An acute phase reaction from zoledronate mimicking symptoms seen in opioid withdrawal: a case report.

BACKGROUND: Zoledronate, a bisphosphonate, is a potent first-line treatment for osteoporosis. It is also a preferred treatment for hypercalcemia especially when unresponsive to intravenous fluids. Bisphosphonates can cause acute phase reactions that mimic opioid withdrawal symptoms, which can confound provider decision-making. Our case highlights cognitive bias involving a patient with opioid use disorder who received zoledronate for hypercalcemia secondary to immobilization and significant bone infection. CASE PRESENTATION: A 41-year-old male is admitted with a past medical history of active intravenous opioid use complicated by group A streptococcal bacteremia with L5-S1 discitis and osteomyelitis, L2-L3 osteomyelitis, and left ankle abscess/septic arthritis status post left ankle washout. His pain was well-controlled by acute pain service with ketamine infusion (discontinued earlier), opioids, acetaminophen, buprenorphine-naloxone, cyclobenzaprine, gabapentin, and naproxen. Intravenous opioids were discontinued, slightly decreasing the opioid regimen. A day later, the patient reported tachycardia, diaphoresis, myalgias, and chills, which the primary team reconsulted acute pain service for opioid withdrawal. However, the patient received a zoledronate infusion for hypercalcemia, on the same day intravenous opioids were discontinued. He had no other medications known to cause withdrawal-like symptoms per chart review. Therefore, it was suspected that an acute phase reaction occurred, commonly seen within a few days of bisphosphonate use. CONCLUSION: Zoledronate, well known for causing acute phase reactions, was likely the cause of withdrawal-like symptoms. Acute phase reactions with bisphosphonates mostly occur in the first infusion, and the incidence decreases with subsequent infusions. Symptoms typically occur 24-72 h post-infusion, and last at most for 72 h. Cognitive bias led the primary team to be concerned with opioid withdrawal rather than investigating other causes for the patient's presentation. Therefore, providers should thoroughly investigate potential etiologies and rule them out accordingly to provide the best care. Health care providers should also be aware of the implicit biases that potentially impact the quality of care they provide to patients.

Surgical Management of Necrotizing Fasciitis of the Head and Neck.

OBJECTIVE: The purpose of this study was to highlight risk factors and surgeries for necrotizing fasciitis (NF) of the head and neck in the literature. NF is rare but can rapidly progress. MATERIALS AND METHODS: A literature search was done using PubMed and SCOPUS. Articles that discussed NF of the head and neck and a specific surgical technique were included. A bivariate Pearson correlation was conducted using an α level of 0.05. RESULTS: The study included 31 articles encompassing 77 patients who presented with head and neck NF. Diabetes mellitus (23.4%) was the most common comorbidity observed. Surgical techniques, such as debridement (96.10%) and incision/exploration (97.40%), were common. CONCLUSION: Immediate surgical intervention should be performed when treating patients presenting with NF of the head and neck.

Impact of an Educational Intervention on the Opioid Knowledge and Prescribing Behaviors of Resident Physicians.

OBJECTIVES: The opioid epidemic is a multifactorial issue, which includes pain mismanagement. Resident physician education is essential in addressing this issue. We aimed to analyze the effects of an educational intervention on the knowledge and potential prescribing habits of emergency medicine (EM), general surgery (GS), and internal medicine residents (IM). METHODS: Resident physicians were provided with educational materials and were given pre-tests and post-tests to complete. Descriptive statistics were used to analyze pre-test and post-test responses. Chi-squared analysis was used to identify changes between the pre-tests and post-tests. A p < 0.05 value was considered statistically significant.  Results: Following the educational intervention, we observed improvement in correct prescribing habits for acute migraine management among emergency medicine residents (from 14.8% to 38.5%). Among general surgery residents, there was a significant improvement in adherence to narcotic amounts determined by recent studies for sleeve gastrectomy (p= 0.01) and laparoscopic cholecystectomy (p= 0.002). Additionally, we observed a decrease in the number of residents who would use opioids as a first-line treatment for migraines, arthritic joint pain, and nephrolithiasis. DISCUSSION: Resident physicians have an essential role in combating the opioid epidemic. There was a significant improvement in various aspects of opioid-related pain management among emergency medicine, internal medicine, and general surgery residents following the educational interventions. We recommend that medical school and residency programs consider including opioid-related pain management in their curricula.

Opioid Knowledge and Prescribing Preferences of Orthopaedic Surgery Residents Before and After an Educational Intervention.

Orthopaedic surgeons are among the highest prescribers of opioids. This study explores the effect of an educational intervention on orthopaedic surgery residents' opioid knowledge and prescribing practices. Orthopaedic residents were surveyed at three urban academic institutions. A pre-survey was administered to residents prior to an educational lecture and case-based session. This included background on the opioid epidemic, multimodal analgesia, opioid consumption in common orthopaedic procedures, and state laws regulating prescribing. Following this intervention, residents were given a post-survey to complete. There was a significant increase in resident confidence concerning their opioid prescribing training (p = 0.03) and their knowledge of alternative pain management therapies (p = 0.03). This was accompanied by an objective improvement in knowledge of state prescribing laws and of metrics regarding the opioid epidemic. Hypothetical opioid pills prescribed after common orthopaedic procedures decreased between the pre- and post-tests. The educational session significantly improved orthopaedic surgery residents' knowledge about opioids and prescribing habits. Formal resident education on opioid knowledge and evidence-based prescribing strategies is an area of potential improvement to combat the opioid crisis. (Journal of Surgical Orthopaedic Advances 31(1):030-033, 2022).

The Prevalence of Esophageal Disorders Among Voice Patients With Laryngopharyngeal Reflux-A Retrospective Study.

OBJECTIVE: The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry. METHODS: A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed. RESULTS: The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively). CONCLUSION: Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

Effects of Particle Size of Inhaled Corticosteroid on the Voice.

OBJECTIVES: The purpose of this study was to determine if inhaled corticosteroid (ICS) particle size influences the development of laryngitis including candida laryngitis, dysphonia, or vocalis muscle atrophy in asthmatic patients. STUDY DESIGN: Retrospective analysis. METHODS: Medical records of patients from a quaternary care laryngology practice who have asthma were reviewed retrospectively. Subjects were divided into two groups determined by the particle size of their ICS, small or standard. Each patient only used one type of inhaler. All subjects had been seen in the office for dysphonia evaluation. Statistical analysis was performed on the collected data using χ2 analysis with Yate's Correction for categorical data and a student t-test for means. A P value of less than 0.05 was considered significant. RESULTS: There was a significant difference in vocal fold atrophy rate between groups. CONCLUSION: Routine use of standard particle size ICS is associated with more atrophy than small size ICS.

Trends of temporal bone cancer: SEER database.

OBJECTIVE: This retrospective review aims to analyze epidemiological trends related to temporal bone cancer, and primarily of the squamous cell subtype. Potential trends analyzed included age, gender, and geographical location. DATA SOURCES: This retrospective review analyzed data found in the National Cancer Institute's SEER Database for cases of carcinomas of the middle ear. Cases were selected between 1975 and 2016 and using the primary site of Middle Ear (Site code C30.1), and then narrowed using additional variables, which included age, sex, and state-county. Languages covered included English. DATA EXTRACTION: The extracted data was entered into an Excel spreadsheet for further analysis in SPSS Version 25. DATA SYNTHESIS: An Analysis of Covariance (ANCOVA) and a Bonferroni correction were applied to the data for further analysis of significant trends. The data was then placed into tables outlining the distribution of cases among select patient characteristics of age and sex, and significant age group pairwise comparisons. CONCLUSIONS: Age at diagnosis of temporal bone cancer is strongly associated with the prevalence of temporal bone cancer. We urge providers to consider subtypes of temporal bone cancer, including squamous cell carcinoma, when evaluating older adults with risk factors for temporal bone cancer and an abnormal physical exam.

Orthopedic Master's in Business Administration: A career path analysis.

In recent years, it has become increasingly important for physicians to understand the healthcare system holistically. Thus, some physicians have sought formal education in business through a Master's in Business Administration (MBA). In this study, we looked specifically at orthopedic MD-MBAs and their career trajectories. We conducted a cross-sectional study of 127 orthopedic surgeons who have both MD and MBA degrees. Through online searches and phone calls, we compiled information regarding years in practice, fellowship training, practice type, non-clinical roles, and business school education. Almost all (96.85%) orthopedic MD-MBAs identified are still practicing clinically. The most common nonclinical roles are administration (38.58%), industry consulting (20.47%), and entrepreneurship (11.02%). Most (65.35%) pursued MBAs after medical school, but dual-degree programs are increasing in popularity. Almost all (88.57%) graduates of such programs have been practicing for less than 15 years. Orthopedic surgeons participate in a variety of nonclinical roles including administration, consulting, and entrepreneurship. For those currently in training, it is important to recognize the many opportunities that exist and the potential paths to pursuing them.