Endoscopic Sphincterotomy Increases the Risk of Pyogenic Liver Abscess: A Retrospective Study Using Real-World Data

Introduction: Pyogenic liver abscess (PLA) after Endoscopic Retrograde Cholangiopancreatography (ERCP) is a rare infectious adverse event. The association between post-ERCP PLA and endoscopic sphincterotomy has not been extensively studied. Methods: We conducted a retrospective study using the TriNetX platform by including patients without history of PLA who received ERCP between October 2015 and December 2020. Two groups were made: the endoscopic sphincterotomy (ES) group (patients who received ES during ERCP) and the control group (patients who did not receive ES). The primary outcome was the risk of developing PLA within 1 year of the index ERCP. The secondary outcomes included sepsis, broad-spectrum antibiotics use, need for PLA drainage, and post-ERCP mortality within one year of the index ERCP. Results: There were 169 patients (1.43%) in the ES group who developed PLA compared to 123 patients (1.04%) in the control group, Relative Risk (RR): 1.37, P-value = 0.007. A total of 241 patients (2.05%) in the ES group developed sepsis compared to 176 patients (1.49%) in the control group, RR: 1.37, P-value = 0.001. A total of 2,954 patients (25.1%) in the ES group received treatment with broad-spectrum antibiotics compared to 2,132 patients (18.1%) in the control group, RR: 1.5, P-value \u3c 0.0001. There was no statistically significant difference in the need for PLA drainage (RR: 1.19, P-value = 0.34) or mortality (RR: 0.969, P-value = 0.49). Conclusion: ES during ERCP was associated with an increased risk for PLA, sepsis, and broad-spectrum antibiotics use. No mortality difference was found

Transjugular Transcatheter Tricuspid Valve Replacement With the Evoque System: A Case Series and Technical Considerations

Transcatheter tricuspid valve replacement (TTVR) with the Evoque tricuspid valve replacement system using a transfemoral (TF) approach has demonstrated safety and efficacy in patients with severe symptomatic tricuspid regurgitation. However, anatomical constraints may preclude TF delivery, necessitating alternative approaches. We present a step-by-step guide for performing TTVR via the transjugular (TJ) route based on 2 successful cases. In the first case, TJ access was selected upfront owing to the presence of an Adams-DeWeese inferior vena cava clip, which created a mechanical obstruction to femoral access. In the second case, TF access was attempted but abandoned owing to unfavorable trajectory, making valve deployment unsuccessful despite attempts from both the right and left femoral veins. This guide provides detailed procedural steps, technical considerations, and an algorithm for patient selection to help operators successfully perform TJ TTVR when TF access is not suitable

Combination therapy with TNF inhibitors plus biologics targeting type 2 inflammatory conditions in patients with rheumatoid arthritis: a case series

Objectives: Patients with RA treated with TNF inhibitors (TNFis) may experience type 2 inflammatory conditions such as asthma, atopic dermatitis or urticaria. Multiple biologic agents targeting type 2 inflammation are available. Combination biologic therapy targeting types 1 and 2 inflammation is not well described. We present a series of patients on a combination TNFi and biologic agent targeting type 2 inflammation. Methods: A retrospective case series of RA patients on TNFi receiving a biologic agent for type 2 inflammatory conditions was compiled. Descriptive data, duration of biologic use, incident bacterial infections and corticosteroid used 6 months before and after combination biologic agent use was collected. Results: Twelve patients were included. The mean overlap of combination biologic therapy was 83.7 weeks (95% CI 56.0, 111.4) and the median was 92.6 weeks [interquartile range (IQR) 36.4-109.8]. The mean corticosteroid cumulative dose 6 months prior to dual biologic agents was 463 mg prednisone equivalent (95% CI 131, 795) and the median was 265 mg (IQR 75-570). The mean corticosteroid cumulative dose 6 months after dual biologic agents was 241 mg prednisone equivalent (95% CI -21, 503) and the median was 0 mg (IQR 0-275). Six bacterial infections occurred prior to combination biologic therapy compared with five after initiating dual biologics. Conclusion: This case series demonstrates that adding a second biologic agent to target type 2 inflammatory conditions in RA patients on TNFi did not increase incident bacterial infections and may decrease corticosteroid use

When an Adrenal Mass Isn\u27t Cancer: A Rare Case of Mycobacterium genavense Mimicking a Neuroendocrine Tumor

An adrenal mass is an abnormal growth or tumor that develops in one or both adrenal glands. These can be benign or malignant. They are common, with a prevalence of 1% to 6% in the general adult population. While opportunistic infections such as histoplasmosis and cryptococcosis are known to rarely cause adrenal masses (\u3c 1%), with histoplasmosis presenting as an adrenal mass in 0.85% of cases in HIV patients, the incidence of Mycobacterium species causing adrenalitis is even lower, making it an infrequent clinical entity. We present a case of a patient without any obvious immunocompromise who presented with a unilateral adrenal mass initially thought to be a neuroendocrine tumor due to markedly elevated pancreatic polypeptide. He underwent a right adrenalectomy due to the increasing size of the mass and was diagnosed with an adrenal Mycobacterium infection. The differential diagnosis of an adrenal mass is discussed, and the role of endocrinologists in diagnosing and managing this case is highlighted

Impact of Timing of Atrial Fibrillation Ablation on AF Recurrence and Clinical Outcomes in Patients With HFpEF and HFrEF

Background: Early catheter ablation for atrial fibrillation (AF) improves outcomes, but the optimal timing, especially in heart failure (HF) subtypes, remains unclear. Objective: To evaluate the impact of ablation timing on outcomes in patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Methods: We used the TriNetX database (2010-2024) to identify HF patients with AF who underwent ablation. Patients were classified as early ablation (≤ 1 year of first AF diagnosis) or delayed ablation (1-3 years), with propensity score matching (PSM) applied to balance the baseline characteristics. The primary outcome was AF recurrence, defined by repeat ablation, direct current cardioversion (DCCV), or antiarrhythmic drug (AAD) use after a 3-month blanking period. Secondary outcomes included stroke, hospitalization, and mortality over 5 years. Results: After PSM, delayed ablation was associated with higher AF recurrence in both HFrEF (HR = 1.28, p \u3c 0.001) and HFpEF (HR = 1.21, p = 0.02), as seen in multivariate analysis. In HFrEF, delayed ablation was associated with higher incidence of re-do ablation, AAD use, and DCCV, while in HFpEF, higher recurrence with delayed ablation was associated with increased AAD use. Both cohorts had similar stroke and mortality rates between early and delayed ablation. Conclusions: Delayed ablation in HFrEF and HFpEF was linked to higher AF recurrence, driven by increased redo ablations, DCCV, AAD use in HFrEF, and higher AAD use in HFpEF. Stroke, HF hospitalization and mortality rates were similar, suggesting earlier ablation may enhance rhythm control over other outcomes

Emerging Risk Factors for Invasive Pulmonary Aspergillosis: A Narrative Review

Aspergillus can cause a spectrum of diseases depending on the immune status and predisposing conditions. Invasive pulmonary aspergillosis (IPA) is classically seen in patients with severe immunocompromise, such as patients with hematologic malignancies, transplant recipients, and chronic corticosteroid use at high doses. Recently, IPA cases in patients without these classic risk factors, including those associated with severe respiratory viral infections, chronic obstructive pulmonary disease, liver failure, and critical illness, are being increasingly recognized. Delayed recognition and missed diagnoses contribute to increased mortality in these patient populations. Maintaining a high index of suspicion and implementation of systematic screening protocols in high-risk patients may help reduce missed or delayed diagnoses and improve patient outcomes. This review describes the pathophysiology, incidence, risk factors, outcomes, and diagnostic and treatment considerations in IPA in patients with emerging risk factors