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Myoglobin cast nephropathy occurs in cases of acute renal injury in which large amounts of myoglobin accumulate in the renal tubules, presenting as muscle pain, reddish-brown urine, and elevated creatine kinase levels. Our case describes a 60-year-old male who came to the emergency department with fevers, mild abdominal pain, and constitutional symptoms one day after returning to the United States from a trip to Nigeria. Initial workup demonstrated an acute kidney injury and elevated aminotransferase levels and the patient was started onatovaquone-proguanil for possible malaria given a recent diagnosis in Nigeria. Two days later, the patient was found to have rhabdomyolysis, resulting in a renal biopsy that showed myoglobin cast nephropathy. Previous literature has suggested mechanisms for the development of rhabdomyolysis in malarial infection, including inflammatory processes, direct effect of parasite accumulation, and drug-induced toxicity. Our case further implicates antimalarial therapy as a cause of rhabdomyolysis and increases awareness of myoglobin cast nephropathy as a potential complication of malaria. [ABSTRACT FROM AUTHOR]

Background. Flea-borne typhus (FBT), an uncommon illness in the United States, typically presents as a high continuous fever with commonly associated symptoms including headache, myalgias, and rashes on the trunk and extremities. Patients infected with FBT may also present with atypical symptoms. As such, the combination of its relatively low incidence in the United States coupled with its variability in associated symptoms poses a diagnostic challenge for clinicians; early empiric treatment with doxycycline is warranted prior to a definitive diagnosis to reduce the risk of damage to vital organs. Case Report. This case describes a 54-year-old male who presented to an emergency room in Houston, Texas, with one week of constant right upper quadrant abdominal pain and fevers up to 40°C. The patient was initially diagnosed with Grade III severe acute cholangitis after abdominal ultrasound revealed gallbladder sludge and wall thickening without ductal dilatation, but a subsequent endoscopic retrograde cholangiopancreatography was unremarkable. Following intermittent fevers and worsening anemia, the patient was started on oral doxycycline for atypical infection, and an infectious disease workup subsequently returned a positive titer for Rickettsia typhi. He experienced rapid symptomatic and clinical improvement, and the patient was discharged home with a final diagnosis of flea-borne typhus. Conclusion. Albeit uncommon, the presentation of this patient's symptoms and final diagnosis of flea-borne typhus demonstrates the importance of (1) keeping atypical infections such as FBT in the differential diagnosis and (2) beginning empiric treatment to prevent damage to vital organs if suspicion of FBT is high. [ABSTRACT FROM AUTHOR]

The current standard of care for muscle-invasive bladder cancer is neoadjuvant chemotherapy followed by radical cystectomy with lymph node dissection. Although this treatment provides therapeutic benefit, it is associated with notable morbidity. Bladder sparing techniques, such as concurrent chemo-radiation, are less invasive and prioritize organ preservation in individuals with invasive bladder cancer and offer comparable disease control. High-dose-rate brachytherapy is an emerging paradigm in the management of muscle-invasive bladder cancer. During high-dose-rate brachytherapy, radioactive sources are introduced to the area of the primary tumor through specialized catheters. The specific placement of brachytherapy catheters results in heightened effectiveness of the radiation treatment with less radiation damage to surrounding structures. For bladder-sparing therapies such as brachytherapy to rival radical cystectomy, these techniques need to be refined further by radiation oncologists. One such modality for developing and practicing these techniques is the use of cadaveric models in innovation-focused clinical training facilities, which provide a simulated sterile surgical environment without the concern for extending intraoperative time. The objective of this technical note is to demonstrate how clinical training facilities such as the Houston Methodist Institute for Technology, Innovation & Education are ideal for the development, testing, and training of novel brachytherapy techniques using cadaveric models. By utilizing a network of similarly innovative training centers, research and development of brachytherapy techniques can be expedited, and novel bladder-sparing treatment methods can be implemented as the standard of care for bladder cancer. [ABSTRACT FROM AUTHOR]

Pelvic lymph node dissection (PLND) is a fundamental component in the management of muscle-invasive bladder cancer (MIBC). Currently, there are no available tools to intra-operatively reliably target and identify lymph nodes which may have metastasis; therefore, a template-based PLND of lymph node landing zones must be performed. Prior studies in animal models have mapped lymph node drainage from the bladder using fluorescent molecules. Hexaminolevulinate HCl dye is a candidate for the proposed application In this study, given its fluorescent properties and ability to differentiate between normal urothelial cells and urothelial carcinoma. This is an investigator-initiated, single-institution, single-arm prospective study to determine the feasibility and safety of Hexaminolevulinate HCl administration into the bladder prior to robotic assisted radical cystectomy (RARC) and assessing for the presence of fluorescence in the lymph node regions and at the surgical margin via blue light laparoscopy. The study will recruit 10 patients with MIBC and either imaging-confirmed cN1 disease or higher risk for nodal metastasis with ≥ cT3 disease. Patients will receive intravesical instillation of Hexaminolevulinate HCl prior to the standard of care: RARC and PLND. The surgeon's subjective assessment of fluorescence during blue light intra-abdominal laparoscopy will be recorded. The obturator node packet will undergo: 1) standard pathologic analysis for nodal metastasis, 2) analysis under epifluorescent microscopy to assess for microscopic fluorescence and 3) ex vivo staining in Hexaminolevulinate HCl dye followed by epifluorescent microscopy. Enrollment opened on December 1, 2022. Results: Conclusions: [ABSTRACT FROM AUTHOR]

This feasibility study outlines a proof-of-concept model – the Houston Methodist Institute for Technology, Innovation & Education (MITIE) – for the use of cadaveric models at research centers to encourage development and training of novel robotic brachytherapy techniques, thereby expediting the incorporation of brachytherapy into the standard of care for muscle-invasive bladder cancer (MIBC). Catheter insertion sites were marked on a male cadaver, and the da Vinci Surgical System(R) (Intuitive Surgical, Inc., Sunnyvale, CA) was docked. A modified catheter-needle system was assembled since pre-assembled bladder-specific catheter-needle systems are not compatible with all brachytherapy afterloaders. Closed-end catheters were inserted into 17-gauge curved needles. The first catheter was placed into the right lateral hypogastric abdominal wall, through the bladder dome wall, and out the opposing side. A single plane implant was completed with 1 cm spacing with the two other catheters (Figure 1a). Catheters were secured with nylon retaining buttons (Figure 1b). A CT simulation scan confirmed placement and a plan was developed for simulated brachytherapy delivery (Figure 1c). Cadaveric models enable physicians to develop new brachytherapy procedures in a controlled and simulated surgical environment without affecting operative time. Physicians can gain familiarity with the procedure and practice alterations to surgical equipment, including the catheter-needle system, which may prevent complications peri- and postoperatively. The proof-of-concept trial in MITIE shows how research and training centers can serve as incubators for the development of brachytherapy techniques. With a network of these centers, experts across the country can collaborate to test new techniques on cadaveric models and accelerate developments in bladder brachytherapy. This network would provide training opportunities for physicians, especially residents, which can familiarize physicians with brachytherapy techniques, promoting their use and providing clinical data to support these techniques as a new standard of care. Currently, institutes like MITIE are limited in number, necessitating travel and coordination of attending and resident physicians' schedules. Although an expanded network of these institutes would alleviate this issue, these training centers are associated with high operating costs, including the acquisition costs and high turnover rate required of cadaveric training models. Therefore, cost may impede scalability and must be considered alongside the benefits of establishing a widespread network of research and training programs for brachytherapy. Robotic brachytherapy is a rarely utilized, minimally invasive treatment modality for MIBC. Innovation-focused facilities with cadaveric models can provide simulated surgical environments for the research, development, and training of robotic brachytherapy techniques and applicators, accelerating the acceptance of brachytherapy as the standard of care for MIBC. [ABSTRACT FROM AUTHOR]

Major depressive disorder during pregnancy can be detrimental to the fetus and patient. Treatments can include electroconvulsive therapy (ECT) for severe cases. The use of ketamine in ECT can provide symptomatic relief as well as induce anesthesia. Here, we describe the case of a 35-year-old gravid woman with a long-standing history of major depressive disorder who presented with treatment-resistant depression with suicidal ideation after an alteration in her antidepressant medication. After psychiatric evaluation, she was deemed to be a good candidate for ECT augmented with ketamine for symptomatic relief. This was complicated by an positive but asymptomatic COVID-19 status. Despite these factors, the patient experienced significant relief after an eight-treatment course of ECT, with a reduction of her PHQ-9 score from 22/27 to 4/27 points. [ABSTRACT FROM AUTHOR]