Necrotizing Vaginitis in a 45-Year-Old Woman With Metastatic Breast Cancer.

Vaginitis emphysematosa (VE) is a rare, benign, and self-limited condition often diagnosed by the presence of intramuscular vaginal air observed on computed tomography (CT) scan. Although it is a nonpathologic, self-limited condition requiring no intervention, it is important to rule out a more serious infectious pathology. This report highlights a clinical dilemma and the potential consequences of over-reliance on CT in distinguishing benign VE from pathologic necrotizing vaginitis. A high clinical suspicion for infection should be maintained, especially when relevant clinical and laboratory markers suggest a more serious pathology. We describe the case of a 45-year-old woman who presented to the hospital with abdominal pain and vaginal bleeding. CT scan demonstrated intramuscular vaginal air, which was reported as VE. Classic imaging findings of VE falsely reassured clinicians. She died shortly thereafter of necrotizing vaginitis.

Assessing Communication Quality in the Intensive Care Unit.

Introduction: Successful shared decision-making for critically ill intensive care unit (ICU) patients requires bidirectional communication. Through observation of ICU conversations, our study aimed to identify communication skill deficiencies in providers who care for patients in the ICU. Methods: This was an observational prospective study performed in a single urban academic medical center (671 beds) from June 2021 through August 2021. Twenty-three providers were recruited from medical and surgical ICU services (56 beds). Thirty-nine surrogate decision makers were identified. Provider skills were assessed using a customized observational tool that examined nonverbal communication, verbal communication, opening the discussion, gathering information, understanding the family's perspective, sharing information, reaching agreements on problems and plans, and providing closure. Results: Thirty-nine conversations were observed for six attending physicians, four fellow physicians, eight resident physicians, two nurse practitioners, and three physician assistants during the coronavirus 19 (COVID19) pandemic. A dedicated critical care provider engaged in 19 observed conversations; 20 discussions occurred with individuals rotating/consulting in the ICU. Communication skill did not depend on experience or area of expertise. Less than half of conversations achieved bidirectional communication proficiency. Scheduled conversations (n = 14) had significantly higher average communication scores than unscheduled encounters (n = 25). Conclusions: Superficial unidirectional communication with decision makers was commonly observed. Providers were less proficient at advanced communication skills needed for shared decision-making. We recommend that providers have more scheduled conversations, which were more productive in achieving bidirectional communication. A targeted simulation curriculum addressing these areas may improve patient, decision maker, and provider satisfaction, while promoting patient-centered care.

Avoiding Opioid Misuse After Surgery in the Era of the Opioid Epidemic : Defining the New Normal.

BACKGROUND: Chronic pain patients at risk of addiction can be identified through pre-prescription screening with the opioid risk tool (ORT); there is no equivalent for surgical patients. Our aims were to validate the ORT in the surgical population and assess the impact of patient education on compliance with proper storage and disposal (S&D) of unused opioid therapy (UOT). METHODS: Each subject completed the ORT, prevideo and postvideo surveys, educational video viewing, and compliance survey. Aberrant behavior was assessed by questionnaire, chart review, and Illinois Prescription Monitoring Program review. RESULTS: We recruited 24 subjects who underwent emergency surgery; 18 (of 24) were prescribed an opioid on discharge and 15 (of 18) were followed for 1 month. Before education, 38% (n = 9 of 24) of subjects identified proper UOT disposal and 63% (n = 15 of 24) identified safe handling of opioids. After education, 75% (n = 18 of 24) identified proper S&D. On ORT, 9 of 24 subjects (38%) scored moderate-risk to high-risk for opioid misuse. Half of subjects who demonstrated aberrant behavior (n = 7 of 12, 58%) scored in the low-risk range on ORT; 67% of subjects (n = 10 of 15) retained UOT, and 67% (n = 10 of 15) safely stored UOT. Few subjects (30%; n = 3 of 10) who stored their UOT reported proper disposal of UOT. DISCUSSION: The ORT is not useful in identifying acute pain surgical patients at risk for aberrant behavior. An educational video increased awareness of, but not compliance with, safe S&D of UOT. Opioid overprescription continues to contribute to opioid misuse.