Sliding hiatal hernias involve displacement of the gastroesophageal junction (GEJ), significantly influencing the development, severity, and treatment outcomes of gastroesophageal reflux disease (GERD). Clinicians should consider an underlying hiatal hernia in patients with chronic or treatment-resistant reflux. Evaluation should assess for gastric herniation and esophageal function with esophagogastroduodenoscopy (EGD), pH monitoring, upper gastrointestinal (UGI) series, and manometry. Anti-reflux surgery (ARS) following hernia repair aims to restore normal anatomy and correct the mechanical disruption contributing to reflux symptoms. This case report focuses on a 33-year-old female with a history of a sliding hiatal hernia and GERD who presented with persistent reflux refractory to medical therapy. After preoperative evaluation, she underwent laparoscopic cruroplasty with placement of a magnetic sphincter augmentation (MRA) device (LINX(R)) around the lower esophageal sphincter (LES). The LINX(R) device recreates a reflux barrier through a ring of magnetic beads that open during peristalsis and maintain closure at rest. Its dynamic function, reversibility, and low complication rate highlight the LINX(R) device as an effective surgical option in the management of long-standing reflux associated with a hiatal hernia.
MRSA PCRs are commonly used for de-escalation of vancomycin when treating patients with respiratory tract infections. Despite less robust data supporting the performance of this test for skin and soft tissue infections (SSTIs), prior retrospective data has demonstrated a high negative predictive value (NPV). Recently at Texas Health Harris Methodist Hospital Fort Worth, an internal pharmacist-driven protocol was implemented where MRSA PCRs are ordered when vancomycin is initiated for SSTIs. The purpose of this study was to determine the impact of utilizing MRSA PCRs on vancomycin days of therapy for SSTIs. A single center, retrospective, observational cohort study of patients receiving vancomycin with indications for cellulitis, abscess, or diabetic foot infection. Patients without a MRSA PCR were included in the pre-group and patients with a MRSA PCR after protocol implementation were included in the post-group. The primary outcome was days of vancomycin therapy. Secondary outcomes evaluated were number of vancomycin levels obtained, in-hospital mortality or 30-day readmission due to the same SSTI, and rate of acute kidney injury. 188 patients were included with 94 patients in each group. Baseline characteristics were similar between both groups except for ethnicity and weight. After protocol implementation, a statistically significant reduction in vancomycin days of therapy was observed in the post-group (3 days vs 4 days, p = 0.0139). No statistically significant difference was observed for in-hospital mortality or 30-day hospital readmission due to an SSTI. Within the post-group, 80.9% (76/94) of MRSA PCRs resulted negative and 56.6% (43/76) of those negative results were utilized to facilitate de-escalation off vancomycin therapy. The MRSA PCR NPV was 98.7% (75/76) in our cohort. Based on the results of this study, the utilization of MRSA PCRs to facilitate de-escalation of vancomycin in SSTIs resulted in fewer days on vancomycin without seeing an increase in re-admission or mortality. While prospective data would be beneficial, our study contributes to the growing body of evidence supporting the use of MRSA PCRs as a safe and effective antimicrobial stewardship tool to help reduce unnecessary antibiotic exposure for patients with SSTIs. All Authors: No reported disclosures
Diagnosing Clostridioides difficile infection remains challenging due to high sensitivity but limited specificity of polymerase chain reaction (PCR) assay, which often detect colonization rather than true infection. Alternative testing with improved specificity like the cell culture cytotoxicity assay (CCCA), the gold standard for toxin confirmation, remains time intensive. Emerging evidence suggests PCR cycle threshold (CT) values may predict toxin presence. This study explores the relationship between CT values and CCCA results to improve diagnostic accuracy and guide treatment decisions. This retrospective cohort study analyzed adults with both C. difficile PCR and CCCA test results available at multiple Texas Health Resources hospitals between April 2023 and December 2024. Patients receiving C. difficile treatment prior to specimen collection or with incomplete data were excluded. Demographic, laboratory, and clinical data were collected from electronic health records. PCR CT values and CCCA results were assessed using ROC curve analysis to determine diagnostic performance. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were analyzed at different CT thresholds. A total of 456 samples from 417 unique patients were included; the median age was 68 years, and 33.5% were male. Most patients were classified as community-acquired (82.5%). The median PCR CT value was 27.8. ROC curve analysis yielded an AUC of 0.288, indicating poor predictive performance. As CT values increased, sensitivity and NPV increased, while specificity and PPV decreased. No definitive CT cutoff was identified. Overall, 55.7% of PCR-positive specimens were confirmed positive by CCCA. Our preliminary findings suggest a potential relationship between lower CT values and CCCA positivity, but no definitive CT cutoff was identified. The trends observed in NPV and PPV of CT values may reflect differences in bacterial burden, but interpretation is currently limited by small sample size. While CT values may provide contextual value in diagnostic interpretation, they remain investigational and should not guide clinical decisions alone. All Authors: No reported disclosures
Pregnancy-associated spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome, most often affecting women during late pregnancy or postpartum. Diagnosis can be challenging because symptoms often mimic other pregnancy-associated cardiopulmonary conditions. A 43-year-old G4P3003 at 39 weeks gestation presented with acute chest pain and shortness of breath. Initial workup at a rural facility suggested the incorrect leading diagnosis; however, further evaluation at a tertiary facility revealed markedly elevated troponins and ST elevation, prompting emergent coronary angiography. Imaging showed SCAD of the mid-to-distal left anterior descending artery. Management included emergent cesarian section and conservative medical therapy. Over time, pregnancy-related hormonal and vascular changes likely contributed to vessel fragility in this multiparous patient. This case highlights the importance of maintaining a broad differential diagnosis in pregnant patients presenting with chest pain, regardless of cardiac risk factors. Early recognition and coordinated management by emergency medicine, cardiology, and obstetrics teams are essential to optimizing maternal and fetal outcomes. Ongoing research is needed to optimize the long-term management and overall outcomes in patients with pregnancy-associated SCAD.
When a patient presents to the emergency department with dizziness, a broad differential diagnosis must be considered. One of the more uncommon disorders that may be overlooked is a cerebellar cyst. The cerebellum is responsible for balance and coordination of the body, and dizziness may be the only presenting symptom in the setting of cerebellar dysfunction. For this reason, it is important to conduct a thorough neurological exam for a patient with dizziness. The presentation of dizziness alone may not warrant a computed tomography (CT) of the head, which would be necessary to identify a cyst. This case report illustrates an uncommon cause of persistent dizziness in a 34-year-old Hispanic male who presented to the emergency department. A CT of the head revealed a cerebellar cyst that was responsible for the dizziness. Because these types of cysts do not manifest symptoms until they grow large enough, there have only been two reported cases in literature. The cause is suspected to be due to a congenital abnormality in the embryonic neural tube segments. In both cases, surgical resection was performed and resulted in complete remission of symptoms. It is hypothesized that there are many unreported cases of small cerebellar cysts in asymptomatic patients. Although cerebellar cysts are extremely rare, the medical community should be educated on the diagnosis of cerebellar cysts and guided on treatment if a patient presents with persistent, severe dizziness.
