Opioid Prescribing Variation After Laparoscopic Cholecystectomy in the US Military Health System.

INTRODUCTION: After laparoscopic cholecystectomy (LC), there is a wide variation in opioid prescription miligram morphine equivalent dose (MED) and refills across US medical institutions. Given wide variation and opioid prescription guidelines, it is essential to conduct thorough health services research across medical, surgical, and patient-level factors that can be implemented to improve system-wide prescribing practices. Therefore, this study describes discharge MED variation and opioid refill probability after emergent and nonemergent LC. MATERIALS AND METHODS: This retrospective cohort study included medical record data of adult patients (N = 20,025) undergoing LC from January 2016 to June 2021 in the US Military Health System. Data visualizations and bivariate analyses examined prescription patterns across hospitals and evaluated the relationship between patient-level, care-level, and system-level factors and each outcome: discharge MED and opioid refill probability. Two generalized additive mixed models evaluated the relationship between predictors and each outcome. RESULTS: There was a significant variation in opioid and nonopioid pain medication prescribing practices across hospitals. While several factors were associated with discharge MED and opioid refill probability, the strongest effects were related to time period (before versus after a June 2018 Defense Health Agency policy release) and receipt of an opioid/nonopioid combination medication. Despite decreases in MED, the MED remained almost twice the recommended dose per prior research. CONCLUSIONS: Variation by hospital suggests the need for system-level changes that target genuine practice change and opioid stewardship. Inclusion of patient-reported outcomes, electronic health record decision support tools, and academic detailing programs may support system-level improvements.

Education without walls: Using a street medicine program to provide real-world interprofessional learning.

Interprofessional education (IPE) is a core component of the curricula for many healthcare and social work training programs and has been shown to increase student self-efficacy, communication skills, and attitudes toward other professions. Street medicine programs expand options for teaching interprofessional, team-based care of vulnerable populations, such as those experiencing homelessness. Street Medicine Phoenix is an interprofessional team of health professions students and faculty that provides outreach to Phoenix's homeless population. This study demonstrates the impact of volunteering in our street medicine program on the perceived development of interprofessional skills and behaviors. Volunteer teams, with representatives from medicine, nursing, social work, physical therapy, occupational therapy, public health, and undergraduate studies, completed the Interprofessional Collaborative Competencies Attainment Survey (ICCAS) before and after semester-long, monthly outreach events. Results demonstrate statistically significant improvements in overall ICCAS scores for all volunteers, but there was no relationship between number of shifts completed and ICCAS score improvement. Based on these findings, street medicine programs could be considered as an option for providing interprofessional learning to students in healthcare and social work degree programs. Street medicine outreach can supplement didactic and simulation skill-building activities in the IPE curricula with point of care, real-world experiential learning.

A Comprehensive Review of Over-the-counter Treatment for Chronic Migraine Headaches.

PURPOSE OF REVIEW: Migraine headaches are a neurologic disorder characterized by attacks of moderate to severe throbbing headache that are typically unilateral, exacerbated by physical activity, and associated with phonophobia, photophobia, nausea, and vomiting. In the USA, the overall age-adjusted prevalence of migraine in female and male adults is 22.3% and 10.8%, respectively. RECENT FINDINGS: Migraine is a disabling disease that ranks as the 8th most burdensome disease in the world and the 4th most in women. The overarching hypothesis of migraine pathophysiology describes migraine as a disorder of the pain modulating system, caused by disruptions of the normal neural networks of the head. The activation of these vascular networks results in meningeal vasodilation and inflammation, which is perceived as head pain. The primary goals of acute migraine therapy are to reduce attack duration and severity. Current evidence-based therapies for acute migraine attacks include acetaminophen, four nonsteroidal anti-inflammatory drugs (NSAIDs), seven triptans, NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and several anti-emetics. Over-the-counter medications are an important component of migraine therapy and are considered a first-line therapy for most migraineurs. These medications, such as acetaminophen, ibuprofen, naproxen, and aspirin, have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks. The lower cost of over-the-counter medications compared with prescription medications also makes them a preferred therapy for some patients. In addition to their efficacy and lower cost, over-the-counter medications generally have fewer and less severe adverse effects, have more favorable routes of administration (oral vs. subcutaneous injection), and reduced abuse potential. The purpose of this review is to provide a comprehensive evidence-based update of over-the-counter pharmacologic options for chronic migraines.

Adverse Childhood Experiences and Depression among Homeless Young Adults: A Social Determinants of Health Perspective.

Homelessness is a pervasive issue in the United States that presents significant challenges to public health. Homeless young adults (HYAs) are at particular risk for increased incidence and severity of depression. Using primary survey data (n = 205) collected in the Phoenix Metropolitan Area, Arizona, from June to August 2022, this study aims to examine the relationship between adverse childhood experiences (ACEs) and depression among HYAs. We adopted the ACEs 10-item scale to measure childhood traumatic experiences, whereas depression was measured by using a PHQ-4 depression scale and diagnosed depression. Regression models were conducted to test the relationships between ACEs and depression outcomes while controlling for the covariates at the individual, interpersonal, and socioeconomic/living environment levels. The average PHQ-4 score was 5.01 (SD = 3.59), and 59.69% of HYAs reported being diagnosed previously with depression. The mean ACEs score was 5.22 out of 10. Other things being equal, for every one unit increase in ACEs scores, the odds of being diagnosed with depression increased by 11.5%, yet it was not statistically significant, while the PHQ-4 score increased by 0.445 (p < 0.001). Overall, HYAs were disproportionately affected by depression. This study elucidates the complex relationship between ACEs and depression among HYAs.

Case Report: Isosulfan Blue-Related Anaphylaxis.

Anaphylaxis is an acute multisystem syndrome typically resulting from the sudden release of mast cell and basophil-derived mediators into the circulatory system. Isosulfan blue dye is a rare, but known, mediator of anaphylaxis with an incidence between 0.16% and 2% of cases. We report two cases of anaphylaxis attributed to the use of isosulfan blue dye in the intraoperative setting. Both of the patients we report had grade 3 anaphylactic reactions requiring vasopressors to correct significant hypotension. Both patients required overnight monitoring in the intensive care unit with the second patient also requiring continued vasopressor support.

Utilization of street-based COVID-19 vaccination clinics in Phoenix's homeless population.

The novel Coronavirus (COVID-19) is a highly contagious viral illness that has caused the most significant global health crisis in recent human history. Individuals experiencing homelessness represent one of the more vulnerable populations for COVID-19 infection and morbidity. Amongst individuals experiencing homelessness in Phoenix, a student-led interprofessional organization called Street Medicine Phoenix (SMP) sought to both reduce the risk of COVID-19 transmission and morbidity/mortality related to infection. Through collaborations with the Maricopa County Department of Public Health and various community organizations, SMP developed a format for street-based vaccination clinics. SMP deployed these clinics on numerous occasions to the streets directly surrounding the community homeless shelter, allowing SMP to vaccinate individuals directly in their encampments. Through SMP's efforts starting in February 2021, 400 individuals experiencing homelessness have received at least one COVID-19 vaccine. Challenges encountered included low health literacy, lack of established rapport and trust, low vaccine confidence, difficulty verifying patients' vaccination status, difficulty obtaining sufficient information from patients to create a record in the Arizona State Immunization Information System (ASIIS), monitoring patients post-vaccination, transporting vaccine supplies from encampment to encampment, and lack of patient awareness of the mobile vaccine clinic services. Despite challenges, SMP's outreach efforts have demonstrated the feasibility and importance of mobile public health services to reach homeless encampments, particularly mobile vaccination clinics in response to disease outbreaks, and the necessity of strategic partnerships with community agencies to effectively meet the needs of underserved populations.

Mpox Case Reports in an Urban Homeless Population and a Proof of Concept for a Street-Based Mobile Mpox Vaccination Clinic.

Mpox is a new public health outbreak that particularly threatens the homeless population. Street Medicine Phoenix (SMP) is a student-led interprofessional volunteer organization that provides medical care and other essential services to individuals experiencing homelessness in Phoenix, Arizona. In addition to core services such as wound care; health screenings (blood pressure and blood glucose.); vision screenings; HIV testing; naloxone education and distribution; flu, COVID-19, and Hepatitis A vaccinations; and community resource referrals, SMP began offering mpox education and vaccination at outreach events. During an outreach event shortly after the onset of the mpox outbreak, SMP identified 2 suspected mpox cases. Accordingly, SMP has partnered with the Maricopa County Public Health Department to set up mobile mpox vaccination clinics on the streets outside of Phoenix Arizona's largest homeless shelter. We share the details of these 2 cases along with our early efforts vaccinating individuals experiencing homelessness for mpox via our mobile vaccination clinic. Our experiences demonstrate the importance of community agencies providing direct outreach to underserved populations where they are at, particularly the homeless population, to address public health concerns such as emerging disease outbreaks like mpox. In addition, these cases highlight the potential significant impact that street medicine programs can have on their respective homeless communities in the context of infectious disease mitigation and emphasize the importance of partnerships with local health departments.

Clinical implications of chemotherapeutic agent organ toxicity on perioperative care.

Cancer is the second most common cause of death in the United States and is a challenging disease to treat. The treatment options for various cancers include but are not limited to surgery, radiation, and chemotherapy. The mechanism behind chemotherapy is intended to promote cellular damage to cells that are proliferating uncontrollably. Unfortunately for the recipients, most chemotherapeutic agents cannot differentiate between malignant cells and healthy cells and tissues. Thus, chemotherapy-induced toxicities are often observed in once-healthy organs. These effects can be acute and self-limiting or chronic, appearing long after chemotherapy is completed. Cancer survivors can then present for non-cancer related surgeries later in life, due to this toxicity. Furthermore, the administration of chemotherapeutic agents can profoundly impact the anesthetic management of patients who are undergoing surgery. This review discusses how chemotherapy-induced organ toxicity can occur in multiple organ systems and what drugs should be avoided if prior toxicity exists in these organ systems.

Review of Interventional Therapies for Refractory Pediatric Migraine.

This is a review of the latest and seminal evidence in pediatric migraine. It covers the etiology and pathophysiology known today, and then will review treatment options, efficacy and safety, quality of data and indications. Though migraine is usually regarded as an infliction in adults, it is not uncommon in the pediatric population and affects up to 8% of children. Children may experience migraine differently than adults, and present not only with headache but also frequent gastrointestinal symptoms. They are frequently shorter in duration than in adults. Traditional migraine treatment in adults is less effective in children. In this population, adjunct therapies - such as interventional techniques - should be considered when traditional treatment fails, including Botulinum Toxin A (BTA) injections, peripheral nerve and ganglion blocks. BTA injections are FDA approved for migraine prophylaxis in adults, but currently not in children; however, recent evidence shows efficacy and safety in pediatric migraine management. Nerve blocks stop nociceptive afferent fibers through injection of local anesthetics, and it may be associated with the local injection of corticosteroids. Although more common in adults, recent data suggests they are safe and effective in children and adolescents. Blocking the sphenopalatine ganglion can be achieved through nasal approach, and achieves a similar action by blocking the entire ganglion. Interventional techniques may provide a key component in the alleviation of this otherwise debilitating chronic migraine pain. Though most studies have been performed in adults, new studies provide encouraging results for treatment in children.

A Review of the Recent Findings in Minimally Invasive Treatment Options for the Management of Occipital Neuralgia.

Occipital neuralgia (ON) is unilateral or bilateral neuralgia in the dermatomal nerve distribution of the greater, lesser or third occipital nerves and is a very common presentation of neuropathic pain. ON, although common and well defined, is still a poorly understood pain syndrome. It often requires invasive treatment for long term and significant pain alleviation; however, the evidence supporting different options is still limited. Several minimally invasive techniques have proven to be efficacious and safe, and the selection depends mostly on response to nerve blocks, patient choice and provider preference. This is a comprehensive review of the latest and seminal literature available about occipital neuralgia and currently available minimally invasive treatment options. It covers the anatomical and physiologic biology at the base of neuralgia, the presentation and diagnostic process. It then reviews the available literature to provide description and comparison of the available methods for alleviation.