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American Journal of Health-system... Jul 2024In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been...
DISCLAIMER
In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
PURPOSE
The objectives of this study were to identify the most performed surgical procedures associated with the highest rates of discharge opioid overprescribing and to implement an electronic health record (EHR) alert to reduce discharge opioid overprescribing.
METHODS
This quality improvement, before-and-after study included patients undergoing one of the identified target procedures-laparoscopic cholecystectomy, unilateral open inguinal hernia repair, and laparoscopic appendectomy-at an academic medical center. The alert notified providers when the prescribed opioid quantity exceeded guideline recommendations. The preimplementation cohort included surgical encounters from January 2020 to December 2021. The EHR alert was implemented in May 2022 following provider education via email and in-person presentations. The postimplementation cohort included surgical encounters from May to August 2022. The primary outcome was the proportion of patients with a discharge opioid supply exceeding guideline recommendations (overprescribing).
RESULTS
A total of 1,478 patients were included in the preimplementation cohort, and 141 patients were included in the postimplementation cohort. The rate of discharge opioid overprescribing decreased from 48% in the preimplementation cohort to 3% in the postimplementation cohort, with an unadjusted absolute reduction of 45% (95% confidence interval, 41% to 49%; P < 0.001) and an adjusted odds ratio of 0.03 (95% confidence interval, 0.01 to 0.08; P < 0.001). Among patients who received opioids, the mean (SD) opioid supply at discharge decreased from 92 (43) oral morphine milligram equivalents (MME) (before implementation) to 57 (20) MME (after implementation) (P < 0.001). The proportion of patients who received additional opioid prescriptions within 1 to 14 days of hospital discharge did not change (P = 0.76).
CONCLUSION
Implementation of an EHR alert along with provider education can reduce discharge opioid overprescribing following general surgery.
PubMed: 38946099
DOI: 10.1093/ajhp/zxae185 -
International Journal of Surgery Case... Jun 2024Goblet cell adenocarcinoma of the appendix is a rare diagnosis with features of both adenocarcinomas and carcinoid tumors. Commonly presenting with chronic abdominal...
INTRODUCTION
Goblet cell adenocarcinoma of the appendix is a rare diagnosis with features of both adenocarcinomas and carcinoid tumors. Commonly presenting with chronic abdominal pain, appendicitis, or abdominal distention, it can also be incidentally discovered during appendectomies.
CASE PRESENTATION
A 50-year-old man with right lower abdominal pain was admitted to our hospital, which is a critical care center. A computed tomography(CT) scan showed ileal narrowing, but endoscopy found no strictures. He was admitted with suspected bowel obstruction and improved with an ileal tube. Laparoscopic surgery revealed a tumor of the appendix. Histologically, he was diagnosed goblet cell adenocarcinoma, suggesting tumor infiltration of nerve fibers impairing peristalsis.
DISCUSSION
Goblet cell adenocarcinoma of the appendix has unique histology and a poor prognosis. Treatment typically involves surgery and chemotherapy. This case highlights challenges in preoperative diagnosis, with the tumor causing bowel pseudo-obstruction by invading the intestinal wall and nerve plexus. Extensive infiltration of Auerbach's plexus was observed, consistent with the length of intestinal stenosis.
CONCLUSION
This case describes goblet cell adenocarcinoma of the appendix leading to bowel pseudo-obstruction due to ileal end stenosis. It emphasizes the importance of considering this diagnosis in cases of bowel obstruction without an obvious mass.
PubMed: 38945017
DOI: 10.1016/j.ijscr.2024.109938 -
Nigerian Journal of Clinical Practice Jun 2024The creation of pneumoperitoneum using higher pressure is believed to be associated with increased postoperative abdominal pain. (Randomized Controlled Trial)
Randomized Controlled Trial Comparative Study
BACKGROUND
The creation of pneumoperitoneum using higher pressure is believed to be associated with increased postoperative abdominal pain.
AIM
This study aimed to compare postoperative abdominal pain following low pressure laparoscopic appendectomy and standard pressure laparoscopic appendectomy.
METHODS
This was a prospective, double-blind, randomized controlled trial of 54 patients aged between 18 and 56 years with clinical and/or radiologic diagnosis of acute appendicitis. The patients were randomly allocated to two groups: low pressure laparoscopic appendectomy (n = 26) and standard pressure laparoscopic appendectomy (n = 28). The intra-abdominal pressure was kept in either low pressure (9 mm Hg) or standard pressure (13 mm Hg). Abdominal and shoulder pain scores were assessed using the visual analog scale at 6 hours and 3 days post procedure. Postoperative analgesia requirement, duration of surgery, complications, and hospital stay were recorded.
RESULTS
Both groups match for the demographic parameters. Three patients required conversion from low to standard pressure. There was no difference between the two groups in terms of abdominal pain (P = 0.86) and shoulder pain (P = 0.33), duration of surgery (P = 0.51), complications (P = 0.17), and length of hospital stay (P = 0.83).
CONCLUSION
The use of low pressure pneumoperitoneum did not reduce the incidence of abdominal pain in patients who had laparoscopic appendectomy. Patients with acute appendicitis can be treated with either low or normal pressure pneumoperitoneum depending on the experience of the surgeon.
Topics: Humans; Appendectomy; Adult; Laparoscopy; Female; Male; Pneumoperitoneum, Artificial; Double-Blind Method; Appendicitis; Middle Aged; Prospective Studies; Pain, Postoperative; Young Adult; Adolescent; Pressure; Length of Stay; Pain Measurement; Treatment Outcome; Abdominal Pain
PubMed: 38943300
DOI: 10.4103/njcp.njcp_802_23 -
Pediatrics and Neonatology Jun 2024
PubMed: 38942614
DOI: 10.1016/j.pedneo.2024.06.003 -
International Journal of Surgery Case... Jun 2024Actinomycosis is a rare, chronic bacterial infection caused by Actinomyces species. While it commonly affects the cervicofacial region, thorax, and abdomen, appendicular...
INTRODUCTION AND IMPORTANCE
Actinomycosis is a rare, chronic bacterial infection caused by Actinomyces species. While it commonly affects the cervicofacial region, thorax, and abdomen, appendicular involvement is extremely uncommon. This case report details the presentation, diagnosis, and management of a 45-year-old female patient with acute appendicitis secondary to actinomycosis.
CASE PRESENTATION
A 45-year-old woman, with an 8-year intrauterine device history, presented with three-day right iliac fossa pain, vomiting, and stable vital signs. Laboratory tests revealed an inflammatory syndrome. Suspecting acute appendicitis, a CT scan confirmed a swollen 10 mm appendix. Laparoscopic surgery revealed a phlegmonous appendix, leading to an uncomplicated appendectomy. Pathological examination confirmed actinomycotic granules, supporting the diagnosis of actinomycosis appendicitis. The patient received 18 million units of intravenous penicillin G daily for 6 weeks followed by a 6-month course of oral amoxicillin (1 g three times daily) thereafter, showing favorable progression with no symptoms. Normal clinical and ultrasound follow-ups were observed at one year.
CLINICAL DISCUSSION
Appendiceal actinomycosis is a rare condition. Women, especially those with intrauterine contraceptives, experience an increase in cases due to chronic inflammation. Typically underdiagnosed, actinomycosis mimics other conditions, presenting with nonspecific symptoms. Laboratory results offer limited assistance, and histological confirmation is crucial. Histopathological examination is mandatory for diagnosis confirmation. Management involves surgical resection and prolonged penicillin-based antibiotics, providing a favorable prognosis with low mortality.
CONCLUSION
This case underscores the importance of considering rare etiologies, such as actinomycosis, in the differential diagnosis of appendicitis. Timely recognition and management are crucial for optimal patient outcomes.
PubMed: 38941730
DOI: 10.1016/j.ijscr.2024.109975 -
Przeglad Gastroenterologiczny 2024The COVID-19 pandemic has had an influence on the number of patients presenting to the emergency department (ED) with surgical conditions.
INTRODUCTION
The COVID-19 pandemic has had an influence on the number of patients presenting to the emergency department (ED) with surgical conditions.
AIM
To evaluate the number of patients presenting with acute appendicitis (AA) and the percentage of complicated appendicitis before and after the COVID-19 disease outbreak.
MATERIAL AND METHODS
This is a retrospective study based on the data of all patients presenting with AA to the ED of a tertiary COVID referral university hospital in Greece. We analysed the number of patients treated with AA, patient characteristics, and the proportion of patients with complicated appendicitis, and we compared the 2 groups of patients treated 12 months before and 12 months after COVID-19 onset in Greece.
RESULTS
A total of 152 patients were included in this study. There was a significant decrease in the number of patients presenting with AA after COVID-19 onset in Greece. Respectively, 91 and 61 patients were subjected to appendectomy 12 months before and after COVID-19 onset. Comparing the 2 groups of patients, there was a statistically significant increase in the operation time ( = 0.01) after COVID-19 onset, whereas the percentage of complicated appendicitis, the duration of symptoms before presenting to the ED (< 24 h, > 24 h), and the type of operation (laparoscopic, open, converted) did not differ significantly between the 2 groups of patients.
CONCLUSIONS
The number of patients presenting to the ED with AA decreased after COVID-19 onset, most likely because patients hesitated to seek help in a COVID-19 referral hospital.
PubMed: 38939065
DOI: 10.5114/pg.2023.129495 -
BMC Women's Health Jun 2024Peutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps in the gastrointestinal tract and mucocutaneous pigmentation on the lips, oral... (Review)
Review
BACKGROUND
Peutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps in the gastrointestinal tract and mucocutaneous pigmentation on the lips, oral mucosa, nose, fingers, and toes. Synchronous mucinous metaplasia and neoplasia of the female genital tract (SMMN-FGT) refers to the occurrence of multifocal mucinous lesions in at least two sites, including the cervix, uterus, fallopian tubes, and ovaries, in the female genital tract. SMMN-FGT and PJS are rare diseases with a very low incidence, especially when occurring simultaneously.
CASE PRESENTATION
We report a case in which a woman with a large mass on the left ovary underwent a gynecological surgery and was diagnosed with cervical gastric-type adenocarcinoma and mucinous lesions in the endometrium, bilateral fallopian tubes, and ovary, i.e., SMMN-FGT, by postoperative paraffin pathology. The patient sought medical attention for abdominal distension and enlargement. A gynecological ultrasound revealed a multilocular cystic mass in the pelvis, while serum tumor markers were within normal limits, with mildly elevated carbohydrate antigen 199 and carbohydrate antigen 125 levels. Cervical thin-prep cytology test result was negative. The patient had a family history of PJS with black spots on her skin and mucous membranes since the age of 8 years. She underwent multiple partial small bowel resections and gastrointestinal polypectomy owing to intestinal obstruction and intussusception. She underwent left adnexectomy, hysterectomy, right salpingectomy, greater omental resection, appendectomy and right ovary biopsy, and received six courses of adjuvant chemotherapy with Lopressor plus Carboplatin. Genetic testing revealed a heterozygous serine threonine kinase 11 germline mutation and there were no signs of recurrence during the 18-month follow-up period after treatment.
CONCLUSIONS
This is a rare case in which PJS was complicated by SMMN-FGT. Owing to its extreme rarity, there are no guidelines, but reported cases appear to indicate a poor prognosis. We retrospectively reviewed all cases of collisions between PJS and SMMN-FGT and explored the clinical features, pathological characteristics, diagnosis, treatment methods, and prognosis when the two diseases coexisted. The aim is to deepen the clinicians' understanding of this disease for early detection, diagnosis and treatment.
Topics: Humans; Female; Peutz-Jeghers Syndrome; Metaplasia; Genital Neoplasms, Female; Adenocarcinoma, Mucinous; Ovarian Neoplasms; Adult; Uterine Cervical Neoplasms; Neoplasms, Multiple Primary
PubMed: 38937781
DOI: 10.1186/s12905-024-03184-y -
Asian Journal of Surgery Jun 2024
PubMed: 38937236
DOI: 10.1016/j.asjsur.2024.06.048 -
Journal of Clinical Medicine Jun 2024-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA)....
Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial.
-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). -Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8-12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. -A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). -Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases.
PubMed: 38929896
DOI: 10.3390/jcm13123363 -
Children (Basel, Switzerland) May 2024This study aims to analyze the impact of the COVID-19 pandemic on the clinical, pathological, and surgical characteristics of acute appendicitis (AA) at the University...
BACKGROUND
This study aims to analyze the impact of the COVID-19 pandemic on the clinical, pathological, and surgical characteristics of acute appendicitis (AA) at the University Hospital Centre (UHC) Zagreb.
METHODS
This retrospective study analyzed demographic, clinical, and surgical data from consecutive AA patients. Data were collected from an electronic database for two periods: 1 January to 31 December 2019 (pre-COVID-19), and 11 March 2020, to 11 March 2021 (COVID-19 pandemic).
RESULTS
During the two study periods, 855 appendectomies were performed, 427 in the pre-pandemic, and 428 during the pandemic. Demographic data were comparable between groups. There was statistically no significant difference in the type of appendectomy ( = 0.33) and the median hospital length of stay (3; (2-5) days, = 0.08). There was an increase in the conversion rate during the pandemic period (4.2% vs. 7.7%, = 0.03). The negative appendectomy rate and the incidence of perforated AA did not differ significantly ( = 0.34 for both).
CONCLUSIONS
We did not observe a significant increase in the rate of AA complications during the COVID-19 pandemic at the UHC Zagreb. This may be attributed to two factors: (1) AA was diagnosed and treated as an emergency, which remained available during the pandemic, and (2) diagnostic and therapeutic protocols remained unaltered. We recommend a laparoscopic approach even during the COVID-19 pandemic.
PubMed: 38929221
DOI: 10.3390/children11060641