Impact of Hydrocodone Rescheduling on Dental Prescribing of Opioids.

INTRODUCTION: In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids. OBJECTIVE: The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States. METHODS: This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation. RESULTS: Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period. CONCLUSION: Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain. KNOWLEDGE TRANSFER STATEMENT: The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.

Transgender patient satisfaction following reduction mammaplasty.

AIM: To evaluate the outcome of reduction mammaplasty in female-to-male transgender patients. METHOD: A 5-year retrospective review was conducted on all female-to-male transgender patients who underwent reduction mammaplasty. A postal questionnaire was devised to assess patient satisfaction, surgical outcome and psychological morbidity. RESULTS: Seventeen patients were identified. The senior author performed bilateral reduction mammaplasties and free nipple grafts in 16 patients and one patient had a Benelli technique reduction. Complications included two haematomas, one wound infection, one wound dehiscence and three patients had hypertrophic scars. Secondary surgery was performed in seven patients and included scar revision, nipple reduction/realignment, dog-ear correction and nipple tattooing. The mean follow-up period after surgery was 10 months (range 2-23 months). Twelve postal questionnaires were completed (response rate 70%). All respondents expressed satisfaction with their result and no regret. Seven patients had nipple sensation and nine patients were satisfied with nipple position. All patients thought their scars were reasonable and felt that surgery had improved their self-confidence and social interactions. CONCLUSION: Reduction mammaplasty for female-to-male gender reassignment is associated with high patient satisfaction and a positive impact on the lives of these patients.

Observations on a consecutive series of patients who have had Trilucent breast implants removed as recommended by the MDA Hazard Notice (May 2000).

A prospective study of 25 female cosmetic-surgery patients who had a total of 50 Trilucent breast implants forms the basis of this paper. All but one patient elected to have new implants, of which all but three patients had silicone implants (the others selected glucose saline implants). The Trilucent implants were more difficult to remove than expected because of a 'Velcro-like' attachment to the internal surface of their capsules. As a result, several implants were ruptured on removal (though none were ruptured on initial exposure). The sites of rupture suggest a structural weakness, possibly related to the microchip panel or folds in the implant shell. Varying degrees of encrustation of the implants and internal capsules were found, which did not appear to be related to the duration of implantation. Histological studies of the capsule changes generally showed lipids and giant cell infiltrations. It would seem that, contrary to expectations, leaking of the filler occurs early and is associated with varying degrees of cellular reactions. The adherence problem appears to be related to the amount and distribution of the leaked material. Only three patients in this series had problems with their Trilucent implants that required additional surgery. One of these remains a significant and unsolved problem.

Skin cancer referrals--could prioritization be a reasonable approach in the new millennium?

With the increasing and ageing population and concomitant increased referral of skin lesions and skin cancer in particular, problems with regard to waiting times to be seen as well as waiting lists currently face us. While several other specialties including radiotherapists, dermatologists, general surgeons, general practitioners may perform surgical and other treatments, there may be some confusion as well as some inefficiencies in the services provided. With a better understanding of the different grades and types of skin cancer, it should be possible to provide a more efficient and fairer service even without a major increase in resources. The question is whether or not the general practitioners and their patients are ready for prioritization?

A three year review of injuries to professional footballers (1995-98) and comparison with previous observations (1990-93).

A prospective study over a three year period (1995-8) of footballers' injuries in first team players was undertaken in a similar fashion to a previous study (1990-3). During the present study the Club had a major cup success and appeared to have a younger squad with less major injury and subsequent time out of action. As a result of the earlier paper it would appear that some lessons and observations may have been put into action and helped produce a more consistent standard for the club. Increasing recognition of the need to reduce and monitor the levels and types of injuries seems now to be established.

Trilucent breast implants--a personal review of the current controversies (May 1999).

Trilucent ("Soya Bean") breast implants were marketed as a safe alternative to silicon implants. Following their use in the UK for the past four years, a reassessment of this has currently been announced (March 1999) and further implantation has been suspended by the Trilucent company in conjunction with the MDA (Medical Devices Agency). This has been the result of some reports of adverse reactions to the triglyceride filling material when the implant ruptures. All patients with trilucent implants were advised to return to their respective surgeons for review and advice. A personal review has been undertaken by the author of this paper. The results obtained are discussed. The majority of patients were concerned, but were happy with cosmetic results, and did not at present wish their implants removed. None appeared as yet to have had serious complications that could be attributed to the implants.

Colonic perforation following prolonged hypovolaemia in a major burns injury.

Perforation of the lower gastrointestinal tract is rare in burns patients. A 41-year-old male, who sustained 40% total body surface area burns and subsequently developed an acute abdomen on day 15 postburn, is presented. Emergency management included a subtotal colectomy and ileostomy formation performed to repair a perforated transverse colon found at laparotomy. The burns were debrided and grafted and the patient required cardiac, renal and respiratory support initially in the ITU setting before making a complete recovery. It is suggested that ischaemia caused the perforated transverse colon due to a prolonged low flow state. This was not detected until invasive cardiovascular catheterisation was performed and revealed a hypovolaemic state, which was corrected by fluids and noradrenaline. Both the previous cardiac history of the patient (Fallot's Tetralogy repair) and the noradrenaline may have exacerbated the low flow state within the mesenteric circulation leading to ultimate perforation. This case highlights the difficulties that may arise in resuscitating a patient who has previously had a cardiac defect repaired. Despite repair, abnormal physiology may persist resulting in misleading observations that produce undetected hypovolaemia with subsequent adverse events, as in this case. In such patients, early invasive cardiovascular monitoring should be considered.

Polaroid photographic referral for skin cancer--a potentially useful method of reducing time to surgery.

A prospective trial was conducted on twenty-five patients referred by dermatologists during 1998 using a referral letter and an accompanying polaroid photograph for prospective plastic surgical management of skin cancers. Using the description and the photograph, suitable patients were given dates for operation without requiring a plastic surgery out-patient clinic appointment. This enabled, not only a saving in the cost of an out-patient appointment, but a significant reduction in waiting time to surgery.

Plastic surgery waiting list--the numbers game fact or fiction?

Previous studies have indicated the importance of work load and operating time in helping to manage a waiting list. While analysis of a waiting list based solely on numbers cannot give an accurate assessment it is only this and "the waiting time" to surgery (apparently irrespective of clinical priorities) that seem to matter to the government, the Trust Hospitals, and to the public. This study examines case numbers on a waiting list over a two year period and links this to the preceding six months elective operations. Further insight into a waiting list construction can be obtained because of the clinical need for some degree of prioritisation, particularly because of malignancies, it is obvious why the bare waiting list numbers and composition can give a false impression of the true situation. The secondary effect on waiting time for less urgent cases can thus be more readily explained. Some form of rationing may be the answer.