BACKGROUND Geriatric hip fracture patients are susceptible to the adverse effects of opioid‐induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN This is a prospective observational study. SETTING A level 1 trauma center in California. PARTICIPANTS From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION All prospectively enrolled patients were given FIBs. For a single‐shot FIB, a 30‐ to 40‐mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0–44.5) versus 29.5 (interquartile range = 6.0–56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0–24.0) versus 29.0 (interquartile range = 12.0–59.0) (P < .001). CONCLUSION FIBs reduce preoperative opioid intake and have low rates of opioid‐related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE The level of evidence was II.

OBJECTIVE Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication. METHODS Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events. RESULTS The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44–0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61–2.91). CONCLUSIONS IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.

The correct diagnosis of acute abdomen in children requires attention to clinical details and a high degree of suspicion. Early surgical intervention in doubtful cases may be necessary to solve diagnostic problems.

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Competence for genetic transformation in Streptococcus pneumoniae has previously been described as a quorum-sensing trait regulated by a secreted peptide pheromone. Recently we demonstrated that competence is also activated by reduction in the accuracy of protein biosynthesis. We have now investigated whether errors upstream of translation in the form of random genomic mutations can provide a similar stimulus. Here we show that generation of a mutator phenotype in S. pneumoniae through deletions of mutX, hexA or hexB enhanced the expression of competence. Similarly, chemical mutagenesis with the nucleotide analog dPTP promoted development of competence. To investigate the relationship between mutational load and the activation of competence, replicate lineages of the mutX strain were serially passaged under conditions of relaxed selection allowing random accumulation of secondary mutations. Competence increased with propagation in these lineages but not in control lineages having wild-type mutX. Resequencing of these derived strains revealed between 1 and 9 single nucleotide polymorphisms (SNPs) per lineage, which were broadly distributed across the genome and did not involve known regulators of competence. Notably, the frequency of competence development among the sequenced strains correlated significantly with the number of nonsynonymous mutations that had been acquired. Together, these observations provide support for the hypothesis that competence in S. pneumoniae is regulated in response to the accumulated burden of coding mutations in the bacterial genome. In contrast to previously described DNA damage response systems that are activated by physical lesions in the chromosome, this pneumococcal pathway may represent a unique stress response system that monitors the coding integrity of the genome.