Successful Treatment of Massive Pulmonary Embolism in Pregnancy with Catheter-Directed Embolectomy

Introduction  Pulmonary embolism (PE) is associated with approximately 10.5% of maternal deaths in the United States. Despite heightened awareness of its mortality potential, there islittle data available to guide its management in pregnancy. We present the case of a massive PE during gestation successfully treated with catheter-directed embolectomy. Case Presentation  A 37-year-old G2P1001 presented with a syncopal episode preceded by dyspnea and chest pain. Upon presentation, she was hypotensive, tachycardiac, and hypoxic. Imaging showed an occlusive bilateral PE, right heart strain, and a possible intrauterine pregnancy. Beta-human chorionic gonadotropin was positive. She was taken emergently for catheter-directed embolectomy. Her condition immediately improved afterward. Postprocedure pelvic ultrasound confirmed a viable intrauterine pregnancy at 10 weeks gestation. She was discharged with therapeutic enoxaparin and gave birth to a healthy infant at 38 weeks gestation. Conclusion  Despite being the gold standard for PE treatment in nonpregnant adults, systemic thrombolysis is relatively contraindicated in pregnancy due to concern for maternal or fetal hemorrhage. Surgical or catheter-based thrombectomies are rarely recommended. Limited alternative options force their consideration, particularly in a hemodynamically unstable patient. Catheter-directed embolectomy can possibly bypass such complications. Our case exemplifies the consideration of catheter-directed embolectomy as the initial treatment modality of a hemodynamically unstable gestational PE.

Unusual Case of Ludwig Angina Caused by Clostridium sporogenes in an Immunocompromised HIV-Positive Patient with Alcoholism and Dental Abscess

BACKGROUND Ludwig angina is a cellulitis of the soft tissues of the neck and floor of the mouth. It is most commonly caused by Viridans streptococcal species, but other bacterial species have been shown to lead to this severe infection. Clostridium sporogenes is an anaerobic gram-positive, spore-producing bacillus found in soil and the human gastrointestinal tract. This report is of a case of a 49-year-old HIV-positive man with alcoholism and poor dental hygiene leading to a molar abscess who presented with Ludwig angina due to C. sporogenes. CASE REPORT A 49-year-old man presented with severe left molar pain, fever, and worsening neck swelling for 5 days. His medical history was significant for AIDS; he was not on antiretroviral therapy. Computed tomography of the neck was positive for extensive subcutaneous emphysema of the left sublingual space. Ludwig angina was diagnosed, and he was taken urgently for incision and drainage of the bilateral neck fascial space. On day 6 of hospitalization, 1 of 2 blood cultures grew C. sporogenes. He left the hospital on day 13 and was readmitted 6 days later with progression of the disease and alcohol withdrawal. CONCLUSIONS This case illustrates the need for rapid diagnosis and treatment of Ludwig angina and the importance of considering commonly pathogenic and rarely pathogenic bacteria when considering the underlying bacterial cause of an infection in an immunocompromised patient. To the best of our knowledge, this is the first case of Ludwig angina caused by C. sporogenes reported in the medical literature.

Progressive Multifocal Leukoencephalopathy Presenting as Primary CNS Malignancy in an Immunocompetent Patient

Progressive multifocal leukoencephalopathy (PML) is an infection caused by the John Cunningham virus (JCV), usually in an immunocompromised host. We present the case of a 74-year-old male who presented with a six-week history of progressive memory loss, episodic confusion, and aphasia. Cranial nerve, motor, sensory, and coordination testing were unremarkable. Magnetic resonance imaging (MRI) of the brain and spectroscopy were concerning for primary CNS lymphoma vs. diffuse glioma. Microscopic examination after the patient underwent left frontal stereotactic brain biopsy was suggestive of a viral infection, and further testing with JCV DNA in-situ hybridization (ISH) confirmed the diagnosis of PML. The patient's condition started resolving without treatment. This case demonstrates, to our knowledge, the first known case of primary PML masquerading as CNS lymphoma in modern literature.

Synoviocyte-Derived Extracellular Matrix and bFGF Speed Human Chondrocyte Proliferation While Maintaining Differentiation Potential

Improving the ability of human chondrocytes to proliferate, while maintaining their differentiation potential, has presented a great challenge in cartilage tissue engineering. In this study, human chondrocytes were cultured under four unique growth conditions at physiologic oxygen tension: tissue culture plastic (TCP) only, synoviocyte matrix (SCM)-coated flasks only, SCM-coated flasks with bFGF media supplement, and TCP with bFGF media supplement. The results indicated that, compared to standard TCP, all test conditions showed significantly increased cell expansion rates and an increase in both glycosaminoglycan (GAG) and collagen content during redifferentiation culture. Specifically, the combined SCM + bFGF growth condition showed an additive effect, with an increase of approximately 36% more cells per passage (5-7 days) when compared to the SCM alone. In conclusion, the results of this study demonstrate that bFGF and SCM can be used as supplements to enhance the growth of human chondrocytes both as individual enhancers and as a combined additive.

Survey on Impact of Operational Policies and Procedures on Patient Satisfaction at a Rural Free Healthcare Clinic in Florida

Aims 

Free healthcare clinics provide highly necessary services for the populations they serve, particularly in rural, low socioeconomic areas. When assessing for quality of clinic performance, it is important to consider the background of the population it serves in addition to observations given by clinic volunteers. Contextualizing the healthcare challenges patients face will help the clinic assist them to a greater capacity. Here, we assess how different areas of clinic operations (service, safety, accessibility, interactions with volunteers, and wait time) impact patient satisfaction in the setting of a small, rural, free clinic.

Methods

Eligible participants were asked to fill out an anonymous, 21-question survey that assessed their experiences and perspectives on various aspects of the clinic. The study was single-blinded with clinic staff unaware of the nature of the study.

Results

Thirty-five patients responded to the survey. Overall, patients were extremely satisfied with the clinic with an average Likert score of 4.8/5; 14 of 15 categories scored a four or higher. Wait time scored lowest (3.6/5), with waits up to eight hours. Additionally, we found that transportation was not a major barrier to patients, with 80% arriving by personal transport.

Conclusions

The clinic provided valued and satisfactory services without coming across as discriminatory to the community. Areas of improvement include wait times, role clarification, and better integration of medical students. Additional studies to further understand the community will facilitate tailoring healthcare to a rural underserved population in the Southeastern United States.