SSM Health Rehabilitation Hospital

Mechanical circulatory support (MCS) devices can be helpful to maintain hemodynamic stability during high-risk percutaneous coronary intervention (PCI). Iliofemoral arterial disease limits the use of transfemoral MCS devices. Impella 5.5, a surgical transaxillary MCS device, represents a viable option for MCS-protected PCI. We report a 74-year-old man with prior endovascular aneurysm repair (EVAR), severe peripheral artery disease (PAD), and newly diagnosed NSTEMI was found to have three-vessel and left main coronary disease with an ejection fraction (EF) of 13%. Due to aortoiliac occlusion, transfemoral MCS was not feasible. Instead, an Impella 5.5 was implanted via a right axillary artery graft, enabling successful orbital atherectomy and bifurcation PCI. In summary, axillary Impella 5.5 insertion is a viable option in anatomically complex patients where femoral access is contraindicated. This approach allows full left ventricular hemodynamic support for revascularization in otherwise inoperable patients.

The growing incidence of carbapenem-resistant Enterobacterales (CRE) poses a challenge to clinical practice. Despite some Klebsiella pneumoniae carbapenemase (KPC)-positive Enterobacterales testing as susceptible to cefepime, in vivo data show that cefepime is not a reliable treatment option for infections caused by carbapenemase-producing CRE (CP-CRE). Contemporary guidance recommends against cefepime use for the treatment of KPC-positive infections; however, the clinical implications of this practice are unknown. Here, we present a case of clinical failure after cefepime treatment for a KPC-producing Escherichia coli urinary tract infection that tested as cefepime-susceptible in vitro that was successfully treated with ceftazidime/avibactam. This case is concordant with the in vivo PKPD findings that the presence of KPC blunted the microbiologic activity of human-simulated cefepime exposures despite MICs that would suggest susceptible or susceptible dose-dependent (SDD) interpretation. This case adds to the growing literature supporting the use of carbapenemase testing for Enterobacterales isolates that demonstrate resistance to one or more carbapenems to guide therapy. Until confirmatory clinical data are available, clinicians and laboratorians must consider selective reporting or other strategies in the setting of contradictory phenotypic susceptibility data and genotypic resistance markers.

IntroductionLateral medullary infarction (LMI) can present with dysphagia, dysphonia, dysarthria, vertigo, nausea, skew deviation, and ipsipulsion. Patients may also exhibit sensory loss and ipsilateral Horner’s syndrome. LMS often develops because of an acute infarct from the vertebral arteries or posterior inferior cerebellar arteries (PICA). The most common mechanism of stroke usually is atherothrombosis, followed by cardioembolic, dissection and embolic source of undetermined source (ESUS). While dysphagia often accompanies the constellation of LMS symptoms, it is rarely the first symptom and has only been reported in a few cases in the literature. In this report we describe the case of a man in his 40s with acute onset dysphagia as the presenting finding ahead of an LMS diagnosis.MethodsThe patient was identified in routine clinical practice.ResultsA man in his 40s with medical history of HTN, type 2 DM and polycystic kidney disease, presented with sudden‐onset dysphagia which started while he was drinking alcohol. Later he noticed that he was unable to keep his balance. His National Health Institute Stroke Scale was 4. Neurologic exam was pertinent for left‐sided miosis, ptosis, and dysmetria. Pinprick and temperature sensation were decreased on the right arm and leg. Facial sensation to light touch was diminished on the left. Brain MRI showed an acute infarct in the left lateral medulla (Figure A). CTA showed calcified atherosclerosis of the V4 segment of left vertebral artery (Figure B). Mechanism of ischemic stroke was artery to artery thromboembolism from the left V4 segment of vertebral artery. For secondary prevention, dual antiplatelet therapy, high intensity statin, and optimization of his risk factors were initiated.ConclusionThis case report demonstrates that dysphagia can be the initial symptom of an acute ischemic stroke. Diagnosis and recognition of an atypical presentation of lateral medullary syndrome can pose a particular challenge especially in this era of “time is brain” but is of the utmost importance to facilitate good outcomes. Patients presenting with dysphagia who have risk factors for stroke and no other obvious etiology for their symptoms should be worked up for possible cerebrovascular etiology.

Scholarly activity among students, residents, and faculty provides the foundation for medical education. However, a decline in the number of physician-scientists has been acknowledged during the past few decades. As a result, institutions have attempted to increase research activity among students and residents through a variety of means. This study describes a replicative model for medical institutions to increase their research enterprises among medical students, residents, and faculty. Des Moines University College of Podiatric Medicine and Surgery (DMU-CPMS) developed a Strategic Research Plan (SRP) to increase scholarly activity in the college. The SRP outlined an innovative model to increase research activity, including creating a Director of Research position, modifying the existing curriculum toward an evidence-based focus, increasing extracurricular research opportunities, and fostering collaborative research efforts among students, residents, and faculty. After SRP implementation, an increase in scholarly activity was observed. In the 6 years before implementing the SRP, DMU-CPMS published 11 manuscripts. In the 6 years after initiating the SRP, manuscript publications increased to 50. During this same period, podium presentations at scientific meetings increased from 6 to 40, and students listed as lead author increased from 0 to 16. The SRP provides a replicative model for medical institutions seeking to increase their research enterprises through collaboration among students, residents, and faculty. To our knowledge, this is the first study to demonstrate a research plan aimed at increasing scholarly activity among a comprehensive scope of individuals in medical education.

Anti-synthetase syndrome (AS) is a heterogeneous group of systemic autoimmune diseases associated with anti-aminoacyl-transfer RNA synthetases. These inflammatory myopathies present with a constellation of symptoms including myositis, arthritis, Raynaud’s phenomenon, and interstitial lung disease (ILD). We present a novel case of a 44-year-old female, who presented with Anti-OJ AS with severe myopathy and rhabdomyolysis without evidence of ILD, which, in our literature review and to the best of our knowledge, has not been previously reported. Furthermore, our patient was initially misdiagnosed, highlighting the paucity of cases and physicians’ unfamiliarity with this disease. After her diagnosis was confirmed, the patient was successfully treated with high-dose steroids and transitioned to azathioprine, and she continues to do well. This case report emphasizes a novel presentation of the rarely diagnosed AS. We also discuss the significant overlap between the inflammatory myopathies and consolidate relevant pathophysiology and current trends in the management of this disease.

Malreduction of a distal fibular fracture can lead to degenerative changes in the ankle joint. Previous studies have shown that the selective use of various fibular reconstructive osteotomies may halt the progression of degenerative arthritis by restoring the normal tibiotalar contact area and decreasing the stresses on the articular cartilage. In this case report, we achieved alignment with restoration of the talocrural angle and Shenton's line of the ankle using a transfibular osteotomy and an allogeneic fresh-frozen femoral head graft to fill the resultant defect. The advantage of this procedure is twofold. First, fibular-lengthening procedures may potentially decrease the eventual need for joint-sacrificing procedures such as an arthrodesis or arthroplasty. Second, an allograft allows for larger deficit correction without concern for donor-site morbidity. To our knowledge, this is the first case report using a fresh-frozen femoral head allograft for a fibular-lengthening osteotomy in the podiatric medical literature. Further research with larger patient populations is needed to establish whether fresh-frozen femoral head allograft is a reliable graft option for fibular-lengthening procedures.