WMJ : official publication of the State Medical Society of Wisconsin最新文献

Introduction: Multiple myeloma is a hematologic malignancy characterized by clonal proliferation of plasma cells. It is rare in young adults and may present in atypical forms, complicating timely diagnosis.

Case presentation: Patient 1 was a 23-year-old female who presented with subacute onset of leg pain, progressive weakness, and urinary retention. Lumbar spine magnetic resonance imaging (MRI) revealed a sacral mass causing cauda equina syndrome. Biopsy confirmed the diagnosis of plasmacytoma. At discharge, she exhibited gait abnormalities, neuropathic pain, and persistent urinary retention. She functioned at a modified independent level, using a manual wheelchair for mobility and performing intermittent self-catheterization. Patient 2 was a 28-year-old female who presented with acute onset of leg pain, weakness, and urinary retention. MRI of the spine revealed an epidural mass extending from T1 to T11, resulting in spinal cord compression. She underwent thoracolumbosacral laminectomies, and biopsy confirmed plasmacytoma. At discharge, she had motor complete paraplegia, neuropathic pain, and urinary retention managed with intermittent self-catheterization. She was modified independent, using a manual wheelchair for mobility.

Discussion: Despite advances in diagnosis and treatment, multiple myeloma remains a complex disease that poses diagnostic and therapeutic challenges. These cases emphasize the importance of standardized treatment protocols in management of spinal cord compressive plasmacytoma.

Conclusions: Early diagnosis, coordinated multidisciplinary care, and comprehensive rehabilitation are essential for improved management and outcomes.

Introduction: Surgical site infection (SSI) after lower extremity procedures is a persistent source of significant morbidity for vascular surgery patients. Frailty scores capture risk factors for postoperative outcomes associated with SSI. This study aimed to retrospectively evaluate the association between SSI and a validated measure of frailty, the Vascular Quality Initiative-Risk Analysis Index (VQI-RAI).

Methods: A retrospective review was performed of patients who underwent open lower extremity revascularization at a single independent academic medical center from January 1, 2007, through December 31, 2019. Frailty score was calculated using VQI-RAI, a composite score based on patient demographic and clinical variables. VQI-RAI scores were compared between patients who developed SSI and those who did not. SSI outcomes were compared between patients defined as frail (VQI-RAI ≥ 35) and not frail (VQI-RAI <  35).

Results: The study population comprised 1130 patients. The overall SSI rate was 8.1%. The median VQI-RAI score was 29 for patients with SSI and 28 for patients without SSI (P = 0.4). No significant association was observed between VQI-RAI and SSI or between patients defined as frail and not frail. Of the individual components of the VQI-RAI score, only body mass index was significantly associated with SSI (P <  .0001).

Conclusions: VQI-RAI frailty score was not associated with risk of SSI in our study population; however, body mass index was significantly associated with SSI. Obesity poses a high risk of SSI, whereas frailty alone may not be associated with an increased risk of SSI.

Introduction: PAPASH spectrum syndrome is a rare autoinflammatory condition encompassing psoriatic arthritis, pyoderma gangrenosum, acne, and hidradenitis suppurativa. Despite the individual prevalence of these conditions, their concurrent manifestation poses a diagnostic challenge that requires high clinical suspicion. This case illustrates the consequences of delayed recognition of this condition and underscores the crucial need for a multidisciplinary approach to optimize management.

Case presentation: We report the case of a 34-year-old African American man with a prior diagnosis of rheumatoid arthritis who developed migratory arthritis, pustular acne, and hidradenitis suppurativa. Despite suggestive clinical features, delayed access to biologic therapy contributed to disease progression and resulted in hospitalization. After extensive genetic and clinical evaluation, he was diagnosed with PAPASH syndrome.

Discussion: PAPASH syndrome is linked to mutations in the PSTPIP1 gene and the overexpression of specific chemokines, which dysregulate interleukin-1 signaling and cause persistent inflammation. Although tumor necrosis factor-α inhibitors remain first-line therapy, limited literature exists on comprehensive treatment strategies, and further research is needed. This case demonstrates how ongoing diagnostic ambiguity and the absence of clear treatment guidelines can complicate the management of PAPASH syndrome.

Conclusions: This case emphasizes the importance of prompt identification of PAPASH syndrome in patients presenting with overlapping inflammatory conditions and highlights the need for clinical vigilance, timely initiation of biologic agents, and coordinated care to improve outcomes in this rare but serious disorder.

Introduction: Nearly 90% of persons living with dementia experience behavioral and psychological symptoms of dementia (BPSD). Primary care clinicians may require more training to address these symptoms.

Methods: We surveyed Wisconsin primary care clinicians to assess their current approaches, needs, and interest in future educational interventions related to managing BPSD.

Results: Over 60% of clinicians reported lack of ability or training in managing BPSD, while over 75% expressed interest in educational interventions that included discussion of treatment algorithms or virtual didactics.

Discussion: Given the apparent widespread demand and need for educational interventions on BPSD for primary care clinicians, future studies are needed to assess the efficacy of such interventions in improving clinicians' preparedness to care for patients with BPSD.

Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug hypersensitivity reaction.

Case presentation: A 59-year-old male with a history of stage IV chronic kidney disease, polycystic kidney disease, hypertension, and hyperuricemia on allopurinol presented to the emergency department directly from an outpatient nephrology appointment with concern for severe DRESS syndrome with acute-on-chronic kidney failure, liver failure, and pancreatic involvement.

Discussion: The existing literature on the course of DRESS syndrome in patients with preexisting kidney dysfunction is limited.

Conclusions: We report a case of DRESS syndrome in a patient with chronic kidney disease who presented after initiating allopurinol for hyperuricemia. Care should be taken to quickly identify DRESS, stop the offending agent, and initiate systemic corticosteroids to prevent long-term morbidity and mortality. Furthermore, patient counseling should emphasize follow-up to identify and treat potential long-term sequelae, including thyroiditis and cardiac disease.

Introduction: Xylazine association with fentanyl poses an emerging threat to public health. We conducted a retrospective study to analyze xylazine-related fatal overdoses in Milwaukee County, Wisconsin from 2019 through 2023.

Methods: Using medical examiner data, we compared fatal xylazine overdoses (n = 243) with fentanyl overdoses without xylazine (n = 1946). Demographic, polysubstance, temporal, and geographic characteristics were analyzed.

Results: Xylazine fatalities have surged since 2019, exhibiting different polysubstance profiles than fentanyl overdoses without xylazine. We identified 8 geospatial clusters contributing to 64% of xylazine overdoses.

Discussion: We encourage localized interventions to address the xylazine-fentanyl syndemic. Policy measures such as Wisconsin Act 217, which legalized xylazine testing materials, promote evidence-based harm reduction tools to mitigate the risks associated with xylazine's increasing prevalence in the Midwest.

Introduction: The growing prevalence of dementia calls for nonpharmacological interventions to reduce negative quality of life effects for those living with dementia and their caregivers. Brain and Body Fitness, a community-based collaborative group program, engages people living with dementia and their caregivers through a combination of physical, cognitive, and socialization strategies, to maximize health benefits for sustained functioning.

Methods: Using an adapted form of the Patient-Reported Outcomes Measurement Information System (PROMIS) Applied Cognition tool, ex post facto data were collected from both participants affected with Alzheimer's disease and related dementias and their caregivers during 12 biweekly sessions of the Brain and Body Fitness program conducted from 2017 through 2021.

Results: Brain and Body Fitness program participants were affected by 4 quality of life indicators: anxiety, sleep, fatigue, and depression. Data reveal significant reductions in anxiety symptoms and significant improvements in fatigue for affected participants. Anecdotally, the program demonstrates nonsignificant trends of overall mood improvement.

Conclusions: Given the positive outcomes, communities may consider adopting a similar program to provide additional support for participants.

Introduction: Froedtert & the Medical College of Wisconsin belongs to a minority of institutions in which opioids are more frequently prescribed to non-Hispanic Black patients than their non-Hispanic White counterparts. The objective of this study was to evaluate racial and ethnic differences in prescribing practices for Medicare patients to determine areas for intervention.

Methods: This was a retrospective review of adult patients with Medicare insurance who received an ambulatory opioid prescription for pain. Outcomes included number of prescriptions, and maximum morphine milligram equivalent (MME). Unadjusted and adjusted linear regression models were used to examine associations between race and ethnicity and each outcome with and without adjustments for covariates.

Results: A total of 17 105 patients were given an ambulatory opioid prescription over the study period. Although most prescriptions were provided to non-Hispanic White patients, non-Hispanic Black patients had a higher mean number of prescriptions (4.36; 95% CI, 4.08 - 4.63) and higher MMEs at 495.31 (95% CI , 445.72 - 544.91). After controlling for demographics and comorbidities, individual comorbidities emerged as independent variables associated with greater numbers of prescriptions, with sickle cell disease (β 9.86; 95% CI, 9.08-10.64; PP <  0.001), drug abuse (β 5.22; 95% CI, 4.96-5.48; PP < 0.001), and paralysis (β 2.20; 95% CI, 1.73-2.67; PP <0.001) having the strongest relationships, while after adjustment, the significance of race and ethnicity was lost.

Conclusions: Institutions should explore reasons for racially inequitable opioid receipt. Individual comorbidities were associated with differences in opioid prescribing, allowing for targeted interventions in these patient groups.