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Furthermore, we need to appreciate less commonly associated conditions such as DKA among patients.Background In the USA, spinal fusion surgery incurs the highest hospital cost. Despite the recent advances in the application of enhanced recovery after surgery (ERAS) protocols in these surgeries, the efficacy of these protocols in improving the perioperative outcomes remains unclear. We conducted a retrospective review as a quality improvement (QI) project to analyze the efficacy of the ERAS protocol with intraoperative modified thoracolumbar interfascial plane (mTLIP) block to determine whether these interventions reduce the length of stay (LOS) and opioid requirements during the postoperative period. Methods Retrospective reviews of adult patients (>18 yrs) who underwent elective lumbar spinal fusion or laminectomy at our institute were reviewed. Patients were administered oral gabapentin and acetaminophen preoperatively. Prior to incision, an mTLIP block was performed using liposomal bupivacaine. Intraoperatively, ketamine, ketorolac, and tranexamic acid were administered. Postoperative, pain control wasAS protocol with the use of regional anesthesia via the mTLIP group (n= 15), opioid requirement was reduced by 38.33% [P = 0.04]. No difference in LOS was observed at 5.4 days vs. 4.88 days (P = 0.28). Conclusion ERAS protocol in patients undergoing lumbar spinal surgery incorporated the use of regional anesthesia via the mTLIP block, we observed there is a statistically significant reduction in the LOS for lumbar laminectomy and a significant reduction in opioid administration for lumbar laminectomies and spinal fusion surgery.Collision tumors are neoplasms composed of two or more distinct cellular lineages coexisting at the same anatomic site. Incomplete biopsy, partial pathological slide examination or failure to include this diagnosis into the clinical differential may complicate and delay appropriate therapy. Although collision tumors are well documented, basal cell carcinoma (BCC) occurring with sebaceous carcinoma (SC) has only been reported in a single case report. The aim of the authors is to present a case of collision BCC and SC to highlight a rare clinicopathological case. We also present this case to advise caution to detect mimickers of BCC that warrant greater clinical workup and use this case to emphasize the importance of Mohs micrographic surgery for the treatment of SC.Visceral artery pseudoaneurysms are rare but potentially life-threatening. Among visceral artery pseudoaneurysm (VAPA), the superior mesenteric artery (SMA) pseudoaneurysm is the rarest type. VAPAs are usually related with infection, inflammatory disease, trauma, or arises as a postoperative complication. Early diagnosis and endovascular or surgical intervention are key in lowering the risk of intestinal infarction and death due to potentially fatal hemorrhage. A 49-year-old man presented with cough, shortness of breath, weight loss, and an incidental finding of spontaneous SMA pseudoaneurysm with localized bleed on CT angiography. An urgent endovascular embolization was performed of the pseudoaneurysm, with an adequate outcome and recovery. SMA pseudoaneurysms associated with infective endocarditis are rare but carry a high risk of rupture and related morbidity and mortality. Direct oral anticoagulants like apixaban (Eliquis) have also been reported to cause pseudoaneurysm formation by slow and constant bleeding, which may have contributed here as a cause of pseudoaneurysm along with infective endocarditis, which was diagnosed later after endovascular embolization. The treatment can be either an endovascular, endoscopic, or open surgical approach.Polycystic ovarian syndrome (PCOS) is a combination of many symptoms resulting from hormonal imbalance, metabolic syndromes, hyperandrogenism, and anovulation. This paper explores the various etiopathology and mechanisms causing depression in women with PCOS and how to prevent and treat PCOS-induced depression. Women with PCOS present with multiple symptoms such as acne, hirsutism, androgenic alopecia, obesity, menstrual irregularities, infertility, and mood disturbances like depression and anxiety. Depression is the most common psychological problem faced by women with PCOS. The various pathophysiological mechanisms that lead to depression are Insulin resistance, disturbance in the hypothalamic pituitary adrenal (HPA) axis, hyperandrogenism and its clinical presentation, obesity, and infertility. Lifestyle modifications such as dietary changes and weight loss play a significant role in preventing and managing PCOS-induced depression. selleck products Cognitive behavioral therapy (CBT) and lifestyle modification have shown to be effective measures for weight loss in obese women with PCOS. Antidepressants also play a part in treating PCOS-induced depression. Over the last decade, the number of cases of depression in women with PCOS has increased. This paper provides detailed data on the fundamental causes of depression in women with PCOS to facilitate a more straightforward treatment approach.Mortality data in most countries are reported using the International Classification of Diseases (ICD), managed by the WHO. In this paper, we show how the ICD is ill-suited for classifying drug-involved deaths, many of which involve polysubstance abuse and/or illicitly manufactured fentanyl (IMF). Opioids identified in death certificates are categorized according to six ICD T-codes opium (T40.0), heroin (T40.1), methadone (T40.3), other synthetic narcotics (T40.4), and other and unspecified narcotics (T40.6). Except for opium, heroin, and methadone, all other opioids except those that are unspecified are aggregated in two T-codes (T40.2 and T40.4), depending upon whether they are natural/semisynthetic or synthetic opioids other than methadone. The result is a system that obscures the actual cause of most drug overdose deaths and, instead, just tallies the number of times each drug is mentioned in an overdose situation. We examined the CDC's methodology for coding other controlled substances according to the ICD and found that, besides fentanyl, the ICD does not distinguish between other licit and illicitly manufactured controlled substances. Moreover, we discovered that the CDC codes all methadone-related deaths as resulting from the prescribed form of the drug. These and other anomalies in the CDC's mortality reporting are discussed in this report. We conclude that the CDC was at fault for failing to correct the miscoding of IMF. Finally, we briefly discuss some of the public policy consequences of this error, the misguided focus by public health and safety officials on pharmaceutical opioids, their prescribers and users, and the pressing necessity for the CDC to reassess how it measures and reports drug-involved mortality.Paranasal sinus osteomas are slow-growing benign tumors. They are generally asymptomatic in most patients and usually diagnosed incidentally with a sinus radiograph or more frequently with a CT scan of the paranasal sinuses. Osteomas can cause various signs and symptoms, depending on the location of the mass. Giant osteomas of the paranasal sinuses are very rare, with only a handful of case reports in the literature. Due to the rarity of giant osteomas, the clinical presentation and treatment are unclear. In this article, we present a case of giant ethmoid sinus osteoma, which was removed with an endoscopic endonasal approach, as well as a review of the literature.Bochdalek hernias are rarely diagnosed in adults and account for 0.17-6% of all diaphragmatic hernias. It is a congenital diaphragmatic hernia caused by a defect in the posterior attachment of the diaphragm due to a failure of the pleuroperitoneal membrane closure in utero. This may rarely cause chest pain, respiratory symptoms, or gastrointestinal symptoms. In this study, we present a case of a laparoscopic paraesophageal repair via Nissen fundoplication. The incidental finding and subsequent repair of a Bochdalek hernia during this case may have resulted in complications of the surgery including pneumothorax due to the defect in the pleuroperitoneal membrane.Background Obstructive sleep apnea (OSA) is a major health problem for people with type 2 diabetes mellitus (DM2) and is associated with poorer glycemic control. Early detection is critical to proper management. In this study, we planned to assess and compare the diagnostic accuracy of various OSA screening tools in patients with DM2. Methods In this cross-sectional study, we consecutively recruited 58 patients with DM2, presenting to the endocrinology department of Services Hospital Lahore between February 2020 to March 2021. Along with demographic and anthropometric measurements, including BMI and neck circumference, participants answered the snoring, tiredness, observed apnea, high blood pressure - BMI, age, neck circumference, and gender (STOP-BANG) questionnaire, Berlin questionnaire, and Epworth sleepiness scale. All participants then underwent an overnight, level 3 polysomnography. Results The overall prevalence of OSA, diagnosed by overnight polysomnography, was 65.5% in type 2 diabeticDM2 patients. The STOP-BANG questionnaire had the highest sensitivity for mild, moderate, and severe OSA i.e., 84.2%, 90.3%, and 100% respectively. Berlin questionnaire also had 100% sensitivity for severe OSA and was most specific for mild and moderate OSA (70% and 63% respectively) whereas the Epworth sleepiness scale had the highest specificity of 53.3% for severe OSA. Conclusion This study shows that OSA is highly prevalent in DM2 patients in Pakistan. The STOP-BANG and Berlin questionnaire proved to be effective screening tools, especially for severe OSA. Results of our study should encourage the routine use of these questionnaires in clinical practice, to help in the early identification of OSA in diabetics.Background Variable epidemiological data are known on medial clavicle fractures (MCFs). Aim To obtain demographic information regarding the etiopathogenesis of MCFs. Materials and methods All fractures were radiographically evaluated. Age; gender; side; date of fracture; fragment dislocation; associated fractures; fracture mechanism were collected. Three age groups were distinguished. Results 1096 patients were enrolled 29 (2.6%) had an MCF. Nineteen (66%) were males; mean age was 51.6 years (SD±24.4; range 18-87). The right side was involved in 19 cases (66%). Nineteen fractures (66%) were un-displaced. Five patients (16.6%) had associated fractures. Accidental falls represent the main cause of fracture. In advanced age (Group III), simple fall was the only cause of fracture. On the occasion of a fall, the right side was significantly more involved (p less then 0.05). Sports injuries were responsible for 22.2% of fractures, but for 42.9% of fractures in younger patients (Group I). Traffic accidents were responsible for five fractures (16.7%). During the sunny seasons, the highest number of fractures occurred; the vast majority of fractures (83.3%) occurred on working days (p less then 0.05). Conclusions Medial clavicle fractures represent 2.6% of all clavicle fractures. Middle-aged males and the right side are more involved. Two-thirds of fractures are un-displaced. Accidental falls represent the main cause of fracture. During sunny seasons, the highest number of fractures occurred.
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