Kaweah Delta Health Care District

Background: Transcranial magnetic stimulation (TMS) is an emerging noninvasive treatment modality for various psychiatric disorders, but its applications in child and adolescent populations remain underexplored. This review aims to synthesize current evidence on the therapeutic potential of TMS in treating psychiatric conditions within this demographic. Methods: A comprehensive literature search was performed using PubMed and Google Scholar databases to identify studies published up to March 2025 that reported on the use of transcranial TMS in child and adolescent psychiatric disorders. Results: We found 32 published studies that included at least one type of TMS. TMS demonstrates potential as a safe and effective intervention for conditions such as depression, autism spectrum disorder, attention-deficit/hyperactivity disorder, obsessive–compulsive disorder, Tourette Syndrome, and childhood schizophrenia. However, the therapeutic outcomes vary significantly across conditions and protocols. Conclusions: TMS offers a promising, well-tolerated option for addressing psychiatric disorders in children and adolescents, but its application requires careful ethical and clinical consideration. To fully realize its potential, future research should focus on refining protocols, standardizing methodologies, and ensuring safety while expanding its use across diverse psychiatric conditions in younger populations.

Ultrasound-guided pericapsular nerve group (PENG) blocks are a type of regional nerve block that has gained increasing popularity for providing effective analgesia in patients with hip fractures. This retrospective case series evaluated the safety and effectiveness of Ultrasound-Guided PENG blocks using Ropivacaine 0.2% performed by emergency physicians in a single institute. Patients were enrolled between May 2019 and June 2021. The procedure was performed by emergency medicine attendings and ultrasound fellows. The patients were part of a convenience sample, with the procedure performed when an attending physician or ultrasound fellow was present in the emergency department and available to perform the procedure. We conducted a single-center retrospective analysis of 13 PENG blocks performed by emergency medicine attendings and ultrasound fellows. This was done at our emergency department, which sees approximately 90,000 patients per year. All patients received between 1 and 3mg/kg of Ropivacaine 0.2% with a max dosage of 120mg (60cc). Patient demographics, procedural details, complications, and pain outcomes were recorded. There is a significant mean (p = 0.007) reduction in pain level of 2.9 when comparing the post-test measurements to the pre-test measurements. This was confirmed by a non-parametric approach, which also found a significant reduction in the median difference (p = 0.009). This was further explained by a non-significant Shapiro-Wilk test, which found no significant evidence of non-normality (p = 0.499). (see Table1). Among the 13 PENG blocks performed, there were no complications. Examples of known complications of regional nerve blocks include local anesthetic systemic toxicity (Barrington and Kluger 38:289-299, 2013;El-Boghdadly and 63:330-349, 2016;) paresthesias lasting more than 5days 3; paresthesias lasting more than 6months (Welch et al. 111:490-497, 2009); and permanent nerve injury3. None of the 13 blocks performed at our institution had complications. Our findings support the effectiveness and safety of ultrasound-guided PENG blocks performed by emergency physicians using Ropivacaine 0.2%. The high degree of pain relief and the absence of complications in our case series demonstrate that emergency physicians can perform PENG blocks with a high level of competency and safety. This retrospective case series, conducted between May 2019 and June 2021, demonstrates the effectiveness and safety of ultrasound-guided PENG blocks performed by emergency physicians. The high rate of pain relief and lack of complications in our patients who received the PENG block demonstrates the benefits of this technique. We suggest that additional research and randomized controlled trials will help to validate these findings and support the increased use of PENG blocks in the emergency department for the treatment of hip fractures.

Elastofibroma dorsi (EFD) is an uncommon benign tumor of mesenchymal origin that usually occurs in the subscapular region. Bilateral and triple EFD are frequently reported in the literature but cases with more lesions have never been described. Our patient is a 50-year-old female with quadruple locations of bilateral suprascapular and subscapular EFD who presented with left shoulder pain and swelling over the affected area.Clinical presentation, computed tomography (CT)and magnetic resonance imaging (MRI), and biopsy were consistent with EFD. Therapeutic excision was performed and successfully alleviated the patient's discomfort. This report presents the first case of quadruple locations of EFD and highlights the value of MRI in the diagnosis of EFD, especially when there are multiple masses with indistinct marginsare deeply located in the chest wall.

Brevibacterium casei is an extremely rare organism that can lead to peritonitis in End-stage renal disease patients of peritoneal dialysis. Out of only five overall Brevibacterium species peritonitis reported worldwide, only two of them had B. casei subspecies peritonitis detected, with both needing peritoneal dialysis catheter removal and change in dialysis modality to hemodialysis. Our patient, an elderly 63-year-old Hispanic male, was on peritoneal dialysis at home and presented with features suggestive of peritonitis. He was diagnosed subsequently with B. casei and started on broad spectrum intraperitoneal antibiotics. However, he did not need dialysis modality change and recovered fully after 3 weeks of appropriate intraperitoneal antibiotics therapy. Longer antibiotics therapy and frequent clinical follow-up plus better clinician awareness are needed to prevent this rare infection.

Patient: Male, 24-year-oldFinal Diagnosis: Gastroparesis • tetrahydrocannabinolSymptoms: VomitingMedication: —Clinical Procedure: —Specialty: AnesthesiologyObjective:Unusual clinical courseBackground:Tetrahydrocannabinol has been implicated in gastroparesis development, a disorder characterized by delayed gastric emptying in the absence of mechanical obstruction. While most patients with gastroparesis present with upper gastrointestinal symptoms, patients with significantly delayed emptying can be asymptomatic, creating a dangerous aspiration risk.Case Report:A 24-year-old man with a body mass index of 22 presented for right lower extremity open reduction and internal fixation. He endorsed daily marijuana use. His last meal was at 10 PM the prior night. After induction of general anesthesia and laryngeal mask airway (LMA) placement, 150 cc of gastric contents filled the LMA. The LMA was immediately removed and 25 to 50 cc of gastric contents was suctioned from the oropharynx. The airway was immediately secured with an endotracheal tube, after which 500 cc of clear gastric contents was suctioned from the stomach. Bronchoscopy revealed no obvious gastric contents in the tracheobronchial tree. The patient maintained adequate ventilation and oxygenation. He was safely extubated and brought to the post-anesthesia care unit, where recovery was uneventful.Conclusions:Our case raises important questions and considerations for management of THC- dependent patients with potential for impacting NPO guidelines. It is unclear whether the quantity and chronicity of THC use effects gastroparesis development. The patient endorsed no signs of hyperemesis syndrome or gastric fullness; therefore, we cannot reliably deem patients risk-free based on their lack of symptomology alone. Until the true incidence of THC-induced gastroparesis is elicited in further studies, it is prudent to take aspiration precautions in all patients who endorse THC use.

Calcific uremic arteriolopathy, commonly referred to as “calciphylaxis,” is a rare life-threatening condition observed in patients with chronic kidney disease and end-stage renal disease on dialysis. This results in necrotic, ischemic, tender dermal lesions anywhere in the body, but mainly on the abdominal wall and lower extremities, where subcutaneous tissue is abundant. Histologically, it is defined by calcification in dermal capillaries, arterioles, and subcutaneous adipose tissues. It can occur in all advanced stages of chronic kidney disease as well as end-stage renal disease patients on hemodialysis or peritoneal dialysis. Our case highlights a successful case of calciphylaxis in a young female patient who underwent parathyroidectomy and intensification of peritoneal dialysis regimen along with the infusion of sodium thiosulphate injection resulting in complete resolution of the lesion in 3 months. With limited evidence of treatment options and increased frequency of this condition in a dialysis patient, our case highlights the key aspects of calciphylaxis management in a young end-stage renal disease patient who didn’t need a change of dialysis modality. We also review the risk factors and current practiced management options of this condition in our article.

BackgroundAerobic gram-negative rods (GNR) are a common cause of bloodstream infections. While the use of oral antibiotics as step-down therapy for GNR bacteremia is generally accepted, there is debate as to which agents are best. Fluoroquinolones have high oral bioavailability but also have concerns for toxicity, while oral beta-lactams have lower achievable blood concentrations and require more frequent dosing. At Kaweah Delta Medical Center, patients are transitioned from IV antibiotics to oral levofloxacin or cephalexin. The purpose of this study is to determine if these two oral agents are comparable when used as step-down therapy for uncomplicated GNR bacteremia.MethodsThis was a single-center, retrospective study of adult patients who were admitted from May 2018 - May 2019 with a positive GNR blood culture. The primary objective was to assess treatment failure defined as a composite outcome of readmission due to recurrent bacteremia or mortality within 60-days. Secondary outcomes included subsequent Clostridioides difficile infection, emergence of resistant GNR bacteria, and hospital length of stay.ResultsA total of 82 patients met inclusion criteria. The combined median age of both treatment groups was 58.2 years (interquartile range [IQR], 46.7–73.5) and greater than 60% of patients were female. Most patients were Hispanic (45.1%) or non-Hispanic white (43.9%). The most common documented source of GNR bacteremia was the urinary tract (74.4%), and the most frequently recovered organism was Escherichia coli (78.0%). Patients were treated with IV antibiotics for a median treatment duration of 4 days (IQR, 4–5) and oral antibiotics for a median treatment duration of 10 days (IQR, 7.3–11) and 9 days (IQR, 7–11) for cephalexin and levofloxacin, respectively. The composite outcome occurred in 2 patients (4.3%) from the cephalexin group and 0 patients from the levofloxacin group (p=0.50). Positive cultures for resistant GNR were found for 3 patients in the cephalexin group. No patients developed subsequent C. difficile infections.ConclusionPatients who received cephalexin or levofloxacin did not have a significant difference in the composite primary outcome. These findings suggest that oral cephalexin is an effective step-down option to treat uncomplicated GNR bacteremia.DisclosuresAll Authors: No reported disclosures