Lean and Green Hand Surgery in the Office: Does It Work?

Decreased Interobserver Variability in Nuclear Atypia of Undetermined Significance After Consensus Review of Thyroid Fine Needle Aspirations.

Diagnosis of lumbar spine pseudoarthrosis: a strain-based approach.

Chagas disease (CD), or American trypanosomiasis, is a parasitic infection caused by Trypanosoma cruzi and transmitted primarily by triatomine "kissing bugs." Once limited to Latin America, CD is now considered endemic in the United States (US), affecting an estimated 280 000 individuals. This article aims to highlight the growing clinical relevance of CD through a case example and review of its epidemiology, clinical features, and management. Globally, 6 to 8 million people are infected, resulting in more than 50 000 deaths annually. Globalization, migration, and climate change have expanded its geographic reach, with increasing detection of infected insect populations in the southern US. CD progresses through acute and chronic phases. The acute phase is often mild or asymptomatic, whereas 30% to 40% of untreated patients progress to chronic disease, most commonly manifesting as cardiomyopathy. Diagnosis is made by serologic or molecular testing, and treatment with benznidazole or nifurtimox is most effective during the early stages of infection. Chronic disease remains incurable, underscoring the importance of early detection and prevention. Containment relies on vector control, screening of blood products and at-risk populations, and prenatal testing. A case of a recently immigrated patient diagnosed at a US urgent care clinic illustrates the need for clinical awareness of this neglected disease. Broader surveillance, education, and integrated public health strategies are essential to reduce CD-related morbidity and mortality.

Biallelic pathogenic variants in PNPT1 cause combined oxidative phosphorylation deficiency 13 (COXPD13) (MIM #614932), linking mitochondrial dysfunction to type I interferon (IFN) activation through cytosolic leakage of mitochondrial double-stranded RNA (mt-dsRNA). This mechanism connects mitochondrial disease to interferonopathies such as Aicardi-Goutières syndrome (AGS). We describe a 7-month-old female infant with compound heterozygous PNPT1 variants presenting with severe hypotonia, feeding difficulties necessitating gastrostomy, dystonia, and elevated serum lactate. Brain magnetic resonance imaging (MRI) demonstrated marked cerebellar, brainstem, and basal ganglia atrophy, with a lactate peak on MR spectroscopy (consistent with an inverted doublet). Serum immune profiling revealed a mild but elevated type I IFN signature. Given the mechanistic overlap with AGS, off-label tofacitinib, a Janus kinase (JAK) inhibitor that blocks IFN-driven JAK/STAT signaling, was initiated following pediatric interferonopathy dosing protocols. Tofacitinib was associated with normalization of serum type I IFN biomarkers, reduction in lactate and transaminases, improvement in dystonic movements, ventilatory stability, and improved growth/nutrition without treatment-limiting adverse events. To our knowledge, this represents the first reported use of JAK inhibition in COXPD13. The observed clinical and biochemical stabilization supports defining COXPD13 as a "mitochondrial interferonopathy" and suggests that IFN-signature screening may identify mitochondrial disease patients who could benefit from targeted immunomodulation.

Successful treatment of balamuthia mandrillaris amebic encephalitis diagnosed by MetaCAP in China: A case report and review of 25 survival cases.

Rheumatic heart disease is not over: Cardiac cirrhosis and multivalvular sequelae in an endemic setting - A case series and review.

Bicruciate-retaining (BCR) total knee arthroplasty (TKA) was developed to better replicate native knee biomechanics by preserving both cruciate ligaments. First-generation BCR implants were notorious for technical challenges and suboptimal survivorship. However, advancements in implant design and surgical techniques have renewed interest in second-generation BCR TKA systems. This study aimed to evaluate the overall survivorship of contemporary (second-generation) BCR primary TKA implants. A systematic review of PubMed, Scopus, Embase, Web of Science, and Cochrane databases was conducted from inception to January 3, 2025. Inclusion criteria were studies that reported the number of revisions following second-generation BCR TKA. We excluded case reports, review articles, and studies that evaluated first-generation BCR TKA. A total of 1046 articles were retrieved; ultimately, 13 were included. Events per person-years pooled analysis was performed to estimate the incidence of all-cause revision, adjusting for duration of follow-up. Heterogeneity was measured using I2 test. A p-value < 0.05 was considered statistically significant. A total of 1,087 BCR TKA implants among 13 studies were analyzed. The mean follow-up was 2.6 years. A total of 62 (5.7%) knees were revised. The overall pooled rate of all-cause revision was 1.6 per 100 person-years (95% confidence interval [CI] 0.009-0.023) Heterogeneity among the analyzed studies was significant (I2 = 75.5%, p < 0.001). Contemporary BCR TKA implants showed improved survivorship compared to historical reports, with a low pooled all-cause revision rate of 1.6 per 100 person-years, corresponding to a 1.6% chance of revision per year of follow-up. Despite the associated heterogeneity, these findings suggest that modern BCR designs offer durable outcomes and support their continued use. Further long-term comparative data are needed to better define their role relative to modern knee implants.

Capnocytophaga canimorsus is a fastidious, capnophilic Gram-negative rod transmitted through exposure to the oral secretions of domesticated dogs and cats and may cause severe infection in immunocompromised hosts. Bacterial peritonitis due to C. canimorsus is rare and has been reported primarily in patients receiving peritoneal dialysis. We describe a 66-year-old man status post simultaneous liver and kidney transplantation who presented with septic shock, neutropenia, acute kidney injury, and worsening ascites. Peritoneal fluid analysis demonstrated neutrophilic ascites consistent with bacterial peritonitis, although cultures were negative. Blood cultures and broad-range bacterial polymerase chain reaction using 16S rRNA gene sequencing identified C. canimorsus, confirming the diagnosis. The patient reported close contact with pet dogs and improved with targeted beta-lactam therapy. This represents the first reported case of C. canimorsus peritonitis in a solid organ transplant recipient and highlights the diagnostic value of molecular testing in culture-negative peritonitis.

Diagnosis of a Rare Gastric Submucosal Accessory Spleen Using Endoscopic Ultrasound-Guided Fine-Needle Aspiration: A Case Report and Review of Literature.

Liver transplantation remains the treatment of choice for hepatopulmonary syndrome (HPS) with severe hypoxemia, but portopulmonary hypertension (PoPH) has traditionally been viewed as a contraindication to liver transplantation owing to its frequent posttransplant deterioration. We describe here the sequential presence of both pulmonary vascular disorders in a cirrhotic patient in the pretransplant period. Liver transplantation was made possible following effective management of pulmonary hypertension, with favorable outcome 3 years post-liver transplantation. Finally, our case report and literature review suggest that the coexistence of HPS and PoPH in patients with advanced liver disease could be more common than previously recognized.

Regional and temporal trends in antimicrobial susceptibility among isolates from bacterial keratitis: a systematic review and meta-analysis.

Coronary Vasospasm Secondary to Ondansetron Use a Case Report and Review of the Literature

Congenital high airway obstruction syndrome (CHAOS) is a rare, life-threatening condition involving complete or near-complete airway obstruction. Fetal laryngoscopy enables direct airway endoluminal visualization of the airway, thereby complementing prenatal imaging to enhance diagnosis and counseling. In this case, CHAOS was diagnosed at 17 weeks of gestation following ultrasound and fetal magnetic resonance imaging, which revealed tracheal dilation and echogenic lungs. Diagnostic fetal laryngoscopy performed at 24 weeks demonstrated a blind-ended trachea that was not amenable to fetal decompression. Despite counseling regarding the limited feasibility of airway establishment, emergent delivery with an ex utero intrapartum treatment (EXIT) procedure was performed at 30 weeks. Airway establishment was unsuccessful, and the neonate died shortly after birth. Significant maternal hemorrhage occurred after delivery, requiring transfusion. This case underscores the complexity of prenatal counseling and family-centered decision-making. Fetal laryngoscopy may be considered an adjunct to improve diagnostic evaluation and counseling, potentially aiding prenatal decision-making in selected cases of CHAOS.

Infective endocarditis (IE) complicated by refractory cardiopulmonary failure carries high mortality, and standardized protocols for extracorporeal membrane oxygenation (ECMO) are lacking. We report a 31 year old male with fulminant IE, severe aortic regurgitation, acute respiratory distress syndrome (ARDS), and refractory cardiogenic shock who was initially supported with venovenous (VV) ECMO for isolated respiratory failure. Due to progressive hemodynamic deterioration, configuration was converted to veno-arterial (VA) ECMO, followed by emergency aortic valve replacement and targeted antimicrobial therapy. The patient achieved successful decannulation and discharge. To contextualize this case, we conducted a systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 21 additional cases (2000-2025), forming a 22-patient cohort. Pooled analysis demonstrated an overall in-hospital survival rate of 81.8% (18/22) with ECMO bridging. Surgical treatment significantly improved survival compared with conservative management (94.4% vs. 25%). These findings suggest that ECMO is a feasible bridge-to-surgery strategy for IE with refractory cardiopulmonary failure. However, given the significant risk of publication bias inherent to case report data, we propose a hypothesis-generating management algorithm emphasizing individualized mode selection and early surgical source control, rather than definitive clinical guidelines. Large-scale prospective studies are required for validation.

Aymé-Gripp syndrome is an ultra-rare autosomal dominant multisystem disorder caused by pathogenic variants in the MAF gene, typically affecting the N-terminal transactivation domain. It is characterized by craniofacial dysmorphism, early-onset cataracts, sensorineural hearing loss, developmental delay or intellectual disability, and variable neurological or skeletal anomalies. Here, we report two unrelated Turkish patients harboring heterozygous MAF variants within the glycogen synthase kinase 3 recognition motif, evaluated using clinical, neuroimaging, and molecular approaches. Targeted next-generation sequencing (NGS) and parental segregation analyses by NGS and Sanger sequencing were performed, and a literature review of cases published between January 2015 and April 2026 was conducted. Both patients presented with craniofacial and neurodevelopmental features. However, one patient showed no clinically detectable ocular abnormalities or hearing impairment at the time of evaluation. The detected variant in this patient was inherited from his asymptomatic father with low-level mosaicism (16% variant allele frequency in blood and 22% in buccal mucosa), representing the first reported case suggestive of paternal germline mosaicism in Aymé-Gripp syndrome. Literature review (n = 38) revealed consistent findings of sensorineural hearing loss (94.5%), cataracts (78.3%), developmental delay/intellectual disability (100%), epilepsy (68.5%), skeletal anomalies (72.7%), and cardiac involvement (55.1%). Additional features, including non-cataract ocular abnormalities, renal involvement, dermatologic findings, and hematological manifestations, have also been reported. All variants clustered within residues 54-69 of the transactivation domain. These findings provide clinically and molecularly relevant insights into Aymé-Gripp syndrome and highlight the importance of molecular diagnosis and the detection of parental mosaicism for accurate recurrence risk assessment and genetic counseling.

Traumatic posterior mediastinal hematoma (TPMH) is a potentially life-threatening entity that, in rare instances, can lead to obstructive shock and sudden death secondary to left atrial compression (LAC). We describe the clinical course and outcomes of seven adult patients with TPMH and LAC. A brief literature review is presented. Seven patients (ages spanning from the 20s to 80s) with TPMH and LAC were identified at a Level 1 trauma center from 2016 to 2023. The first 2 patients were identified following standard quality improvement case reviews for unexplained death. The subsequent five patients were prospectively identified during initial trauma evaluation. A retrospective evaluation of all patients was performed using the chart and computed tomography review. All seven patients sustained polytrauma. The mechanisms of injury were motor vehicle crash (4), motorcycle crash (1), golf cart crash (1), and bicycle crash (1). The first two patients with TPMH and LAC died shortly after admission (167 and 339min) of suspected obstructive shock without evidence of significant hemorrhage. The subsequent five patients were identified during initial trauma evaluation, and each underwent aggressive fluid resuscitative management with 100% survival. TPMH may lead to significant LAC, which can result in sudden death. Our experience suggests that TPMH with LAC is associated with mid-thoracic spine fractures, rib fractures, and polytrauma secondary to high-energy mechanisms. Emphasis on its early recognition is paramount, with a focus on aggressive fluid and blood resuscitation, vasopressor support when needed, and immediate correction of any coagulopathy. In reviewing the literature, nonoperative management is often successful. Selective cases requiring angiography with embolization or hematoma evacuation via thoracotomy have been documented. Our goal is to raise awareness of this entity and its potential lethality. ( J Trauma Acute Care Surg . 2026;101: 173-177. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). V.

Early endometrial metastasis from triple-positive breast cancer is a rare phenomenon in young patients, especially when anti-human epidermal growth factor receptor 2 (HER2) target therapy is used as the primary treatment. We present a case of a 24-year-old patient with advanced triple positive breast cancer. The patient developed abnormal uterine bleeding during chemotherapy combined with anti-HER2 therapy (trastuzumab plus pyrotinib). Due to the transvaginal sonography are not characteristic and the low incidence rate of endometrial metastasis from breast cancer, this potential diagnosis was overlooked. The disease progressed rapidly thereafter, and the overall survival was only 13 months. The swift and devastating progression highlight the immense challenges in managing such complex cases. It remains a current challenge to identify such cases at an early stage and explore more effective therapeutic regimens. Based on this case review and previous studies, we speculate that disease progression might be attributed to the absence of endocrine therapy, chemotherapy resistance, or insufficient anti-HER2 therapeutic intensity. This case provides new insights into the metastatic pattern of HER2-positive breast cancer under targeted drug resistance. Clinicians should be alert to the possibility of reproductive system metastasis during anti-tumor treatment. Timely diagnosis and appropriate treatment are expected to improve patient prognosis.

We present two cases with glaucoma who presented with blurred vision or metamorphopsia; the common feature was the ongoing medication with prostaglandin analogue latanoprost and neither patient received systemic corticosteroids or reported stress. Fundus image, optical coherence tomography and angiography confirmed presence of subretinal fluid and diagnosis of central serous chorioretinopathy (CSCR). These cases resolved on withdrawing the offending drug latanoprost, and when the drug was reintroduced for better intraocular pressure management, the serous detachment recurred. We analyse these cases for the role of proinflammatory and haemodynamic effects of prostaglandin analogues (PGA) on initiating CSCR. A review of other similar cases reported earlier is included. The key learning point is to consider potential association of this group of drugs with CSCR, when other risk factors have been excluded.

Episodic ataxia type 2 (EA2) is an autosomal dominant channelopathy caused by CACNA1A mutations, typically presenting with recurrent episodes of ataxia, vertigo, and hemiplegic migraine, often with a normal brain MRI or cerebellar atrophy. This report describes a 47-year-old man with a 22-year history of recurrent severe headaches, limb weakness, truncal ataxia, sensory disturbances, and profound fatigue, triggered by stress or minor trauma. Interictal recovery was complete, but serial MRI revealed extensive T2/FLAIR white matter hyperintensities, initially raising concern for multiple sclerosis or cerebral vasculitis. Lumbar puncture was unremarkable. Genetic testing identified a pathogenic heterozygous CACNA1A variant (c.7411C > T, p.R2471*), confirming EA2. Symptomatic management with acetazolamide and trigger avoidance improved episode frequency and severity. This case highlights the diagnostic challenges of EA2 when MRI shows atypical white matter lesions and emphasizes the value of genetic testing in atypical presentations. Recognizing these findings can prevent misdiagnosis, guide targeted therapy, and inform family counseling. Pearls: · The variability of CACNA1A- related disorders is broad and continues to expand. The gene-phenotype spectrum includes episodic ataxia type 2 (EA2), familial hemiplegic migraine type 1 (FMH1), sporadic hemiplegic migraine (SHM), spinocerebellar ataxia type 6, epilepsy and developmental epileptic encephalopathy. · Patients with episodic ataxia type 2 have either a normal MRI or cerebellar atrophy, mainly at the vermis. · Episodic ataxia type 2, may be treated with acetazolamide and 4-aminopyridine. Oysters: · EA2 may present in the absence of family history. · It is very common for patients with EA2, to be erroneously diagnosed with another disorder, and the disease is very infrequent. · CACNA1A associated diseases may present with clinical overlap.