The Impact of Computed Tomography Scans on the Management and Wait Times in Perianal Abscess Diagnoses.

Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.

Novel Application of Balloon Tamponade in Management of Acute Lower Gastrointestinal Hemorrhage.

We present a case of acute lower gastrointestinal (GI) bleeding in the emergency department, in which specialists were not emergently available to render their support. A quick intervention using balloon tamponade technique with a Minnesota tube helped stabilize the patient until intensive care, gastroenterology, and surgical specialists could intervene. We also review previous cases from the literature in which a balloon tamponade method was used to control GI hemorrhage. Our novel application of the Minnesota tube is important for emergency physicians to consider for cases of acute lower GI bleeding, particularly in emergent presentations when specialists are not readily available in-hospital.

Evaluation of the effect of methamphetamine on traumatic injury complications and outcomes.

BACKGROUND: This study investigates the impact of methamphetamine use on trauma patient outcomes. METHODS: This retrospective study analyzed patients between 18 and 55 years old presenting to a single trauma center in San Bernardino County, CA who sustained traumatic injury during the 10-year study period (January 1st, 2005 to December 31st, 2015). Routine serum ethanol levels and urine drug screens (UDS) were completed on all trauma patients. Exclusion criteria included patients with an elevated serum ethanol level (> 0 mg/dL). Those who screened positive on UDS for only methamphetamine and negative for cocaine and cannabis (MA(+)) were compared to those with a triple negative UDS for methamphetamine, cocaine, and cannabis (MA(-)). The primary outcome studied was the impact of a methamphetamine positive drug screen on hospital mortality. Secondary outcomes included length of stay (LOS), heart rate, systolic and diastolic blood pressure (SBP and DBP, respectively), and total amount of blood products utilized during hospitalization. To analyze the effect of methamphetamine, age, gender, injury severity score, and mechanism of injury (blunt vs. penetrating) were matched between MA(-) and MA(+) through a propensity matching algorithm. RESULTS: After exclusion, 2538 patients were included in the final analysis; 449 were patients in the MA(+) group and 2089 patients in the MA(-) group. A selection of 449 MA(-) patients were matched with the MA(+) group based on age, gender, injury severity score, and mechanism of injury. This led to a final sample size of 898 patients with 449 patients in each group. No statistically significant change was observed in hospital mortality. Notably, a methamphetamine positive drug screen was associated with a longer LOS (median of 4 vs. 3 days in MA(+) and MA(-), respectively, p < 0.0001), an increased heart rate at the scene (103 vs. 94 bpm for MA(+) and MA(-), respectively, p = 0.0016), and an increased heart rate upon arrival to the trauma center (100 vs. 94 bpm for MA(+) and MA(-), respectively, p < 0.0001). Moreover, the MA(+) group had decreased SBP at the scene compared to the MA(-) group (127 vs. 132 bpm for MA(+) and MA(-), respectively, p = 0.0149), but SBP was no longer statistically different when patients arrived at the trauma center (p = 0.3823). There was no significant difference in DBP or in blood products used. CONCLUSION: Methamphetamine positive drug screens in trauma patients were not associated with an increase in hospital mortality; however, a methamphetamine positive drug screen was associated with a longer LOS and an increased heart rate.

Postoperative antibiotic use and the incidence of intra-abdominal abscess in the setting of suppurative appendicitis: a retrospective analysis.

BACKGROUND: Although guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. METHODS: We retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. RESULTS: Of 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. CONCLUSIONS: The administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use.

A rare case of concurrent signet-ring carcinoma of breast and microangiopathic hemolytic anemia.

Microangiopathic hemolytic anemia (MAHA) can be an uncommon presentation of an underlying malignancy, most often due to signet-ring cell carcinoma (SRCC). Additionally, pure SRCC in a breast primary-tumor comprises <2% of all breast cancers (Shin SY, Park H, Chae SW, Woo HY. Microangiopathic hemolytic anemia as the first manifestation of metastatic signet-ring cell carcinoma of unknown origin: a case report and review of literature. Kor J Lab Med 2011;31:157-61). To the best of our knowledge, the combination of these two entities, pure breast primary SRCC along with MAHA, has not been reported. Here, we present such a rare case. We also evaluate the current literature regarding this and similar disease processes, of which evidence is scarce and further research is needed.

Cutaneous Metastasis of Rectal Cancer: A Case Report and Literature Review.

Cutaneous metastasis of rectal cancer is rare. It typically indicates widespread disease and poor prognosis. We report an exceedingly rare case of rectal cancer with metastasis to the skin and review the literature on cutaneous metastasis of rectal cancer. A 47-year-old man presented with stage IV unresectable adenocarcinoma of the rectum and received palliative chemoradiation for local pain control. About a year later he developed extensive skin lesions involving the genital area, bilateral groin, and perineum. Biopsy specimen showed mucinous adenocarcinoma compatible with rectal origin. Palliative treatment with radiation therapy was initiated. The patient responded well to treatment and is still alive more than a year after diagnosis of cutaneous metastasis. Surgeons should maintain strong suspicion of cutaneous metastases when patients with rectal cancer have new or evolving skin lesions.

Soft Tissue Sarcoma With Tongue Metastasis: A Case Report and Literature Review.

Soft tissue sarcomas are rare malignant tumors that develop from mesenchymal cells. Metastasis is predominantly hematologic, with the lungs being the most common site. Metastasis to the oral cavity is a rare occurrence. The most common primary tumors to metastasize to the oral cavity are adenocarcinoma of the lung, breast, and kidney. This report describes a case of a 41-year-old man who was diagnosed with myxofibrosarcoma of the lower extremity and underwent neoadjuvant chemoradiation followed by surgical resection. Two years later, he presented with metastasis to the tongue and lungs. The literature on tongue metastasis of soft tissue sarcoma is reviewed and discussed. Surgeons providing care to patients with a soft tissue sarcoma should maintain a strong clinical suspicion for distant metastases in patients with this type of tumor.

Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide inpatient sample database.

CONTEXT: Postoperative neck hematoma is a well-known complication of thyroid and parathyroid surgery. Better understanding of risk factors for hematoma formation will help define high-risk populations. OBJECTIVE: To examine possible risk factors for neck hematoma after thyroid or parathyroid surgery. DESIGN: Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample database. METHODS: Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedures codes, we identified adults who underwent thyroid or parathyroid surgery and in whom neck hematoma subsequently developed. Information about demographic, clinical, and hospital characteristics was collected. Multivariate regression analyses were used to predict independent risk factors for neck hematoma. RESULTS: We identified 147,344 thyroid and parathyroid operations performed nationwide between 2000 and 2009. Overall incidence of postoperative neck hematoma was 1.5% (n = 2210). In multivariate analysis, age 65 years and older (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.4-2.1), male sex (OR = 1.3, 95% CI = 1.2-1.4), African-American race (OR = 1.5, 95% CI = 1.2-1.7), being from the South (OR = 1.3, 95% CI = 1-1.4), comorbidity score of 3 or more (OR = 2, 95% CI = 1.6-2.6), history of alcohol abuse (OR = 2.7, 95% CI = 1.6-2.5), Graves disease (OR = 3, 95% CI = 2.1-4.1), and substernal thyroidectomy (OR = 3.3, 95% CI = 2.8-3.9) were associated with a higher risk of neck hematoma. CONCLUSION: We identified demographic and clinical factors associated with increased risk of neck hematoma after thyroid or parathyroid surgery.

Impact of surgeon volume on incidence of neck hematoma after thyroid and parathyroid surgery: ten years' analysis of nationwide in-patient sample database.

The study's objective is to examine the impact of surgeon experience on the incidence and the severity of neck hematoma after thyroid and parathyroid surgery using a nationwide database. The Nationwide In-patient Sample is a nationwide clinical and administrative database. We used the International Classification of Diseases, 9th Revision diagnosis and procedures codes to identify adult patients who underwent thyroid and parathyroid surgery and subsequently developed neck hematoma. Patient and hospital characteristics were collected along with surgeon volume to predict patient outcomes. Surgical procedures were stratified into three groups according to surgeon volume: low (less than 10 operations), intermediate (10 to 99), and high (100 or more). We identified 147,344 thyroid and parathyroid surgery performed between 2000 and 2009 nationwide. Overall incidence of postoperative neck hematoma was 1.5 per cent (n = 2210). This was 2.1, 1.4, and 0.9 per cent among procedures performed by low-volume, intermediate-volume, and high-volume surgeons, respectively. After adjusting for other confounders, compared with procedures performed by low-volume surgeons, those performed by intermediate- (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.6 to 0.8; P < 0.01) and high-volume surgeons (OR, 0.5; 95% CI, 0.4 to 0.6; P < 0.01) were less to likely to develop neck hematoma. Surgeon experience is significantly associated with the development of neck hematoma after thyroid and parathyroid surgery.