Princeton Baptist Medical Center

Bilateral eyelid ptosis presents a rare and diagnostically challenging clinical scenario, particularly when accompanied by multiple intracranial lesions. We present the case of a 68-year-old woman with bilateral ptosis, vertical diplopia, and progressive confusion. Imaging revealed a dorsal midbrain lesion and bilateral frontal lobe masses. Clinical examination ruled out common causes of ptosis, such as myasthenia gravis and muscular dystrophies. The patient’s constellation of symptoms, bilateral ptosis without pupillary involvement and vertical diplopia, localized the lesion to the midbrain rather than the cortex. This case highlights the importance of integrating clinical examination with neuroimaging to refine localization in challenging presentations of cranial nerve pathology.

Abstract Background Clostridioides difficile infection (CDI) is a spore-forming anaerobic Gram-positive bacillus and the leading cause of nosocomial infectious diarrhea. 2017 IDSA/SHEA C. difficile guidelines recommend a multistep algorithm approach for CDI diagnosis. This algorithm entails stool testing via enzyme-linked immunosorbent assay (EIA) for glutamate dehydrogenase (GDH) and C. difficile toxins A/B (Tox). Discordant samples are arbitrated by nucleic acid amplification test (NAAT) for tcdB gene. GDH EIA has sensitivities >90%, while Tox EIA has sensitivities ranging from 50-90%. We aimed to evaluate the diagnostic performance of GDH and Tox EIA using the multistep algorithm as the gold standard. Methods We performed a secondary analysis of an inpatient dataset collected in a tertiary community health system in the Southern US, including 9-months of the incident population from 2019 to 2020. All adults ≥ 18-years old from Princeton Baptist Medical Center (Birmingham, AL) tested for C. difficile were included. Alere TechLab C. difficile Quik Chek Complete® was used to determine GDH and Tox EIA, and Alethia C. difficile DNA Amplification Assay®, a NAAT, for discordant samples. CDI case was defined as positivity for Tox and GDH, or positivity of either Tox or GDH in addition to positive NAAT. Retesting within the same admission was allowed. Results Overall, 288 tests were performed. Concordant positivity for GDH & Tox was found in 29 (10.1%) tests; concordant negativity in 226 (78.5%). Discordant positivity for GDH or Tox was observed in 33 (11.5%) tests; all were tested with NAAT. Only 1 of 33 (3.03%) discordant tests was GDH negative & Tox positive, which had a positive NAAT. The remaining 32 (96.97%) discordant tests were GDH positive and Tox negative, of which 18 (56.3%) were positive for NAAT (Table 1). Performance characteristics for the above tests were calculated (Table 2). Table 1:Clostridioides difficile infection case distributions per GDH and ToxinTable 2:Test performance characteristics Conclusion Taking the multistep algorithm as a gold standard, the performance characteristics of GDH and Tox are concordant to previous descriptions in the literature, with GDH being highly sensitive and Tox being highly specific. A diagnostic algorithm lacking GDH and NAAT would miss over one-third of CDI cases. A diagnostic algorithm lacking Tox and NAAT could potentially overdiagnose about one-fifth of tested patients. Disclosures All Authors: No reported disclosures.

BackgroundThe role of extracorporeal membrane oxygenation (ECMO) for patients with refractory respiratory failure due to coronavirus 2019 (COVID‐19) is still unclear even now over a year into the pandemic. ECMO is becoming more commonplace even at smaller community hospitals. While the advantages of venovenous (VV) ECMO in acute respiratory distress syndrome (ARDS) from COVID‐19 have not been fully determined, we believe the benefits outweighed the risks in our patient population. Here we describe all patients who underwent VV ECMO at our center.MethodsAll patients placed on ECMO at our center since the beginning of the pandemic, May 5, 2020, until February 20, 2021 were included in our study. All patients placed on ECMO during the time period described above were followed until discharge or death. The primary endpoint was in‐hospital death. Secondary outcomes included discharge disposition, that is, whether patients were sent to a long‐term acute care center (LTAC), inpatient rehabilitation, or went directly home.ResultsA total of 41 patients were placed on VV ECMO for refractory acute respiratory failure. Survival to discharge, the primary end point, was 63.4% (26/41). Inpatient mortality was 36.6% (15/41).ConclusionsWe show here that a successful high‐volume VV ECMO program for ARDS is achievable at even a medium‐size community hospital. We think our success can be replicated by most small‐ and medium‐size community hospitals with cardiothoracic surgery programs and intensivist teams.

In many developing countries, antimicrobials are available without prescriptions in pharmacies and stores. We performed a survey to describe antimicrobial availability, training, and use recommendations for common symptoms in the Dominican Republic. Pharmacy recommendations varied, whereas aminopenicillins are routinely recommended at bodegas. Frontline staff are gatekeepers and potential targets for stewardship education.

To compare the efficacy and safety of nonvitamin K oral anticoagulants (NOACs) and vitamin K antagonists (VKAs) following bioprosthetic cardiac valve replacement. This was a retrospective analysis conducted at a community teaching hospital in the southeastern United States between August 2015 and August 2018. Patients 18 years of age and older who underwent cardiac valve replacement and were prescribed oral anticoagulation were screened for inclusion. Patients were excluded if they had a mechanical valve replacement, experienced a venous thromboembolism, cerebrovascular accident, or acute coronary syndrome within 1 month before valve replacement, changed oral anticoagulation during the study period, were lost to follow-up, or declined to participate in the follow-up survey. The primary outcome was a composite of thromboembolic events within 90 days following bioprosthetic cardiac valve replacement. The safety outcome was major bleeding within 180 days of bioprosthetic cardiac valve replacement. The primary outcome of a composite of thromboembolic events within 90 days following bioprosthetic cardiac valve replacement occurred in 1 patient (4.3%) in the VKA group and 4 patients (7.4%) in the NOAC group. Major bleeding occurred in 2 patients (8.7%) in the VKA group and 0 patients in the NOAC group. Our study is the first to report the efficacy and safety of NOACs compared with VKA therapy following bioprosthetic cardiac valve replacement irrespective of an atrial fibrillation diagnosis. Notably, two of the thromboembolic events in the NOAC group occurred while therapy was held or inappropriately dosed; when these events are removed, the rate of thromboembolism is 3.8%. This rate is consistent with the VKA group. Our study adds to a small pool of literature regarding the use of NOACs following bioprosthetic cardiac valve replacement and suggests that NOACs may have similar efficacy and improved safety as compared with VKA therapy. Large randomized controlled trials are warranted to confirm our observations.

To describe outcomes after suprasternal (SS) transcatheter aortic valve replacement (TAVR) as a new alternative access approach. There still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. SS-TAVR is a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route. We retrospectively reviewed all patients from New York Presbyterian Hospital, Columbia University Medical Center and Princeton Baptist Medical Center who underwent SS-TAVR from 2015 to July 2018. A total of 84 patients were included in the study. Technical success was achieved in all cases. Thirty-day survival was 98.8% (n = 83). There were minimal complications. Most notably, there were no transient ischemic attacks or strokes (0%, n = 0). Reexploration for bleeding was 3.6% (n = 3), and major bleeding was 1.7% (n = 1). We also achieved satisfactory results with a mean aortic valve gradient of 6.07 ± 3.79 mmHg and an aortic valve area of 2.21 ± 0.51 cm2 . No patients had anything more than mild paravalvular leak. The mean length of stay (LOS) in the intensive care unit was 1.42 ± 1.23 days, and hospital LOS was 4.20 ± 3.29 days. SS access for TAVR is an extremely important technique to have in any valve team's alternative access armamentarium. This technique can be safely and reliably reproduced with any standard hybrid operating room setup and no additional equipment, and it can be used with any commercially available valve system. In the current experience, minimal complications and excellent early term results were obtained.

Objective:This study presents anthropometric data for individuals with high body mass index (BMI). Modified anthropometric dimensions were also developed to address the challenges of obtaining accurate and repeatable data for this population segment.Background:The prevalence of obesity affects approximately 40% of the U.S. adult population. Anthropometric data are needed to guide product design and safety, but few individuals with high BMI have been measured in available datasets.Method:Anthropometric data for a convenience sample of 288 adults with high BMI (≥30 kg/m2) were collected. To increase participation and minimize participant discomfort, measurements were collected at three bariatric weight loss clinics and one academic research institution.Results:The current obese cohort are heavier than the U.S. general population, with a difference in mean body weight of 47 kg for women and 56 kg for men. The obese cohort are also heavier and have a higher BMI compared with the NIOSH (National Institute for Occupational Safety and Health) truck driver population. Waist circumferential measures of the current obese cohort were larger than women or men in either population compared, a result indicative of meaningful body shape differences.Conclusion:To our knowledge, this study is the first to collect anthropometric data for the obese population segment and conduct comparisons to the U.S. general population and available occupational databases. The obese cohort differed substantially with respect to the distributions of anthropometric variables.Application:These data provide insights about the obese population segment that are relevant to product design, and establish a foundation for future data collection efforts.