2 Minute Medicine Rewind September 14, 2026
1. No statistically significant difference in urethrocutaneous fistula incidence was found between caudal and penile blocks, though wide confidence intervals preclude ruling out clinically meaningful differences.
2. Caudal block offered superior perioperative analgesia with reduced opioid requirements, suggesting an analgesic advantage
Evidence Rating Level: 1 (Excellent)
Retrospective data on the relationship between caudal block and urethrocutaneous fistula (UCF) after hypospadias repair have been inconsistent, largely due to inadequate control for hypospadias severity. To address this, a multicenter, randomized, non-inferiority trial was conducted across 16 Pediatric Regional Anesthesia Network centers, enrolling children aged 2 years or younger undergoing primary single-stage midshaft or distal hypospadias repair. Patients were randomized to receive either a caudal block or a penile block in conjunction with general anesthesia. The primary endpoint was UCF formation within three months postoperatively, while secondary endpoints included perioperative opioid use and postoperative pain as measured by FLACC scores. Among 161 patients completing follow-up, UCF rates were similar between the caudal (8.9%) and penile (7.3%) block groups (RR 0.98, 95% CI 0.35–2.76, p=0.9), while proximal meatal position independently increased UCF risk. Patients receiving caudal blocks required significantly less intraoperative and rescue opioid administration and had lower PACU pain scores. The trial was terminated early due to incomplete enrollment and loss to follow-up, limiting the precision of these estimates.
1. This case demonstrates the first reported use of ultrasound-guided percutaneous peripheral nerve stimulation of the vagus nerve, achieving durable, complete resolution of refractory chronic pain.
Evidence Rating Level: 3 (Average)
PTSD and chronic pain commonly co-occur and are frequently resistant to standard treatment approaches. Vagus nerve stimulation (VNS) has gained interest as a neuromodulatory strategy for addressing autonomic dysregulation and central pain processing, but it has typically been delivered via transcutaneous or surgically implanted systems; ultrasound-guided percutaneous peripheral nerve stimulation of the vagus nerve had not been previously reported. This case report describes a woman in her late twenties with refractory chronic pain, PTSD, post-traumatic headaches, and occipital neuralgia stemming from multiple traumatic brain injuries sustained during domestic violence. After conservative management failed, she underwent ultrasound-guided percutaneous implantation of a left-sided vagus nerve peripheral nerve stimulator for a 60-day trial period. Over 8 weeks, her pain scores improved from 10/10 to 0/10, accompanied by resolution of gastrointestinal symptoms and fatigue, with analgesic benefit maintained at 4-month follow-up. PTSD symptoms, measured by the PCL-5, appeared to worsen over the same interval; however, the absence of a baseline pre-procedure score precludes determining the true magnitude of change from pretreatment status. The authors detail their ultrasound-guided implantation technique alongside this novel application.
1. Urgent Emergency Department referral for outpatient potassium greater than 6.2 mmol/L is associated with substantially reduced short-term mortality, supporting current urgent-referral thresholds
Evidence Rating Level: 2 (Good)
Outpatient hyperkalemia poses a management dilemma, since guideline-recommended therapies require hospital administration, yet clinicians and patients are often reluctant to pursue emergency department (ED) referral, and evidence on the mortality benefit of urgent presentation has been limited. This Ontario population-based retrospective cohort study identified 57,607 adults with an outpatient potassium result greater than 6.2 mmol/L (2007–2021) and propensity-matched (1:1) 6,557 patients with an ED encounter within 24 hours to 6,557 without one, examining all-cause death at 1, 3, and 7 days. Death occurred in 1.6% of the matched cohort within 7 days. ED presentation was associated with significantly lower mortality at all time points: risk ratios of 0.39 at 1 day, 0.47 at 3 days, and 0.69 at 7 days, corresponding to absolute risk reductions of 0.5–0.7%. Benefit was greatest among patients with potassium greater than 6.6 mmol/L and eGFR less than 30 mL/min/1.73m², while no clear benefit was seen with milder hyperkalemia or preserved kidney function.
1. Executive function (EF) deficits are not universal in Alcohol Use Disorder and may be less pronounced in treatment-naïve, higher-functioning, low-comorbidity patients.
2. Routine EF testing may have limited clinical utility for predicting treatment response in this subgroup, and cognitively demanding behavioral therapies remain appropriate first-line options.
Evidence Rating Level: 1 (Excellent)
This study examined whether executive function (EF) impairments—commonly reported in alcohol use disorder (AUD)—are present in a less severe, treatment-naïve population, and whether EF predicted treatment response. Prior research on EF deficits in AUD has relied heavily on recently detoxified inpatients with high psychiatric comorbidity, limiting generalizability to the broader AUD population, particularly those with mild-to-moderate severity and low comorbidity. Investigators recruited 147 adults with moderate AUD and a treatment goal of controlled drinking from a randomized trial comparing Behavioral Self-Control Training versus Motivational Enhancement Therapy. Participants completed eight CANTAB® neuropsychological tests at baseline, assessing response inhibition, working memory, cognitive flexibility, and delay discounting, and were compared to 72 non-clinical controls; regression models then tested whether baseline EF (Stop Signal Task, Information Sampling Task) predicted drinking outcomes at 12 and 26 weeks. Patients with AUD performed comparably to controls on nearly all EF measures, with only attention-switching congruency cost showing poorer performance in the AUD group, and neither response inhibition nor delay discounting predicted reductions in alcohol consumption or drinking days at follow-up. EF deficits are not universal in AUD and may be less pronounced in treatment-naïve, higher-functioning, low-comorbidity patients. Routine EF testing may have limited clinical utility for predicting treatment response in this subgroup, and cognitively demanding behavioral therapies remain appropriate first-line options.
1. This trial did not establish non-inferiority of bicarbonate-buffered solution versus compound sodium lactate (CSL) for end-of-surgery standard base excess (SBE), and results should not be interpreted as evidence of equivalence.
2. Lower lactate with bicarbonate-buffered solution was an exploratory finding unaccompanied by acid-base or clinical benefit, so routine substitution for CSL cannot yet be recommended pending larger, adequately powered trials.
Evidence Rating Level: 1 (Excellent)
This single-center, open-label, randomized non-inferiority trial (n=50) compared bicarbonate-buffered solution with compound sodium lactate (CSL) as the intraoperative crystalloid in high-risk adults undergoing elective major abdominal surgery. Bicarbonate-buffered fluids avoid exogenous lactate, but comparative physicochemical data against CSL in this setting have been limited. The primary estimand was the mean difference in end-of-surgery standard base excess (SBE), with a prespecified non-inferiority margin of −1.5 mEq/L. In the intention-to-treat analysis (multiple imputation for two missing CSL values), the mean SBE difference was −0.42 mEq/L (95% CI, −1.92 to 1.09), and the per-protocol complete-case estimate was −0.48 mEq/L (95% CI, −2.02 to 1.06); both lower bounds fell below the margin, so non-inferiority was not established, though neither interval indicated inferiority or superiority. Sensitivity analyses (Hodges–Lehmann estimate, observed-range imputation scenarios) yielded consistent conclusions. End-of-surgery lactate was lower with bicarbonate-buffered solution (median 0.9 vs 1.2 mmol/L, unadjusted P=0.031), without corresponding differences in SBE, pH, or clinical outcomes.
Image: PD
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