bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cryptococcoma Presenting as a Central Nervous System Mass in an Immunocompetent Patient
Authors: Vasiloudes Kritos , Trivedi Shivani , Brown Alyssa , Garcia Cristina 
Published: February 2023

Abstract

Cryptococcus neoformans and Cryptococcus gattii are rare fungal pathogens that typically present in immunocompromised patients making it a rare differential diagnosis in an immunocompetent patient. We present a case of an immunocompetent 39-year-old patient who was diagnosed with a central nervous system cryptococcoma from a biopsy pathology report that was originally evaluated for high-grade glioma. Subsequently, the patient underwent lumbar puncture with cerebrospinal fluid analysis that indicated an active central nervous system infection. Although this patient's diagnosis and management of cryptococcosis did not unfold in a traditional manner, combination of surgical resection and antifungal therapy completely resolved his neurological symptoms.
Panophthalmitis in Patient With Dengue Hemorrhagic Fever
Authors: Mathur Mohit , Shukla Ashutosh , Khurana Saurbhi , Gera Ravinder Kumar , Garg Vivek 
Published: February 2023

Abstract
Dengue fever can lead to serious complications of severe bleeding, massive capillary leakage causing dengue shock syndrome and vital organ involvement. Ocular manifestations in dengue fever are rare but may sometimes lead to permanent disability. Here we report a case of rare complication of dengue fever in a 35-year-old man presenting with panophthalmitis, leading to rapidly progressive and painful visual loss. With this case, it can be emphasized that early identification and management of dengue complication may prevent vision loss.
Clozapine
Authors: Flanagan Robert James , Hunter Samora , Obee Stephen John , Reeves Suzanne 
Published: February 2023

Abstract

Background
Guidance on clozapine dosing in treatment refractory schizophrenia is based largely on data from young adult male White patients.

Aim
This study aimed to audit the plasma clozapine and N-desmethylclozapine (norclozapine) concentrations attained in male and female patients of different ethnicity and smoking habit.

Method
The effect of dose, sex, ethnicity, age, body weight, and smoking habit on plasma clozapine and norclozapine concentrations were studied using data from a therapeutic drug monitoring service, 1993 to 2017.

Results
There were 371,610 samples (48,098 patients, 32,855 male). Ethnicity was recorded for 763 Afro-Caribbean, 536 Asian, and 7940 White patients. Males were prescribed significantly higher median doses than females but attained significantly lower median plasma clozapine and norclozapine concentrations. Asian and Afro-Caribbean males were prescribed significantly lower and higher median doses, respectively, than White males but attained significantly higher and lower median plasma clozapine and norclozapine concentrations, respectively. Data from 78,431 samples (23,516 patients) were analyzed using a linear mixed model. The predicted dose to attain a predose plasma clozapine concentration of 0.35 mg/L in a nonsmoking White male aged 40 years, with weight of 70 kg, and plasma clozapine-norclozapine ratio of 1.32 was 344 mg/d (95% confidence interval, 227–526 mg/d). The predicted dose was 33% higher and 20% lower in otherwise analogous Afro-Caribbean and Asian patients, respectively. In all cases, the predicted dose was increased by 36% in smokers and decreased by 22% in females.

Conclusions
Research is needed to further investigate the complex relationships between dose, sex, ethnicity, plasma clozapine and norclozapine concentrations, and clinical outcome such as weight gain.
Improving glucose control in patients with type 2 diabetes using retrospective continuous glucose monitoring
Authors: Diamond Katlyn 
Published: February 2023

ABSTRACT

Background:
The prevalence and cost of type 2 diabetes mellitus (T2DM) is rising. Diabetes care should be individualized based on patient risk factors and goals. Professional continuous glucose monitoring (CGM) is a tool for primary care providers to assist patients with diabetes management.

Local Problem:
Nurse practitioners at an outpatient primary care practice began using CGM in patients with T2DM in 2019 to guide treatment due to the high number of patients not reaching glucose targets. There was no policy in place to guide patient selection for CGM.

Methods:
This quality improvement (QI) project, conducted in an outpatient primary care clinic, evaluated the effect of retrospective CGM use in patients with T2DM through a retrospective chart review to create a policy for use.

Interventions:
Hemoglobin A1c (HbA1c) measurements pre-CGM and post-CGM use were compared. CGM reports were evaluated for the presence of hypoglycemia. Additionally, number of times a patient used CGM between HbA1c laboratory examinations as well as insulin status were determined by reviewing the electronic health record.

Results:
Patients using CGM for HbA1c higher than goal (n = 60) noted a 1.01% decrease in HbA1c (p < .01). The decrease was similar regardless of exogenous insulin status. Hypoglycemia was detected in 54.3% of patients (n = 44), including 45% (n = 27) of those with elevated HbA1c levels.

Conclusions:
Retrospective CGM is a cost-effective tool to individualize management of patients with T2DM in primary care. A policy was created to guide CGM use in patients not reaching glucose goals and those with concern for hypoglycemia.
Nursing care of a patient with rupture and bleeding of cystic artery pseudoaneurysm
Authors: Wang Changshuai , Yi Dan , Jiang Yu , Zhang Shuang , Gao Yan , Fu Xiaochen , Zhao Lijing 
Published: February 2023

Rationale:
Biliary bleeding, a rare cause of upper gastrointestinal bleeding, is rarely caused by cystic artery pseudoaneurysms. In this article, a case of abdominal hemorrhage caused by a ruptured cystic artery pseudoaneurysm is reported and its main nursing measures are outlined.

Patient concerns:
A 50-year-old man was admitted to the emergency room with intermittent pain in the right upper abdomen lasting for a month that had become worse for 1 day.

Diagnosis:
The main manifestations included pain in the right upper abdomen, rebound pain, and muscle tension. Celiac angiography revealed an aneurysm of the cystic artery. Imaging revealed a hematoma in and around the duodenum. Nursing evaluation revealed a painful face, elevated body temperature, and moist skin with a potential risk of shock. The diagnosis was ruptured and bleeding of a cystic artery pseudoaneurysm.

Interventions:
The patient underwent cholecystic artery embolization under local anesthesia, followed by ultrasound-guided gallbladder puncture, drainage, and cholecystectomy carried out successively. Accurate nursing care was provided to the patient for delirium, paralytic intestinal obstruction, septic shock, and thrombus during hospitalization.

Outcomes:
The patient was hospitalized for a total of 20 days, discharged after careful treatment and care, and followed-up by nurses by telephone once a month for half a year.

Lessons:
Although rupture and bleeding of cystic artery pseudoaneurysms are rare, they can cause complications that may occur quickly and even threaten life. Therefore, it is necessary to carefully observe changes in the patient condition during the nursing process and provide comprehensive and high-quality care to promote patient recovery.
Isolated right oculomotor nerve palsy as the first presenting manifestation of metastatic renal Ewing’s sarcoma
Authors: Al-Mashdali Abdulrahman F. , Naser Mohammad S. , Murshed Khaled , Aakel Hassan , Shablak Alaaeldin 
Published: February 2023

Introduction:
Extraskeletal Ewing’s sarcoma is a rare malignancy in the adult population, and its primary renal involvement is even rarer. Renal Ewing’s sarcoma is often metastatic at the initial presentation and has a poor prognosis.

Patient concern:
We present the case of a 53-year-old Filipino woman who presented to our emergency department with acute right oculomotor nerve palsy.

Diagnosis:
Imaging revealed metastatic lesions involving the skull and vertebra as well as the presence of a left kidney mass. Renal biopsy result of the kidney confirmed the diagnosis of renal Ewing's sarcoma.

Intervention:
The patient was started on doxorubicin, vincristine, and cyclophosphamide, alternating with ifosfamide and etoposide.

Outcomes:
The patient developed severe adverse effects from chemotherapy and died 4 months after diagnosis.

Conclusion:
To our knowledge, this is the first case of renal Ewing’s sarcoma that initially presented with neurological manifestations secondary to bone metastasis in the absence of any urological manifestations, such as flank pain or hematuria.
A case report of multiple Mycobacterium Kansasii bone infection with pathological fracture of T11 vertebral body and thoracic spinal cord injury
Authors: Sun Kui , Wang Weiqun , Chen Deyuan , Xu Yaoning , Chi Weidong , Huang Fuli , Zhou Xingmao 
Published: February 2023

Rationale:
Cases of vertebral infection with bone destruction and spinal cord injury caused by Mycobacterium kansasii infection are rarely reported, and the infection is usually associated with severe immunosuppression.

Patient concerns:
A 62-year-old male patient was hospitalized for 10 days due to recurrent low back pain with diminished skin sensation below the umbilical level.

Diagnosis:
The patient had no underlying disease. MRI showed multiple bone destruction lesions throughout the body, pathological fractures of the T11 vertebral body, and compression and degeneration of the thoracic spinal cord. Complete back abscess puncture examination, CT-guided vertebral puncture examination, metagenomic next-generation sequencing and bone marrow puncture and other examinations to confirm the diagnosis of Mycobacterium kansasii infection.

Intervention:
According to the drug susceptibility test of pathogenic bacteria, combined antiinfective treatment was given. After 3 weeks of drug treatment, the patient underwent thoracic posterior debridement, spinal canal decompression, and pedicle screw internal fixation.

Outcome:
The skin sensation of the patient’s lower limbs was improved 1 month after the operation compared with that before the operation. After adhering to oral drug treatment, the inflammatory index decreased steadily. Four months after the operation, the skin sensation of the patient’s lower extremities returned to normal.

Lessons:
Regular, adequate, and full course of drug treatment is the key to the treatment of Mycobacterium kansasii infection. Next-generation metagenomic sequencing can improve the efficiency and accuracy of the detection of Mycobacterium kansasii. For patients with abscesses and spinal nerve compression, surgical decompression and abscess removal are effective treatment options.
Usefulness of inhaled iloprost in managing exercise-induced pulmonary hypertension in a patient with systemic sclerosis-associated interstitial lung disease
Authors: Kinoshita Natsu , Nawata Takashi , Mochizuki Mamoru , Asami-Noyama Maki , Wada Yasuaki , Yano Masafumi 
Published: February 2023

Rationale:
Inhaled iloprost has been used as a selective pulmonary vasodilator in the treatment of pulmonary arterial hypertension; however, it is unclear whether it is an effective treatment for exercise-induced pulmonary hypertension (PH).

Patient concerns:
A 66-year-old Japanese woman with systemic sclerosis-associated interstitial lung disease presented with dyspnea, worsening during exertion.

Diagnosis:
Overlap of exercise-induced PH and group 3 PH.

Interventions:
Inhaled iloprost was administrated.

Outcomes:
Exercise echocardiography revealed that inhaled iloprost therapy improved her exercise-induced PH.

Conclusion:
Exercise echocardiography and inhaled iloprost revealed that the patient’s PH included both group 3 and group 1 PH. This case suggests that a combination of exercise echocardiography and inhaled iloprost may be useful in distinguishing patients with systemic sclerosis-associated interstitial lung disease in whom group 1 and group 3 PH overlap. In addition, this method might also be useful for determining the therapeutic effects of iloprost.
Synchronous tongue squamous cell carcinoma and papillary thyroid carcinoma with Collision metastasis to a single cervical lymph node
Authors: Fareed Ahmed M. , Awny Shady , Ali Khadiga M. , Atallah Khalid , Sallam Abdel Aziz A. , Abdellattif Ahmed M. , Zaid Amir M. , Hegazy Mohamed A.F. 
Published: February 2023

Introduction:
The frequency of synchronous malignant tumors in patients with squamous cell carcinoma (SCC) of the oral tongue is relatively low (2%), with the oral cavity being the most frequent secondary site, followed by the pharynx.[1] Collision tumors are defined as 2 histologically distinct neoplasms that originate from topographically separate primaries, and abut and intermix with 1 another. The main site for intermixing of 2 tumors is the lymph node. There are no areas of transition between the 2 tumors. However, collision tumors can be summarized as tumor-to-tumor metastasis with exceedingly rare incidence.[1] Proper treatment of the thyroid gland is debatable when metastatic papillary thyroid carcinoma is incidentally encountered during neck dissection for the index treatment of primary SCC of the oral tongue, considering the good prognosis for thyroid cancer and the difficulty to find the primary tumor.[2]

Case report:
We report a 28 years old woman with synchronous tongue squamous cell carcinoma and papillary thyroid carcinoma, with a lymph node containing metastasis from both tumors (collision node).

Conclusion:
Although the extreme rarity of this synchronous tumor may make it impossible to draw a significant conclusion regarding proper treatment of thyroid disease, it is important to be aware that even when primary head and neck SCC is at an advanced stage, a cure is possible. Active management of the thyroid carcinoma should be considered because it may affect prognosis, as in the present case.
Does prophylactic local tobramycin injection lower open fracture infection rates?
Authors: Aneja Arun , Kavolus Matthew W. , Teasdall Robert J. , Sneed Chandler R. , Pectol Richard W. , Isla Alexander E. , Stromberg Arnold J. , Obremskey William 
Published: February 2023

Abstract

Objective: To determine whether local aqueous tobramycin injection in combination with systemic perioperative IV antibiotic prophylaxis will reduce the rate of fracture-related infection (FRI) after open fracture fixation.

Other Outcomes of Interest: (1) To compare fracture nonunion rates and report differences between treatment and control groups and (2) compare bacterial speciation and antibiotic sensitivity among groups that develop FRI.

Design: Phase 3 prospective, randomized clinical trial.

Setting: Two level 1 trauma centers.

Participants: Six hundred subjects (300 in study/tobramycin group and 300 in control/standard practice group) will be enrolled and assigned to the study group or control group using a randomization table. Patients with open extremity fractures that receive definitive internal surgical fixation will be considered.

Intervention: Aqueous local tobramycin will be injected into the wound cavity (down to bone) after debridement, irrigation, and fixation, following closure.

Main Outcome Measurements: Outcomes will look at the presence or absence of FRI, the rate of fracture nonunion, and determine speciation of gram-negative and Staph bacteria in each group with a FRI.

Results: Not applicable.

Conclusion: The proposed work will determine whether local tobramycin delivery plus perioperative standard antibiotic synergism will minimize the occurrence of open extremity FRI.

Level of Evidence: Level 1.
Usage of orthopaedic trauma registries among members of the International Orthopaedic Trauma Association: How are we doing?
Authors: Nguyen Mai P. , Paull Thomas Z. , Miclau Theodore , Marmor Meir T. ,   on behalf of the International Orthopaedic Trauma Association
Published: February 2023

Abstract

Introduction: The use of national databases for orthopaedic research has increased significantly in the past decade. The purpose of this study was to report on the current state of orthopaedic trauma registries in 21 countries represented by 20 member societies of the International Orthopaedic Trauma Association (IOTA).

Methods: A web-based survey was circulated to all IOTA member societies. The survey consisted of 10 questions (five open-ended and five multiple-choice).

Results: Representatives from all 21 countries replied. Five countries (24%) do not currently have or plan to start a registry. One country (5%) had a registry that is now closed. Two countries (10%) are building a registry. Thirteen countries (62%) reported at least one active registry, including four countries with more than one registry. Of the 14 countries that reported the existence of a registry, there were 17 registries noted that included patients with fracture. There were seven registries dedicated to high-energy trauma and four registries that included elderly hip fractures. In addition, 9/17 representatives reported the utilization of a fracture classification and 9/17 noted some level of mandate from medical providers. All responders but one reported that data were manually entered into their registries.

Conclusions: Despite the shared vision of quality control and outcome optimization, IOTA society representatives reported significant variability in the depth and format of the orthopaedic trauma registry among IOTA members. These findings represent an opportunity for collaboration across organizations in creating fracture registries.

Level of Evidence: Level IV.
Change in Gustilo-Anderson classification at time of surgery does not increase risk for surgical site infection in patients with open fractures: A secondary analysis of a multicenter, prospective randomized controlled trial
Authors: Axelrod Daniel , Comeau-Gauthier Marianne , Prada Carlos , Bzovsky Sofia , Heels-Ansdell Diane , Petrisor Brad , Jeray Kyle , Bhandari Mohit , Schemitsch Emil , Sprague Sheila ,   on behalf of the FLOW Investigators
Published: February 2023

Abstract

Introduction:
Open fractures represent a major source of morbidity. Surgical site infections (SSIs) after open fractures are associated with a high rate of reoperations and hospitalizations, which are associated with a lower health-related quality of life. Early antibiotic delivery, typically chosen through an assessment of the size and contamination of the wound, has been shown to be an effective technique to reduce the risk of SSI in open fractures. The Gustilo-Anderson classification (GAC) was devised as a grading system of open fractures after a complete operative debridement of the wound had been undertaken but is commonly used preoperatively to help with the choice of initial antibiotics. Incorrect preoperative GAC, leading to less aggressive initial management, may influence the risk of SSI after open fracture. The objectives of this study were to determine (1) how often the GAC changed from the initial to definitive grading, (2) the injury and patient characteristics associated with increases and decreases of the GAC, and (3) whether a change in GAC was associated with an increased risk of SSI.

Methods:
Using data from the FLOW trial, a large multicenter randomized study, we used descriptive statistics to quantify how frequently the GAC changed from the initial to definitive grading. We used regression models to determine which injury and patient characteristics were associated with increases and decreases in GAC and whether a change in GAC was associated with SSI.

Results:
Of the 2420 participants included, 305 participants had their preoperative GAC change (12.6%). The factors associated with upgrading the GAC (from preoperative score to the definitive assessment) included fracture sites other than the tibia, bone loss at presentation, width of wound, length of wound, and skin loss at presentation. However, initial misclassification of type III fractures as type II fractures was not associated with an increased risk of SSI (P = 0.14).

Conclusions:
When treating patients with open fracture wounds, surgeons should consider that 12% of all injuries may initially be misclassified when using the GAC, particularly fractures that have bone loss at presentation or those located in sites different than the tibia. However, even in misclassified fractures, it did not seem to increase the risk of SSI.
The Deterioration Risk Index: Developing and Piloting a Machine Learning Algorithm to Reduce Pediatric Inpatient Deterioration*
Authors: Rust Laura O. H. , Gorham Tyler J. , Bambach Sven , Bode Ryan S. , Maa Tensing , Hoffman Jeffrey M. , Rust Steven W. 
Published: February 2023

OBJECTIVES:
Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program.

DESIGN:
Retrospective cohort study.

SETTING:
Nationwide Children’s Hospital, a freestanding, quaternary-care, academic children’s hospital in Columbus, OH.

PATIENTS:
All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization.

INTERVENTIONS:
We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021.

MEASUREMENTS AND MAIN RESULTS:
The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001).

CONCLUSIONS:
The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.