Surgery and pain relief: A closer look at opioid prescription trends.

BACKGROUND: Published guidelines to reduce the use and misuse of opioids in pediatrics are limited. After the implementation of an opioid stewardship program, we aimed to investigate the prescribing patterns in pediatric surgery. METHODS: A retrospective chart review of pediatric patients who underwent general pediatric surgery procedures at a single institution between July 2021 and July 2023 was conducted. Demographics, procedure details, and opioid prescriptions at discharge were collected. The Texas Prescription Monitoring Program was cross-referenced for prescription-filled data. Descriptive statistics were performed. RESULTS: Of the 4,323 patients included, 9% (391) received an opioid prescription at the time of discharge. Among these, 82% were for burns, 7% for trauma, and 4% for pectus excavatum. Appendectomy, inguinal hernia repair, umbilical hernia repair, and circumcision did not receive any opioid prescriptions. In those who received a prescription, the median age was 4.2 years (interquartile range (IQR) 1.6, 10.4), with 58.6% being male. A total of 82.6% of patients also received prescriptions for nonopioid analgesics. The median number of prescribed doses was 13 (IQR 7, 15) for burns, 12 (IQR 9, 15) for trauma, and 12 (IQR 10, 12) for pectus excavatum. In total, 87% of prescriptions were filled. CONCLUSION: A small proportion of pediatric patients who underwent general surgery received opioid prescriptions at the time of discharge and were limited to a few conditions. Common pediatric operations received no opioid prescriptions in the 2-year study period. A total of 13% of the written prescriptions were unfilled. Future studies are needed to optimize the target pediatric patient population for opioid prescribing.

Less Dose, Same Care: Evaluating Computed Tomography Utilization for Pediatric Appendicitis.

BACKGROUND: An ultrasonography-first, magnetic resonance imaging-second protocol, and attention to dose reduction was implemented to reduce computed tomography rates for appendicitis at our institution. We aimed to compare current computed tomography usage and report radiation doses at our children's associated system hospitals and referring nonsystem hospitals. METHODS: A retrospective study of pediatric patients who underwent appendectomy and had a preoperative computed tomography scan between June 2020 and June 2023 was performed. Demographics and imaging details were abstracted from the medical record. Size-specific dose estimates and effective dose estimates were calculated for each computed tomography. Size-specific dose estimates were compared with American College of Radiology Dose Index Registry diagnostic reference levels. RESULTS: Of 1,419 patients, 409 (29%) received a computed tomography for appendicitis, a 56% reduction from previous years (2012-2015) (P < .001). Overall, 352 computed tomography scans had dose data available, of which 291 (83%) were performed at system hospitals and 61 (17%) at nonsystem hospitals. The median size-specific dose estimate per computed tomography was 11.0 mGy (interquartile range 7.0, 17.4) for nonsystem hospitals and 9.1 mGy (interquartile range 6.6, 14.0) for system hospitals. The median effective dose per computed tomography was 6.7 mSv (interquartile range 4.3, 12.9) at nonsystem hospitals and 5.1 mSv (interquartile range 3.3, 9.4) at system hospitals. Nienty-three (n = 273) computed tomography scans performed at system hospitals and 30 computed tomography scans (n = 61) at nonsystem hospitals exceeded American College of Radiology Dose Index Registry age-based diagnostic reference levels. CONCLUSION: The ultrasonography-first, magnetic resonance imaging-second protocol resulted in a significant decrease in computed tomography use for appendicitis diagnosis. Comparison of doses to American College of Radiology Dose Index Registry reference levels suggests that computed tomography protocol optimization may allow for dose reduction at some facilities.

Exposure to Secondhand Tobacco Smoke at Airport Terminals.

Background: Airports may represent significant sources of secondhand smoke (SHS) exposure for both travelers and employees. While previously common smoking rooms have largely disappeared from US airports, smoking continues to occur outdoors at terminal entrances. SHS may be especially high at arrival areas, since they oftentimes are partially enclosed by overhead departures, creating stagnant microenvironments. This study assessed particulate matter <2.5 microns in diameter (PM2.5), a common surrogate for SHS, at airport terminal locations to evaluate both outdoor exposure risk and possible indoor drift of SHS from outdoor sources. Methods: A convenience sample of nine airport terminal arrival areas in the US state of Florida was surveyed between February and July 2018. PM2.5 levels were assessed outdoors and indoors at terminal entrances and at control areas far into terminal interiors. We also examined the impact of smoking location on SHS exposure by correlating cigarette and passing vehicle counts with PM2.5 levels at terminals with contrasting proximity of designated smoking locations to terminal entrances. Results: Although outdoor PM2.5 levels (mean 17.9, SD 6.1 µg/m3) were significantly higher than indoors (p < 0.001), there was no difference between indoor areas directly inside terminal entrances and areas much further interior (mean 8.8, SD 2.6 vs mean 8.5, SD 3.0 µg/m3, p=0.49). However, when smoking areas were in close proximity to terminal entrances, the number of lit cigarettes and vehicular traffic per minute predicted 70% of the variance of PM2.5 levels (p < 0.001), which was attributable mostly to the cigarette number (ß = 0.83; 95% CI (0.55 to 1.11); p < 0.001). This effect was not observed at smoking areas further away. Conclusion: PM2.5 data did not suggest indoor drift from outside smoking. Nevertheless, absolute exposure outdoors was high and correlated with the location of designated smoking areas. Further studies are needed to examine the effect of microclimate formation on exposure risk.

Mandibular Osteomyelitis Associated with Candida Albicans in Marijuana and Heroin Abusers.

Osteomyelitis of the mandible is most commonly caused by bacterial infections and is rarely linked to fungal infections. In 2003, Friedman et al. studied the relationship of multiple drugs including marijuana, opioids, nicotine, and alcohol and its effect on the immune system. It is important to consider potential risks and complications of patients who are immunocompromised and present a history of substance abuse. These complications include infections and osteomyelitis which can be associated with multiple microorganisms; some of the most common microorganisms isolated in mandibular osteomyelitis include Streptococcus, Eikenella, and Candida. Candida albicans is commonly found in the skin and mucosa of healthy individuals; however, it has been proven to cause disease in individuals who are immunocompromised. Two cases of mandibular osteomyelitis after routine dental extractions and a history of drug abuse, including heroin and marijuana, are presented in this case series. These specific infections were resistant to multiple antibiotic therapy and grew C. albicans species in cultures collected. These cases were treated with irrigation and debridement or mandibular resection in combination with antimicrobial treatment and fluconazole with complete resolution. Although osteomyelitis is most commonly caused by bacterial infections, special attention must be given to patients with medical histories of immunosuppression and intravenous drug use. Patients who do not respond to broad-spectrum antibiotics might benefit from bacterial and fungal cultures and sensitivity. Antifungal treatment with an antifungal agent, such as oral fluconazole, is indicated if fungal organisms are yielded in the culture.

Disseminated superficial actinic porokeratosis treated with ingenol mebutate gel 0.05.

Disseminated superficial actinic porokeratosis (DSAP) is a chronic condition characterized by numerous atrophic papules and patches with a distinctive peripheral keratotic ridge, typically found on sun-exposed areas. Treatment of DSAP is warranted not only for cosmetic and symptomatic benefits but also to prevent malignant transformation. Successful treatment of DSAP often is difficult and frequently requires the use of multiple modalities. Ingenol mebutate gel 0.05% is a topical medication primarily used for the treatment of actinic keratosis (AK) by inducing cell death. We report a case of DSAP treated effectively with ingenol mebutate gel 0.05%.