Texas Health Resources Foundation

Introduction: Needle thoracostomy is a life-saving intervention for tension pneumothorax, but improper placement, especially in the prehospital setting, can cause catastrophic complications such as penetrating cardiac injury. We present a case of iatrogenic cardiac injury from a misplaced prehospital needle decompression, underscoring the critical importance of strict adherence to anatomical landmarks and established guidelines even during urgent field interventions. Description: A man in his fifties sustained severe blunt trauma from a high-speed all-terrain vehicle (ATV) crash. He presented with altered consciousness and respiratory distress, raising suspicion for tension pneumothorax. Emergency responders performed a needle decompression at the left third intercostal space, midclavicular line, inserting an 8 cm Russell PneumoFix-8 catheter to its full length. Immediately, pulsatile bleeding from the insertion site indicated a possible cardiac injury. Trauma center imaging confirmed that the catheter had pierced the left ventricle, causing a pericardial effusion. On arrival, the patient was intubated and sedated, with active bleeding from the thoracostomy site; evaluation revealed skull base fractures and a subarachnoid hemorrhage. An urgent median sternotomy was performed: the hemopericardium was evacuated, the intramyocardial catheter fragment was removed, and a small left ventricular laceration was repaired without cardiopulmonary bypass. His postoperative recovery was prompt, with extubation on postoperative day one and discharge from the ICU by day four. Discussion: This case illustrates a rare, life-threatening complication of prehospital needle thoracostomy: a penetrating cardiac injury resulting from improper catheter placement. It highlights that even life-saving procedures like needle decompression carry significant risks when anatomical landmarks are not strictly observed. The case also demonstrates successful cardiac repair without cardiopulmonary bypass, a strategy chosen to avoid exacerbating the patient’s intracranial hemorrhage. In acute trauma, effective management requires rapid diagnosis using multiple imaging modalities, including ultrasound and computed tomography, prompt surgical decision-making, and strict adherence to procedural guidelines to minimize iatrogenic risk.

Anterior cruciate ligament reconstruction induces deleterious neuromuscular alterations. Musculoskeletal ultrasonography provides an accessible method to quantify muscle size and quality in patients with anterior cruciate ligament reconstruction who suffer from persistent skeletal muscle atrophy. This study compares rectus femoris and vastus intermedius muscle thicknesses and echo intensities using extended field-of-view ultrasonography in individuals with a history of anterior cruciate ligament reconstruction versus non-injured controls. Twenty-six individuals with previous anterior cruciate ligament reconstruction and 20 controls were participated in this study. Extended field-of-view ultrasonography was used to analyze the muscle thickness in the proximal, middle, and distal regions of the thigh, while the echo intensity was measured to assess the muscle quality. Findings indicate significant asymmetries in the muscle thickness (p<0.01 and η p 2=0.312) and echo intensity (p=0.024 and η p 2=0.111) for the anterior cruciate ligament reconstruction group, favoring the uninvolved leg, with no site-specific differences between groups. Results show muscle-specific size differences, with greater vastus intermedius muscle thickness than rectus femoris muscle thickness in controls (p<0.01 and d=0.609), but no difference between muscles in either leg of the anterior cruciate ligament reconstruction group (p>0.05 and d=0.094). Overall, these results highlight unique skeletal muscle changes between the biarticular rectus femoris and the monoarticular vastus intermedius following anterior cruciate ligament reconstruction, likely reflecting postoperative deficiencies in knee extensor function.

Abstract Background: Pneumocystis jiroveci pneumonia (PJP) is an opportunistic fungal infection primarily affecting immunocompromised individuals. It carries a high mortality rate of 33-69% [1,2]. Recent studies have shown that COVID-19 can have prolonged effects on pulmonary function and immune system regulation [3,4]. Additionally, COVID-19 has been associated with temporary immunosuppression, potentially increasing susceptibility to opportunistic infections [5]. This case series investigates the occurrence of PJP in patients with a history of COVID-19 infection, contributing to the amplifying amount of evidence on post-COVID complications. Methods: This case series examines six patients diagnosed with PJP following COVID-19 infection. The study group comprised of predominantly males (83.3%), with ages ranging 37 to 69 years (mean 54). Comorbidities were prevalent, notably diabetes mellitus type 2 and hyperlipidemia (66.7% each), hypertension (50%), and a history of tobacco use (66.7%). All patients tested positive for fungitell and two (33.3%) tested positive for PJP. The interval between COVID-19 infection and PJP diagnosis varied from one week to 22 months. Treatment strategies differed, ranging from trimethoprim-sulfamethoxazole alone to combinations with corticosteroids. The mortality rate was 33.3%, with two patients succumbing during hospitalization. Survivors were discharged on prophylactic trimethoprim-sulfamethoxazole, underscoring the potential long-term implications of this opportunistic infection in post-COVID patients. Discussion: The affected patients had diverse demographics, ranging from 37 to 69 years old, with various comorbidities. The timing between COVID-19 infection and PJP diagnosis varied, spanning from 1 week to 22 months. Patients underwent different treatments, including the use of trimethoprim-sulfamethoxazole and corticosteroids. The mortality rate of 33.3% emphasizes the severity of PJP in post-COVID patients. Previous case series enforced our observation that high-risk patients should be monitored for PJP and other opportunistic infections after a COVID-19 infection [6]. This case series emphasizes the need for continued research of long-term effects of COVID-19 on the immune system and potential increased vulnerability to opportunistic infections. Conclusion: This case series suggests a link between prior COVID-19 infection and opportunistic infections like PJP, even in patients without traditional risk factors such as HIV. It emphasizes the importance of monitoring post-COVID patients for unusual infections and further investigating the long-term immune system effects of COVID-19. Healthcare providers should maintain a high index of suspicion for PJP and other opportunistic infections in patients with a history of COVID-19, even months after recovery. Further large-scale studies are warranted to better understand this relationship and inform future prevention strategies and treatment protocols.

Neurosarcoidosis, particularly in the absence of extra-neurologic systemic manifestations of sarcoidosis, is a challenging diagnosis that has a wide array of presentations. Most oftenpresenting with cranial neuropathies, basilar meningitis or pituitary/hypothalamic dysfunction, isolated involvement of the spinal cord without cranial manifestations is exceptionally rare, often involving intramedullary lesions. Here, we present the unique case of a 64-year-old female with atypical neurosarcoidosis presenting with myelopathy from extra-dural nodules without other neurologic or systemic symptoms. Pathology results from the extra-dural nodules were consistent with a neurosarcoidosis diagnosis. This is the first case report in the literature to our knowledge of atypical neurosarcoidosis presenting as isolated intradural extramedullary nodules without cranial or systemic manifestations of sarcoid disease.

During the COVID-19 pandemic, acute care nurse managers functioned in a critical role by helping to advance the mission and goals of their organization while navigating a rapidly evolving healthcare landscape. This resulted in high levels of ongoing job-related stress which is linked to negative physical, psychological, and job-related outcomes. Little is known about the perceptions regarding their own professional well-being during this time. The aim of this study was to qualitatively describe acute care nurse managers' perceptions of and barriers to their professional well-being. Using a qualitative descriptive approach, nurse managers from a hospital system in the southwestern United States responded to two short-answer, survey-based questions in 2022: (1) "Describe the definition of nurse-manager well-being in your own words" and (2) "What do you feel is your biggest barrier to professional well-being?" Reflexive thematic analysis was utilized to analyze participant responses (N = 80). Professional well-being is a complex concept influenced by the nurse manager's ability to navigate work-life balance; care for their own physical, emotional, and spiritual selves; give and receive support from stakeholders; and manage feelings of thriving vs. struggling in the role. Barriers most cited as influencing well-being included having too little time to get things done coupled with increasing workloads, feeling stuck in the middle among stakeholders, and coping with ongoing staffing challenges. The definition of and barriers to well-being are influenced by the specific needs and experiences of the nurse manager. While not all barriers can be immediately removed, the identification of individual and organization-specific barriers needs to be taken seriously, reviewed by those who can promote change, and evidence-based solutions for improvement piloted or implemented when feasible.