Ketamine Induced Acute Systolic Heart Failure.

Background: Studies have shown major cardiovascular effects associated with ketamine use disorder including dose-dependent negative inotropic effects. Preoperative ketamine use has been linked to ketamine-induced stress cardiomyopathy. Case presentation: A 28-year-old female with a history of recurrent cystitis and ketamine use disorder (twice weekly for 14 years) presented with bilateral lower extremity oedema and shortness of breath for 3 months. She was tachycardic with a troponin level of 0.07 ng/ml and a B-type natriuretic peptide (BNP) level of 2511 pg/ml. Electrocardiogram showed normal sinus rhythm and transthoracic echocardiography (TTE) showed left ventricular ejection fraction (EF) of 15%, dilated left ventricle, and severe tricuspid and mitral regurgitation. Computed tomography (CT) scan of the chest and abdomen showed bilateral pleural effusions with congestive hepatopathy and ascites. The patient was started on intravenous furosemide, metoprolol, and sacubitril/valsartan. Rheumatological workup including complement levels, and antinuclear anti-double-stranded DNA was negative. A repeat TTE 2 weeks later revealed an EF of 25% and moderate tricuspid regurgitation. Four months later, the EF was 54% with normal left ventricular cavity size. Conclusion: Although ketamine use disorder is increasing, data on long-term side effects is minimal. Screening for ketamine use disorders should be considered in patients presenting with acute systolic heart failure. Long-term studies are needed to evaluate the benefits of adding ketamine screening to standard urine toxicology. LEARNING POINTS: Ketamine use disorder can lead to severe cardiovascular complications, including acute systolic heart failure, likely due to its direct negative inotropic effects and dose-dependent impact on cardiac function.Clinicians should consider screening for ketamine use disorder in young adults presenting with acute systolic heart failure, especially when other common aetiologies have been ruled out.Early recognition and prompt treatment of ketamine-induced heart failure with diuretics and guideline-directed medical therapy can lead to significant improvement in cardiac function, but long-term management should also focus on ensuring cessation of ketamine use disorder.

GLP-1 receptor agonists: A novel pharmacotherapy for binge eating (Binge eating disorder and bulimia nervosa)? A systematic review.

Objective: Systematically review evidence on using GLP-1RAs for reducing BEB in BED and BN. Methods: Comprehensive literature search (PubMed and Google Scholar) conducted for studies evaluating GLP-1Ras for BEB. Extracted data on study characteristics, efficacy, and safety. Results: Studies show that GLP-1RAs (liraglutide and dulaglutide) reduce BE frequency and comorbidities in addition to favorable psychiatric side effect profile compared to current options. However, large-scale, blinded placebo-controlled trials are lacking. Conclusion: Early findings suggest promising effects of GLP-1RAs on BEB. However, rigorous clinical trials are needed to firmly establish efficacy, dosing, safety, and comparative effectiveness before considering GLP-1RAs a viable novel approach.

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review.

PURPOSE OF REVIEW: The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain. RECENT FINDINGS: Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

The Acute Perioperative Pain Service: Impact, Organization, and Future Directions.

PURPOSE OF REVIEW: The Acute Perioperative Pain Service has been established as a relatively new but important concept and service in clinical patient care. Many surgical institutions have dedicated inpatient acute pain services with variable compositions. This review aims to investigate the purpose, clinical and economic implications, and future direction of the Acute Perioperative Pain Service (APPS). RECENT FINDINGS: There is growing evidence of the multiple benefits of a dedicated APPS, especially pertaining to patients at higher risk of poorly controlled postoperative pain. Healthcare providers furthermore realize the importance of the perioperative pain management continuity of care, consisting of preoperative pain evaluations and post-discharge follow-up in an outpatient pain management setting, in coordination with the primary teams. The Transitional Pain Service (TPS) has emerged as the next step in this evolution and has been successfully implemented at various medical centers. With the growing number of surgical procedures and the increasing complexity of the patient population, effective management of acute postoperative pain continues to be challenging, despite ongoing advances in clinical care, analgesic modalities, and research. The APPS is becoming the clinical standard of care for managing postoperative pain, and its role continues to expand worldwide.

Epidemiology of Bladder Cancer in the Arab World: 2019 Global Burden of Disease Data.

BACKGROUND: Urinary bladder cancer (UBC) has unique epidemiology. It is well known that some Arab countries have higher incidence of UBC due to certain risk factors, including schistosomiasis and smoking. METHODS: We systematically reviewed the Global Burden of Disease study (GBD) database for the year 2019. We queried GBD study database using results tool for UBC in the 22 Arab countries and compared the age-standardized incidence rate (ASIR), death rate (ASDR), mortality-to-incidence ratio (MIR) and Disability-Adjusted Life Years (ASDALYs) in Arab countries with global values. RESULTS: The Arab population represents 5.6% of the global population. There was an estimated number of 27,503 patients diagnosed with UBC in 2019 in the Arab world. The ASIR for developing UBC in the Arab countries was 9.9/100,000; which is higher than the average global ASIR (6.5/100,000). Specifically, the ASIR was higher than the global average in 11 out of the 22 Arab countries. Notably, the age-specific incidence in Egypt showed that younger individuals had higher incidence of UBC than other countries, reflecting unique epidemiology. It is estimated that 10,532 patients died of UBC in the Arab world in 2019. The average mortality-to-incidence ratio (MIR) was estimated to be 0.448. The burden of UBC as estimated by the number of DALYs in the Arab world was 272,976 years representing 4% of cancer burden in Arab countries and 6.2% of the global DALYs related to UBC. CONCLUSION: UBC has high incidence in many Arab countries, particularly in North Africa.  Risk factors are known and are modifiable, making prevention the most optimal way to reduce disease burden. High MIR in many Arab countries reflects suboptimal management and a window for improvement.

Fluoroscopy-Guided Transfacet Lumbar Epidural Steroid Injection for Symptomatic Synovial Cyst Treatment: A Case Report.

We report the case of a patient with a right-sided L4 synovial cyst, which had been causing significant pain, who had a successful transfacet epidural steroid injection to rupture the cyst. Using fluoroscopy, the needle was advanced through the right L4 facet joint and the cyst was ruptured using saline. The needle was then advanced into the epidural space and a transfacet epidural steroid injection was done. The patient's symptoms resolved. Repeat magnetic resonance imaging (MRI) done 2 years later showed no recurrence of the cyst. We discuss the role of transfacet epidural steroid injection in synovial cysts treatment.

Survival and metastasis in muscle-invasive bladder cancer patients who present with indeterminate pulmonary nodules before treatment.

BACKGROUND: Indeterminate pulmonary nodules (IPNs) are common during initial evaluation of bladder cancer patients. Their significance is still unknown. OBJECTIVE: Determine the significance of indeterminate pulmonary nodules, including their size and number, in muscle-invasive bladder cancer patients before definitive local therapy by surgery or chemo-radiotherapy. DESIGN: Retrospective review, single-center descriptive study. SETTINGS: A tertiary cancer center. PATIENTS AND METHODS: We performed a retrospective review of patients who underwent definitive local therapy of bladder cancer by either radical cystectomy and lymph node dissection or with chemo-radiotherapy between January 1997 and December 2015. We identified patients with baseline CT scans done during staging work-up prior to definitive treatment. Patients with proven clinical metastasis at pre.sentation were excluded, while patients who had IPNs without features suggesting metastasis were included. MAIN OUTCOME MEASURES: Disease-free survival and overall survival. SAMPLE SIZE: 168 patients. RESULTS: The median age of patients at diagnosis was 66 years; 92% were males and 56% were smokers. IPNs (3 cm or less) were present in 74 patients (44.0%). Median follow-up was 24 months. IPNs were associated with decreased disease-free survival while IPNs did not affect the overall survival (HR=1.9; 95% CI: 1.1-3.4); P=.01 and HR=1.5; 95% CI: 1.0-2.5); P=.07, respectively. In addition, nodules greater than 1 cm had reduced disease-free survival (HR=2.5; 95% CI: 1.1-5.9); P=.04. In the surgery group (n=126), the median number of lymph nodes excised was 14, with no association between lymph nodes status and the presence of IPNs (P=.08). CONCLUSION: The presence of IPNs, especially nodules greater than 1 cm had a negative effect on disease-free survival. Tailored postoperative follow-up of these patients may impact disease outcomes. LIMITATIONS: The retrospective nature, the lack of standardized preoperative imaging protocols, the lack of a central radiology review and the small number of patients. CONFLICT OF INTEREST: None.

Trends of partial and radical nephrectomy in managing small renal masses.

OBJECTIVE: Use of partial nephrectomy (PN) for renal tumors appears to have relatively lower incidence rates in Jordan. We sought to characterize its trend at King Hussein Cancer Center for the last 10 years. MATERIAL AND METHODS: A retrospective review of our renal cell cancer data was performed. We identified 169 patients who had undergone surgery for renal tumors measuring ≤7 cm between 2005 and 2015. We characterized tumor size, pathology, type of surgery and clinical outcomes. Factors associated with the use of PN were evaluated using univariable and multivariable logistic regression models. RESULTS: Of the 169 patients, 34 (20%) and 135 (80%) had undergone partial and radical nephrectomy (RN) respectively for tumors ≤7 cm in diameter. Total number of 48 patients with tumors of ≤4 cm in diameter had undergone either PN (n=19; 40%) or RN (n=29; 60%). The frequency of PN procedures steadily increased over the years from 6% in 2005-2008, to 32% in 2013-2015, contrary to RN which was less frequently applied 94% in 2005-2008, and 68% in 2013-2015. In multivariable analysis, delayed surgery (p=0.01) and smaller tumor size (p=0.0005) were significant independent predictors of PN. During follow-up period, incidence of metastasis was lower in PN versus RN (13% and 32%, respectively, p=0.043). Local recurrence rates were not significantly different between PN (6.9%) and RN (7.2%) (p=0.99). The mean tumor sizes for patients who had undergone PN and RN were 4.1 and 5.5 cm respectively, (p<0.0001). The mean follow-up period for PN was 20 months, and for RN 33 months, (p=0.0225). CONCLUSION: Partial nephrectomy for small renal tumors is relatively less frequently applied in Jordan, however an increase in its use has been observed over the years. Our data showed lower rates of distant metastasis and similar rates of local recurrence in favor of PN.

Clinicopathologic Features of Translocation Renal Cell Carcinoma.

BACKGROUND: Translocation renal cell carcinomas (TFE3 RCC) are associated with variable genetic rearrangements of the TFE3 gene on chromosome Xp11.2. Translocation tumors represent 1% to 5% of all cases of RCC, with the greatest frequency among children and young adults. We sought to characterize the clinicopathologic features of translocation RCC at a Middle Eastern institution. MATERIALS AND METHODS: The clinical and pathologic data from a single institution were retrospectively reviewed. A total of 14 patients with translocation RCC had been diagnosed from 2005 to 2014. The outcome measures included patient characteristics, clinical manifestations, pathologic features, treatment outcomes, cancer-specific survival, and progression-free survival. RESULTS: The mean age at diagnosis was 35 years. Of the 14 patients, 5 were female. Translocation RCC was an incidental diagnosis for all but 2 of the 14 patients. The mean tumor size was 9 cm; 1 patient had bilateral tumors, and 3 presented with positive lymph nodes. Three patients underwent partial nephrectomy. Three patients had developed metastasis at 4 months, 5 months, and 3 years after diagnosis. One patent had died 4 months after surgery and one had died 21 months after surgery (both of metastases). The disease-free survival rate was 71% at a mean follow-up of 31 months. CONCLUSION: Translocation RCC is a rare and potentially aggressive subtype of kidney cancer. An overall survival of > 3 years has been noted, unless metastasis is present at diagnosis.

Clinico-pathological outcomes of post- primary and salvage chemotherapy retroperitoneal lymph node dissection for mixed germ cell tumors, King Hussein Cancer Center experience.

OBJECTIVE: We sought to characterize clinical and pathologic outcomes of advanced mixed germ cell tumors after retroperitoneal lymph node dissection for post-chemotherapy residual masses. MATERIAL AND METHODS: Between January 2006 and November 2015, 56 patients underwent retroperitoneal lymph node dissection (RPLND) for residual masses of greater than 1 cm after receiving either primary chemotherapy or salvage chemotherapy. Retrospective review of the patients' characteristics, clinical, pathological, and treatment outcomes were performed after institutional review board (IRB) and ethics committee approval. RESULTS: The mean age at diagnosis was 30 years. Ninety percent of the patients received 3-4 cycles of BEP (bleomycin/etoposide/cisplatin) as primary chemotherapy, and 29% of them salvage chemotherapy prior to lymph node dissection. The mean size of the residual masses after chemotherapy was 6 cm. The histological findings were necrosis in 30%, viable tumor in 34% and teratoma in 36% of the retroperitoneal masses. The mean time to relapse after RPLND was 11 months, out of 9 relapses, 6 were in the retroperitoneum, 1 in the lung and 1 in the kidney and 1 in the contralateral testicle. CONCLUSION: Our results indicated higher incidence of viable germ cell tumor in the retroperitoneal residual masses after primary and salvage chemotherapy when compared with previously reported global incidence rates.