Comparison of epidural infusion versus intrathecal morphine block as part of enhanced recovery after open pancreatoduodenectomy

BACKGROUND AND OBJECTIVES

The accepted approach to pain management following open pancreatoduodenectomy (PD) remains controversial, with the most recent enhanced recovery after surgery (ERAS) protocols recommending epidural anesthesia (EA). Few studies have investigated intrathecal (IT) morphine, combined with transversus abdominis plane (TAP) blocks. We aim to compare the different approaches to pain management for open PD.

METHODS

Patients who underwent open PD at our institution from 2020 to 2022 were included in the study. Patient characteristics, pain management, and postoperative outcomes between EA, IT morphine with TAP blocks, and TAP blocks only were compared using univariate analysis.

RESULTS

Fifty patients were included in the study (58% male, median age 66 years [interquartile range, IQR: 58-73]). Most patients received IT morphine (N = 24, 48%) or EA (N = 18, 36%). The TAP block-only group required higher doses of postoperative narcotics while hospitalized (p = 0.004) and at discharge (p = 0.017). The IT morphine patients had a shorter median time to Foley removal (p = 0.007). Postoperative pain scores, non-opioid administration, postoperative bolus requirements, postoperative outcomes, and length of stay were similar between pain modalities.

CONCLUSIONS

IT morphine and EA showed comparable efficacy with superior results compared to TAP blocks alone. Integration of IT morphine into PD ERAS protocols should be considered.

Cardiovascular Outcomes Among Older Individuals With Depression Prescribed Amphetamines: A Retrospective Cohort Study

BACKGROUND

Prescription amphetamines are utilized for treatment of depression in older adults, yet cardiovascular risks in this population are not well described. The purpose of this study is to evaluate risk of cardiovascular events among adults aged 65 and older with depression who were prescribed amphetamines.

METHODS

We conducted a retrospective matched cohort study utilizing the TriNetx database and statistical software. The 1:1 propensity score matching technique was performed using logistic regression to balance the baseline characteristics of the population. Inclusion criteria were a diagnosis of depression and age 65 years and older. We excluded individuals with an adverse cardiovascular event or diagnosis of attention deficit and hyperactivity disorder prior to enrollment. Individuals were followed from January 1, 2018 to December 31, 2020. Those prescribed an amphetamine were considered exposed and others served as controls. We used descriptive statistics and calculated risk ratios to assess the relationship between amphetamine prescriptions and cardiovascular events in these cohorts.

RESULTS

There were 4 434 included in the exposed cohort and 4 434 matched controls in the unexposed group. The cohort exposed to amphetamines had higher high-density lipoprotein along with lower low-density lipoprotein, total cholesterol, hemoglobin A1C, systolic blood pressure, and body mass index than the control group, but increased risk of cardiovascular events (risk ratio: 8.9; 95% confidence interval: 6.39, 12.48).

CONCLUSIONS

Amphetamines offer potential benefits to people with depression; however, these data suggest increased risk of cardiovascular events among older individuals. Additional research is warranted to fully characterize risk among subpopulations of older adults and inform patient-provider decision making.

Invasive papillomatosis and squamous carcinoma complicating juvenile laryngeal papillomatosis

Juvenile laryngeal papillomatosis (JLP), usually a benign, self-limited disease, occasionally has a highly aggressive course characterized by extension of neoplastic cells into the tracheobronchial tree, lung, and soft tissues. Less frequently, squamous carcinoma has arisen in JLP, most commonly following radiation therapy. Rarely, carcinoma has occurred without previous irradiation, but distant metastases do not generally occur. We describe a 14-year-old boy, with a particularly aggressive form of JLP, who developed invasion of the lungs, intrapulmonary lymph nodes, and arteries by cytologically benign neoplastic tissue. He also developed a metastasizing squamous carcinoma of the lung and humoral hypercalcemia of malignancy. A discussion of the implications of the case and a review of the current literature are provided.

Effect of spinal cord transection on spontaneous activity recorded from type I neurons of the medial vestibular nucleus in compensated hemilabyrinthectomized gerbils

Spontaneous activity was recorded from type I neurons of the medial vestibular nuclei (MVN) in unanesthetized, decerebrate gerbils to determine the effect of spinal cord transection on compensation following labyrinthectomy. Immediately after labyrinthectomy there was an increase in activity of type I neurons on the intact side and an absence of activity on the injured side. Following compensation from labyrinthectomy, the distribution and activity rates approximated those of nonlabyrinthectomized animals. Spinal cord transection resulted in an increase in activity in type I MVN neurons contralateral to the labyrinthectomy in compensated animals and bilaterally in nonlabyrinthectomized animals. These results illustrate that type I neurons apparently are under an indirect inhibitory control from both the contralateral labyrinth and the spinal cord. In compensated animals spinal cord inhibition exists only on the intact side. This suggests that the symmetry in type I activity bilaterally in the compensated animal is in part the result of asymmetric spinal cord input.

Epiglottitis and laryngotracheobronchitis

Epiglottis and laryngotracheobronchitis are potentially life-threatening infections in the pediatric population. Unlike epiglottitis, laryngotracheobronchitis is very common. While both diseases may present with stridor and signs of respiratory obstruction, it is important to distinguish between them because the management strategies differ. Laryngotracheobronchitis usually responds to humidification. Epiglottitis requires an artificial airway and intensive antibiotics. The use of steroids remains controversial.