Southeast Georgia Health System

ABSTRACTPsoriasis is a chronic inflammatory skin condition mediated by T‐helper 1 (Th1) and T‐helper 17 (Th17) cytokines, including interleukin (IL)‐12, IL‐23, IL‐17, and tumor necrosis factor alpha (TNF‐α). Ustekinumab, a human monoclonal antibody against the p40 subunit of IL‐12/23, has revolutionized treatment of moderate to severe psoriasis but carries a risk of opportunistic infections due to impaired cell‐mediated immunity. We describe a 54‐year‐old man from Kentucky with type 2 diabetes and chronic sinusitis, receiving ustekinumab for 1 year for plaque psoriasis. He presented with recurrent pneumonia unresponsive to multiple courses of amoxicillin‐clavulanate, azithromycin, and levofloxacin. Chest imaging consistently demonstrated left lower lobe airspace opacities, initially attributed to nonresolving bacterial pneumonia or possible malignancy. On bronchoscopy with bronchoalveolar lavage, scattered broad‐based budding yeast were visualized, and culture confirmed Blastomyces dermatitidis. The patient was initiated on oral itraconazole, resulting in symptomatic relief and gradual radiographic resolution over 6 months of follow‐up. Although pulmonary blastomycosis is rare (1–2 cases per 100,000 in endemic areas), clinicians should maintain a high index of suspicion for endemic mycoses in immunosuppressed patients on biologic therapies presenting with persistent pulmonary infiltrates. Early invasive diagnostics and targeted antifungal therapy are critical to prevent morbidity and improve outcomes.

IntroductionDeveloping and implementing trauma clinical guidance is integral to providing quality care to all trauma patients while maintaining a minimum standard of treatment. A mixed-methods novel consensus-building approach was used to identify the current barriers to developing and implementing trauma clinical guidance and highlight the priority areas for change to better support end users.MethodsAs part of year 1 of the Design for Implementation: The Future of Trauma Clinical Guidance and Research Conference Series, preconference participant surveys and hybrid, professionally facilitated, structured dialogue were used to define the ideal future state of trauma clinical guidance development and dissemination. Novel to this context, in-person and virtual “user stories”, a form of structured focus group, were generated, and a “minimum viable product” (MVP), a form of brokered dialogue, was developed. Descriptive statistics and thematic analysis were used to evaluate preconference survey and “user story” results.Results72 in-person and up to 35 virtual attendees participated. The majority (92%) of in-person attendees and nearly half (48%) of virtual attendees completed the preconference survey. Participants identified barriers along the continuum of clinical guidance development, dissemination, and adoption. Areas for improvement centered around the creation, storage, and use of guidance. Across the survey and user stories, participants expressed the need for clinical guidance that is comprehensive, evidence-based, coordinated, and easily accessible by all clinicians both domestically and abroad. The MVP targeted the risks and objectives to improved guidance. A prominent theme throughout this consensus-building assessment was the imperative for collaboration between professional societies for clinical guidance development and dissemination.DiscussionTrauma clinical guidance must be current, consolidated, and coordinated with patient-centered outcomes prioritized. Next steps include turning the MVP produced into a prototype and refining it to inform a national redesign of trauma clinical guidance.Level of evidenceLevel III.

Psychiatrists frequently incorporate strategies learned in their psychotherapy training into medication visits. This final installment in a 4-part series focuses on the integration of pharmacotherapy and cognitive-behavioral therapy (CBT), which is the most extensively studied form of psychotherapy for depressive and anxiety disorders. Evidence supporting the value of combined treatment (as compared with pharmacotherapy alone) is strong, but these data come almost exclusively from studies in which the 2 components of treatment were delivered by separate providers. Data are sorely lacking for the integrated approach described in this paper. We hope that the apparent face validity of this approach is evident and helps to foster a new generation of pragmatic research addressing issues that are truly relevant to the contemporary practice of psychiatric medicine, including the possibility that it is more cost-effective when a single provider delivers both modalities.

BACKGROUND. Coronary artery calcium (CAC) scoring is used to stratify acute coronary syndrome (ACS) risk. Nonetheless, patients with a CAC score of zero (CAC0) remain at risk from noncalcified plaque components. OBJECTIVE. The purpose of this study was to explore CTA-derived coronary artery plaque characteristics in symptomatic patients with CAC0 who subsequently have ACS through comparisons with patients with a CAC score greater than 0 (CAC> 0) who subsequently have ACS as well as with patients with CAC0 who do not subsequently have ACS. METHODS. This study entailed a secondary retrospective analysis of prior prospective registry data. The international multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry collected longitudinal observational data on symptomatic patients who underwent clinically indicated coronary CTA from January 2004 to May 2010. ICONIC (Incident Coronary Syndromes Identified by CT) was a nested cohort study conducted within CONFIRM that identified patients without known coronary artery disease (CAD) at the time of CTA who did and did not subsequently have ACS (i.e., the ACS and control groups, respectively) and who were propensity matched in a 1:1 ratio on the basis of CAD risk factors and CAD severity on CTA. The present ICONIC substudy selected matched patients in the ACS and control groups who both had documented CAC scores. CTA examinations were analyzed using artificial intelligence software for automated quantitative plaque assessment. In the ACS group, invasive angiography findings were used to identify culprit lesions. RESULTS. The present study included 216 patients (mean age, 55.6 years; 91 women and 125 men), with 108 patients in each of the ACS and control groups. In the ACS group, 23% (n = 25) of patients had CAC0. In the ACS group, culprit lesions in the subsets of patients with CAC0 and CAC> 0 showed no significant differences in fibrous, fibrofatty, or necrotic-core plaque volumes (p > .05). In the CAC0 subset, patients with ACS, compared with control patients, had greater mean (± SD) fibrous plaque volume (29.4 ± 42.0 vs 5.5 ± 15.2 mm3, p < .001), fibrofatty plaque volume (27.3 ± 52.2 vs 1.3 ± 3.7 mm3, p < .001), and necrotic-core plaque volume (2.8 ± 6.4 vs 0.0 ± 0.1 mm3, p < .001). CONCLUSION. After propensity-score matching, 23% of patients with ACS had CAC0. Patients with CAC0 in the ACS and control groups showed significant differences in volumes of noncalcified plaque components. CLINICAL IMPACT. Methods that identify and quantify noncalcified plaque forms may help characterize ACS risk in symptomatic patients with CAC0.

Title: Diagnostic Dilemma of Culture Negative Infective Endocarditis in the Setting of Intermittent Complete Heart BlockAuthors: Gabriel Velez Oquendo, MD1; Nivedha Balaji, DO1; Sheriff N. Dodoo, MD2; Shalabh Chandra, MD3

Endoaortic balloon occlusion (EABO) and transthoracic cross-clamping have been shown to have comparable safety profiles for aortic occlusion in minimally invasive mitral valve surgery (MIMVS). However, few studies have focused exclusively on the totally endoscopic robotic approach. We sought to compare outcomes for patients undergoing totally endoscopic robotic mitral valve surgery with aortic occlusion via EABO and transthoracic clamping after a period where EABO was unavailable required us to use the transthoracic clamp. Retrospective review identified 113 patients who underwent robotic mitral valve surgery at our facility between 2019 and 2021 with EABO (n = 71) or transthoracic clamping (n = 42). Relevant data were extracted and compared. Preoperative characteristics were similar other than a higher rate of coronary artery disease [EABO: 69.0% (49/71) vs clamp: 45.2% (19/42), p = .02] and chronic lung disease [EABO: 38.0% (27/71) vs clamp: 9.5% (4/42), p < .01] in the EABO group. Median percutaneous cardiopulmonary bypass time, operative time, and cross-clamp time were comparable. Similar rates of postoperative bleeding complications were observed, and no aortic complications were observed. One patient in each group underwent conversion to an open approach. 30-day mortality and readmission rates were comparable. EABO and transthoracic clamp were associated with similar bleeding and aortic outcomes, and mortality and readmission rates were comparable at thirty days postoperatively. Our findings support the comparable safety of the two techniques, which is well documented in studies encompassing all MIMVS techniques, within the specific context of the totally endoscopic robotic approach.