POCUS-first for nephrolithiasis: A Monte Carlo simulation illustrating cost savings, LOS reduction, and preventable radiation.

OBJECTIVES: Non-contrast computed tomography (NCCT) is the gold standard for nephrolithiasis evaluation in the emergency department (ED). However, Choosing Wisely guidelines recommend against ordering NCCT for patients with suspected nephrolithiasis who are <50 years old with a history of kidney stones. Our primary objective was to estimate the national annual cost savings from using a point-of-care ultrasound (POCUS)-first approach for patients with suspected nephrolithiasis meeting Choosing Wisely criteria. Our secondary objectives were to estimate reductions in ED length of stay (LOS) and preventable radiation exposure. METHODS: We created a Monte Carlo simulation using available estimates for the frequency of ED visits for nephrolithiasis and eligibility for a POCUS-first approach. The study population included all ED patients diagnosed with nephrolithiasis. Based on 1000 trials of our simulation, we estimated national cost savings in averted advanced imaging from this strategy. We applied the same model to estimate the reduction in ED LOS and preventable radiation exposure. RESULTS: Using this model, we estimate a POCUS-first approach for evaluating nephrolithiasis meeting Choosing Wisely guidelines to save a mean (±SD) of $16.5 million (±$2.1 million) by avoiding 159,000 (±18,000) NCCT scans annually. This resulted in a national cumulative decrease of 166,000 (±165,000) annual bed-hours in ED LOS. Additionally, this resulted in a national cumulative reduction in radiation exposure of 1.9 million person-mSv, which could potentially prevent 232 (±81) excess cancer cases and 118 (±43) excess cancer deaths annually. CONCLUSION: If adopted widely, a POCUS-first approach for suspected nephrolithiasis in patients meeting Choosing Wisely criteria could yield significant national cost savings and a reduction in ED LOS and preventable radiation exposure. Further research is needed to explore the barriers to widespread adoption of this clinical workflow as well as the benefits of a POCUS-first approach in other patient populations.

Mindfulness-Based Interventions for the Reduction of Postoperative Pain in Hip and Knee Arthroplasty Patients: A Systematic Review and Meta-Analysis.

PURPOSE: The aim of this systematic review and meta-analysis is to evaluate the effect of mindfulness-based interventions (MBIs) on post-surgical pain in patients undergoing a total hip replacement (THR) or total knee replacement (TKR). METHODS: We performed a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A search of multiple databases, including PubMed and EMBASE, was performed for studies from database inception through March 2nd, 2022. Data were extracted, and pooled estimates of standardized mean differences in pain scores were calculated using a random effects model and inverse probability weighting. RESULTS: Two randomized control trials were eligible for inclusion (299 patients). The average ages of participants in each study were similar at 65.5 and 64.8 years, and both studies were predominantly female at 72.4% and 61.9%. The mindfulness intervention ranged from an eight-week program to a 20-minute session. Both individual studies reported statistically significant reductions in postoperative pain for MBI groups. The pooled standardized mean difference in pain scores for the MBI groups compared to the control groups was -1.94 (-3.39; -0.48). CONCLUSIONS: There exists preliminary evidence for the beneficial effect of MBIs on reducing the postoperative pain experience in this patient population. Given the significant consequences of postoperative pain and the necessity for non-opioid forms of analgesia, this topic represents a promising area of research that warrants future randomized control trials to better understand the role of MBIs for postoperative analgesia.

Novel techniques in performing extraoral ultrasound in diagnosing dental abscesses.

INTRODUCTION: Dental abscesses are a common reason patients present to the emergency department (ED). Facial and dental imaging are sometimes necessary to support the clinical diagnosis. While radiographs and computed tomography scans are frequently used, point-of-care ultrasound (US) offers several advantages, including decreased radiation exposure, reduced costs, and shorter patient length of stay. This report outlines the use of US in evaluating patients with suspected dental abscesses in the ED. DISCUSSION: The typical orofacial US techniques include examining the affected area for cobblestoning or fluid collections. To improve the accuracy of diagnoses, novel techniques such as the Oral Hydroscan (OHS) and the Tongue Pointing Techniques (TPT) may be employed in specific cases. The OHS utilizes a water-filled oral cavity to enhance the spatial resolution of ultrasound images, providing improved visualization of near-field structures and preventing air accumulation between the gingiva and the buccal mucosa. The TPT involves asking the patient to extend their tongue towards the affected area, pointing to the painful location, and serving as a visual reference for an extraoral US. CONCLUSION: US presents several advantages as an alternative imaging method for patients with suspected dental abscesses in the ED. Using innovative techniques such as the OHS and the TPT can further increase the visibility of tissue planes and help define the area of interest in these cases.

Structure of the C-terminal guanine nucleotide exchange factor module of Trio in an autoinhibited conformation reveals its oncogenic potential.

The C-terminal guanine nucleotide exchange factor (GEF) module of Trio (TrioC) transfers signals from the Gαq/11 subfamily of heterotrimeric G proteins to the small guanosine triphosphatase (GTPase) RhoA, enabling Gαq/11-coupled G protein-coupled receptors (GPCRs) to control downstream events, such as cell motility and gene transcription. This conserved signal transduction axis is crucial for tumor growth in uveal melanoma. Previous studies indicate that the GEF activity of the TrioC module is autoinhibited, with release of autoinhibition upon Gαq/11 binding. Here, we determined the crystal structure of TrioC in its basal state and found that the pleckstrin homology (PH) domain interacts with the Dbl homology (DH) domain in a manner that occludes the Rho GTPase binding site, thereby suggesting the molecular basis of TrioC autoinhibition. Biochemical and biophysical assays revealed that disruption of the autoinhibited conformation destabilized and activated the TrioC module in vitro. Last, mutations in the DH-PH interface found in patients with cancer activated TrioC and, in the context of full-length Trio, led to increased abundance of guanosine triphosphate-bound RhoA (RhoA·GTP) in human cells. These mutations increase mitogenic signaling through the RhoA axis and, therefore, may represent cancer drivers operating in a Gαq/11-independent manner.