Opioid Use in Pelvic Fractures: The Impact of Opioid Prescribing Laws in Pennsylvania.

Pennsylvania's Prescription Drug Monitoring Program (PDMP) was established in 2016, but its impact on opioid use for pelvic fractures is understudied. We compared opioid use in 277 pelvic fracture cases between two periods: 2015-2017 (T1) and 2018-2020 (T2). Outcomes included daily inpatient morphine milligram equivalents (MME), long-term opioid use (LOU) 60-90 days post-discharge, and intermediate-term opioid use (IOU) 30-60 days post-discharge. T1 and T2 had comparable baseline characteristics. T2 was associated with a decrease in average daily inpatient MME (58.6 vs 78.5, P = .02), particularly in younger patients. Regression analyses showed age and Injury Severity Score (ISS) were significant predictors for daily inpatient MME, while time period was not. Geriatric patients in T2 had significantly decreased IOU (30% vs 9%, P = .05). Pelvic fracture type and daily MME predicted IOU, while pelvic fracture type predicted LOU. This study suggests a modest impact of these laws, but further study is needed.

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

BACKGROUND: We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients. METHODS: We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated. RESULTS: Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis). CONCLUSION: Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary. SUMMARY: For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.

Cost-effectiveness of transfacial gland-preserving removal of parotid sialoliths.

OBJECTIVE: Examine outcomes of transfacial gland-preserving removal of difficult parotid stones and compare the cost and operative time to traditional parotidectomy. STUDY DESIGN: Cost-effectiveness analysis and retrospective chart review. METHODS: Patients who underwent transfacial removal of symptomatic parotid sialoliths at a tertiary medical center from June 2010 to July 2015 were evaluated. Outcomes included operative technique, stone size, stone location, complications, and symptom relief. In addition, patients who underwent traditional parotidectomy for chronic sialadenitis were identified. The charges and times for both procedures were reviewed and compared. RESULTS: Forty-four patients underwent transfacial resection for symptomatic parotid sialolithiasis. Stones were most often located in the main duct and hilum (53.3%), with fewer intraglandular stones (46.7%). No facial nerve weakness was observed. Of those with follow-up, 33 (87%) patients reported at least partial resolution of symptoms. Overall transfacial technique charges were significantly less expensive (U.S.$) than parotidectomy (mean difference -8,064.09; 95% confidence interval [CI] -13,472.78 to -2,655.40; P = 0.033). Anesthesia charges (mean difference -2,997.85; 95% CI, -5,748.81 to -246.89; P = 0.035) and operating room charges (mean difference -4,793.91; 95% CI, -8,958.09 to -629.72; P = 0.028) were also less expensive for the transfacial technique. Finally, mean procedure time for transfacial removal of parotid stones was shorter than for parotidectomy (120.2 ± 49.9 vs. 178.4 ± 41.3 minutes, respectively; P = 0.002). CONCLUSION: Transfacial gland-preserving removal of difficult parotid stones is a well tolerated and effective alternative to parotidectomy. Moreover, it is faster and less expensive than parotidectomy, maximizing both surgeon time and hospital resources. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1080-1086, 2017.

Decision tree algorithms predict the diagnosis and outcome of dengue fever in the early phase of illness.

BACKGROUND: Dengue is re-emerging throughout the tropical world, causing frequent recurrent epidemics. The initial clinical manifestation of dengue often is confused with other febrile states confounding both clinical management and disease surveillance. Evidence-based triage strategies that identify individuals likely to be in the early stages of dengue illness can direct patient stratification for clinical investigations, management, and virological surveillance. Here we report the identification of algorithms that differentiate dengue from other febrile illnesses in the primary care setting and predict severe disease in adults. METHODS AND FINDINGS: A total of 1,200 patients presenting in the first 72 hours of acute febrile illness were recruited and followed up for up to a 4-week period prospectively; 1,012 of these were recruited from Singapore and 188 from Vietnam. Of these, 364 were dengue RT-PCR positive; 173 had dengue fever, 171 had dengue hemorrhagic fever, and 20 had dengue shock syndrome as final diagnosis. Using a C4.5 decision tree classifier for analysis of all clinical, haematological, and virological data, we obtained a diagnostic algorithm that differentiates dengue from non-dengue febrile illness with an accuracy of 84.7%. The algorithm can be used differently in different disease prevalence to yield clinically useful positive and negative predictive values. Furthermore, an algorithm using platelet count, crossover threshold value of a real-time RT-PCR for dengue viral RNA, and presence of pre-existing anti-dengue IgG antibodies in sequential order identified cases with sensitivity and specificity of 78.2% and 80.2%, respectively, that eventually developed thrombocytopenia of 50,000 platelet/mm(3) or less, a level previously shown to be associated with haemorrhage and shock in adults with dengue fever. CONCLUSION: This study shows a proof-of-concept that decision algorithms using simple clinical and haematological parameters can predict diagnosis and prognosis of dengue disease, a finding that could prove useful in disease management and surveillance.

A molecular epidemiological assessment of extrapulmonary tuberculosis in San Francisco.

The epidemiology of extrapulmonary tuberculosis (TB) is not well understood. We studied all cases of extrapulmonary TB reported in San Francisco during 1991-2000 to determine risk factors for extrapulmonary TB and the proportion caused by recent infection. Isolates were analyzed by IS6110-based restriction fragment-length polymorphisms analysis. There were 480 cases of extrapulmonary TB, of which 363 (76%) were culture positive; isolates were genotyped for 301 cases (83%). Multivariate analysis identified young age, female sex, and HIV infection as independent risk factors for nonrespiratory TB (excluding pulmonary, pleural, and disseminated TB). Pleural TB was less common in HIV-seropositive persons and women than were nonrespiratory forms of extrapulmonary TB. Pleural TB is different from other forms of extrapulmonary TB and is associated with the highest clustering rate (35% of cases) of all forms of TB. This high rate of clustering occurs because pleural TB is often an early manifestation of recent infection.