Faculty Bibliography

Coccidioidomycosis rarely presents as a lung mass, hypereosinophilia, and disseminated pericarditis with pericardial effusion. Even rarer is a case that presents with the constellation of all these findings. We present a case of coccidioidomycosis in an immunocompetent young Jamaican male with all these features, set against an interesting epidemiological context of a likely exposure to coccidioidomycosis spores during an on-foot crossing of the Mexican border into Texas. His treatment course was complicated by declining liver and kidney function due to triazole antifungal therapy, necessitating titration of these doses to tolerable levels. This case highlights the importance of a detailed travel history in unraveling infectious disease diagnoses and underscores the need for high clinical suspicion for coccidioidomycosis, even in patients outside of known endemic regions.

Disseminated cutaneous herpes zoster (DCHZ), defined as lesions involving three or more dermatomes, is strongly associated with immunocompromised states and remains exceptionally rare in young immunocompetent adults. We present a case of DCHZ in a previously healthy 25-year-old male from Guatemala who presented with an eight-day history of a painful vesicular rash involving the right V2/V3, C3-C5, and T2-T3 dermatomes. Comprehensive evaluation for occult immunocompromise, including HIV testing, complete blood count, hemoglobin A1c, and urinalysis, was unrevealing. Treatment with high-dose intravenous acyclovir was complicated by acute kidney injury after four doses, with creatinine rising from 0.80 mg/dL to 2.60 mg/dL. Renal function improved following discontinuation of IV acyclovir and transition to oral valacyclovir. This case highlights the rarity of disseminated zoster in young immunocompetent adults and underscores the importance of targeted evaluation for underlying immunologic vulnerability and thorough investigation of acute kidney injury in the setting of DCHZ.

Achalasia is an uncommon primary esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and absent esophageal peristalsis. These changes result in progressive esophageal dilation and functional obstruction. Although classically associated with dysphagia and regurgitation, respiratory manifestations may predominate due to chronic aspiration of retained esophageal contents, which can obscure the underlying diagnosis and delay appropriate management. We report the case of a 20-year-old male with a history of asthma, gastroesophageal reflux disease, and gastroparesis who presented with one day of shortness of breath and productive cough, initially treated as an asthma exacerbation. Imaging performed to evaluate new-onset respiratory symptoms for one day prior to admission revealed a markedly dilated, fluid-filled esophagus and radiographic findings consistent with aspiration pneumonia. He was initially treated with one dose of 2 mg IV cefepime, then modified to Unasyn 3 mg and doxycycline 100 mg. Subsequent endoscopic evaluation confirmed severe esophageal dilation with retained food contents, supporting the diagnosis of advanced achalasia. This case highlights how achalasia may present primarily with pulmonary complications in young patients, particularly when coexisting respiratory disease is present. Delayed recognition can result in significant morbidity, including recurrent aspiration, malnutrition, and progressive esophageal dysfunction. Early consideration of esophageal motility disorders in patients with refractory respiratory symptoms and GI history is essential to prevent complications and guide timely therapeutic intervention.

BACKGROUND:Renal cell carcinoma (RCC) accounts for 3% of solid malignancies, with clear cell RCC (ccRCC) comprising 80% of cases. Although 20%-30% of RCC cases are metastatic at diagnosis, cardiac metastases are rare. CASE SUMMARY/METHODS:A 65-year-old man with a remote history of ccRCC developed progressive dyspnea. Evaluation showed pulmonary nodules and a fluorodeoxyglucose-avid left ventricular mass. Surgical resection confirmed ccRCC. He received dual immune checkpoint inhibitor therapy and achieved a complete response. His treatment was complicated by pneumonitis, which resolved with corticosteroids. He remains in remission off therapy. DISCUSSION/CONCLUSIONS:This is a rare case of oligorecurrent RCC with cardiac metastasis without inferior vena cava involvement after prolonged remission. It emphasizes the complexity of decision-making because of extracardiac metastasis and treatment complications. TAKE-HOME MESSAGES/CONCLUSIONS:Cardiac metastasis is rare in oligorecurrent RCC, but relapse may occur even after prolonged latency periods. Appropriate treatment requires identification of other metastatic sites and a multidisciplinary approach.

BACKGROUND/UNASSIGNED:Cervical spine pathologies causing nerve-root compression are treated with use of decompression through a variety of techniques. Although several operative management options exist, cervical foraminotomy may be indicated in patients with isolated, unilateral cervical radiculopathy. Biportal endoscopic cervical foraminotomy allows decompression with minimal soft-tissue disturbance and excellent visualization. DESCRIPTION/UNASSIGNED:The procedure is performed with the patient in a prone position with routine neuromonitoring. Intraoperative fluoroscopy is utilized to identify the operative level, and 2 paramedian incisions are made for the portal sites at a 20° to 30° angle to the desired disc space. The working portal is utilized for surgical instruments, and the second portal serves as a viewing portal for the endoscope. Sequential dilators are utilized to establish the working portal, and a semi-tubular sheath of the desired length is placed. For the viewing portal, an endoscopic trocar is advanced through the fascia, and the camera is introduced. After endoscope insertion, surgical landmarks are identified, beginning with the interlaminar V point that marks the junction of adjacent laminae at the medial border of the facet joint. Once identified, overlying soft tissue is removed using radiofrequency ablation, and decompression of the nerve root can begin. We alternate between utilizing a high-speed diamond burr and a Kerrison rongeur to perform a laminoforaminotomy. Care is taken to minimize the facetectomy extent to <50% in order to reduce the risk of iatrogenic instability. The ligamentum flavum is preserved until the end in order to protect the dura from fluid pressure and surgical instruments. In the presence of disc herniation, disc fragments are removed through the working portal after gentle nerve root retraction. Once decompression of the neural foramen is completed to the lateral border of the pedicle, meticulous hemostasis is achieved using radiofrequency ablation, bone wax, and flowable thrombin-based hemostatic agents. Patients are typically discharged home on the same day. ALTERNATIVES/UNASSIGNED:Patients can undergo cervical foraminotomy utilizing traditional open, microscopic tubular, or uniportal endoscopic techniques. Alternatively, patients may undergo anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA), according to surgeon preference and individual patient pathology. RATIONALE/UNASSIGNED:. However, minimally invasive approaches are associated with earlier discharge, and reduced muscle damage and operative blood loss. Although tubular foraminotomy is a traditional minimally invasive option, endoscopic approaches offer distinct benefits. First, biportal endoscopy allows for greater maneuverability and visualization of the neural foramen. Second, compared with ACDF and CDA, foraminotomy obviates the need for instrumentation, preserves segmental motion, and avoids the anterior approach, which is associated with dysphagia, dysphonia, and potential for vascular injury. EXPECTED OUTCOMES/UNASSIGNED:. IMPORTANT TIPS/UNASSIGNED:Achieve adequate endoscopic visualization before starting osseous resection.Avoid inserting instruments blindly into the interlaminar space.Complete removal of the medial superior articular process up to the lateral border of the pedicle.Ensure palpation of the lateral aspect of the cranial and caudal pedicles.Inspect for extruded disc material.Maintain the ligamentum flavum until the end of the decompression.Achieve hemostasis to prevent postoperative epidural hematoma. ACRONYMS AND ABBREVIATIONS/UNASSIGNED:NSAID = nonsteroidal anti-inflammatory drugACDF = anterior cervical discectomy and fusionCDA = cervical disc arthroplastyESI = epidural steroid injectionRFA = radiofrequency ablation.

PURPOSE/OBJECTIVE:Lumbar spinal stenosis (LSS) is a common degenerative spinal condition and a leading cause of pain and disability in adults. With increasing use of artificial intelligence (AI) for medical information, this study evaluated and compared the accuracy and completeness of responses generated by large language models (LLMs) and Google Search to standardized patient-oriented questions about LSS, aiming to characterize AI performance in patient education. METHODS:Eight frequently asked questions regarding LSS were identified using NHS hospital websites, NASS clinical guidelines, Google "People Also Ask," Reddit discussions, and common ChatGPT prompts. Each question was submitted to Google Search, ChatGPT, Gemini, and Perplexity under standardized conditions. Orthopedic spine surgeons independently rated responses for accuracy and completeness using 5-point Likert scales. Parametric (one-way ANOVA) and non-parametric (Kruskal-Wallis) tests evaluated overall differences. A minimal clinically important difference (MCID) was established as a ≥ 1.0-point delta, with post-hoc pairwise comparisons evaluated using Tukey's Honestly Significant Difference. RESULTS:Gemini achieved the highest completeness (4.47 ± 0.67) and accuracy (4.34 ± 0.65), followed by Perplexity (completeness 4.03 ± 0.82; accuracy 4.00 ± 0.95). Google and ChatGPT demonstrated similar completeness (3.75 ± 1.04 vs. 3.78 ± 0.71), though Google showed slightly higher accuracy than ChatGPT (3.78 ± 0.91 vs. 3.63 ± 0.75). Global performance variations were highly significant across both omnibus parametric testing (completeness: p = 0.002; accuracy: p = 0.004) and non-parametric Kruskal-Wallis testing (completeness: p = 0.003; accuracy: p = 0.004). Post-hoc pairwise testing via Tukey's HSD confirmed that this statistical significance was driven solely by Gemini, which outperformed both ChatGPT (completeness p = 0.006; accuracy p = 0.004) and Google Search (completeness p = 0.004; accuracy p = 0.036). No other isolated pairwise combinations achieved statistical significance (p > 0.05). Despite these isolated statistical boundaries, no platform pairing cleared the predefined ≥ 1.0-point threshold for clinical significance, with maximum mean score deltas reaching only 0.72 for completeness and 0.71 for accuracy. CONCLUSIONS:Although newer-generation and search-augmented LLMs demonstrate clear statistical superiority over traditional web results in synthesizing structured spine information, these differences do not yet translate into clinically meaningful quality shifts under concise prompt constraints. Substantial inter-rater variability and the lack of threshold-clearing clinical significance reinforce that these emerging AI platforms should serve as supplements to, rather than substitutes for, physician-guided counseling in degenerative spine care.

BACKGROUND:Bispecific T-cell-engaging antibodies against BCMA and GPRC5D demonstrate high efficacy in relapsed/refractory multiple myeloma (RRMM) but are associated with cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), traditionally prompting inpatient monitoring when commencing therapy. Contemporary step-up dosing and prophylactic strategies may enable safe outpatient administration. PATIENTS AND METHODS/METHODS:We conducted a single-center retrospective study evaluating outpatient step-up dosing (SUD) of teclistamab or talquetamab in adults with RRMM. Patients met institutional outpatient eligibility criteria and received standard pre-medications; prophylactic tocilizumab was administered at physician discretion. The primary endpoint was incidence and severity of CRS/ICANS. Secondary endpoints included SUD completion, healthcare utilization, and need for hospitalization. RESULTS:Thirty-eight patients underwent 43 outpatient SUD initiations (teclistamab n = 30; talquetamab n = 13). Median age was 72 years, and disease burden was high. SUD completion occurred in 93%. CRS occurred in 26% of initiations and was exclusively grade 1-2; no grade ≥ 3 CRS occurred. One possible grade III ICANS event (2%) occurred after completion of SUD. CRS incidence was similar with and without prophylactic tocilizumab (29% vs 32%). Most events occurred during the first two step-up doses. Hospitalization occurred in 5 (12%) SUD initiations for CRS/ICANS events and overall healthcare utilization was modest. CONCLUSION/CONCLUSIONS:Outpatient administration of teclistamab and talquetamab SUD in RRMM is feasible and safe with low rates of low-grade CRS. Toxicities occur early and are manageable with structured monitoring, supporting outpatient delivery in appropriately selected patients.

OBJECTIVES/OBJECTIVE:To compare growth z-scores and prematurity-related comorbidities for preterm infants receiving Soybean Oil-Intravenous Lipid Emulsion (SO-ILE) versus Soybean + Medium-chain triglycerides + Olive + Fish oil ILE (SMOF-ILE). STUDY DESIGN/METHODS:A multicenter, retrospective cohort study of 347 preterm infants <32 weeks' gestational age with birth weight ≤1500 grams who received SO-ILE or SMOF-ILE for at least seven consecutive days. RESULTS:SO-ILE group (n = 179) demonstrated significantly improved growth for length (p ≤ 0.001) and head circumference z-scores (p = 0.015) at 36 weeks' postmenstrual age and significantly worse growth for weight z-scores at 1 month (p = 0.017) compared to the SMOF-ILE group (n = 168). SO-ILE group had significantly lower rates of bronchopulmonary dysplasia (BPD) (p < 0.001) and urinary tract infections (UTI) (p = 0.045). CONCLUSION/CONCLUSIONS:In this population, SO-ILE had better outcomes for growth, BPD, and UTI compared to SMOF-ILE. Therefore, SO-ILE remains a reasonable lipid emulsion for preterm infants until more evidence is available.

Background Stroke remains a leading cause of death and long-term disability. Although stem cell-based approaches are being investigated as possible regenerative strategies for stroke, public perceptions of their potential benefits, risks, mechanisms, and clinical use are not well-characterized. This exploratory survey described responses to an investigator-developed questionnaire about stem cell therapy for stroke. Methods A 10-item cross-sectional questionnaire was distributed electronically through Google Forms (Google, Inc., Mountain View, CA) to 36 individuals in a convenience sample; 26 completed questionnaires were received (response rate: 72.2%). The questionnaire was investigator-developed and was not validated as a measure of factual knowledge, clinical efficacy, or safety. Responses were categorized as "yes," "no," or "maybe"; one item used time-based response categories. Counts and percentages were calculated using the total number of completed questionnaires as the denominator. The survey was independently conducted as a student-led summer academic project and did not undergo review by an institutional review board, school ethics committee, or independent ethics authority. Results Twenty-six responses were analyzed. For the item asking whether embryonic stem cells are effective in stroke treatment, eight respondents (30.77%) selected "yes," 16 (61.54%) selected "maybe," and two (7.69%) selected "no." For the item asking whether stem cell treatment has advantages for stroke, 21 respondents (80.77%) selected "yes," four (15.38%) selected "maybe," and one (3.85%) selected "no." "Maybe" was the majority or joint-most-frequent response for six of 10 items, including items about animal testing, adverse effects, alternative regenerative treatments, and use during pregnancy. Conclusions In this small convenience sample, responses to an investigator-developed questionnaire suggested favorable perceptions of possible benefits of stem cell therapy for stroke, alongside frequent uncertainty about safety, mechanisms, the timing of improvement, and use in special populations. Because the questionnaire was not validated as a factual-knowledge instrument, findings should be interpreted strictly as descriptive perceptions rather than as evidence of respondents' medical knowledge, treatment confidence, or the clinical efficacy or safety of stem cell therapy. Larger studies using validated instruments and representative sampling are needed.