National Trends and Predictors of Opioid Administration in Patients Presenting With Abdominal Pain to the Emergency Department (2010-2018).

Given the current opioid crisis, in this study, we assess the national trend and factors associated with opioid administration for patients presenting to the emergency department with abdominal pain. This is a retrospective cross-sectional study conducted using the National Hospital Ambulatory Medical Care Survey from 2010 to 2018. Weighted multiple logistic regression was applied to assess the independent factors associated with opioid administration in the emergency department. Trends of opioid administration were evaluated using the linear trend analysis. There were an estimated total of 100,925,982 emergency department visits for abdominal pain. Overall, opioid was administered in 16.8% of visits. Age less than 25 years was associated with lower odds of receiving opioids. Patients living in the Northeast had the lower odds of receiving opioids (odds ratio [OR] = 0.82, p = .006) than patients living in the Midwest. Patients in the West had the highest odds of receiving opioids (OR = 1.16, p = .01). Non-Hispanic White patients had higher odds of opioid administration (OR = 1.29, p < .001). Trend analysis demonstrated a statistically significant reduction in opioid administration. From 2010 to 2018, opioid administration has approximately decreased in half. Living in the West and the non-Hispanic White racial group were the significant factors associated with a higher risk of opioid administration.

A Novel Case of Biliary Stent Migration Causing Sigmoid Diverticula Entrapment.

Pancreaticobiliary obstruction is a rare but life-threatening complication. Plastic biliary stents are a temporary utility to maintain the patency of the common bile ducts, typically lasting about four months. Biliary stents can rarely have complications, with the most common being migration through the gastrointestinal tract. We present a case of a patient with a plastic stent placed over five years, which was complicated by severe hematochezia due to the retention of the stent in a diverticulum. Given the increased risk of life-threatening complications post-stent life expectancy, there should be systems in place to prevent patients from being lost to follow-up.

Innovative Approaches to Safe Surgery: A Narrative Synthesis of Best Practices.

By encompassing a wide range of best practices within the ever-changing realm of modern surgical care, this exhaustive narrative compendium attempts to unravel the complex tapestry of novel approaches to safe surgery. Within the context of a dynamic surgical environment, this research endeavors to illuminate and integrate state-of-the-art methods that collectively methodically improve patient safety. The narrative elucidates a diverse array of practices that seek to revolutionize the paradigm of safe surgery, emphasizing technological progress, patient-centric approaches, and global viewpoints. The combined effectiveness of these methods in fostering an all-encompassing culture of safety, improving surgical precision, and decreasing complications is revealed by the results obtained from their implementation. The recognition of the dynamic interplay among multiple components, including the active participation of patients, the integration of cutting-edge technologies, and the establishment of comprehensive quality improvement programs, is fundamental to this narrative. By their collective composition, these components support the notion that secure surgical practices are intricate and interrelated. The present synthesis functions as a fundamental resource for healthcare professionals, policymakers, and researchers, providing an enlightening examination of the current condition of secure surgical practices. By emphasizing the promotion of innovation, continuous development, and the utmost quality of patient care, it offers a strategic guide for navigating the complex terrain of safe surgery. In the ever-evolving landscape of surgical care, this narrative synthesis serves as a guiding principle for stakeholders striving to understand better and implement safe surgical procedures in various healthcare environments.

The Boseman Effect: A Missed Opportunity?

Introduction Public figures, namely celebrities, are highly influential people whose actions and thoughts are often emulated, especially regarding healthcare. Understanding trends in public interest may provide an opportunity for further patient education. Given the changes of the COVID-19 pandemic along with the highly publicized death of actor Chadwick Boseman, who died from complications of colon cancer, we analyzed trends in colon cancer searches over a 15-month period. Methods Google Trends (Google, Mountain View, California) was used to access search histories in the United States from January 1, 2020, through April 30, 2021. Four search terms were analyzed: "colon cancer", "colonoscopy", "Cologuard", and "virtual colonoscopy". Google Trends reports data as relative search volume (RSV), a scaled number from 0-100 reflecting interest in a particular search term over a set time. Search terms were analyzed on the same RSV scale with one-way ANOVAs comparing search volumes during four eight-week blocks. Results Google Trends data was reported weekly. Search volume for colon cancer was higher (17.3, p=0.00) over the eight weeks following Boseman's death, while search volume for colonoscopy returned to normal (21.5, p=0.95) when compared to pre-pandemic levels. Conclusion The peak in colon cancer searches in late August of 2020 corresponds to the death of Chadwick Boseman on 8/28/2020. Colonoscopy interest decreased during the COVID-19 pandemic before returning to previous levels around the time of Boseman's death without experiencing the same spike in interest. This discrepancy represents a missed opportunity for patient education on this preventable disease.

Endoscopic Management of Ingested Narcotic Substances: A Case Report and Literature Review.

Management of swallowed narcotics remains in contention despite the increased frequency of occurrence. International societies recommend conservative therapy with escalation to surgical interventions in cases where drug packets do not progress. However, multiple studies demonstrate a treatment benefit of endoscopic intervention. We report the case of a 27-year-old male who presented after ingesting heroin bundles and failed the 48-hour of conservative therapy. Repeat computed tomography scanning demonstrated no movement of the package. Endoscopic retrieval was successful, and the patient was discharged the same day. Endoscopic intervention in the removal of bagged narcotics should be considered in patients presenting after purposely ingesting narcotics as means of planned concealment.

A Rare Case of a Sickle Cell Patient With Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis and Pseudoaneurysm Formation: An Association Worth Exploring.

Pancreatitis is commonly seen with alcohol use and gallstones, but it can be a post-procedural complication from endoscopic retrograde cholangiopancreatography (ERCP). Inflammation of the pancreas can lead to pseudoaneurysm formation, which is rare but extremely dangerous if ruptures, with high mortality and morbidity. Sickle cell disease can also cause vascular injury from repeated vaso-occlusion, inflammation, and ischemia. Here, we present a case of a 27-year-old patient with sickle cell disease who underwent ERCP for stent placement for gallstones and subsequently developed pancreatitis complicated by pseudoaneurysm formation of the inferior pancreaticoduodenal artery (IPDA) that was managed by endovascular embolization.

Plasma Cell Leukaemia: A Rare Yet Aggressive Plasma Cell Dyscrasia With A Very Poor Response To Conventional Therapy.

Plasma cell leukaemia (PCL) is a very rare plasma cell dyscrasia with a significant number of monoclonal plasma cells in the peripheral blood. It is diagnosed by the presence of ≥ 2x109 /L plasma cells in the blood or by plasma cells making up ≥20% of the leukocyte count. It can arise from a leukemic transformation of multiple myeloma, or more commonly it can be primary. Regardless of its origin, it carries a very dire prognosis. It responds very poorly to the traditional chemotherapy regimens used for multiple myeloma. We present the case of a 50 years old female who presented to our hospital with a complicated UTI and severe generalized body aches. She was diagnosed as a case of plasma cell leukaemia and was treated with cyclophosphamide and dexamethasone, however she failed to go into remission. Her condition deteriorated and she ultimately passed away 1.5 months after diagnosis. The recommended treatment for PCL is aggressive combination chemotherapy followed by stem cell transplantation. However, there is no consensus regarding the treatment of plasma cell leukaemia, and treatment should be individualized based on the patient profile. Once diagnosed, the prognosis is poor.

Efficacy and Safety of Tranexamic Acid in Orthopaedic Fracture Surgery: A Meta-Analysis and Systematic Literature Review.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to be effective in reducing blood loss and the need for transfusions after several orthopaedic surgeries. However, the effectiveness of TXA use in orthopaedic fracture surgeries still remains unclear. The purpose of this meta-analysis was to review existing literature with interest in the effectiveness and safety of TXA treatment in reducing total blood loss and transfusion rates for patients who underwent surgery for fracture repairs. METHODS: An electronic literature search of PubMed, Embase, OVID, and the Cochrane Library was conducted to identify studies published before December 2016. All randomized controlled trials and cohort studies evaluating the efficacy of TXA during fracture repair surgeries were identified. Primary outcome measures included the number of patients receiving a blood transfusion and perioperative total blood loss. Data were analyzed using Comprehensive Meta-Analysis (CMA) statistical software. RESULTS: Seven studies encompassing 559 patients met the inclusion criteria for the meta-analysis. Our meta-analysis indicated that when compared with the placebo control group, the use of TXA in fracture surgeries significantly reduced total blood loss by approximately 330 mL (P = 0.009), reduced the transfusion rate with a relative risk of 0.54 (P < 0.001), and decreased the drop of hemoglobin by 0.76 g/dL (P < 0.001). There was no significant difference between the number of thromboembolic events among the study groups (P = 0.24). CONCLUSIONS: This study demonstrated that tranexamic acid may be used in orthopaedic fracture surgeries to reduce total blood loss, transfusion rates, and the drop in hemoglobin level, without increasing risk of venous thrombo-embolism. A limitation to these findings is the small number of studies available. Further studies need to be conducted to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Pancreatic Duct Stones.

pancreatitis appears to exist in the presence of such calculi upon radiology. Having said that, pancreatic ductal stone due to biliary causes (origin), in face of acute pancreatitis, is rare. To the best of our knowledge this was the first case of its kind presented to our hospital in recent past. A 25-year-old female presented to the emergency department of our hospital with an acute episode of pancreatitis. Computerized tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP) & magnetic resonance cholangiopancreatography (MRCP) concluded acute pancreatitis (AP) with dilated main pancreatic duct left side branches and intra ductal calculi. The findings were not suggestive of any chronic pancreatitis. Conservative treatment was given for the episodic attack of AP. After the episode resolved, an exploration and extraction of the pancreatic ductal calculus was performed successfully. The pancreatic duct stones were removed by lateral pancreaticojejunostomy (partington-rochelle procedure). The patient made a remarkable recovery after the procedure and was perfectly healthy and well-oriented in time and space at 4-months follow up. Acute pancreatitis is an inflammatory condition of pancreas, when, associated with pancreatic duct stones a lateral pancreaticojejunostomy is done, which, results in better outcomes decreasing the mortality and morbidity. Acute pancreatitis due to ductal calculi is rare for which extraction is safe after resolution of the episode of AP. Studies need to be carried out to look for the outcome and the effectiveness of the procedure, when, specifically and specially done for this condition.

A Mobile-Based Surgical Simulation Application: A Comparative Analysis of Efficacy Using a Carpal Tunnel Release Module.

PURPOSE: The utilization of surgical simulation continues to grow in medical training. The TouchSurgery application (app) is a new interactive virtual reality smartphone- or tablet-based app that offers a step-by-step tutorial and simulation for the execution of various operations. The purpose of this study was to compare the efficacy of the app versus traditional teaching modalities utilizing the "Carpal Tunnel Surgery" module. We hypothesized that users of the app would score higher than those using the traditional education medium indicating higher understanding of the steps of surgery. METHODS: A total of 100 medical students were recruited to participate. The control group (n = 50) consisted of students learning about carpal tunnel release surgery using a video lecture utilizing slides. The study group (n = 50) consisted of students learning the procedure through the app. The content covered was identical in both groups but delivered through the different mediums. Outcome measures included comparison of test scores and overall app satisfaction. RESULTS: Test scores in the study group (89.3%) using the app were significantly higher than those in the control group (75.6%). Students in the study group rated the overall content validity, quality of graphics, ease of use, and usefulness to surgery preparation as very high (4.8 of 5). CONCLUSIONS: Students utilizing the app performed better on a standardized test examining the steps of a carpal tunnel release than those using a traditional teaching modality. The study findings lend support for the use of the app for medical students to prepare for and learn the steps for various surgical procedures. CLINICAL RELEVANCE: This study provides useful information on surgical simulation, which can be utilized to educate trainees for new procedures.

Pleomorphic Adenoma Of Minor Salivary Glands.

Pleomorphic adenoma is the most common benign tumour of salivary glands which is Known for its wide pleomorphic architecture. It accounts for 45-75% of all salivary gland neoplasm. It can involve major as well as minor salivary glands. Among minor salivary glands (5-10% of cases) the palate lip, nasal cavity, pharynx, larynx and trachea are the most common sites. Diagnosis is made with biopsy along with histopathology. Wide excision with biopsy and removal of underlying extension of tumour is the treatment of choice. Sixty years old farmer presented with painless swelling in the upper lip for the last 8 years. History revealed recurrent mass in the midline of upper lip with no other complaints. He was operated 3 times for this complaint in the past. Belonging to poor socioeconomic status no biopsy records were found. On examination 3×4 cm hard and mobile mass was found. Lymph nodes of head and neck and parotid gland revealed no enlargement. Surgery by wide excision was planned. After baseline investigation surgery was done and the mass sent for histopathology. Biopsy reports showed pleomorphic adenoma on unusual site. Dissection of salivary gland tumour is important as they have propensity to metastasize. Wide local excision along with biopsy is the method of choice. Proper surgical techniques are required to avoid recurrence.

Eales Disease.

Eales disease is an eponym after a British ophthalmologist Henry Eales. The aetiology behind Eales disease is ill-understood and stands controversial. Various systemic diseases associated with peripheral retinal revascularization and Retinal vasculitis could imitate the proliferative and inflammatory phases of Eales' disease, respectively. We present a case of a 30 years old female patient with Eales disease and discuss the clinical features, treatment plan and its outcome in our patient. Tuberculosis appears to be the cause of Eales disease but the relation is yet to be established and clinically proven. Steroid therapy is usually the main stay of treatment with tapering doses of systemic corticosteroids. Other interventions are vitrectomy, photocogulation or cryotherapy.

p107-Dependent recruitment of SWI/SNF to the alkaline phosphatase promoter during osteoblast differentiation.

The retinoblastoma protein family is intimately involved in the regulation of tissue specific gene expression during mesenchymal stem cell differentiation. The role of the following proteins, pRB, p107 and p130, is particularly significant in differentiation to the osteoblast lineage, as human germ-line mutations of RB1 greatly increase susceptibility to osteosarcoma. During differentiation, pRB directly targets certain osteogenic genes for activation, including the alkaline phosphatase-encoding gene Alpl. Chromatin immunoprecipitation (ChIP) assays indicate that Alpl is targeted by p107 in differentiating osteoblasts selectively during activation with the same dynamics as pRB, which suggests that p107 helps promote Alpl activation. Mouse models indicate overlapping roles for pRB and p107 in bone and cartilage formation, but very little is known about direct tissue-specific gene targets of p107, or the consequences of targeting by p107. Here, the roles of p107 and pRB were compared using shRNA-mediated knockdown genetics in an osteoblast progenitor model, MC3T3-E1 cells. The results show that p107 has a distinct role along with pRB in induction of Alpl. Deficiency of p107 does not impede recruitment of transcription factors recognized as pRB co-activation partners at the promoter; however, p107 is required for the efficient recruitment of an activating SWI/SNF chromatin-remodeling complex, an essential event in Alpl induction.