42 to-0.02), and educational interventions were especially effective (effect size,-0.36; 95% CI,-0.69 to-0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis. Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management. Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement. Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.A 72-year-old man presented to the ED following witnessed cardiac arrest. After return of spontaneous circulation, an ECG was performed which demonstrated a wide complex rhythm with "shark fin" morphology. With careful examination it is possible to identify the J point and determine that the electrocardiogram (ECG) findings actually represent massive ST-elevation indicative of occlusion myocardial infarction (OMI). Initial troponin was undetectable. The patient underwent emergent cardiac catheterization and had a 100% proximal LAD occlusion that was successfully stented. The patient was discharged home neurologically intact several days later. This case highlights the importance of careful ECG interpretation and the limitations of troponin assays in the evaluation of acute coronary syndrome. Most importantly, we demonstrate how to evaluate for ST elevation in the context of a widened QRS complex.Headache is a frequent emergency department (ED) complaint. Secondary headache, due to infectious causes, must be carefully evaluated as a differential diagnosis. Red flag signs and classic physical examination findings are available to aid the diagnosis and evaluation of secondary headache. These findings, however, are limited by poor sensitivity and predictive value. We present a case of Herpes zoster (HZ) meningitis in a young healthy male adult with major presenting symptom of headache and new-onset rash to underscore the variation in atypical presentations of aseptic meningitis. HZ-associated aseptic meningitis often presents with characteristic, but at times atypical rash. We recommend skin lesions be thoroughly evaluated, along with classic signs of fever and nuchal rigidity, to assist in the diagnosis of meningitis. To describe interventional oncology therapies combined with immune checkpoint inhibitor (ICI) therapy targeting the programmed death 1 pathway in patients with different neoplasms. This was a retrospective cohort study of patients who underwent tumor-directed thermal ablation, embolization, or selective internal radiation therapy (SIRT) between January 1, 2011, and May 1, 2019, and received anti-programmed death 1/PD-L1 agents ≤ 90 days before or ≤ 30 days after the interventional procedure. Immune-related adverse events (irAEs) and procedural complications ≤ 90 days after the procedure were graded according to the Common Terminology Criteria for Adverse Events version 5.0. The study included 65 eligible patients (49% female; age 63 years ± 11.1). https://www.selleckchem.com/products/ipi-145-ink1197.html The most common tumors were metastatic melanoma (n= 28) and non-small cell lung cancer (NSCLC) (n= 12). Patients underwent 78 procedures (12 patients underwent > 1 procedure), most frequently SIRT (35.9%) and cryoablation (28.2%). The most common target organs were liver (46.2%), bone (24.4%), and lung (9.0%). Most patients received ICI monotherapy with pembrolizumab (n= 30), nivolumab (n= 22), and atezolizumab (n= 6); 7 patients received ipilimumab and nivolumab. Seven (10.8%) patients experienced an irAE (71.4% grade 1-2), mostly affecting the skin. Median time to irAE was 33 days (interquartile range, 19-38 days). Five irAEs occurred in patients with melanoma, and no irAEs occurred in patients with NSCLC. Management required corticosteroids (n= 3) and immunotherapy discontinuation (n= 1); all irAEs resolved to grade ≤ 1. There were 4 intraprocedural and 32 postprocedural complications (77.8% grade < 3). No grade 5 irAEs and/or procedural complications occurred. No unmanageable or unanticipated toxicities occurred within 90 days after interventional oncology therapies combined with ICIs. No unmanageable or unanticipated toxicities occurred within 90 days after interventional oncology therapies combined with ICIs. Appendicitis is a common pediatric surgical emergency, and the diagnosis may be delayed or missed because of nonspecific findings in children. Not all patients with abdominal pain need to be imaged for appendicitis, and laboratory evaluation may improve diagnostic accuracy in this population. To determine if C-reactive protein (CRP) and symptom duration could be used to improve diagnosis of appendicitis compared with white blood cell count (WBC) and absolute neutrophil count (ANC). This was a retrospective chart review from June 2017 to 2019 at our tertiary academic children's hospital. A consecutive sample of all children <18years of age being evaluated for appendicitis who had magnetic resonance imaging ordered were included. The diagnostic accuracy of WBC, ANC, and CRP were compared for patients with symptom duration ≤1day compared with symptom duration for >1day. Five hundred thirty-nine patients were identified. The sensitivity and specificity of WBC (10,000cells/μL) was 87.1% and 65.2%, respectively; ANC (7,500cells/μL) was 86.5% and 70.8%, respectively; and CRP (0.5mg/dL) were 73.7% and 58.1%, respectively. At >1day of symptom duration, the specificity of WBC and ANC increased to 74.9% and 80.9%, respectively, and the sensitivity of CRP increased to 88.9%. Three patients with appendicitis (2.8%) had no laboratory abnormalities. No laboratory test studied has adequate characteristics to be used alone. CRP adds minimal sensitivity beyond WBC and ANC when symptoms are >1day but with poor specificity, making it of limited utility. 1 day but with poor specificity, making it of limited utility. The varicella zoster virus, which lies dormant in the dorsal root ganglion, can be reactivated as herpes zoster in times of acute stress or immunosuppression. The herpes zoster lesions can be very painful, both at the time of eruption and after healing, as postherpetic neuralgia. During the acute outbreak time period, many patients visit the emergency department (ED) for pain control, often requiring opioids. Here, we demonstrate two cases for which an erector spinae plane (ESP) nerve block with ropivicaine was used as an alternative to opioids, resulting in immediate and safe analgesia in the ED. Both patients had lesions across the back that were significantly impairing their daily lives; one with distribution in the thoracic region, one in the lumbar region. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? ESP blocks can offer quick, easy, and effective analgesia in the ED and can be used in place of parenteral or oral analgesia. It also can be used to reduce opioid prescriptions issued from the ED.