Jamaica Hospital

Introduction: Intracranial aneurysms (IAs) are focal dilatations of cerebral arteries that carry a significant risk of rupture and subarachnoid hemorrhage (aSAH). Advances in basic science have improved understanding of vascular wall biology, hemodynamic stress, inflammation, and genetic contribution to aneurysm rupture. Rapid progress in neurovascular therapeutics highlights the need to evaluate emerging molecular and pharmacologic strategies targeting IAs. Methodology: This narrative review synthesizes evidence from 2015 to 2025 on the cellular, molecular, and biomechanical mechanisms underlying IA pathophysiology. A structured search of PubMed, Scopus, and Embase identified studies examining molecular pathways, genetic determinants, and therapeutic approaches. Discussion: Aneurysm initiation involves endothelial responses to abnormal shear stress, activating NF-κB, MAPK, and calcium-dependent pathways that promote inflammation, smooth-muscle cell apoptosis, and extracellular matrix degradation. Pharmacologic candidates including MCP-1 antagonists, PPARγ agonists, and IL-6/STAT3 inhibitors reduce inflammatory remodeling, while doxycycline and cathepsin inhibitors preserve matrix integrity. Emerging strategies like microRNA modulation, tyrosine-kinase inhibition, and gene-based delivery offer potential for localized, durable stabilization with minimal systemic toxicity. Conclusions: Integrating surgical and biologic therapies may shift IA management from reactive repair to rupture prevention.

Antiphospholipid antibodies (aPL) are directed against phospholipids and phospholipid-binding proteins. Laboratory assays used to detect aPL include serological tests for aPL against β2-glycoprotein 1, cardiolipin and other molecules, as well as functional assays for lupus anticoagulant. The presence of aPL can lead to endothelial dysfunction or a hypercoagulable state through prothrombotic and antifibrinolytic mechanisms. These processes, often in conjunction with a 'second hit', such as trauma, surgery, or other causes of hypercoagulability or stasis, can lead to venous or arterial thrombosis. The thrombotic risk associated with aPL is best recognized in thrombotic antiphospholipid syndrome, characterized by a persistently positive test for lupus anticoagulant or seropositivity for aPL associated with venous, arterial or microvascular thrombosis. However, aPL seropositivity and its clinical effect on thrombotic events have been increasingly recognized in a broader group of individuals who do not meet traditional research criteria for thrombotic antiphospholipid syndrome. In this Review, we provide an overview of the evidence related to aPL seropositivity in individuals with or without previous thrombosis and the clinical relevance of aPL seropositivity in predicting the risk of thrombotic cardiovascular events. We discuss potential management strategies and identify key knowledge gaps that warrant further research.

Emergency department observation units (EDOUs) have been shown to improve hospital operations and capacity during normal operations; however, their role in a disaster or surge event remains unclear. This is a retrospective case series of hospitals that leveraged an EDOU in the setting of a disaster or surge event. Cases were solicited from members of the American College of Emergency Physicians Observation Medicine Section and a review of published literature. Cases were organized under the context of CBRNE (Chemical, Biological, Radiological, Nuclear, Explosives) and environmental disasters. Seven cases were identified across chemical (2), biological (3), and environmental (2) disaster types. In all instances, EDOUs supported continued ED operational flow, enhanced patient surge capacity, and preserved inpatient resources. Five potential models for an EDOU involvement are described: no change, combine disaster and usual patients in the EDOU, only disaster patients in the EDOU, alternative use of the EDOU, and virtual observation care. There was a variable impact of each model on the flow of hospital observation patients and disaster patients. In the setting of a disaster or surge event, the EDOU can play a significant role in ED and hospital operations. Their adaptability, efficiency, and existing infrastructure make them uniquely suited to respond quickly. Opportunities exist for the integration of EDOUs into hospital disaster planning.

Abstract Motivational interviewing (MI) is a well-established strategy for promoting behavior change, but it has been understudied for older adults with complex health conditions. As part of a holistic patient-centered approach to the care of older patients with multi-complexity, such as those served by home-based primary care (HBPC), use of MI could be instrumental in identifying patients’ priorities, strengthening interdisciplinary care, and engaging patients in managing their own healthcare decisions. A multi-pronged approach to training a home-based primary care team in using MI was undertaken to train HBPC providers in practicing MI regularly during patient care. A gamification teaching strategy was utilized to train 24 members of an interprofessional HBPC in use of MI skills. A 90-minute workshop was comprised of a 30-minute didactic and a 60-minute skills-focused game, led by three MI experts within the team. Participants were asked to complete brief pre- and post-session knowledge checks. The number of participants correctly identifying the stages of behavior change and MI microskills increased from 54% and 75% respectively before the training, to 100% on both concepts after the session. Qualitative feedback was obtained from a focus group conducted with team members after the training highlighted collaboration and feeling valued as positive impacts of using MI. Sustainability efforts following the training included having time during team meetings to share of stories about using MI with patients and building in in-home coaching sessions by MI experts within the team to demonstrate MI skills with patients and help coach staff who requested additional learning.

Case Description: A 69-year-old female with rheumatoid arthritis (RA) on methotrexate, rituximab, and prednisone presented with pleuritic chest pain, fever and cough. Vitals were stable. EKG showed diffuse ST elevation with PR depression, suggestive of pericarditis. TTE showed no pericardial effusion. She was discharged on colchicine. She returned 6 days later with worsening chest pain, dyspnea, and orthopnea. Vitals: BP 96/63 mm Hg, pulse 88 bpm. Exam revealed increased work of breathing, muffled heart sounds, no murmurs, no JVD. EKG showed low-voltage QRS with electrical alternans. CXR revealed bilateral opacities and cardiomegaly. CRP was 18.6 mg/dL, ESR 44 mm/hr, and Mycoplasma IgM was positive. Repeat TTE showed a moderate pericardial effusion (2 cm) near the RV free wall. There was no RV diastolic collapse, but >25% MV E-wave respiratory variation was seen. Cardiology was consulted and she underwent ultrasound-guided pericardiocentesis, draining 450 cc serosanguinous fluid. Fluid analysis showed exudative effusion (WBC 24,194, protein 5.5 g/dL, LDH 1,642). Rheumatology was consulted who suspected immunosuppression-related M. pneumoniae pericarditis. Immunosuppressants were held. She was treated with doxycycline, colchicine, and ibuprofen. With normal follow-up TTEs, pericardial drain was removed. She was discharged in stable condition after 7 days. Discussion: This case demonstrates a cardiac tamponade due to rapid accumulation of moderate pericardial fluid from immunosuppresion-induced Mycoplasma pneumoniae pericarditis. Tamponade may occur with moderate effusions with rapid accumulation or in low-pressure like diuretic-use or dry tamponade post-procedure. Pericardial effusion aetiologies include idiopathic, malignancy, infection, uremia, connective tissue disease, surgery. Viral pericarditis is most common infection, often due to Coxsackievirus or Influenza. Bacterial causes like S. pneumoniae or S. aureus may lead to purulent effusion. M. pneumoniae typically mimics viral pericarditis and may be overlooked. Without Mycoplasma IgM testing, diagnosis and treatment may be delayed. ESC’s 2014 guidance for triaging cardiac tamponade patients recommends urgent pericardiocentesis for scores >6; our patient’s score was 11.5, supporting intervention. This case emphasizes the importance of considering atypical pathogens like M. pneumoniae in immunocompromised hosts with pericarditis and using clinical scoring and imaging for timely intervention.

To evaluate factors influencing slide in statically locked single lag screw cephalomedullary nail constructs for reverse obliquity (RO) fractures. Retrospective comparative study. A multicenter academic urban hospital system (4 hospitals). Patients with an RO fracture (OTA/AO 31A3) treated with a cephalomedullary nail (Gamma or TFNA) and statically locked single lag screw from 2014 to 2024, with at least 1 follow-up radiograph (minimum 3 months or documentation of healing). Lag screw sliding was measured as the difference in screw position between immediate postoperative imaging and final follow-up radiographs. Tip-to-head distance (ΔTHD) and screw protrusion ratio (ΔPR) were recorded. Patients were grouped as <5 mm, 5-10 mm, or >10 mm slide. Comparisons included fracture subtype, nail brand, angle, and length. Bivariate analyses tested associations with slide. Of the 219 patients identified with a 31A3 type fracture, 85 (38.8%) met inclusion criteria. The average age was 81.0 (±9.3) years with 65 (76.5%) women. Mean radiographic follow-up was 19.9 months, with a follow-up range of 74-2576 days. The mean slide was 7.8 mm (±5.2 mm). In total, 74 patients (87.1%) had slide >2 mm. ΔTHD was negligible (-0.1 ± 7.0 mm) and ΔPR 0.2 (±0.1) significantly exceeded 0 ( P < 0.001). Neither nail length (Short: 9.4 ± 5.3 mm vs. Long: 7.1 ± 5.0 mm, P = 0.083), nail angle (125 degrees: 8.0 ± 5.4 mm vs. 130 degrees: 6.5 ± 4.0 mm; P = 0.286), nor nail brand had a significant effect (Gamma: 7.6 ± 5.1 mm vs. TFNA: 9.1 ± 6.2 mm; P = 0.921). Fracture subtype (31A3.1: 9.1 ± 6.1 mm vs. 31A3.2: 10.4 ± 5.1 mm vs. 31A3.3: 6.9 mm ± 4.6 mm; P = 0.114) and demographic factors ( P > 0.05) were not significantly associated with slide severity. Surgeons should expect some degree of lag screw slide and subsequent proximal fragment displacement when a Gamma nail or TFNA nail cephalomedullary nail is used for a reverse obliquity fracture, even when statically locked. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To compare functional outcomes of distal third humeral shaft fractures (OTA 12A-C and 13A2-3) treated with either triceps-splitting or triceps-sparing surgical approach. Secondarily, the purpose was to compare healing and complication rates between the two surgical approaches. A retrospective review of a prospectively collected humeral shaft registry was performed from 01/2018-12/2024. Inclusion criteria was: age > 18yo, OTA 12A-C or 13A2-3 distal third humeral shaft fracture, either triceps-splitting or triceps-sparing surgical approach, and minimum 1-year follow-up. The primary outcome was 1-year postoperative functional status measured using the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcomes measures included surgical time, radiographic union times, union rates, iatrogenic nerve injury, fracture related infection, hardware failure, reoperation, and documented range of motion (ROM) at last follow-up. Univariate analysis with two-tailed Student's t-tests and chi-square tests was used to compare demographics, injury and surgical characteristics. A total of 39 patients met inclusion criteria: 27 (69.2%) underwent a triceps-splitting approach and 12 (30.8%) a triceps-sparing approach. There were no significant differences in baseline demographics. At final follow-up, functional outcomes were comparable. DASH scores were similar between groups (7.7 ± 13.8 vs 7.0 ± 9.0, p = 0.89), as were fracture healing times (5.5 ± 2.2 vs 6.1 ± 3.6months, p = 0.63), with all fractures achieving union. Surgical duration was shorter in the splitting group (83 ± 42 vs 103 ± 52min, p = 0.26), though not statistically significant. No hardware-related complications were reported. Two radial nerve palsies (7.6%) occurred in the splitting group, while one postoperative infection (8.3%) occurred in the sparing group (all p > 0.05). Elbow range of motion was similar. Mean flexion was 137.9 ± 10.0° in the splitting group vs 131.3 ± 30.0° in the sparing group (p = 0.47); mean extension was 2.3 ± 4.7° vs 4.6 ± 5.5°, respectively (p = 0.21). There is no difference in 1-year functional outcomes as measured by the DASH score between the triceps-splitting versus triceps-sparing approach for surgical fixation of the OTA 12A-C and 13A2-3 distal third humeral shaft fractures. Either surgical approach is viable for distal third humeral shaft fractures. Level III.

The purpose of this study is to examine the effect of age on outcomes following repair of acute displaced patella fractures. A total of 248 patients who sustained a displaced patella fracture and underwent open reduction and internal fixation were identified. Patients included underwent a similar operative protocol, were prescribed a standard postoperative protocol of therapy, and were seen at standard follow-up intervals. Patients were divided into groups of <65 years old (young) and ≥65 years old (older). Statistical analysis was run to determine if there was a significant difference in range of knee motion and rate of major complications. Of the 248 patients, 149 were young and 99 were older. The mean age of the old group was 74.5 ± 6.7 and the mean age of the young group was 50 ± 12. Fracture pattern and BMI were the same across the groups. However, the old group had a higher average Charlson Comorbitiy Index (CCI) (p < 0.001). Additionally, the groups had similar length of follow-up (p = 0.693) and similar mean time to radiographic healing (p = 0.533). Older patients had limited knee extension at 6 months compared with young patients (p = 0.031). Finally, old patients had a higher rate of all complications compared with young patients. About 2% of old patients developed a fracture-related infection (FRI), 4% developed a symptomatic nonunion, and 11% were underwent reoperation including removal of hardware, total knee replacement, irrigation and debridement, and manipulation under anesthesia. Complication rates following patella fracture fixation in older patients were worse than young patients, despite having similar injury patterns, surgical treatment, and follow-up. These findings can better inform treating physicians during surgical intervention of older patients with patella fractures.