Dual Disseminated Aspergillosis and Mucormycosis Diagnosed at Autopsy: A Report of Two Cases of Coinfection and a Review of the Literature.

Coinfection with invasive aspergillosis and mucormycosis in immunocompromised patients has been reported but is rarely confirmed by tissue histology or autopsy. Serum fungal biomarkers and culture are the primary diagnostic tools but are suboptimal for detecting fungal coinfection. Here, we present the cases of two patients who were immunocompromised due to hematologic malignancy where disseminated aspergillosis and mucormycosis coinfection was only diagnosed upon autopsy despite extensive fungal diagnostic workup, and also review recent literature of such instances of coinfection.

Myocarditis and endomyocardial biopsy: achieving consensus diagnosis on 100 cases.

The two histopathology benchmarks used to diagnose myocarditis are the Dallas Criteria, developed in 1984 and the European Society of Cardiology criteria, developed in 2013, which added immunohistochemistry for the detection of CD3+ T cells (lymphocytes) and CD68+ macrophages. Despite their near universal acceptance, the extent to which pathologists use these criteria or their own criteria to consistently render the diagnosis of myocarditis on endomyocardial biopsy (EMB) is unknown. We digitally scanned slides from 100 heart biopsies, including a trichrome stain and immunostaining, that were chosen as representative of myocarditis, non-myocarditis, and borderline myocarditis, as diagnosed per one institution's use of the Dallas Criteria. Eight blinded international cardiovascular experts were asked to render diagnoses and offer a confidence score on each case. No clinical histories were shared. There was full initial agreement across all experts on 37 cases (16 myocarditis and 21 non-myocarditis) and moderate consensus on 35 cases. After individual inquiries and group discussion, consensus was reached on 90 cases. Diagnostic confidence was highest among the myocarditis diagnoses, lowest for borderline cases, and significantly different between the three diagnostic categories (myocarditis, borderline myocarditis, non-myocarditis; P-value=8.49 × 10-57; ANOVA). Diagnosing myocarditis, particularly in cases with limited inflammation and injury, remains a challenge even for experts in the field. Intermediate cases, termed "borderline" in the Dallas Criteria, represent those for which consensus is particularly hard to achieve. To increase consistency for the histopathologic diagnosis of myocarditis, we will need more specifically defined criteria, more granular descriptions of positive and negative features, clarity on how to incorporate immunohistochemistry findings, and improved nomenclature.

Initial Opioid Prescriptions Predict Continued Narcotic Use: Analysis of 24,594 Reduction Mammaplasty Patients.

BACKGROUND: The objective of this study was to establish whether a particular perioperative opioid regimen was associated with a higher risk of opioid refilling in the reduction mammaplasty patient population. METHODS: A retrospective cohort study was conducted on subjects that underwent bilateral reduction mammaplasty with no history of opioid use in the year before surgery. Patients were followed for a period of 4 months after surgery. Multivariable logistic regression was used to establish factors associated with prescription refilling. Predictive probabilities of opioid refilling, given various perioperative opioid regimens, were explored. RESULTS: A total of 24,594 subjects met all criteria for inclusion in the study, 13 percent of whom demonstrated continued opioid use following surgery. The probability of refill in patients receiving 15 to 59 daily morphine milligram equivalents perioperatively was significantly lower than in those receiving less than 15 daily morphine milligram equivalents (e.g., 15 mg of codeine every 4 hours) or more than 60 daily morphine milligram equivalents (e.g., 10 mg of oxycodone every 6 hours). CONCLUSIONS: The probability of refilling prescription opioids is increased by nonmodifiable risk factors, such as age. However, modifiable risk factors exist as well, most notably the amount of narcotic prescribed during the perioperative period. Overprescribing was found to be common in the reduction mammaplasty patient population. Limiting outpatient opioid exposure to a range of 15 to 59 daily morphine milligram equivalents (e.g., 5 mg of hydrocodone every 6 hours) during the perisurgical period may reduce the probability that the surgeon will need to prescribe further narcotics. Further studies are needed to validate our findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Reconstructive limb-salvage surgery after lower extremity soft tissue sarcoma resection: A 20-year experience.

BACKGROUND: Reconstructive surgery is often required following lower extremity soft tissue sarcoma resection. The relationship between the method of plastic surgery reconstruction and postoperative wound healing or functional oncologic outcomes in this patient population is poorly understood. METHODS: We performed a retrospective review on all adult patients that underwent soft tissue reconstruction following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution. RESULTS: One hundred and thirty-six patients were identified. Wound complications occurred within 6-months postoperatively in 72 patients (52.9%). Average time to heal was 13.0 weeks. Limb survival was 94.9%. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease, respectively. There was no significant difference in the incidence of overall wound complications, time to heal, limb survival, local recurrence, or metastatic disease between the different reconstructive methods. CONCLUSIONS: In our cohort, the utilization of different reconstructive techniques did not correlate with a difference in postoperative wound complications or oncologic outcomes. Local flaps can effectively reconstruct the majority of lower extremity sarcoma defects that cannot be closed primarily. However, alternative reconstructive techniques may be utilized when indicated without a significant increase in postoperative morbidity in this patient population.

Eighteen-year-old man with autism, obsessive compulsive disorder and a SHANK2 variant presents with severe anorexia that responds to high-dose fluoxetine.

The SHANK2 gene codes for a protein involved in organising the postsynaptic density and disruptions have been associated with autism spectrum disorders (ASDs). ASDs are frequently comorbid with intellectual disability and anxiety disorders and emerging evidence suggests potentially common aetiologies. Here, we report the case of an 18-year-old man with ASD who presented with severe anorexia due to fear of food contamination, food avoidance and stereotypies attributable to underlying obsessive compulsive disorder (OCD). The patient was found to be heterozygous for c.2518C>T (p.Pro840Ser), a likely damaging coding variant in the proline rich region of SHANK2 Interestingly, the patient's disordered eating behaviour began to improve only after high-dose fluoxetine was initiated to target OCD symptoms. Overall, this case highlights the utility of molecular genetic testing in clinical psychiatry and provides an example of how genetic information can inform clinicians in the treatment of complex neuropsychiatric syndromes.