Predictors of colorectal carcinoma and inflammatory bowel disease in patients with colonic wall thickening.

Background and Aim: Colonic wall thickening (CWT) is commonly associated with clinically significant pathologies, but predictive factors of such pathologies are not well known. This study aims to identify the predictors of clinically significant pathologies, such as colorectal carcinoma (CRC) and inflammatory bowel disease (IBD), in patients with CWT. Methods: Subjects with an abnormal abdominal computed tomography (CT) and a follow-up colonoscopy between 2010 and 2020 were retrospectively reviewed. Patients with CWT in the CT were included and examined in this study. A multivariable logistic regression analysis was performed to assess for factors independently associated with CRC or IBD in these subjects. Receiver operating characteristic (ROC) curve analysis was used to further examine significant parameters in multivariable logistic regression analysis. Results: Among 403 patients with CWT on CT scans who underwent a colonoscopy, 269 subjects who met the inclusion criteria were identified and studied. On multivariable logistic regression models, elevated platelet count, low hematocrit, and localized CWT were found to be independently associated with CRC, while elevated platelet count and younger age were independently associated with IBD. On ROC curve analysis for CRC, area under the curve (AUC) for hematocrit, platelets, and localized CWT was 0.76, 0.75, and 0.61, respectively. On ROC curve analysis for IBD, AUC for age and platelets was 0.90 and 0.69, respectively. Conclusion: Elevated platelet count, low hematocrit, and localized CWT can be potentially used as predictors of CRC in patients with CWT. Elevated platelet count and young age can be used to predict IBD in these patients.

Biology of COVID-19 and related viruses: Epidemiology, signs, symptoms, diagnosis, and treatment.

Coronaviruses belong to the family Coronaviridae order Nidovirales and are known causes of respiratory and intestinal disease in various mammalian and avian species. Species of coronaviruses known to infect humans are referred to as human coronaviruses (HCoVs). While traditionally, HCoVs have been a significant cause of the common cold, more recently, emergent viruses, including severe acute respiratory syndrome coronavirus (SARS-CoV-2) has caused a global pandemic. Here, we discuss coronavirus disease (COVID-19) biology, pathology, epidemiology, signs and symptoms, diagnosis, treatment, and recent clinical trials involving promising treatments.

Supply, Demand, and Quality: A Three-Pronged Approach to Blood Product Management in Developing Countries.

While transfusion of blood and blood products is instinctively linked to the provision of emergent care, blood and blood products are also routinely used for the treatment of subacute and chronic conditions. Despite the efforts of the World Health Organization and others, developing countries are faced with a three-part problem when it comes to access to and delivery of transfusions: insufficient supply, excessive demand, and inadequate quality of available supply. Developing countries rely heavily on replacement and remunerated donors rather than voluntary nonremunerated donors due to concerns regarding donation- and transfusion-transmitted infection as well as local and cultural beliefs. While increased awareness of HIV and improved testing techniques have jointly reduced infection-related apprehensions and improved the quality of available blood and blood products, continued efforts are warranted to bolster testing for other bloodborne pathogens. Similarly, although prevalence rates of anemia are high in some areas of the world, success in adequate widespread management of these conditions has been limited. One of the keys to expanding access to high-quality blood and blood products is thus to improve medical management of conditions that would otherwise require transfusion. Through a three-pronged approach to address quantity, quality, and demand, developing countries can enable themselves to build toward self-sufficient blood management services and increased independence from the support of international organizations.

Management of Patients With Chronic Pain in Ambulatory Surgery Centers.

In the setting of increasingly streamlined surgical techniques and perioperative care, the United States healthcare system is seeing a steady rise in the number of procedures being carried out at ambulatory surgery centers. Concurrently, awareness and diagnosis of both chronic pain conditions and substance use disorders have also improved in recent years. As a result of these two shifts, the demographic characteristics of patients undergoing procedures at ambulatory surgery centers are actively evolving. Chronic pain and substance use disorders are difficult to manage in both the outpatient and inpatient settings and present unique challenges in the context of perioperative planning. Both conditions are associated with worsened postoperative outcomes, including refractory pain, decreased functional status, increased length of stay, increased readmission rates, and increased economic costs. There has been a recent movement to include a preoperative risk stratification calculation for these patients, followed by the implementation of enhanced recovery after surgery (ERAS) protocols in these patient cohorts. Taking a step further, patients benefit when standard ERAS protocols are augmented by integrating designated pain specialists into the ambulatory surgery team. This multimodal and multidisciplinary approach must be assessed in the context of the human and financial resources of a given institution and surgery center, but has been shown to improve the quality and safety of perioperative care effectively.

Maximization of Non-Opioid Multimodal Analgesia in Ambulatory Surgery Centers.

Ambulatory surgery centers aid the healthcare system by not only providing a cost-effective option for delivery of care but also by helping to reduce overwhelming case volumes at inpatient facilities. While outpatient protocols have been designed for an increasing number of surgical procedures, the inpatient to outpatient transition of surgery remains limited by both procedure type and patient comorbidities. This limitation stems in part from the heavy emphasis on accelerated discharge following outpatient procedures, given that prolonged recovery time is associated with delayed turnover and increased nursing care demands. Since its inception, enhanced recovery after surgery (ERAS) has aimed to primarily reduce the disruption of physiologic homeostasis that occurs secondary to surgery. More recently, the aim of ERAS has evolved to help transition inpatient procedures to outpatient settings and may even be useful in more emergent cases. It should be noted, however, that outpatient surgery even in combination with ERAS is not the best option for all patients, and the use of ERAS protocols should be complemented with predictive assessments of patient risk. Beyond augmenting the efficiency of outpatient surgery, ERAS protocols, when used in eligible patients and especially when combined with regional anesthetic techniques, are effective in delivering opioid-sparing pain management while increasing overall outcomes and patient satisfaction rates.

Investigating the Impact of Gadolinium-Based Contrast Agents on the Corrected QT Interval.

Introduction The manufacturing labels for all currently marketed gadolinium-based MRI contrast agents describe adverse cardiac events reported during post-market use. The goal of this study was to determine prolongation of the rate-corrected QT interval occurs in the immediate setting after gadolinium-based MRI contrast agent injection. Methods This study enrolled adults scheduled to have a gadolinium-based MRI contrast agent injection as part of a diagnostic MRI. A single-lead electrocardiogram was recorded using the AliveCor Kardia® ECG (Mountain View, CA) device before and after injection. The rate-corrected QT interval was subsequently measured by two independent investigators. The QT interval was corrected for rate using the two most common formulas, originally cited by Bazett and Fridericia. These rate-corrected QT intervals from before and after gadolinium-based MRI contrast agent injection were compared using the Wilcoxon signed-rank test paired analysis. Results A total of 24 consenting adults had electrocardiogram that were free of motion artifact. The mean age of the final patient cohort was 59.4 years. There was an equal split of 12 men and 12 women. The mean pre-injection, rate-corrected QT interval, corrected using Bazett's formula, was 395 msec. The mean post-injection, rate-corrected QT interval, corrected using Bazett's formula, was 396 msec. The corrections using Fridericia's formula were 384 and 381 msec, respectively. There was no statistically significant change in Bazett-corrected QT interval (QTc-B) when pre-injection and post-injection values were directly compared. Discussion The results of the present investigation support the conclusion that gadolinium-based MRI contrast agents do not commonly affect rate-corrected QT interval in routine clinical use. While the frequency of rate-corrected QT interval prolongation might be overstated, the severity of adverse events is definitively not. A role for concomitant rate-corrected QT interval-prolonging drugs or unidentified rare factors such as genetic predisposition cannot be ruled out. The limitations of this study include its relatively small size and the implementation of a single-lead electrocardiogram to measure rate-corrected QT interval. Conclusion The present investigation revealed that significant rate-corrected QT interval prolongation, while previously reported in as many as 55% of patients after gadolinium-based MRI contrast agent injection, is not a common occurrence in the routine clinical setting.

An Overview of Current Recommendations and Options for the Management of Cancer Pain: A Comprehensive Review.

It is estimated that one-third of oncologic patients in the USA do not receive analgesia proportional to or adequate for the intensity of their pain. A mechanism-based approach to oncologic pain therapy is critical to ensure that analgesia regimens are individualized and effective. Since the mechanisms that lead to cancer pain are complex, healthcare providers must be willing to elicit and recognize the symptoms of each individual patient since these factors influence both the experience of pain and response to treatment. This process is centered on the use of detailed history in order to understand symptom expression in the context of primary tumor diagnosis and progression, history of cancer pain, psychological distress, sleep disturbances, cognitive function, and addictive behavior. Incorporating all of these factors into the assessment of a patient's pain condition can facilitate management decisions and help predict patient response to treatment.

Truncal regional nerve blocks in clinical anesthesia practice.

Regional anesthetic techniques are important components of successful multimodal analgesic strategies. When used successfully, truncal nerve blocks of the chest wall, abdomen, and, paraneuraxial nerves, in combination with other analgesic modalities, may offer similar analgesic efficacy as neuraxial techniques, which are associated with a greater risk profile. Moreover, in comparison to neuraxial techniques, truncal nerve blocks are relatively simple to perform and technically straightforward to learn. The transversus abdominus plane (TAP) block is often incorporated into the multimodal analgesia regimen for surgical patients undergoing various abdominal and gynecological procedures. Rectus sheath blocks (RSB) were originally introduced to help relax the anterior abdominal wall during surgery and as an adjunct pain therapy. With the advancement of technology and the development of ultrasound guided techniques, RSB now have a more ubiquitous role and have been shown to decrease postoperative pain and opioid consumption. Different variations of the quadratus lumborum block may provide visceral and sensory analgesic coverage. Moreover, truncal blocks, including ilioinguinal, iliohypogastric, pectoralis nerve (PECS) blocks, serratus anterior, intercostal, and erector spinae plane blocks, have gained routine clinical use for various surgeries. In this review, we discuss the techniques, anatomy, indications, complications, and benefits of truncal nerve blocks commonly used in clinical practice.

Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey.

OBJECTIVES: As shared decision making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED. METHODS: We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person. RESULTS: Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85%-92%, depending on decision type) expressed a desire for some degree of involvement in decision making in the ED, while 8% to 15% preferred to leave decision making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved. CONCLUSION: We found that the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision making.