Implementing a Discharge Opioid Bundle in Adult Trauma Patients Decreases the Amount of Opioids Prescribed at Discharge.

BACKGROUND: Opioids remain the mainstay treatment of acute pain caused by trauma. The lack of evidence driven prescribing creates a challenging situation for providers. We hypothesized that the implementation of a trauma discharge opioid bundle (TDOB) would decrease the total morphine milligram equivalents (MME) prescribed at discharge while maintaining pain control. METHODS: This was a pre-post study of adult trauma patients before and after implementation of a TDOB to guide the prescription of opioids and discharge prescription education in patients discharged from a level one trauma center. The pre-group and post-group, included consecutively discharged patients from September through November in 2018 and 2019. The primary outcome was the total MME prescribed at discharge. RESULTS: A total of 377 patients met inclusion criteria. One hundred and fifty-one patients were included in the pre-group and 226 in the post-group. The total MME prescribed at discharge (225 ± [150-300] pre vs 200 ± [100-225] post, P = < .001) and maximum MME/day (45 ± [30-45] vs 30 ± [20-45], P = .004) were significantly less in the post-group. Incidence of outpatient refills within fourteen days were similar. More non-opioid pain adjuncts were prescribed post-intervention and discharge pain education was provided more frequently. CONCLUSION: The implementation of a TDOB significantly reduced the MME prescribed at discharge without increasing the number of opioid refills.

Clinician-family relationships may impact neonatal intensive care: clinicians' perspectives.

OBJECTIVE: Collaborative clinician-family relationships are necessary for the delivery of successful patient- and family-centered care (PFCC) in the NICU. Challenging clinician-family relationships may undermine such collaboration and the potential impacts on patient care are unknown. STUDY DESIGN: Consistent caregivers were surveyed to describe their relationships and collaboration with families of infants hospitalized ≥ 28 days. Medical record review collected infant and family characteristics hypothesized to impact relationships. Mixed methods analysis was performed. RESULTS: Clinicians completed 243 surveys representing 77 families. Clinicians reported low collaboration with families who were not at the bedside and/or did not speak English. Clinicians perceived most clinician-family relationships impact the infant's hospital course. Negative impacts included communication challenges, mistrust or frustration with the team and disruptions to patient care. CONCLUSION: This study identifies features of clinician-family relationships that may negatively impact an infant's NICU stay. Targeting supports for these families is necessary to achieve effective PFCC.

Allopurinol-Induced Drug Reaction With Eosinophilia and Systemic Symptoms: A Case Report.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon yet serious adverse cutaneous drug reaction that results from a hypersensitivity reaction. Drug reaction with eosinophilia and systemic symptoms is often misdiagnosed because of vague and confounding signs and symptoms. The most common clinical manifestations of DRESS are shared with many other diseases and include rash, lymphadenopathy, and fever. Because the syndrome can be difficult to diagnose, patients are often in the late stages of the disease process before treatment is initiated. The mainstay of treatment is stopping the culprit medication. Drug reaction with eosinophilia and systemic symptoms is associated with a high mortality rate, most often from liver failure and failure to diagnose. Emergency providers should be able to recognize the clinical manifestations of DRESS, know what diagnostic studies are indicated, and be familiar with the appropriate treatment.

Skin and Soft Tissue Infections: A Case of Necrotizing Fasciitis.

Necrotizing fasciitis is a rapidly progressing soft tissue infection associated with a high rate of mortality. Vibrio vulnificus, a gram-negative bacillus found in warm seawater, is a rare but serious cause of necrotizing fasciitis. Definitive treatment is often delayed because of the vague clinical manifestations associated with the early stages of the disease. Delays in diagnosis are directly associated with increased mortality. Because infection with V. vulnificus progresses more rapidly than other causes of necrotizing fasciitis, patients presenting with soft tissue symptoms and who have been in contact with raw seafood or seawater should be considered at high risk for V. vulnificus-associated necrotizing fasciitis. Health care providers in northern and inland areas must be aware of patients who have recently traveled to regions where V. vulnificus is more common, such as warm coastal regions. Early fasciotomy, debridement, and culture-directed antimicrobial therapy are essential to improve survival. The case presented in this report highlights the importance of early diagnosis of V. vulnificus-associated necrotizing fasciitis.

Irreversible electroporation of the lumbar vertebrae in a porcine model: is there clinical-pathologic evidence of neural toxicity?

PURPOSE: To evaluate the effects of irreversible electroporation (IRE) in the porcine spine. MATERIALS AND METHODS: This study was approved by the institutional animal care and use committee. Twenty computed tomographically guided IRE ablations in either a transpedicular location or directly over the posterior cortex were performed in the lumbar vertebrae of 10 pigs by a single operator. T1- and T2-weighted magnetic resonance (MR) imaging was performed with and without contrast material 2 or 7 days after ablation. Mathematical modeling was performed to estimate the extent of ablation. Clinical, radiologic, pathologic, and simulation findings were analyzed. The Miller low-bias back transformation was used to construct 95% confidence intervals for the mean absolute percentage difference between the maximum length and width of the ablation zone on MR images and pathologic measurements by using square-root-transformed data. RESULTS: Bipolar IRE electrode placement and ablation were successful in all cases. The mean distances from the IRE electrode to the posterior wall of the vertebral body or the exiting nerve root were 2.93 mm ± 0.77 (standard deviation) and 7.87 mm ± 1.99, respectively. None of the animals had neurologic deficits. Well-delineated areas of necrosis of bone, bone marrow, and skeletal muscle adjacent to the vertebral body were present. Histopathologic changes showed outcomes that matched with simulation-estimated ablation zones. The percentage absolute differences in the ablation measurements between MR imaging and histopathologic examination showed the following average errors: 24.2% for length and 28.8% for width measurements on T2-weighted images, and 26.1% for length and 33.3% for width measurements on T1-weighted contrast material-enhanced images. CONCLUSION: IRE ablation in the porcine spine is feasible and safe and produces localized necrosis with minimal neural toxicity. Signal intensity changes on images acquired with standard MR imaging sequences demonstrate the ablation zone to be larger than that at histopathologic examination.

Effects of Near-infrared Laser Irradiation of Biodegradable Microspheres Containing Hollow Gold Nanospheres and Paclitaxel Administered Intraarterially in a Rabbit Liver Tumor Model.

PURPOSE: To evaluate the effects of near-infrared (NIR) laser irradiation of microspheres (MS) containing hollow gold nanospheres (HAuNS) and paclitaxel (PTX) administered intraarterially in an animal model. MATERIALS AND METHODS: For the ex vivo experiments, VX2 tumor-bearing rabbits underwent administration of MS-HAuNS or MS via the hepatic artery (HA). The animals were killed, the liver tumors were subjected to NIR irradiation, and temperature changes were estimated with magnetic resonance (MR) imaging. For the in vivo study, VX2 tumor-bearing rabbits were randomly assigned to three groups: MS-HAuNS-PTX-plus-NIR, MS-HAuNS-PTX, and saline-plus-NIR. Laser irradiation was delivered at 1 hour and at 3 days after administration of saline or MS-HAuNS-PTX via the HA. Animals were euthanized, and tumors were analyzed for necrosis and apoptosis. Plasma samples were collected from the MS-HAuNS-PTX-plus-NIR animals for PTX analysis. RESULTS: Ex vivo experiments showed intratumoral heating in animals that received MS-HAuNS but no temperature change in animals that received MS. Animals treated with MS-HAuNS-PTX-plus-NIR showed a transient increase in plasma PTX levels after each NIR irradiation and significantly greater tumor necrosis than animals that received MS-HAuNS-PTX or saline-plus-NIR (44.9% vs 13.8% or 23.7%; P < .0001). The mean apoptotic index in the MS-HAuNS-PTX-plus-NIR group (5.01 ± 1.66) was significantly higher than the mean apoptotic index in the MS-HAuNS-PTX (2.99 ± 0.97) or saline-plus-NIR (1.96 ± 0.40) groups (P = .0013). CONCLUSIONS: NIR laser irradiation after MS-HAuNS-PTX administration results in intratumoral heating and increases the efficacy of treatment. Further studies are required to evaluate the optimal laser settings to maximize therapeutic efficacy.