Mercy Clinic Neurology

Constrictive pericarditis (CP) results from persistent or insufficiently controlled pericardial inflammation arising from diverse etiologies. It remains a challenging clinical condition, typically presenting with non-specific symptoms that demand a high degree of clinical suspicion and meticulous imaging assessment. As CP progressively impairs both left- and right-sided cardiac function, it can lead to overt heart failure and a marked decline in quality of life, making early recognition crucial. Multimodality imaging plays an essential role in the diagnostic and prognostic evaluation of CP, enabling distinction from restrictive cardiomyopathy (RCM), detection of active pericardial inflammation, and guidance of therapeutic decision-making. Echocardiography provides key hemodynamic insights, including ventricular interdependence and respiratory variation in flow patterns. Cardiac Computed Tomography (CT) offers high-resolution delineation of pericardial thickening and calcification, while Cardiac magnetic resonance (CMR) allows comprehensive characterization of pericardial anatomy, myocardial-pericardial coupling, and inflammatory burden through late gadolinium enhancement (LGE) and parametric mapping. Additionally, positron emission tomography (PET) imaging can identify metabolically active inflammation, aiding in determining the suitability of medical therapy versus pericardiectomy. By integrating these complementary modalities, clinicians can achieve greater diagnostic precision, refine risk stratification, and tailor management strategies, ultimately improving outcomes for patients with constrictive pericarditis.

Abstract Background: Breast cancer is the most common non-cutaneous malignancy among women, with around 10% of cases involving germline mutations in DNA repair genes. Germline mutations in BRCA1/2 genes significantly increase breast cancer risk. Other relevant genes to increase the risk of breast cancer include TP53, PTEN, PALB2, CHEK2, and ATM. Multigene panel testing can sequence many genes, sometimes identifying non-disease-related genes and variants of unknown significance. Methods: We reviewed patients with newly diagnosed breast cancer diagnosis from 2022 to 2024 in our institution. Germline genetic testing was offered to all newly diagnosed breast cancer patients at the time of diagnosis irrespective of their family history. Testing was offered to patients with invasive breast cancer and ductal carcinoma in situ. The goal of this study was to identify the prevalence of genes not attributed to increasing the risk of breast cancer and the implications of those results. Results: A total of 478 patients (Invasive cancer and DCIS) were seen in our oncology clinic from January 2022 to December 2024. The median age at diagnosis was 66 years (range 28-91). Invasive ductal cancer (IDC) was the most common subtype (66%), followed by DCIS (18%). Most patients had estrogen-positive cancer (81%), and approximately 14% had HER2-positive disease (62% HER2 low). We found 27 patients with pathogenic germline mutations which are not related to breast cancer risk. The most common mutation was MUYTH (7 patients), followed by FH gene (3 patients). MSH3, LZTR1, and HOXB13 genes were each found in 2 patients. APC, BAP1, BLM, BRIP1, NTHL1, SDHA, SDHB, MSH6, MITF, and FLCN genes were each identified in one patient. All patients with MUYTH mutations had hormone-positive (HER 2 negative) disease contrary to the limited observation of triple-negative breast cancer related to the MUYTH gene in the available literature. Patients with positive mutations were offered genetic counseling and referred to a high-risk genetics' clinic. FANCM was observed in one patient which has rarely been associated with an increased risk of triple-negative breast cancer. Conclusion: We present our single institution's experience of germline mutations in breast cancer patients. Previously, we observed CHEK2 being the most common breast cancer-related germline mutation in our patient population. This analysis focuses on identifying germline mutations without an increased risk of breast cancer. MUTYH was the most common pathogenic mutation identified. Further studies are needed to determine the actual risk percentage of breast cancer associated with the MUTYH gene. Universal testing for all breast cancer patients is feasible with the lower cost of multi-gene panels. However, identifying other non-disease-related genes, as observed in our study, has implications. Patients must be informed about the consequences of a positive result, including genetic counseling, additional screening tests, and testing of immediate family members. Citation Format: M. Zafar, M. Krishnakumar, A. Reddy. Non-breast cancer related germline mutations in breast cancer patients: a single institution experience [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS3-05-18.

Facet incompetency can lead to altered spine biomechanics. However, while total posterior arthroplasty techniques in lieu of fusion are of increasing interest, unilateral techniques are yet to be investigated. This study aimed to assess the biomechanical effect of a unilateral facet arthroplasty (UFA) system on motion and loading characteristics at the treated L4-5 level. Seven cadaveric spines from L3-Sacrum were tested within the multidirectional pure moment bending model between 0 to ± 10 Nm in flexion-extension (FE), flexion-extension with 400 N of compressive follower load (FE-FL), axial rotation (AR), and lateral bending (LB). We measured the L4-L5 angular range of motion, the intradiscal pressure, and the contralateral facet contact force. Each specimen was tested in intact (I), capsulotomy (C), medial facetectomy (MF), total facetectomy (TF), and UFA conditions. We also measured the load transfer at the bone-implant interface in the UFA condition. UFA significantly restored 93% (FE), 77% (FE-FL), 123% (AR), and 106% (LB) of the native range of motion (p<.05). UFA significantly restored the native intradiscal pressure during compressive follower load (I:173±67KPa vs. TF:103± 82KPa vs. UFA:174±69KPa), and partially during contra-axial rotation (I:32±27KPa vs. TF:81±55KPa vs. UFA:59±46KPa). No significant changes were observed in facet contact force. Contra-axial rotation induced the most substantial loads transferred through the bone-implant interface. UFA is most effective at restoring native intervertebral disc load transfer without altering facet loading at the treated level. UFA is equivalent to the intact condition in FE, FE-FL, and LB, but larger in AR, even after reverting 55% of induced instability.

Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.

Introduction: Pancreatic duct stents (PDS) are widely used for the prevention of post-ERCP pancreatitis and for pancreatic endotherapy in chronic pancreatitis patients. Several commercially available PDS are commonly utilized. However, there is a paucity of data regarding the adverse events associated with PDS placement. This study aims to investigate the reported adverse events and device failures related to PDS, utilizing the Manufacturer and User Facility Device Experience (MAUDE) database maintained by the U.S. Food and Drug Administration (FDA). Methods: Post-marketing surveillance data from January 2010 to May 2023 were extracted from the FDA's MAUDE database to analyze the outcomes associated with PDS. Reports pertaining to the use of commonly used PDS including Advanix (Boston Scientfic), Geenan (Cook endoscopy), and Zimmon (Cook endoscopy) pancreatic stents were analyzed. The primary outcomes of interest were device problems and patient-related adverse events. Statistical analysis was performed using Microsoft Excel 2010, with calculation of pooled numbers and percentages for each device and patient adverse event. Results: During the study period, a total of 540 device problems and 582 patient-related adverse events were identified. Device failures (Figure 1) were primarily attributed to device or usage problems (n=145, 26.9%), followed by off-label use (n=144, 26.7%), and material or component issues (n=120, 22.2%). The most common patient-related adverse events were reported as having no harm or consequences to patients (n=400, 68.7%). Other reported patient adverse events included inflammation (n=24, 4.1%), perforation (n=16, 2.7%), foreign body presence (n=14, 2.4%), and pancreatitis (n=10, 1.7%). The highest number of device failures was associated with Zimmon pancreatic stents (n=217, 40.2%), followed by Geenen pancreatic stents (n=216, 40%) and Advanix (n=107, 19.8%). Device or usage problems were most frequently reported with the use of Zimmon stents (n=79, 36.4%), followed by Geenen stents (n=60, 27.8%). Conclusion: Most reported device-related issues were attributed to device or usage problems, and the majority of device failures did not result in harm to patients. Information from this study can be used in improving pancreatic duct stent designs for future iterations.Figure 1.: A) Device Failures associated with pancreatic stents. B) Patient-related adverse Events associated with pancreatic stents. Device or Use Problems (Adverse Event Without Identified Device or Use Problem, no apparent adverse events, Use of Device Problem, Improper or Incorrect Procedure or Method, Device Operates Differently Than Expected), Activation, Positioning or Separation Problem (Activation Failure, Activation, Difficult or Delayed Positioning, Positioning or Separation Problem, Positioning Failure, Positioning Problem), Material or Component Problems (Break, Material Deformation, Material Integrity Problem, Material Puncture/Hole, defective device, component failing, fracture), Device Markings or Packaging Problems (Device Markings/Labelling Problem, Device Packaging), Difficulties with Device (Difficult to Advance, Difficult to Remove, Device Difficult to Setup or Prepare, failure to advance), Migration (Migration or Expulsion of Device, Migration, Detachment of Device or Device Component), Sterilization (Problem with sterilization, Contamination /Decontamination Problem), Others (Entrapment of Device, Retraction Problem; Stretched, off label use, biocompatibility, fluid/blood leakage, appropriate code not available, insufficient information, obstruction of flow, leak/splash) Pain related (Abdominal pain/pain/implant pain), Bleeding-related (Bleeding/hemorrhage, blood).

Objectives: Children and adolescents with medical complexity benefit from care coordination and specialized pediatric care, but many access barriers exist. We implemented a virtual wraparound model to support patients with medical complexity and their families and used an economic framework to measure outcomes. Methods: Children with medical complexity were identified and enrolled in a virtual complex care program with a dedicated multidisciplinary team, which provided care coordination, education, parental support, acute care triage, and virtual visits. A retrospective pre- and postanalysis of data obtained from the Hospital Industry Data Institute (HIDI) database measured inpatient, outpatient, and emergency department (ED) utilization and charges before implementation and during the 2-year program. Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate. Conclusions: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.

Diarrhea is a common symptom in medical practice that often gets overlooked. This article is intended to increase the awareness of physicians and other providers on a subtle but important cause of chronic diarrhea.