Rejected

Acute and chronic cholecystitis can be related to gallstone disease, although in childhood acalculous cholecystitis may be the most frequent form. Chronic acalculous cholecystitis is a subtype of pediatric chronic abdominal pain. The overall incidence of cholecystitis in children appears to be increasing. Studies suggest a widely variable but predominant female, Caucasian and late adolescent preponderance to the affected population. The Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), a national emergency department, pediatric and adult inpatient admission coding-based database was accessed for the population-weighted demographic characteristics related to documented principal diagnoses (International Classification of Diseases, Ninth Revision, Clinical Modification) of acute and chronic cholecystitis; pediatric and adult age range 2006-2012 (emergency department), 1997-2012 (inpatient service). ED-derived data show pediatric admissions at the smallest age category (1%), averaging 3.7/100 000 persons; discharges were highest in the 15-17 age range. Inpatient admission was more likely in older (93% >10 years), female (F:M 3.7:1) children, and patients from lower median household income residences. Over the study period, there was a significant relative increase in males. Mean length of inpatient stay was 3.2 days, tended to be shorter in female and older patients; this pattern was reflected in the overall hospital charges which rose threefold over the study period (1997-2012). Our study establishes the gender distribution of cholecystitis-related diagnoses and as yet poorly understood admission discrepancies based on gender and socioeconomic status. Length of admission has overall decreased but costs have risen threefold over the study period.

Immunoglobulin G4 (IgG4)-related disease is a recently described autoimmune disease that can involve diverse organ systems, causing pancreatitis, cholangitis, retroperitoneal fibrosis, and thyroiditis to name a few. Key histological features include storiform fibrosis, obliterative venulitis, and intense inflammatory infiltrate composed of lymphoplasmacytic cells. The disease has a tendency to present with mass-forming lesions, often difficult to differentiate from malignant processes. We report the case of a 48-year-old male from an area endemic for gallbladder cancer (north India). He presented with a short history of abdominal pain and was found to have asymmetric thickening of the gallbladder wall with a soft-tissue mass invading the adjacent liver. In addition, the bile duct was dilated throughout its extent. A clinical and radiological diagnosis of gallbladder cancer with choledochal cyst was made, and the patient underwent radical cholecystectomy with bile duct excision. Histopathology surprisingly demonstrated IgG4-related disease with no evidence of malignancy. Notably, serum levels of immunoglobulins were found to be normal. Preoperative diagnosis was challenging due to the absence of other manifestations. IgG4-related disease is a possible diagnostic pitfall and should be included as a possible differential diagnosis for gallbladder masses.

Non-traumatic bowel perforation caused by cytomegalovirus (CMV) and Mycobacterium avium complex (MAC) infections has become rare among patients with acquired immunodeficiency syndrome (AIDS) in the era of combination antiretroviral therapy (cART); however, CMV-associated and MAC-related immune reconstitution inflammatory syndrome (IRIS) has subsequently emerged owing to the wide use of integrase inhibitor-based regimens. Here we report a case of spontaneous perforation of the jejunum in a patient with human immunodeficiency virus (HIV) infection with good compliance to cART.

Advances in 3-dimensional (3D) printing technology permit the rapid creation of detailed anatomical models. Integration of this technology into neurosurgical practice is still in its nascence, however. One potential application is to create models depicting neurosurgical pathology. The goal of this study was to assess the clinical value of patient-specific 3D printed models for neurosurgical planning and education.

This operative video highlights a rare case of a neuroenteric cyst at the ventral craniocervical junction. The case involved a 30-year-old man who initially presented 13 years earlier with acute onset of headache and visual changes. At that time, he was found to have a small, enhancing ventral intradural extramedullary mass at the rostral aspect of C1 thought to be a meningioma. The lesion was managed conservatively, and surveillance imaging tracked its slow progressive enlargement to a size of 1.4 cm ( Fig. 1A, B ). Although he remained asymptomatic, nonurgent elective resection was recommended because of his age and mass progression. The patient underwent a left far lateral approach to the craniocervical junction for resection of the mass. This involved dissection of the suboccipital musculature to expose the C1 transverse process in the suboccipital triangle and ultimately the vertebral artery. After a small craniectomy and C1 hemilaminectomy, the dura was opened and a cystic lesion encountered ( Fig. 2 ). The cystic contents were debulked and the capsule resected. Histopathologic examination revealed abundant goblet cells consistent with a neuroenteric cyst. Dural closure was bolstered with fascia lata and autologous fat graft. Postoperative magnetic resonance imaging (MRI) was consistent with gross total resection ( Fig. 1C, D ). The patient tolerated the procedure well with no new postoperative neurological deficits and was discharged home on postoperative day 2. On completing a 3-day decadron taper, he developed steroid-responsive symptoms consistent with aseptic meningitis, possibly related to cerebrospinal fluid contamination with the cyst contents during resection. The link to the video can be found at: https://youtu.be/SskETPe5PXQ .

Previous studies have demonstrated increased risk of acute coronary syndrome among patients with chest pain and renal dysfunction. The objective of this study was to investigate the impact of renal dysfunction on cardiac outcomes in patients with chest pain in an emergency department observation unit (EDOU).

Ultrasonography (US) is often the first-line imaging study used to evaluate women who present with acute or chronic pelvic pain. Detection of nongynecologic causes of pelvic pain is critical, because delay in diagnosis can cause significant morbidity and mortality. Evaluation of these entities requires a variety of transducers to achieve optimal imaging depth and changes in patient positioning. Specific imaging techniques (such as graded compression) may be required if bowel pathology is suspected. Contrast-enhanced ultrasonography is increasingly used to improve detection of certain entities. The US appearance of common gastrointestinal and urinary tract-related causes of pelvic pain is reviewed.

To evaluate whether programmed intermittent epidural bolus (PIEB) reduces the incidence of maternal intra-partum fever compared with continuous epidural infusion (CEI) during labor.

There remains debate regarding the need for venous imaging in pediatric intracranial hypertension.

Opioids are the mainstay of intraoperative pain control, but they have several deleterious effects. Alternative medications and strategies to opioids, while effective in producing intraoperative analgesia, are underutilized by anesthesia providers. The purpose of this study was to examine and describe Certified Registered Nurse Anesthetists' perspectives and practices on administering opioids vs nonopioid or opioid-sparing strategies ("opioid alternatives") to treat intraoperative pain. A qualitative study design using semistructured interviews was conducted (N = 12). Study participants described their perspectives and practices on treating intraoperative pain. Two key themes emerged: (1) barriers to intraoperative opioid-alternative administration and (2) facilitators to intraoperative opioid-alternative administration. Barriers expressed by study participants included opioid superiority, inconsistent analgesic effects of intraoperative opioid alternatives, limited experience with opioid alternatives, limited resources on opioid alternatives, negative experiences with intraoperative opioid-alternative administration, and patient comorbidities. Facilitators expressed by study participants included the adverse effects of opioids, institutional policy and procedures, positive experiences with opioid-alternative administration, and regional anesthesia superiority. This study highlights the importance of improving education, training, and institutional policies in support of opioid-alternative medications and strategies to treat intraoperative pain and better prevent opioid addiction and abuse.