Richter Transformation in Chronic Lymphocytic Leukemia with Hypercalcemia and Acute Kidney Injury Presenting as Altered Mental Status: A Case Report

Introduction: Richter’s transformation is a deadly complication of chronic lymphocytic leukemia (CLL) associated with high mortality. This transformation involves the development of an aggressive, diffuse large B cell lymphoma in the setting of a chronic, underlying case of CLL. Although it is rare, Richter’s transformation is important to identify in patients with a history of CLL because of its significant mortality if left untreated. In the setting of CLL, there are many ways in which patients can present if they are currently undergoing a Richter’s transformation. Case Description: Patients may present with symptoms common to CLL which include but are not limited to fatigue, easy bruising, weight loss, etc., or they may present more unusually, as in the case that will be presented here: with altered mental status, fall, hypercalcemia and acute kidney injury (AKI). Discussion: With the current state of affairs due to COVID-19, it is also important to recognize the potential complications of patients with this disease state that are positive for COVID-19, leading to further complications such as disseminated intravascular coagulation (DIC). Recognizing these patients, and directing their care appropriately is important for their disease progression and outlook

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Impact of dedicated pediatric neuro-oncological services in a developing country: A single-institution, Pakistani experience

Introduction: Brain tumors are the most common solid neoplasms and the second most common malignancy in the pediatric age group. Due to the complexity of their management, pediatric central nervous system (CNS) tumors are not a priority in low- and middle-income countries (LMICs).Methods: In an attempt to improve the survival rate and overall care, we introduced a dedicated pediatric neuro-oncology service in our institute and evaluated its impact by dividing the pre- and post-era into two cohorts and comparing them: 1998-2013 (16 years: cohort A) and 2014-2019 (6 years: cohort B, after the start of dedicated neuro-oncology services).Results: We observed that after the implementation of a proper neuro-oncology service, the proportion of patients treated with curative intent increased, and survival improved in cohort B. The patient volume also increased from 15.5 per year in cohort A to 44.8 per year in cohort B. The percentage of children given radiation therapy also increased significantly, while the proportion of children treated with chemotherapy remained stable.Conclusion: A dedicated multidisciplinary team trained and knowledgeable in the specialty of pediatric neuro-oncology can enhance and improve outcomes, and supportive care and help can provide good quality of life to children and their families with brain neoplasms

Parents’ behaviour toward antibiotic self-medication in children and incidence of resistance: a cross-sectional study from Punjab, Pakistan

Background. Antibiotic resistance is mostly brought about through antibiotic self-medication, which is a common issue in impoverished countries. The most at-risk group is children, while there is no protection evidence released for them. Due to a lack of proper knowledge, parents often inappropriately administer antibiotics to their children. Objectives. The current study aims to evaluate the parents’ knowledge of antibiotic use and their knowledge of the medical conditions for which self-medication is used. Material and methods. A cross-sectional descriptive study was carried out in parents. Parents’ direct interviews and self-administered questionnaires were used to gather the data. Descriptive analysis and chi-square tests were performed to determine the significance of these findings using IBM SPSS Statistics version 22. Results. There were 1,034 individuals who self-medicated their children in total. Male participants outnumbered female participants by a small margin. In the past 12 months, 88.6% of parents gave antibiotics to their children. Pharmacy advice and past prescriptions were the main causes of this behaviour, whilst cough, fever and tooth discomfort were the conditions for which antibiotics were prescribed. Throughout the course, 45.5% of patients changed antibiotics on their own. Conclusions. The findings of this study underscore the urgent need to address the issue of self-medication of antibiotics in children, emphasising the potential harm it can cause. Parents often resort to self-medication without a proper understanding of the underlying causes of their children’s illnesses, relying on antibiotics as a panacea. To mitigate this practice and protect the well-being of children, it is imperative to implement a multifaceted approach involving regulatory measures and educational initiatives beyond the scope of pharmacist interventions