Standing Intravenous Acetaminophen Is Associated With a Reduction of Post-operative Opioid Use in Infants Aged Less Than 1 Year Treated on the Acute Care Floor.

INTRODUCTION: Given the negative clinical effects opiates can have, the search for alternative forms of analgesia to treat post-operative pain continues. We implemented an opiate reduction strategy using standing intravenous (IV) acetaminophen for infants aged less than 1 y who underwent abdominal or anorectal surgery and recovered on the acute care floor. MATERIALS AND METHODS: Infants were administered standing IV acetaminophen every 6 h for a minimum of 48 h as the main form of post-operative analgesia. Pain severity was objectively scored using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. A before-and-after retrospective cohort analysis was performed and process control charts were used to examine trends in post-operative opiate use in our pre-intervention (January 2012 to January 2016), roll-out (January 2016 to December 2016), and post-intervention (December 2016 to December 2020) cohorts. RESULTS: A total of 131 infants were included: 56 in the pre-intervention, 17 in the roll-out, and 58 in the post-intervention group. Patient demographics were equivalent. The intervention was associated with a 36-fold reduction in post-operative morphine equivalents (median 0.36 mg/kg in the pre-intervention group versus 0.0 mg/kg in the post-intervention group, P < 0.0001). The median and maximum FLACC pain scores along with clinical safety profiles were statistically equivalent between the groups. The intervention was associated with a 2-d reduction in post-operative length of stay (P < 0.0001). CONCLUSIONS: Standing IV acetaminophen is associated with a reduction of post-operative opioid use in infants being treated on the acute care floor while maintaining equivalent FLACC pain scores. Similar opiate reduction strategies may be of value at other institutions.

Male Sex, Cartilage Surgery, Tobacco Use, and Opioid Disorders are Associated with an Increased Risk of Infection After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To identify patient-related risk factors for infection following anterior cruciate ligament reconstruction (ACLR). METHODS: The Mariner database within PearlDiver was queried for patients from 2010 to 2019 undergoing primary arthroscopic ACLR. Patients undergoing ACLR with concomitant open surgery or additional ligament reconstructions were excluded. Postoperative diagnoses or procedures for superficial or deep infection within 6 months were assessed. A multivariable logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < .05 considered statistically significant. RESULTS: In total, 217,541 patients underwent ACLR and 1779 (0.8%) patients had a postoperative infection within 6 months. Significant independent risk factors included male sex (OR 1.58, 95% CI 1.43-1.75, P < .001), obesity (OR 1.22, 95% CI 1.05-1.43, P = .020), morbid obesity (OR 2.54, 95% CI 2.11-3.06, P = .002), tobacco use (OR 1.36, 95% CI 1.19-1.55, P < .001), age younger than 40 years (OR 1.21, 95% CI 1.07-1.37, P = .033), depression (OR 1.18, 95% CI 1.04-1.34, P = .012), opioid disorder (OR 1.50, 95% CI 1.22-1.85, P < .001), concomitant simple cartilage surgery (OR 1.63, 95% CI 1.43-1.86, P < .001), and complex cartilage surgery (OR 1.67, 95% CI 1.20-2.32, P = .002). Partial meniscectomy and meniscal repair at the time of ACLR were not associated with an increased risk of infection. CONCLUSIONS: In a large national sample, male sex, obesity, tobacco use, older age, depression, opioid disorders and concomitant cartilage surgery were significant risk factors for infection following ACLR. LEVEL OF EVIDENCE: Therapeutic Level IV, retrospective case series.

Risk of Periprosthetic Infection Following Intra-Articular Corticosteroid Injections After Total Knee Arthroplasty.

BACKGROUND: Recent literature has advocated for the effectiveness of postoperative steroid injections following total knee arthroplasty (TKA) for improving pain and range of motion when other correctible causes of these symptoms have been eliminated. The safety of such injections has not been thoroughly evaluated. The aim of this study was to determine the risk of acute infection following intra-articular corticosteroid injection into a preexisting TKA. METHODS: The Humana dataset was used to identify patients who underwent TKA from 2007 to 2017. Patients with ipsilateral knee corticosteroid injections in the postoperative period were then identified and compared to a 2:1 matched control cohort. A diagnosis of infection within 6 months and 1 year following the injection and an ipsilateral procedure for infection at any time postoperatively were then assessed and compared to controls using a multivariate binomial logistic regression analysis. RESULTS: Of the 166,946 TKA performed during the study period, 5628 patients had a postoperative corticosteroid injection (3.4%). Patients with injections had a significantly higher rate of periprosthetic infection compared to noninjection matched controls at all studied time points. CONCLUSION: In a large national database, about 3% of patients who undergo TKA have a postoperative steroid injection into their postoperative knee. While there is some existing literature demonstrating improvement in pain and stiffness symptoms after TKA with postoperative injections, the present study demonstrates a significant correlation between postoperative intra-articular corticosteroid injections in patients with preexisting TKA and periprosthetic joint infection compared to matched controls who did not receive an injection.

Rapidly progressing ascites in a pregnancy with a massive fibroid: A case report and review of pseudo-Meigs syndrome.

Meigs syndrome is a classic triad of ascites, pleural effusions, and an ovarian fibroma with resolution following excision. Pseudo-Meigs syndrome presents similarly but is caused by a pelvic mass other than an ovarian fibroma, such as a fibroid. We present a case report of a 33-year-old gravida 2 para 0-0-1-0 woman with a massive, pedunculated fibroid who developed rapid onset of ascites and edema beginning at 5 weeks of gestation. Malignant, cardiac, renal, hepatic, and rheumatologic causes were ruled out. Her symptoms resolved following myomectomy and delivery via cesarean. Pseudo-Meigs syndrome was suspected. Pseudo-Meigs syndrome is a diagnosis of exclusion and requires surgical management for resolution. Pregnancy may be an inciting factor. Myomectomy may be done safely at the time of cesarean.

Condyloma lata mimicking vulvar carcinoma in an immunocompromised patient: A case report.

Background: Syphilis is a sexually transmitted infection with increasing incidence in the United States. Presentations of syphilis vary widely and can be easily mistaken for other diagnoses, including cancer, especially in atypical cases. Case description: At her delivery after no prenatal care, a 35-year-old woman was found to have exophytic vulvar and perianal lesions, inguinal lymphadenopathy, and a new diagnosis of HIV, with a strong clinical concern for vulvar and/or anal carcinoma. She was subsequently diagnosed with presumed late latent syphilis and began weekly intramuscular penicillin G benzathine treatment. CT imaging demonstrated a perineal plaque-like area with bilateral inguinal, external iliac and retroperitoneal lymphadenopathy. She was seen in gynecologic oncology clinic one week after her initial presentation with notable improvement in the vulvar lesions, raising suspicion for condyloma lata rather than invasive or preinvasive disease on the vulva, however concern remained for dysplasia in the perianal lesion. Another week later, she underwent an exam under anesthesia with vulvar and perianal biopsies revealing chronic inflammation and granulomatous change without evidence of malignancy or dysplasia. At the four week post operative visit, there was almost complete resolution of the lesions. Conclusion: Syphilis should be considered in the differential diagnosis of atypical vulvar lesions.

Reduction of post-operative opioid use in neonates following open congenital diaphragmatic hernia repairs: A quality improvement initiative.

BACKGROUND: A limited number of post-operative opioid reduction strategies have been implemented in the neonatal population. Given the potential neurodevelopment effects of prolonged opioid use, we created a quality improvement initiative to reduce opioids in our NICU and evaluated the intervention in our CDH population. METHODS: Our opioid reduction intervention was based on standing post-operative IV acetaminophen, standardizing post-surgical sign-out between the surgical, anesthesia and NICU teams and a series of education seminars with NICU providers on post-operative pain control management. A historical control was used to perform a retrospective cohort analysis of opioid prescribing patterns in addition to a utilizing process control charts to investigate time trends in prescribing patterns. RESULTS: Forty-five children with CDH underwent an operation were included in our investigation- 18 in our pre-intervention cohort, 6 in a roll-out cohort and 21 in our post-intervention cohort. Each cohort was clinically similar. The intervention reduced total post-operative opioid use (morphine equivalents) from 82.2 (mg/kg) to 2.9 (mg/kg) in our post-intervention group (p < 0.0001). Our maximum Neonatal Pain and Agitation Sedation Score over the first 48 post-operative hours were equivalent (p = 0.827). Safety profiles were statistically equivalent. The opioid reduction intervention reduced post-operative intubation length from 156 to 44 h (p = 0.021). CONCLUSION: A multi-tiered intervention can decrease opioid use in post-surgical neonates with complex surgical pathology including CDH. The intervention proposed in this investigation is safe and does not increase pain or sedation scores in neonates, while lessening post-operative intubation length. EVIDENCE LEVEL: Level II.

Managing the SOS Response for Enhanced CRISPR-Cas-Based Recombineering in E. coli through Transient Inhibition of Host RecA Activity.

Phage-derived "recombineering" methods are utilized for bacterial genome editing. Recombineering results in a heterogeneous population of modified and unmodified chromosomes, and therefore selection methods, such as CRISPR-Cas9, are required to select for edited clones. Cells can evade CRISPR-Cas-induced cell death through recA-mediated induction of the SOS response. The SOS response increases RecA dependent repair as well as mutation rates through induction of the umuDC error prone polymerase. As a result, CRISPR-Cas selection is more efficient in recA mutants. We report an approach to inhibiting the SOS response and RecA activity through the expression of a mutant dominant negative form of RecA, which incorporates into wild type RecA filaments and inhibits activity. Using a plasmid-based system in which Cas9 and recA mutants are coexpressed, we can achieve increased efficiency and consistency of CRISPR-Cas9-mediated selection and recombineering in E. coli, while reducing the induction of the SOS response. To date, this approach has been shown to be independent of recA genotype and host strain lineage. Using this system, we demonstrate increased CRISPR-Cas selection efficacy with over 10 000 guides covering the E. coli chromosome. The use of dominant negative RecA or homologues may be of broad use in bacterial CRISPR-Cas-based genome editing where the SOS pathways are present.