Hackensack University Medical Center

We report a pediatric case of severe isolated mitochondrial myopathy because of the rare m.3251A>G variant of the MT-TL1 gene. A 7-year-old boy presented to the hospital with acute-on-chronic weakness and respiratory insufficiency. Initial laboratory tests were notable for elevated lactate, aldolase, and lactate dehydrogenase. Despite a negative autoimmune panel, he was presumed to have myositis and treated with steroids and intravenous immunoglobulin. He continued to deteriorate, eventually requiring intubation and ventilation. Muscle biopsy revealed numerous ragged red fibers, abnormal intracellular lipid droplets with no lymphocytic inflammation, and increased succinate dehydrogenase reactivity, reflecting mitochondrial proliferation in many fibers. Steroids were discontinued, and he was started on a mitochondrial cocktail of cofactors with clinical improvement. Genetic testing identified the m.3251A>G variant, confirming primary mitochondrial disorder. This case expands the known phenotype of the m.3251A>G mutation. We also discuss clinical and histopathological differences between mitochondrial and inflammatory myopathies.

Introduction: Acute eosinophilic pneumonia (AEP) is a rare, rapidly progressive pulmonary disorder that can lead to acute respiratory failure requiring ICU-level support and invasive mechanical ventilation (IMV). Although case reports and small series have described its clinical course, national-level data on hospitalization patterns, illness severity, and resource utilization remain limited. We aimed to fill this research gap. Methods: We analyzed adult hospitalizations with a primary diagnosis of AEP(ICD-10 codes) from the 2022 Nationwide Readmissions Database. Survey weights were applied to generate nationally representative estimates. Illness severity was categorized into three mutually exclusive groups: floor admission, ICU admission without intubation, and ICU admission with intubation. Primary outcomes included in-hospital mortality, length of stay (LOS), and total hospital charges. Seasonal variation and the prevalence of comorbid asthma and gastroesophageal reflux disease (GERD) were also assessed. Descriptive statistics and survey-weighted subgroup comparisons were performed. Results: A total of 10,035 weighted hospitalizations (n = 3,912 unweighted) were identified. The median age was 60 years (IQR: 45–72), and 61.2% of the participants were female. Asthma and GERD were significantly more prevalent in AEP hospitalizations compared to non-AEP hospitalizations (58.9% vs. 7.0% and 30.8% vs. 16.2%, respectively; p < 0.001). AEP discharges peaked in November (18.5%), with seasonal clustering from June to October and less frequent from January to March. ICU admission occurred in 42%, and 14.1% required IMV. LOS ranged from 4.8 to 8.0 days, and charges from $59,198 to $170,057, increasing with severity. Mortality was 0.24% (floor), 0.26% (ICU without IMV), and 4.18% (ICU with IMV). Conclusions: In our study, AEP hospitalizations show a clear severity-outcome gradient, with higher ICU use, ventilation need, mortality, and cost as illness advances. These findings highlight AEP as a resource-intensive condition with a substantial impact on survival in severe cases. Although asthma and GERD were common, their impact on outcomes was not assessed, and treatment data were not available. Early recognition and triage based on severity may reduce resource burden and improve outcomes.

BACKGROUND Central nervous system (CNS) manifestations of tuberculosis (TB) account for approximately 1-2% of all TB cases worldwide. Tuberculomas, which are granulomatous lesions of the CNS diagnostically confirmed through biopsy, can mimic more common intracranial pathologies, including abscesses and neoplasms. This report describes a patient with pulmonary TB who presented with seizure and was ultimately diagnosed with a right temporal lobe TB mimicking a brain abscess. CASE REPORT A 30-year-old woman with alcohol use disorder, polysubstance use, and pulmonary TB previously treated with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) presented to the emergency department (ED) following a generalized seizure. Anti-tuberculous therapy had been interrupted for several months due to alcohol-related hepatotoxicity. Prior imaging demonstrated a small right temporal lobe lesion, which subsequently enlarged and developed rim-enhancing features after RIPE therapy was interrupted. Given the diagnostic uncertainty and her clinical course, neurosurgical intervention was pursued. Craniotomy with surgical exploration and biopsy revealed necrotizing granulomas and a Ziehl-Neelsen stain confirmed acid-fast bacilli (AFB), confirming intracranial tuberculoma. Postoperatively, she was restarted on a modified anti-tuberculous regimen. CONCLUSIONS Intracranial tuberculoma should remain a key differential diagnosis for ring-enhancing lesions, even in immunocompetent patients and in low-incidence regions. Further, it underscores the importance of maintaining therapy continuity to prevent disease progression. Importantly, when response to therapy is uncertain or adherence is questionable, clinicians should maintain a low threshold for deciding to perform early biopsy to confirm the etiology.

As robotic total knee arthroplasty (TKA) adoption grows, the learning curve for new users remains a concern for both physicians and staff. Previous studies have reported on clinical outcomes for TKA with a novel implant-agnostic, handheld, wireless robotic TKA system (rTKA). This study investigates the rTKA adoption learning curve relevant to multiple clinical stakeholders. This multicenter, multi-surgeon observational study includes up to the first 25 rTKA procedures by 7 surgeons. Observers noted timing and workflow at 8/25 rTKA cases and 2 standard-of-care benchmark TKAs (prior manual or robotic use by user), and analyzed logs for all rTKA cases. Learning curves were assessed via benchmark TKA time neutrality, statistical comparison between early and later cases, and cumulative sum (CUSUM) analysis. Surgeon and staff surveys followed each observed rTKA case. Each analysis type demonstrated a different learning curve duration: surgeons averaged approximately 10 cases to time neutrality, with 2 not reaching time neutrality within the observed case series. Cases 3 and onward were significantly faster than cases 1–2 (p = 0.0454), indicating early operative time improvement after initial system exposure. Average observed skin-to-skin time was 68 min. Surgeons and staff rated the system easy to use and were familiar with the system after 4 cases. Use of the handheld surgical robot for rTKA demonstrated a short learning curve and high reported ease of adoption by surgeons and staff. This study demonstrates the rTKA system exhibits a short learning curve and high reported ease of adoption, and may compare favorably with previously reported learning curves for other robotic TKA systems. Level of evidence: IV.

Neuromodulation is a rapidly advancing field in pain medicine, providing targeted, reversible interventions for patients with chronic pain unresponsive to conventional therapies. Advances in waveform technology, device design, and stimulation strategies have shifted neuromodulation from a last-resort approach to a core element of multidisciplinary pain management. Despite its growing adoption, variability in training, terminology, and clinical implementation underscores the need for consensus-driven frameworks to ensure safety, efficacy, and uniformity across practice settings. This review aims to define current and emerging concepts in neuromodulation, summarize the supporting evidence, and offer clinicians an evidence-informed framework for individualized application in chronic pain management. Narrative review. We conducted a comprehensive synthesis of neuromodulation strategies spanning spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRGS), peripheral nerve stimulation (PNS), motor cortex stimulation (MCS), deep brain stimulation (DBS), and targeted drug delivery (TDD). The review integrates data from published studies and reviews to cover emerging concepts, classifications, indications, technological advancements, device features, clinical applications, and practical guidance for patient-specific decision-making. Over the past decade, neuromodulation use has expanded significantly, driven by technological and mechanistic innovations. Peripheral nerve stimulation (PNS) has become increasingly precise for focal neuropathic pain, demonstrating efficacy in migraine, hemiplegic shoulder pain, persistent spinal pain syndrome, post-amputation neuropathic pain, trigeminal neuralgia, plexus injuries, and multifidus dysfunction. SCS remains a mainstay for widespread neuropathic pain, including CRPS, painful diabetic neuropathy, and post-surgical syndromes, with innovations such as 10-kHz high-frequency and burst stimulation offering paresthesia-free analgesia and improved patient satisfaction. DRGS provides targeted relief for localized neuropathic pain, including post-herniorrhaphy and post-thoracotomy syndromes, with more predictable outcomes. Neurophysiological refinements, including differential target multiplexed (DTM) stimulation and closed-loop systems with evoked compound action potential (ECAP) feedback, enable real-time spinal control and consistent analgesia. Multiphase and surround-inhibition paradigms further enhance segmental coverage, energy efficiency, and rapid analgesic onset. TDD has evolved into a precise adjunctive therapy, with programmable pumps delivering morphine, baclofen, and ziconotide safely, minimizing systemic exposure while allowing individualized dosing. Collectively, these innovations support precision-guided, personalized neuromodulation with durable efficacy and improved patient-centered outcomes across diverse chronic pain conditions. Heterogeneity in published evidence and the lack of large-scale, head-to-head randomized trials for certain waveforms and technologies limit the conclusions of this review. Neuromodulation continues to advance at the intersection of neuroscience, bioengineering, and clinical practice. Harmonizing definitions, classifications, and education will guide future innovation and help ensure that neuromodulation fulfills its promise of safe, effective, and equitable patient care.