Marijuana's Influence on Pain Scores, Initial Weight Loss, and Other Bariatric Surgical Outcomes.

INTRODUCTION: Pain management can be challenging following bariatric surgery, and patients with obesity tend to increase opioid use after undergoing surgery. This report quantifies marijuana (MJ) use and its relationship to pain and other surgery-related outcomes in a population from a state that has legalized MJ. METHODS: Data were collected for consecutive patients undergoing weight reduction surgeries between May 1, 2014 and July 31, 2015. Demographics, preoperative comorbidities, medications, and perioperative opioid use were analyzed. The primary outcome evaluated was inpatient opioid pain medication use quantified using natural log morphine equivalents. Secondary outcomes included percentage of total body weight loss after three months, postoperative complications, and changes in medical comorbidities. RESULTS: A total of 434 patients, among whom 36 (8.3%) reported MJ use, comprised the study population. Perioperative opioid requirements were significantly higher in the MJ-user group (natural log morphine equivalents of 3.92 vs 3.52, p = 0.0015) despite lower subjective pain scores (3.70 vs 4.24, p = 0.07). MJ use did not affect percentage of 90-day total body weight loss, development of postoperative complications, or improvement in medical comorbidities. CONCLUSION: Perioperative opioid use was significantly higher in the MJ-user group despite lower subjective pain scores. The difference in opioid requirements suggests an interaction between MJ use and opioid tolerance or pain threshold. The percentage of total body weight loss, improvement in medical comorbidity, and incidence of postoperative complications at 90-day follow-up were not affected by MJ use in this cohort analysis.

Hyperthyroidism · myalgia · rapidly progressing paralysis · Dx?

A 26-year-old Hispanic woman presented to the emergency department (ED) with myalgia and weakness. There were no prior symptoms and family history was negative for endocrinopathies. She was admitted and started on methimazole 10 mg twice a day for thyroid suppression and given propranolol 10 mg twice a day for anticipated hyperadrenergic adverse effects. The remainder of her hospital stay was uneventful and she was discharged 6 days after admission. Soon after, an outpatient thyroid scan ordered by her primary care physician confirmed that the patient had Graves' disease.

Laparoscopic management of duodenal obstruction resulting from superior mesenteric artery syndrome.

IMPORTANCE: Duodenal obstruction by compression from the superior mesenteric artery (SMA) can be managed using minimally invasive techniques initially developed for bariatric patients requiring gastric bypass. OBSERVATIONS: This retrospective review evaluates 12 patients with SMA syndrome who were treated with laparoscopic enteric bypass. Technical considerations are presented in detail. The study group comprised 5 men and 7 women, with ages ranging from 21 to 65 years (mean, 36.8 years). Operative times ranged from 53 to 126 minutes (mean, 72.4 minutes). Mean length of hospital stay was 4.2 days (range, 3-7 days). Obstructive symptoms were improved or eliminated in 11 patients (92%). One patient required readmission for inadequate control of generalized abdominal pain. No patients in this series developed postoperative bowel obstruction, wound complications, or anastomotic leaks or died. CONCLUSIONS AND RELEVANCE: Laparoscopic duodenojejunostomy is safe and effective and should be considered the optimal treatment for patients presenting with duodenal obstruction from SMA syndrome. Advances in minimally invasive surgery have demonstrated the safety and low morbidity of laparoscopically created enteric anastomoses. The shorter hospital stay, low morbidity, and high success of laparoscopic enteric bypass make this approach favorable to traditional open techniques.

A Clinician's Guide to the Diagnosis and Management of Gallbladder Volvulus.

INTRODUCTION: Gallbladder volvulus (GV), or torsion of the gallbladder, is an uncommon surgical emergency. This article reviews the world literature related to GV. We examine the history of gallbladder torsion and highlight the critical constellation of presenting signs and symptoms, which guide the acute care physician and surgeon to accurate and timely diagnosis of GV before surgical intervention. METHODS: A comprehensive review of all published cases of GV was performed using the National Library of Medicine (PubMed) database. RESULTS: Lists of typical symptoms and clinical presentations are provided to allow clinicians to establish an accurate preoperative diagnosis. CONCLUSION: GV is frequently undiagnosed before surgical intervention. However, clinical presentation and associated radiographic findings can lead to an accurate diagnosis if the clinician is aware of this uncommon condition. When the diagnosis has been established before operative intervention, expeditious laparoscopic cholecystectomy can be performed safely. Delays in diagnosis may mandate open cholecystectomy if laparoscopic extraction is contraindicated because of undesirable sequelae of gallbladder necrosis, specifically perforation, bilious peritonitis, and hemodynamic instability.

Identification of novel candidate oncogenes and tumor suppressors in malignant pleural mesothelioma using large-scale transcriptional profiling.

Malignant pleural mesothelioma (MPM) is a highly lethal, poorly understood neoplasm that is typically associated with asbestos exposure. We performed transcriptional profiling using high-density oligonucleotide microarrays containing approximately 22,000 genes to elucidate potential molecular and pathobiological pathways in MPM using discarded human MPM tumor specimens (n = 40), normal lung specimens (n = 4), normal pleura specimens (n = 5), and MPM and SV40-immortalized mesothelial cell lines (n = 5). In global expression analysis using unsupervised clustering techniques, we found two potential subclasses of mesothelioma that correlated loosely with tumor histology. We also identified sets of genes with expression levels that distinguish between multiple tumor subclasses, normal and tumor tissues, and tumors with different morphologies. Microarray gene expression data were confirmed using quantitative reverse transcriptase-polymerase chain reaction and protein analysis for three novel candidate oncogenes (NME2, CRI1, and PDGFC) and one candidate tumor suppressor (GSN). Finally, we used bioinformatics tools (ie, software) to create and explore complex physiological pathways. Combined, all of these data may advance our understanding of mesothelioma tumorigenesis, pathobiology, or both.