Opioid-related xylazine toxicity manifesting as myonecrosis, rhabdomyolysis, multifocal ischemic cerebral infarcts, and cerebral edema.

This article provides a report of a case of organ dysfunction, myonecrosis, rhabdomyolysis, multifocal ischemic cerebral infarcts, and cerebral edema after a patient's use of xylazine and fentanyl. Within the US opioid epidemic, xylazine is emerging as a troubling national sub-story. The prevalence of xylazine within illicitly manufactured opioids and the proportion of opioid-involved overdose deaths with detected xylazine are rising dramatically, the latter increasing 276% between 2019 and 2022. A 27-year-old woman with opioid use disorder, active intravenous drug use, and prior bacteremia presented to our institution's emergency department (ED) with left lower extremity pain and associated weakness, new acute bilateral hearing loss, multiple electrolyte derangements, and cerebral infarcts followed by cerebral edema, leading to an emergent sub-occipital decompressive craniectomy and placement of an external ventricular drain. A definitive mechanism was not determined; however, we hypothesized that xylazine toxicity played a role in her clinical presentation, which could have future clinical implications, including the possibility to incorporate xylazine as part of toxicology screens.

Impact of low-dose computed tomography screening on lung cancer incidence and outcomes.

PURPOSE OF REVIEW: To review findings from clinical trials of lung cancer screening (LCS), assess contemporary issues with implementation in clinical practice, and review emerging strategies to increase the uptake and efficiency of LCS. RECENT FINDINGS: In 2013, the USPSTF recommended annual screening for individuals aged 55-80 years and currently smoke or quit within the past 15 years based on reduced mortality from lung cancer with annual low-dose computed tomography (LDCT) screening in the National Lung Screening Trial. Subsequent trials have demonstrated similar mortality outcomes in individuals with lower pack-year smoking histories. These findings, coupled with evidence for disparities in screening eligibility by race, resulted in updated guidelines by USPSTF to broaden eligibility criteria for screening. Despite this body of evidence, implementation in the United States has been suboptimal with fewer than 20% of eligible individuals receiving a screen. Barriers to efficient implementation are multifactorial and include patient, clinician, and system-level factors. SUMMARY: Multiple randomized trials have established that annual LCS reduces mortality from lung cancer; however, several areas of uncertainty exist on the effectiveness of annual LDCT. Ongoing research is examining approaches to improve the uptake and efficiency of LCS, such as the use of risk-prediction models and biomarkers for identification of high-risk individuals.

A Two-Surgeon Approach Improves Performance for Young Surgeons in Adolescent Idiopathic Scoliosis.

Adolescent idiopathic scoliosis (AIS) is a complex 3-dimensional deformity. Previous studies have suggested a learning curve in the successful execution of this technically demanding procedure. A 2-surgeon model may be helpful for less experienced surgeons by facilitating greater consistency in surgical metrics. The objective of this study was to show no significant difference in the parameters examined for surgeries done by inexperienced primary surgeons with a 2-surgeon model compared with those done by their more experienced cohorts. All surgeries with a primary diagnosis of AIS that were performed from January 2012 to December 2015 and had a minimum of 2-year follow-up were included for analysis. Three groups were created based on surgeon experience: inexperienced surgeons (IS) group, experienced surgeons (ES) group, and a third group where the primary surgeon was in the experienced group and the assistant surgeon was in the inexperienced group (EIS). Variables included for analysis were age, Lenke classification, number of levels fused, length of surgery, length of stay, percent curve correction, ratio of estimated blood loss to levels fused, surgical blood loss, and complications. There were no significant differences between the groups in terms of operative time, blood loss, number of levels fused, lower estimated blood loss ratio to the number of levels fused, or percent curve correction (P>.05). The IS group was found to have a significant shorter length of stay (P=.004). The 2-surgeon model is an effective tool for inexperienced surgeons to achieve consistent and reproducible operative performance that is comparable with their more experienced peers. [Orthopedics. 2021;44(3):e347-e352.].

Posttraumatic Pigmented Villonodular Synovitis of the Elbow After Occult Fracture: A Literature Review.

Pigmented villonodular synovitis (PVNS) is a disease rarely found in the elbow. In the setting of previous trauma, there are no documented reports of PVNS occurring in the posttraumatic state. We report a case of elbow PVNS in a 16-year-old male with a history of traumatic injury to the supracondylar humerus and olecranon, resulting in nondisplaced fractures, diagnosed 3 years prior to presentation. We diagnosed posttraumatic PVNS of the elbow using a combination of plain radiographs, ultrasonography, and MRI, along with an infectious, hematologic, and rheumatologic workup. This workup cumulates in open elbow débridement of synovial tumor, with pathology confirming our preoperative diagnosis of PVNS. A literature search and review of PVNS in the elbow yield only 54 results, none of which is related to previous fracture. In the neurosurgery literature, however, there is a case report of a pathological fracture of the odontoid related to PVNS.

Development of Postoperative Spinal Arteriovenous Fistula After Lumbar Laminectomy, Decompression, and Posterior Spinal Fusion.

Spinal dural arteriovenous fistulas are a rare cause of low back pain, bilateral lower extremity weakness, or pain with sensory changes. They are typically found in males in the fifth and sixth decades of life, associated with a progressive decline in symptoms that make initial diagnosis challenging in some patients. We present a case report and literature review of an 80-year-old woman with a long-standing history of progressively worsening back pain and lower extremity pain that has limited her daily activities. When preoperative MRI of the lumbar spine showed high-grade stenosis and listhesis of L4-L5, the patient was taken to the operating room for an L4-L5 laminectomy, decompression, facetecomy, and instrumented fusion. Her postoperative course did not show improvement of symptoms, which in fact worsened, leading to gait imbalance and instability. Postoperative MRIs of the patient were concerning for a spinal dural arteriovenous fistula, which was confirmed and treated by spinal angiography and embolization.