Variation in postoperative narcotic prescribing after pediatric appendectomy.

BACKGROUND: Overuse of prescription opioids by both pediatric and adult patients has garnered significant attention in recent years. Educational interventions have been shown to decrease prescription opioids post-operatively in the adult population; similar data have not previously been reported in pediatrics. METHODS: Educational interventions included staff education, institution of opioid standardization protocol, and distribution of educational materials to families. Chart review was performed pre- and post-intervention to compare prescribing practices following appendectomy in patients less than 19 years of age. Follow-up phone calls were used to assess patient satisfaction and pain control. RESULTS: Three hundred thirteen cases were identified pre-intervention [PRE] and compared to 119 cases postintervention [POST]. 84.3% of patients were given a prescription for opioids at time of discharge in the PRE cohort compared to 6.7% (p < 0.001) POST. There was a significant increase in non-opioid analgesia (p < 0.001) POST. There was no significant variability in opioid usage by type of surgery performed, attending provider, or patients' gender or age. Of the patients in the POST cohort, 60.5% were available for telephone follow-up. More than 80% of patients were given acetaminophen and/or ibuprofen POST and 94.4% reported adequate pain control; 88.9% reported that they would agree to avoid opioids again in the future. On follow-up survey, there was no increase in emergency department visits or phone calls for poorly controlled pain following the intervention. CONCLUSION: Low-fidelity educational interventions and creation of a standardized pathway is an effective tool to reduce opioid prescribing and promote alternative means of analgesia without an increase in readmissions or presentation for pain. LEVEL OF EVIDENCE: III.

Alcoholism and dampened temporal limbic activation to emotional faces.

BACKGROUND: Excessive chronic drinking is accompanied by a broad spectrum of emotional changes ranging from apathy and emotional flatness to deficits in comprehending emotional information, but their neural bases are poorly understood. METHODS: Emotional abnormalities associated with alcoholism were examined with functional magnetic resonance imaging in abstinent long-term alcoholic men in comparison to healthy demographically matched controls. Participants were presented with emotionally valenced words and photographs of faces during deep (semantic) and shallow (perceptual) encoding tasks followed by recognition. RESULTS: Overall, faces evoked stronger activation than words, with the expected material-specific laterality (left hemisphere for words, and right for faces) and depth of processing effects. However, whereas control participants showed stronger activation in the amygdala and hippocampus when viewing faces with emotional (relative to neutral) expressions, the alcoholics responded in an undifferentiated manner to all facial expressions. In the alcoholic participants, amygdala activity was inversely correlated with an increase in lateral prefrontal activity as a function of their behavioral deficits. Prefrontal modulation of emotional function as a compensation for the blunted amygdala activity during a socially relevant face appraisal task is in agreement with a distributed network engagement during emotional face processing. CONCLUSIONS: Deficient activation of amygdala and hippocampus may underlie impaired processing of emotional faces associated with long-term alcoholism and may be a part of the wide array of behavioral problems including disinhibition, concurring with previously documented interpersonal difficulties in this population. Furthermore, the results suggest that alcoholics may rely on prefrontal rather than temporal limbic areas in order to compensate for reduced limbic responsivity and to maintain behavioral adequacy when faced with emotionally or socially challenging situations.

Comparison of image quality between conventional and low-dose nonenhanced head CT.

BACKGROUND AND PURPOSE: Increasing use of CT for evaluating neurologic disease may expose patients to considerable levels of ionizing radiation. We compared the image quality of low-mAs head CT scans with that of conventional nonenhanced scans. METHODS: Conventional head CT scans were obtained in 20 patients (all >65 years with history of non-CNS malignancy) by using a multidetector technique: 170 mA and 1-second scanning time (ie, 170 mAs), 140 kVp, table speed of 7.5 mm per rotation, pitch of 0.75, section thickness of 5 mm, and field of view of 25 mm. A limited volume helical data acquisition covering four 5-mm-thick images was obtained by using 90 mAs but otherwise the same parameters. Three neuroradiologists visually rated the resulting images for quality in a blinded comparison. Representative 1- to 4-mm(2) regions of interest were chosen in gray matter and white matter locations. Conspicuity and the contrast-to-noise ratio were analyzed. Statistical comparisons were done by using the Student t test. RESULTS: Mean gray matter conspicuity was not significantly different between the 170- and 90-mAs groups (0.39 +/- 0.19 vs 0.41 +/- 0.03, P =.32). Mean gray matter contrast-to-noise ratio was approximately 22% higher with 170 mAs than with 90 mAs (1.77 +/- 0.52 vs 1.39 +/- 0.38, P =.005). All 90-mAs images were rated as having slightly greater image noise than the 170-mAs scans but with sufficient perceived resolution. CONCLUSION: Although 90-mAs head CT images were moderately noisier than 170-mAs images, they were rated as having acceptable diagnostic quality.