Naltrexone-Associated Non-ST-Elevated Myocardial Infarction.

Medications for opioid use disorder (MOUD) and opioid agonist therapy (OAT) are the mainstays of treatment in opioid use disorder. Significant caution is encouraged upon initiation to reduce the precipitation of opioid withdrawal. Cardiac events in the setting of opioid withdrawal are rare and incompletely understood. A 46-year-old woman with a history of opioid-use disorder, hypertension, hyperlipidemia, diabetes, tobacco-use disorder, and rheumatoid arthritis presented with nausea, vomiting, and lightheadedness after taking naltrexone following buprenorphine. She was found to be hypertensive and tachycardic in the emergency department, with a troponin of 0.38 ng/mL (reference: 0.00-0.30 ng/mL) and an electrocardiogram (ECG) without ST or T-wave changes. She was admitted for a non-ST-elevation myocardial infarction (NSTEMI) and hypertensive emergency in the setting of opioid withdrawal. Her blood pressure was controlled, and she received full-dose aspirin and high intensity atorvastatin. Afterwards she was started on a modified OAT regimen of buprenorphine 8 mg daily. Her cardiac enzymes down-trended and her condition became stable after which she was discharged home. Cardiac events are an uncommon yet lethal occurrence in opioid withdrawal. The likely etiology of NSTEMI in our patient was demand ischemia induced by opioid withdrawal, augmented by her various other cardiac risk factors. Practitioners should be aware of these possible adverse events, especially in those with preexisting cardiac disease. Meticulous efforts should be made to instruct patients as to the proper dosing schedule when initiating opioid therapy, and when initiating MOUD/OAT in order to prevent poor outcomes.

The Effect of Forced Cough to Minimize Pain and Discomfort at the Time of Colposcopy-Guided Cervical Biopsy.

OBJECTIVE: The aim of the study was to determine whether forced cough during colposcopy-guided cervical biopsy affected pain and anxiety levels. MATERIALS AND METHODS: The study was conducted at the University Hospital (Newark, NJ) Ambulatory Care Center from December 2016 to June 2018 and evaluated 110 patients at the time of a colposcopy-guided cervical biopsy. Study patients were randomized to either cough or no cough group during the biopsy procedure. Pain level was assessed using a visual analog pain scale before, during, and immediately after a colposcopy-guided cervical biopsy. Study patients also completed a standardized anxiety survey before and after the procedure. T tests, Pearson χ, or Cochran-Mantel-Haenszel were used to compare baseline characteristics between the cough and no cough groups. Multivariate linear regression analysis was used to identify potential confounders and then compare pain levels across both groups. RESULTS: There was no statistically significant difference in pain scores between the cough and no cough group when analyzed for each demographic variable even when confounders were accounted for. The anxiety scores for both study groups before and after the procedure were similar and not significantly reduced. CONCLUSIONS: We observed a trend that cough reduced pain associated with the colposcopy-guided cervical biopsy but did not reach statistical significance. A similar outcome was observed in anxiety level, where anxiety was reduced in the cough group but was not statistically significant as compared with the no cough group. Further studies are necessary to assess various modalities in reducing pain and anxiety associated with colposcopy-guided cervical biopsy.

Are Short Umbilical Cords Seen in Pathology Really Short?

PURPOSE: Short umbilical cords are associated with adverse perinatal outcomes. Clinicians may rely on measurements made by pathologists, which do not include portions of the cord remaining n the child or sent for blood gasses. METHODS: This was a retrospective chart review of term placentas. Sequential cases from January through August 2017 were reviewed from the Pathology archive. RESULTS: 198 placentas were recorded as either third trimester of mature, of which 146 were 37 or greater weeks of gestation. Of these 146, 142 had cords measuring less than 35 cm, the definition of short. Mean cord length was 19.6 cm. Of the 146 placentas, 50(34%) had had blood gases submitted. CONCLUSIONS: 34% of short cords by Pathology measurement had had blood gases sent. The fact that 142 out of 146 sequential placentas were recorded as "short" suggests an additional unmeasured loss of length due to cord attached to the infant. Pathology laboratory measurements should not be interpreted as truly short without clinical correlation.

Pseudosarcomatous Vaginal Polyp.

BACKGROUND: Although rare, pregnant women can present with fibroepithelial polyps of the vagina. Most likely hormonally related, these polyps have been described in various locations of the lower female genital tract. They can be mistaken for malignant lesions due to hypercellularity and cytologic atypia. CASE: We describe the case of a 31-year-old woman who presented with a polyp of the vagina during a postpartum visit. RESULTS: Atypical cells were seen in hypercellular areas of the stroma of the polyp. CONCLUSION: A pitfall to avoid is classifying these benign lesions as malignant based on atypical histopathology.