M.I.C.A.H. Project HEAL: Sustainability of a Faith-Based Community Health Advisor Training Program in Urban Underserved Communities in the USA.

Faith-based organizations (FBOs) can play an important role in improving health outcomes. Lay community health advisors (CHAs) are integral to these efforts. This paper assesses the sustainability of a CHA training program for congregants in African-American and Latino FBOs and subsequent implementation of educational workshops. The program is unique in that a health care chaplain in an academic medical center was central to the program's development and implementation. Forty-eight CHAs in 11 FBOs were trained to teach workshops on cardiovascular health, mental health, diabetes, and smoking cessation. Two thousand four hundred and forty-four participants attended 70 workshops. This program has the potential to be a model to educate individuals and to address health inequities in underserved communities. Health care chaplains in other medical centers may use this as a model for enhancing community engagement and education.

Presence of opioid safety initiatives, prescribing patterns for opioid and naloxone, and perceived barriers to prescribing naloxone: Cross-sectional survey results based on practice type, scope, and location.

BACKGROUND AND OBJECTIVES: The opioid epidemic is a public health crisis in the United States (US) and is associated with devastating consequences, including opioid misuse and related overdose. In response to the opioid crisis, the US Department of Health and Human Services is advancing improved practices in pain management. Strategies to help mitigate opioid risks include physician safety programs, hospital- or practice-based initiatives, patient education, and harm reduction campaigns that include the use of naloxone. To date, little information is available regarding the use of these strategies among healthcare providers. A survey was conducted to identify the presence of opioid safety initiatives, prescribing patterns of opioids and naloxone, and perceived barriers to prescribing naloxone. The presence of these strategies was compared between different practice types (hospital-based/academic vs. private practice), practice scope (chronic pain vs. "other"), and practice location (in the US vs. outside the US) Regarding "outside the US," the actual geographical distribution of those countries was not captured by respondents. METHODS: A 13-question web-based anonymous cross-sectional survey was sent to members of the American Society of Regional Anesthesia and Pain Medicine and the Women in Pain Medicine online community via email and social media (Twitter and Facebook). Survey questions were designed to ascertain the presence of opioid safety initiatives, opioid and naloxone prescribing patterns, and perceived barriers to prescribing naloxone based on practice type (hospital-based/academic vs. private practice), scope (chronic pain vs. "other"), and location (in the US vs. outside the US). RESULTS: Opioid safety initiatives: The presence of physician safety initiatives was found to be statistically higher among hospital-based/academic practices. No statistical difference was found for hospital- or practice-based, patient education, or harm reduction initiatives for different practice types (hospital-based/academic vs. private practice). The presence of patient education initiatives is statistically higher for chronic pain providers versus others. No statistical difference was found for physician safety, hospital- or practice-based, or harm reduction initiatives among the different practice scopes (chronic pain vs. others). The presence of opioid safety initiatives is statistically higher in the US compared with outside the US Prescribing patterns for opioids: Hospital-based/academic practices are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, a mandatory medication treatment program, and/or a current methadone maintenance program, and those having difficulty accessing emergency medical services. Chronic pain providers are more likely to prescribe opioids to patients taking antidepressants compared with "other" providers. Other providers are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, in mandatory medication treatment programs, in current methadone maintenance programs, and patients having difficulty accessing emergency medical services. There is no difference in opioid prescribing patterns based on practice location. Prescribing pattern for naloxone: Chronic pain providers and providers in the US are more likely to prescribe/recommend naloxone and are more aware of a state's medical board guidelines on naloxone prescribing. There is no statistical difference between practice types. Most providers, regardless of practice type, scope, or location, will coprescribe naloxone at a morphine milligram equivalent per day threshold of >50. Hospital-based/academic practices are more likely to prescribe naloxone to patients with opioid prescriptions and coexisting respiratory disease. Chronic pain providers are more likely to prescribe naloxone for patients with methadone prescriptions in opioid-naïve populations, coexisting respiratory, hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, and those having difficulty accessing emergency medical services. Based on practice location, providers in the US are more likely to prescribe naloxone for patients with opioid prescriptions and coexisting hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, recently released from a correctional facility, opioid detoxification program or mandatory abstinence program, and those having difficulty accessing emergency medical services. Perceived barriers to prescribing naloxone: We found no statistical difference regarding obstacles to prescribing naloxone based on practice type. The cost of the medication and lack of interest from patients are perceived barriers encountered by chronic pain providers versus other providers who do not have enough knowledge regarding when and how to prescribe for a patient. Based on practice location, perceived barriers for providers in the US are related to medication costs and lack of interest from patients. CONCLUSION: While some improvements have been achieved in the fight against the opioid epidemic, our survey results indicate that further knowledge is needed to determine the potential obstacles to implementing opioid safety initiatives, understanding prescribing practices for opioids and naloxone, and lowering the barriers to prescribing naloxone based on practice type, scope, and location.

Sphenopalatine Ganglion Blocks in the Management of Head and Neck Cancer-Related Pain: A Case Series.

Head and neck cancer can be painful, debilitating, and refractory to oral medications. Due to the association of the sphenopalatine ganglion (SPG) with maxillary nerve sensory fibers, SPG blocks may be used to treat the pain of the hard and soft palate, tonsils, nasal cavity, paranasal sinuses, oral gingiva, premaxillary soft tissue, maxilla, and orbital floor. We present the first case series of performing SPG blocks utilizing TX360 nasal atomizers or angiocatheters to treat head and neck cancer-related pain. Pain scores were reduced by 38% to 80% with an average pain relief duration of 23 days.

Management of the lateral neck compartment in patients with sporadic medullary thyroid cancer.

BACKGROUND: The purpose of this retrospective analysis was to evaluate the benefits of an elective lateral neck dissection (ELND) in patients with medullary thyroid cancer (MTC) without radiographically apparent lateral neck metastases. METHODS: Patients with sporadic MTC without radiographic evidence of lateral neck metastasis who underwent definitive surgery were divided into 2 groups based on surgical approach: no ELND (the observation group) and ipsilateral or bilateral ELND (the ELND group). Primary outcomes were biochemical cure, locoregional recurrence, distant metastasis, and overall survival (OS). RESULTS: Sixty-six patients met inclusion criteria: 44 patients (67%) in the observation group and 22 patients (33%) in the ELND group. Two of 44 patients (5%) in the observation group developed subsequent (ipsilateral) lateral neck disease. At last follow-up, locoregional disease control rates among the observation and ELND groups were 98% and 100% (P > .999), respectively, whereas biochemical cure rates were 82% and 85% (P > .999), respectively, and 5-year OSs were 84% and 100% (P = .156), respectively. CONCLUSION: Patients with MTC without lateral neck metastasis have similar biochemical cure rates with observation or elective dissection of lateral neck compartments.

Diagnostic Criteria for Detection of Vestibular Schwannomas in the VA Population.

OBJECTIVE: To investigate the prevalence of vestibular schwannoma (VS) and asymmetric sensorineural hearing loss in the Veterans Administration hospital population and analyze a more efficient method of diagnosing VS in a population with significant noise exposure. STUDY DESIGN: Retrospective review of South Central (VISN 16) Veterans Administration hospitals. METHODS: Record query for ICD-9 codes for asymmetric sensorineural hearing loss or VS between 1999 and 2012. Patient demographics, signs and symptoms at presentation, audiogram and imaging data, and management data were collected and analyzed. Audiograms from tumor patients were compared with controls matched for age, sex, combat experience, and medical comorbidity (2:1 control to case ratio). RESULTS: The prevalence of VS was 1 per 1,145 patients in this population, with average age at diagnosis of 62. Patients with VS presented more commonly with unilateral tinnitus, rollover, and absent acoustic reflexes when compared with matched controls, but positive predictive value was low. Published criteria for defining hearing asymmetry showed variable sensitivity (51-89%) and low specificity (0-42%) for the detection of VS in this population. Criteria meeting the definitions of significant asymmetry with specificity for VS of 80% or greater were as follows: >15 dB threshold difference at 3 kHz and unilateral tinnitus, ≥45 dB threshold difference at 3 kHz regardless of tinnitus, or when the word recognition score difference was ≥80%. With serial audiograms 2.5 years apart or greater, a ≥10 dB threshold increase at any frequency between 0.5 and 4 kHz had a 100% sensitivity for tumor and a ≥10 dB increase at 3 kHz had a specificity of 84%. The majority of patients were observed, whereas only 30% had surgery. Patients who were observed were older than those treated with surgery or radiation (p <0.001). CONCLUSION: Typical audiometric screening criteria should be modified in the veteran population to improve cost efficiency of diagnosis. Observation is the primary management strategy in the veteran population because of age.

Tres casos interesantes de uso de terapia de vacío en neonatos / Three interesting cases of use of vaccum assisted closure in newborns

Antecedentes y Objetivos. La terapia de vacío es una herramienta adicional en el arsenal terapéutico actual del cirujano plástico y se aplica frecuentemente en el tratamiento de heridas complejas como paso intermedio hasta el tratamiento definitivo de las mismas, y como medida de disminución del tiempo que transcurre hasta su cierre. En el caso de los neonatos, es especialmente crítico conseguir disminuir este tiempo hasta el cierre definitivo de las heridas; sin embargo, la bibliografía al respecto no aporta suficiente información sobre el uso de esta modalidad terapéutica en épocas tempranas de la vida. Pretendemos por tanto compartir la experiencia clínica en este tema de nuestra Unidad de Cirugía Plástica Pediátrica. Material y Método. Describimos 3 casos en los que el uso de terapia de vacío permitió un tratamiento adecuado y definitivo de heridas de diferente etiología y diferentes localizaciones en pacientes neonatos. Conclusiones. Consideramos que la terapia de vacío constituye una excelente herramienta para la preparación de heridas complejas como paso previo al tratamiento definitivo y como una medida terapéutica segura también en neonatos (AU)

Background and Objectives. Vacuum assisted therapy is considered as a valuable tool on the daily practice of plastic surgeons to treat complex injuries as a previous step until the definitive closure is achieved. However, the literature reporting its use on newborn patients is spare, and more research is needed in order to develop well established protocols for its use in this patients. Our objective is to share the clinical experience of our Pediatric Plastic Surgery Unit. Method. We present 3 cases of newborn patients in whom vacuum assisted therapy was highly effective to get a proper and definitive treatment of injuries from different ethology and localization. Conclusions. We consider vacuum assisted therapy as an excellent tool for the preparation of complex wounds as a previous step to the definitive surgical treatment on many patients, including newborns (AU)

The cost and inpatient burden of treating mandible fractures: a nationwide inpatient sample database analysis.

OBJECTIVE: To discuss patient demographics, hospitalization characteristics, and costs associated with the treatment of mandible fractures. STUDY DESIGN: Cross-sectional study. SETTING: The 2009 Nationwide Inpatient Sample (NIS) database. SUBJECTS/METHODS: Patient demographics, hospital characteristics, fracture locations, and common comorbidities for patients with isolated mandible fractures were analyzed, and variables associated with increased cost and length of hospitalization stay were ascertained. RESULTS: A total of 1481 patients were identified with isolated mandible fractures. The average age was 32, 85.4% were male, 39% were Caucasian, and 25% African American. Forty percent were from the lowest median household income quartile, and 77% were uninsured or government funded. The average length of stay (LOS) was 2.65 days, and average hospitalization cost was $35,804. A statistically significant increased LOS was associated with alcohol abuse, drug abuse, mental illness, diabetes mellitus type 2, cardiovascular disease, HIV, and age over 40. There was a statistically significant increased total cost associated with drug abuse, alcohol abuse, mental illness, cardiovascular disease, and age over 40. CONCLUSION: The average cost for treatment of mandible fractures was $35,804 per person with increased expenditures for older patients and those with a history of mental illness, cardiovascular disease, or substance abuse. To improve outcomes and reduce hospital charges, outpatient resources and inpatient protocols should be implemented to address the factors we identified as contributing to higher costs and increased hospital stay.