How low can you go: Achieving postoperative outpatient pain control without opioids.

BACKGROUND: Postoperative outpatient narcotic overprescription plays a significant role in the opioid epidemic. Outpatient opioid prescription ranges from 150 to 350 oral morphine equivalent (OME) for a laparoscopic cholecystectomy or appendectomy, with 75 OME (10 pills of 5 mg of oxycodone) being the lowest recommendation (National Institute on Drug Abuse, 2018). We hypothesized that the addition of nonopioid medications to the outpatient pain control regimen would decrease the need for narcotics. METHODS: In this prospective, observational pilot study, we prescribed a 3-day regimen of ibuprofen and acetaminophen to patients after uncomplicated laparoscopic cholecystectomies and appendectomies. An additional opioid prescription for 5 pills of 5 mg of oxycodone (37.5 OME) was written for breakthrough pain. During their postoperative visit, we evaluated patients' adherence to the pain control regime, their postdischarge opioid use, and the adequacy of their pain control. RESULTS: Sixty-five patients were included in the study (52% male). The majority (80%) of surgeries were performed urgently or emergently. The visual analog scale pain score at home was significantly better than upon discharge (3.7 vs. 5.5, p = 0.001). The average number of oxycodone pills taken postdischarge was 1.8 pills. Half (51%) of the patients did not take any opioids. All but four patients reported that their pain was adequately controlled. No patient required additional opioid prescriptions or visited the emergency department. CONCLUSION: This study demonstrated that opioids can be eliminated in at least half of the patients and that five pills of 5 mg of oxycodone (37.5 OME) is sufficient for outpatient pain control when a 3-day course of ibuprofen and acetaminophen is prescribed. LEVEL OF EVIDENCE: Therapeutic study, level V.

Duplicate appendix with acute ruptured appendicitis: a case report.

Duplication of the appendix is a rare congenital anomaly that, in adults, is most often found incidentally during surgery for other reasons. Appendicitis in the duplicated appendix is very rare and has been reported less than 10 times in the medical literature. We describe a 33-year-old woman with worsening periumbilical pain, nausea, vomiting, and fever. Physical examination showed localized peritonitis in the right lower quadrant. She had an elevated white blood cell count with neutrophilia. Computed tomography showed acute ruptured appendicitis. Diagnostic laparoscopy showed 2 appendices attached via separate bases to a single cecum with no other concurrent anomalies. Both appendices were removed laparoscopically. Histopathology confirmed normal appendiceal tissue in one and severe acute transmural appendicitis in the other. Awareness of appendiceal duplication and a thorough intraoperative inspection are critical to assess the presence of significant associated anomalies and avoid life-threatening complications.

A founder mutation in the MPL gene causes congenital amegakaryocytic thrombocytopenia (CAMT) in the Ashkenazi Jewish population.

Congenital amegakaryocytic thrombocytopenia (MIM #604498) (CAMT) is a rare inherited disease presenting as severe thrombocytopenia in infancy. Untreated, many CAMT patients develop aplastic anemia within the first decade of life; the only effective treatment of CAMT is bone marrow transplantation. CAMT is the result of the presence of homozygous or compound heterozygous mutations in the thrombopoietin receptor-encoding gene, MPL. We report here the identification and characterization of a founder mutation in MPL in the Ashkenazi Jewish (AJ) population. This mutation, termed c.79+2T>A, is a T to A transversion in the invariant second base of the intron 1 donor splice site. Analysis of a random sample of 2018 individuals of AJ descent revealed a carrier frequency of approximately 1 in 75. Genotyping of six loci adjacent to the MPL gene in the proband and in the 27 individuals identified as carriers of the c.79+2T>A mutation revealed that the presence of this mutation in the AJ population is due to a single founder. The observed carrier frequency predicts an incidence of CAMT in the AJ population of approximately 1 in 22,500 pregnancies. The identification of this mutation will enable population carrier testing and will facilitate the identification and treatment of individuals homozygous for this mutation.