Rhabdomyosarcoma presenting as intramuscular haematoma due to brachioradialis tear after trauma.

A man in his 40s with a history of neurofibromatosis type 1 presented to the emergency department with worsening anterior elbow pain and swelling after falling from a chair 2 months prior. An X-ray showed soft tissue swelling without fracture and the patient was diagnosed with a rupture of the biceps muscle. MRI of the right elbow showed a brachioradialis tear with a large haematoma along the humerus. This was initially thought to be a haematoma; therefore, wound evacuation was done twice. When the injury failed to resolve, a tissue biopsy was performed. This revealed a grade 3 pleomorphic rhabdomyosarcoma. It is important to consider malignancy in the differential diagnosis with rapidly growing masses even if the initial presentation is suggestive of a benign condition. Neurofibromatosis type 1 is also associated with a higher risk of malignancy than the general population.

Hyperpigmented lesion on left palm.

The location of the lesion and an insight into the patient's regular activities revealed the clinical diagnosis.

Effects of Implementing a Comprehensive Opioid Reduction Protocol on Overall Opioid Prescribing Among Patients with Chronic, Non-Cancer Pain in a Rural Family Medicine Clinic: A Controlled Cross-over Trial.

BACKGROUND: The opioid crisis presents many challenges for family practice providers in rural communities who treat patients with chronic non-cancer pain (CNCP). Unfortunately, evidence for effective opioid reduction strategies is sparse. We evaluated the effects of implementing a comprehensive opioid reduction protocol on overall opioid prescribing among patients with chronic non-cancer pain in our rural family medicine clinics. METHODS: We compared mean daily milligrams morphine equivalent (MME) prescribed to patients with CNCP in our rural family medicine clinic (n = 93) with another matched clinic (n =93) after implementation of our comprehensive protocol. We also compared mean daily MME prescribed to our patients with CNCP before and after implementation of the protocol. In a subsequent cross over phase, we examined the effects of the protocol when applied to the original control group patients. RESULTS: Mean daily MME in the intervention clinic (29.77) was significantly lower than the control clinic (93.2) after the intervention (t = 6.03; P < .00). Mean daily MME in the intervention group was significantly lower after implementation of the protocol (29.77) than before the protocol (MME 80.34) (t = 5.889; P < .00). After crossover, the mean daily MME was significantly lower (14.34) in the original control group than prior to the cross over intervention (85.68); (t = 8.19; P = .00). DISCUSSION: Our comprehensive opioid reduction protocol led to significant reductions in opioid prescribing in our rural family medicine clinics. Future studies should include important qualitative outcome measures such as patient function.

Outcomes in octogenarians with subdural hematomas.

OBJECTIVE: In the majority of literature concerning age in TBI, specifically in subdural hematomas (SDH), the mean age of patients considered elderly is 55-65. Limited data in SDH patients>75 years suggest an increased mortality rate. The impact of medical decision making on these data is not well-documented. PATIENTS/METHODS: We use the Nationwide Inpatient Sample (NIS) database to compare outcomes between SDH patients 60-79 and ≥80. As administrative databases have some shortcomings, i.e. in-hospital data only, acute and chronic SDHs listed together, we examined institutional data to evaluate the impact of these factors on medical decision making which may falsely elevate mortality rates. RESULTS: In-hospital mortality was increased in NIS patients>80 treated both surgically and non-surgically (P<0.05). Our institutional data confirmed higher in-hospital mortality rates in patients>80 with SDHs as a group. However, the SDH patients>80 who underwent surgery at our institution had much lower mortality rates. We found that patients≥80 made up 87% of all patients with "surgical lesions" that were not operated on. Type of subdural, admission GCS, and baseline cognitive status appeared to have a significant impact on surgical decision making. CONCLUSION: This study examines mortality rates in patients>80 with SDHs who are managed surgically and non-surgically using a large administrative database and institutional data. It provides preliminary insight into medical decision making which make affect mortality rates of the very elderly.