Perioperative use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors for diabetes mellitus.

Type 2 diabetes mellitus is an increasingly common long-term condition, and suboptimal perioperative glycaemic control can lead to postoperative harms. The advent of new antidiabetic drugs, in particular glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors, has enabled perioperative continuation of these medicines, thus avoiding the harms of variable rate i.v. insulin infusions whilst providing glycaemic control. There are differences between medicines regulatory agencies and organisations on how these classes that are most often used to treat diabetes mellitus, (but also in the case of SGLT2 inhibitors chronic kidney disease and heart failure in those without diabetes) should be managed in the perioperative period. In this commentary, we argue that GLP-1 receptor agonists should continue during the perioperative period and that SGLT2 inhibitors should only be omitted the day prior to a planned procedure . The reasons for the differing advice advocated between regulatory agencies and what anaesthetic practitioners should do in the face of continuing uncertainty are discussed.

Decoding behaviour change techniques in opioid deprescribing strategies following major surgery: a systematic review of interventions to reduce postoperative opioid use.

BACKGROUND AND OBJECTIVES: METHODS: A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen's d effect sizes were calculated. BCTs were identified using a validated taxonomy. RESULTS: 22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward. CONCLUSIONS: Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors. PROSPERO REGISTRATION NUMBER: CRD42022290060.

Small Bowel Perforation Due to Rare Metastasis From Stage IV Lung Adenocarcinoma.

Lung adenocarcinoma commonly metastasizes to the lymph nodes, bone, nervous system, liver, respiratory system, and adrenal gland. Metastasis to the small bowel is extremely rare and the literature deals mostly with few published case reports. We present a case of a 70-year-old male with a previous history of stage IV lung adenocarcinoma with brain and liver metastases treated with radiotherapy and chemotherapy. He presented to the emergency department with peritonitis and sepsis due to bowel perforation. He underwent an emergency exploratory laparotomy and small bowel resection. Surgical pathology revealed metastatic lung adenocarcinoma as the cause of bowel perforation. He tolerated and recovered from surgery well and was discharged on postoperative day 7. On one-month follow-up as an outpatient, he was doing well and had no complications or complaints from his recent surgery.

A study to improve the identification of pancreatobiliary adenocarcinoma utilizing fine-needle aspiration cytology and immunohistochemical application for KOC and S100P.

INTRODUCTION: The identification of pancreatic adenocarcinoma by fine-needle aspiration (FNA) cytology is a difficult, yet critical, task. This study uses a panel of two immunohistochemical (IHC) markers, KOC and S100P, to augment the interpretation of pancreatic adenocarcinoma using cytopathology specimens and to compare these to corresponding surgical specimens. MATERIALS AND METHODS: We retrospectively reviewed 33 surgical specimens with pancreatic adenocarcinoma and 33 corresponding, preceding FNA cytology specimens. IHC studies for KOC and S100P were performed on both the surgical specimens and cytology cell blocks. Three pathologists reviewed the staining intensity and amount of tumor cell staining within these blocks. The findings were then analyzed for sensitivity, specificity, and combined sensitivity and specificity for the 2 markers. RESULTS: KOC performed similarly to S100P in sensitivity for surgical specimens (90.9% for both) and better for FNA specimens (92.3% versus 82.7%, respectively). The specificity of KOC was significantly better than S100P for surgical and FNA specimens (100% for KOC in both specimens versus 72.7% and 89.7% for S100P in both specimens, respectively). The combined sensitivity of the panel of KOC and S100P was 99.2% for surgical specimens and 98.7% for FNA specimens. The combined specificity was 72.7% for surgical specimens and 89.7% for FNA specimens. CONCLUSIONS: We found using KOC and S100P on FNA cell block cytology specimens to be a useful adjunct for interpretation when an interpretation of atypical or suspicious for pancreatic ductal adenocarcinoma is being considered and there are atypical epithelial cell groups in the cell block.

Recurrent inflammatory pseudotumor of the jaw with perineural intracranial invasion demonstrating sustained response to Rituximab.

Corticosteroids are the mainstay of treatment of inflammatory pseudotumor (IPT) of the head and neck; however, involvement of the skull base and mandible can be unresponsive to steroids and require surgical resection. IPT is known to usually contain a CD20+ lymphocyte subgroup. Rituximab, a chimeric anti-CD20 antibody, has been successfully utilized in the treatment of other CD20+ diseases, including the similar idiopathic orbital inflammatory disease. This is the first report to describe successful treatment with Rituximab of a recurrent IPT of the mandible with trigeminal spread and leptomeningeal involvement with clinical and radiologic evidence demonstrating a sustained response to therapy.