Congenital syphilis presenting with granulomatous scalp nodules.

We describe a case of congenital syphilis in an adopted infant with a unique dermatologic presentation of scalp granulomas, along with lymphadenopathy, anemia, and elevated liver transaminases. To our knowledge, this cutaneous morphology has not been previously reported in the literature. This case highlights the varied clinical presentation of congenital syphilis and the diagnostic challenge it poses for clinicians, especially in the context of unknown prenatal history/unknown risk factors, or if syphilis is acquired during pregnancy after routine screening is performed. As the incidence of congenital syphilis has more than tripled in recent years, this diagnosis should be considered when a neonate or infant presents with unexplained skin nodules.

Reduction of Opioid Consumption After Outpatient Orthopaedic Trauma Surgeries Using a Multimodal Pain Protocol.

INTRODUCTION: Because of the dearth of literature in the orthopaedic trauma population, we aimed to analyze how a multimodal pain protocol after outpatient surgery affects opioid consumption, pain scores, and patient satisfaction. METHODS: This was a cohort study with a historical control at an urban level 1 trauma center. Forty consecutive outpatients were given a peripheral nerve block and a multimodal pain protocol between September 2019 and March 2020 and compared with 70 consecutive preprotocol patients who received a peripheral nerve block and hydrocodone-acetaminophen. The primary outcome was morphine milligram equivalents (MMEs) consumed. Our secondary aims were pain scores and satisfaction. RESULTS: Patients in the protocol were younger (36.45 versus 45.09 years, P = 0.007), butthere was no difference in sex, body mass index, American Society of Anesthesiologists, or surgical duration. There was a 59% reduction in opioids consumed in the first 4 days after surgery (3.83 MME versus 9.29 MME, P < 0.001). At the postoperative day-14 time point, protocol patients consumed a total of 5.59 MMEs, which is 40% less than just the first 4 days of the preprotocol (P = 0.02). Protocol patients assigned a higher rating of "least pain" on postoperative day 1 (1.24 versus 0.52, P = 0.04) but had higher satisfaction scores on day 1 (9.68 versus 8.54, P < 0.001) and day 2 (9.66 versus 8.61, P < 0.001). CONCLUSION: Implementation of a multimodal pain management protocol after outpatient orthopaedic trauma surgeries reduced opioid consumption by >50% in the first 4 days postoperatively. Additional studies are needed to refine the multimodal pain protocol used in this study. LEVEL OF EVIDENCE: II.

Vitamin D deficiency in the oncology setting.

BACKGROUND: Vitamin D deficiency is common in the United States. Regardless of whether or not vitamin D deficiency increases the risk of cancer and decreases survival of cancer, the established adverse impact of its deficiency on bone health is of particular concern for cancer patients. The extent of vitamin D deficiency is not well defined in the oncology setting, and there are no standardized protocols for screening and supplementation for individuals found to be deficient in vitamin D. OBJECTIVE: To determine the prevalence of vitamin D deficiency as measured by levels of serum 25-hydroxyvitamin D (25[OH]D) in cancer patients at an outpatient oncology practice. METHODS: A total of 177 patients representing a range of oncologic diagnoses were tested for 25(OH)D between January 1, 2011 and December 31, 2011. Suboptimal vitamin D levels were defined either as less than 20 ng/mL or less than 30 ng/mL, according to standards proposed by the Institute of Medicine and the Endocrine Society, respectively. LIMITATIONS: The point of testing was subjective to the clinician. Some patients may have had their vitamin D levels tested and treated elsewhere, therefore that data was not captured. RESULTS: At baseline, 18.1% of patients tested had vitamin D levels of less than 20 ng/ml, and 49.1% of patients had vitamin D levels of less than 30 ng/ml. Follow-up rates were low. In all, 54% of patients with 25(OH)D levels of less than 30 ng/ml obtained a second reading, and only 38% of those patients achieved sufficient levels at the second reading. CONCLUSION: Vitamin D deficiency is prevalent in patients with cancer and should be monitored in patients who are at high risk for vitamin D deficiency or poor bone health.