming more evident that chronic inflammation from microplastic inhalation can contribute to development of severe ILD over time. Our case highlights the role of environmental tire fiber exposure in the development of ILD. Regulations on occupational hazards of exposure to microplastics need to be further explored and education to workers to be further enhanced.

Abstract Rationale: Each year, about 1.6 million people in the US discover a new pulmonary nodule, often turning to search engines or artificial intelligence (AI) tools like ChatGPT, OpenEvidence AI, and Google Gemini for information. This study evaluates and compares the accuracy, consistency, and readability of their responses to nonexpert questions about pulmonary nodules. Methods: Three authors presented 30 nonexpert questions regarding pulmonary nodules to ChatGPT 4, OpenEvidence AI, Google Gemini, Google search, and Bing. Each answer was judged to be correct, partially correct, incorrect, or unanswered. Consistency was judged based on whether all three answers aligned, regardless of accuracy. Logistic regression analysis assessed the association between response accuracy and consistency with each AI tool, using Google Gemini as the standard of comparison. Readability was measured using the Flesch Reading Ease Score and Gunning Fog Index. Results: Of the 90 answers given by OpenEvidence AI, 69 (76.7%) were correct, 12 (13.3%) partially correct, and 9 (10.0%) incorrect. ChatGPT answers were rated 67 (74.4%) correct, 17 (18.9%) partially correct, and 6 (6.7%) incorrect. Google Gemini answers were assessed as 42 (46.7%) correct, 30 (33.3%) partially correct, and 18 (20.0%) incorrect. The Google search engine answered 64 (71.1%) correct, 18 (20.0%) partially correct, and 8 (8.9%) incorrect. Bing's search engine answered 25 (29.4%) correct, 34 (40.0%) partially correct, 26 (30.6%) incorrect, and 5 unanswered. ChatGPT and Google's search engine were over 5 times (OR = 5.714, P=.0044) more likely to provide correct answers compared to Google Gemini. Likewise, OpenEvidence was 4.6 times (OR=4.571, P=.0094) more likely to provide correct answers than Google Gemini. Logistic regression with response consistency indicated ChatGPT and OpenEvidence both have higher odds of consistent responses compared to Google Gemini, but this association was not statistically significant. The average Flesch-Reading Ease Scores were 40.78 (±3.76) for Google, 38.67 (±2.29) for Google Gemini, 38.32 (±5.05) for Bing, 33.83 (±1.82) for ChatGPT, and 19.89 (±2.04) for OpenEvidence. The Gunning Fog Indexes were 13.39 (±0.31) for ChatGPT, 13.72 (±0.41) for Google Gemini, 14.22 (±1.20) for Google, 15.01 (±1.60) for Bing, and 19.66 (±0.56) for OpenEvidence. Conclusion: OpenEvidence and ChatGPT were more accurate than Google Gemini. They also had higher, but not significant, odds of consistency. None of the tools answered at the recommended sixth to eighth grade level for patient health information. OpenEvidence's answers were the most complex at a college graduate level while the lowest complexity was ChatGPT at a college level.

BackgroundData regarding change in neurocognitive function after transcatheter aortic valve replacement (TAVR) are conflicting. We sought to investigate the change in cognition up to 6 months post-TAVR in patients with mild cognitive impairment (MCI).MethodsThis is a prospective, observational, nonrandomized, cohort study of patients with MCI who underwent TAVR between February 2022 and June 2023 in a multicenter health care system. The inclusion criteria were TAVR patients with MCI, defined as a score of ≤25/30 on the Mini Montreal Cognitive Assessment (Mini MoCA) exam. The Mini MoCA exam was evaluated pre-TAVR, 30 days post-TAVR, and 6 months post-TAVR.ResultsOf 81 enrolled TAVR patients, 73 (90.1%) and 66 (81.5%) completed 30-day and 6-month post-TAVR MoCA exams, respectively. The median age was 81 (IQR: 75.0-86.0) years and 47.4% were male. At baseline, history of stroke, transient ischemic attack, and dementia were 17.3, 9.9%, and 9.9%, respectively. The Mini MoCA scores showed a small but significant increase from the preoperative assessment to the 30-day interval (21.0 [17.5-22.5] vs. 22.0 [18.5-24.5]; p < ​0.001) and was improved in 64.4% of patients. At 6 months, the Mini MoCA scores were increased in 89.4% of patients and had an absolute and significant increase of 2.3 points compared to preoperative assessment (23.3 [20.5-25.0] vs. 21.0 [17.6-22.9], p < ​0.001).ConclusionsAmong patients with baseline MCI undergoing TAVR, neurocognitive function as measured by the Mini MoCA exam significantly improved at 30 days and 6 months postprocedure. TAVR in the setting of MCI is a safe therapeutic option for patients with aortic valve disease.

Pressure injuries (PIs) pose a significant health burden, particularly among hospitalised patients. Understanding the sociodemographic factors influencing length and cost of hospital stay is crucial for addressing healthcare disparities. This study investigated the associations between sociodemographic factors and hospital stay outcomes among patients with pressure injuries in the United States from 2009 to 2019. Using the National Inpatient Sample (NIS), we analysed data from 1,252,729 patients with pressure injuries. We performed survey-weighted multivariable linear regression to assess the impact of sociodemographic factors on hospital stay duration and costs. Minority racial groups, lower-income patients, and those with non-Medicare insurance experienced longer hospital stays and higher costs. Older age groups (≥30 years) had shorter stays and lower costs. Significant disparities exist in hospital outcomes for patients with pressure injuries. Targeted interventions are needed to address these inequalities and improve patient care.