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Nalini Vadivelu,1 Alice M Kai,2 Vijay Kodumudi,3 Jack M Berger4 1Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, 2Stony Brook University School of Medicine, Stony Brook, NY, 3Department of Molecular and Cell Biology, College of Liberal Arts and Sciences, University of Connecticut, Storrs, CT, 4Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Abstract: Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed. Keywords: outpatient surgery analgesia, ambulatory surgery pain control, acute pain, ­ambulatory surgery center, opioids, substance abuse

Nalini Vadivelu,1 Sukanya Mitra,2 Erika Schermer,3 Vijay Kodumudi,4 Alan David Kaye,5 Richard D Urman61Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA; 2Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India; 3Yale College, New Haven, 4School of Liberal Arts and Science, University of Connecticut, Storrs, CT, 5Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, 6Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USAAbstract: Pain from surgical procedures occurs as a consequence of tissue trauma and may result in physical, cognitive, and emotional discomfort. Almost a century ago, researchers first described a possible relationship between intraoperative tissue damage and an intensification of acute pain and long-term postoperative pain, now referred to as central sensitization. Nociceptor activation is mediated by chemicals that are released in response to cellular or tissue damage. Pre-emptive analgesia is an important concept in understanding treatment strategies for postoperative analgesia. Pre-emptive analgesia focuses on postoperative pain control and the prevention of central sensitization and chronic neuropathic pain by providing analgesia administered preoperatively but not after surgical incision. Additional research in pre-emptive analgesia is warranted to better determine good outcome measurements and a better appreciation with regard to treatment optimization. Preventive analgesia reduces postoperative pain and consumption of analgesics, and this appears to be the most effective means of decreasing postoperative pain. Preventive analgesia, which includes multimodal preoperative and postoperative analgesic therapies, results in decreased postoperative pain and less postoperative consumption of analgesics.Keywords: preventive analgesia, central sensitization, chronic pain, pre-emptive analgesia, multimodal analgesia, acute pain

Nonhuman primates living in proximity to humans increase risks for sylvatic arbovirus transmission. We collected serum samples from nonhuman primates in Hlawga National Park near Yangon, Myanmar, and detected antibodies against chikungunya (33%) and Japanese encephalitis (4%) viruses. Buffer zones between primate and human communities might reduce cross-species arbovirus transmission.

The increasing prevalence of individuals with multiple food allergies and the need to distinguish between foods containing homologous, cross-reactive proteins have made the use of single-analyte antibody-based methods (e.g., ELISAs) sometimes insufficient. These issues have resulted in the need to conduct multiple analyses and sometimes employ orthogonal methods like mass spectrometry or DNA-based methods for confirmatory purposes. The xMAP Food Allergen Detection Assay (xMAP FADA) was developed to solve this problem while also providing increased throughput and a modular design suitable for adapting to changes in analytical needs. The use of built-in redundancy provides the xMAP FADA with built-in confirmatory analytical capability by including complementary antibody bead sets and secondary analytical end points (e.g., ratio analysis and multi-antibody profiling). A measure of a method's utility is its performance when employed by analysts of varying expertise in multiple laboratory environments. To gauge this aspect, a multi-laboratory validation (MLV) was conducted with 11 participants of different levels of proficiency. The MLV entailed the analysis of incurred food samples in four problematic food matrices, meat sausage, orange juice, baked muffins, and dark chocolate. Except for a couple of instances, involving two confirmatory components in the analysis of baked muffins, the allergenic foods were detected by all participants at concentrations in the analytical samples comparable to ≤ 10 μg/g in the original food sample. In addition, despite high levels of inter-lab variance in the absolute intensities of the responses, the intra-laboratory reproducibility was sufficient to support analyses based on the calibration standards and direct comparison controls (DCCs) analyzed alongside the samples. In contrast, ratio analyses displayed inter-laboratory %CV (RSDR) values < 20%; presumably because the ratios are based on inherent properties of the antigenic elements. The excellent performance of the xMAP FADA when performed by analysts of varying proficiency indicates a reliability sufficient to meet analytical needs.

Botulism outbreak due to consumption of food contaminated with botulinum neurotoxins (BoNTs) is a public health emergency. The threat of bioterrorism through deliberate distribution in food sources and/or aerosolization of BoNTs raises global public health and security concerns due to the potential for high mortality and morbidity. Rapid and reliable detection methods are necessary to support clinical diagnosis and surveillance for identifying the source of contamination, performing epidemiological analysis of the outbreak, preventing and responding to botulism outbreaks. This review considers the applicability of various BoNT detection methods and examines their fitness-for-purpose in safeguarding the public health and security goals.

This paper describes the spatial and temporal distribution of cases, demographic characteristics of patients, and clinical manifestations of Zika virus (ZIKV) during the 2016 outbreak in Grenada. The first reported case was recorded in St. Andrew Parish in April, and the last reported case was seen in November, with peak transmission occurring in the last week of June, based on test results. Data were collected from a total of 514 patients, of whom 207 (40%) tested positive for ZIKV. No evidence was found that testing positive for ZIKV infection was related to age, gender, or pregnancy status. Clinical presentation with rash (OR = 2.4, 95% CI = 1.5 to 3.7) or with lymphadenopathy (OR = 1.7, 95% CI = 1.0 to 2.9) were the only reported symptoms consistent with testing positive for ZIKV infection. During the Zika outbreak, the infection rate was 20 clinical cases per 10,000 in the population compared to 41 cases per 10,000 during the chikungunya outbreak in Grenada in 2014 and 17 cases per 10,000 during the dengue outbreak in 2001-2002. Even though the country has employed vector control programs, with no apparent decrease in infection rates, it appears that new abatement approaches are needed to minimize morbidity in future arbovirus outbreaks.

Prior research has demonstrated that early treatment of port-wine birthmark (PWB) with pulsed dye laser (PDL) yields optimal patient outcomes. Given the known variations in practice patterns among dermatologists offering PDL, we conducted a cross-sectional analysis in order to determine the travel distance and time to practice locations offering PDL therapy for PWB among the pediatric population. We determined the travel time and distance from each county population center in the United States to the nearest PDL site using ArcGIS and linked the data to demographic characteristics in each census tract. 1,243 practice sites were identified that offer PDL treatment for PWB for patients under the age of 18. Children living in urban areas were found to have a significantly shorter median travel time and distance to PDL sites (6.1 miles, 11.8 minutes) compared to children living in rural areas (60.9 miles, 66.7 minutes). Additionally, uninsured children were found to travel longer average distances (32.2 miles) than insured children (24.2 miles). These findings suggest that certain socioeconomically disadvantaged groups have increased travel burden when obtaining PDL treatment for PWB. Transportation resources and support may need to be given to certain patients to ensure timely and effective PDL treatment., Competing Interests: DISCLOSURES: Dr. Feng has consulted for Cytrellis Biosystems, Inc. and Soliton, Inc. All other authors report no conflicts of interest relevant to this article., (Copyright © 2023. Matrix Medical Communications. All rights reserved.)

This continuing medical education (CME) series assesses key features and ongoing transformations within the dermatology workforce. Part 1 of this series described precipitants and implications of recent workforce changes. Part 2 reviews the influence that these workforce dynamics have had on patient access, outcomes, and satisfaction. Additionally, it assesses potential solutions for optimizing care for underserved groups and the broader dermatologic patient population., Competing Interests: Conflicts of interest Dr Brodell serves as a principal investigator for a clinical trial (Novartis) and for the Corevitas psoriasis biologic registry and has stock ownership in Veradermics, Inc. He serves on editorial boards of the American Medical Student Research (faculty advisor), Practice Update Dermatology (Editor-in-Chief), Journal of the American Journal Academy of Dermatology (Associate Editor), Practical Dermatology, Journal of the Mississippi State Medical Society, SKIN: The Journal of Cutaneous Medicine, and Archives of Dermatological Research. He has no relevant conflict of interest with relations to the content of this CME. Dr Grant-Kels serves as the Deputy Editor of the Journal of the American Journal Academy of Dermatology and is the Chief Medical Officer, member of the Board, and stockholder of VeraDermics, Inc; she is a consultant and stockholder for DermaSensor, Inc. She has no relevant conflict of interest with relations to the content of this CME. Dr Mostow is the Associate Editor of Practice Update Dermatology. Dr Feng is a consultant at Soliton Inc and Cytrellis Biosystems. He has no relevant conflict of interest with relations to the content of this CME. Dr Kodumudi has no conflict of interest to declare., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

The dermatology workforce continues to evolve to meet the growing and diversified demands of the US population. Part 1 of this continuing medical education series is designed to provide an overview of the dermatology workforce as well as delineate the motivators and socioeconomic implications of significant workforce transformations which are impacting dermatologic health care. Part 2 of the series will consider the impact of workforce challenges on patient outcomes and discuss potential actions that may help to optimize workforce organization and care delivery., Competing Interests: Conflicts of Interest Brodell – No relevant conflict of interest with relations to the content of this CME. For full disclosure: Dr Brodell serves as a principal investigator for a clinical trial (Novartis) and for the Corevitas psoriasis biologic registry. Stock Ownership: Veradermics, Inc. He serves on editorial boards of American Medical Student Research (faculty advisor); Practice Update Dermatology (Editor-in-Chief); Journal of the American Journal Academy of Dermatology (Associate Editor); Practical Dermatology; Journal of the Mississippi State Medical Society; SKIN: The Journal of Cutaneous Medicine and Archives of Dermatological Research. Grant-Kels reports no relevant conflict of interest with relations to the content of this CME. For full disclosure of all financial interests, Dr Grant-Kels serves as Deputy Editor of Journal of the American Journal Academy of Dermatology and is Chief Medical Officer and member of the Board and stockholder of VeraDermics, Inc. She is a consultant and stock holder for DermaSensor, Inc. Mostow is an associate editor for Practice Update Dermatology. Feng reports no relevant conflict of interest with relations to the content of this CME; for full disclosure of all financial interests, he is a consultant in Soliton Inc and Cytrellis Biosystems. Gronbeck, Kodumudi has no conflicts of interest., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest Hao Feng has consulted for Cytrellis Biosystems, Inc and Soliton, Inc. The other authors report no conflicts of interest.

There is a documented shortage of Black dermatologists in the United States, with little known about their practice characteristics. We analyzed the practice patterns (e.g., location, group setting, beneficiary characteristics, local geographic characteristics) of 221 self-identified Black dermatologists in the Black Dermatologist Directory through analysis of publicly available Medicare datasets. Compared to non-Black dermatologists, Black dermatologists were more likely to be female (80.1% vs. 51.1%), practice in the South (49.8% vs. 34.9%), work in solo practices (35.8% vs. 19.8%) or academic centers (18.1% vs. 15.5%), and practice in counties with a higher proportion of non-Hispanic Black individuals (21.0% vs. 13.2%). Black dermatologists treated a higher proportion of non-Hispanic Black Medicare beneficiaries (21.7% vs. 2.7%) and dual Medicare-Medicaid beneficiaries (15.0% vs. 9.7%). Major limitations include reliance on public data which may incompletely capture all practicing Black dermatologists. Overall, the findings support the important role of Black dermatologists in treating minority and Medicaid beneficiaries; increased representation of Black dermatologists may ultimately allow for improved patient access and promote awareness and knowledge of specific dermatologic needs of Black patients among the broader dermatology community., Competing Interests: DISCLOSURES: Dr. Feng is a consultant with Cytrellis Biosystems Inc. and Soliton Inc., (Copyright © 2023. Matrix Medical Communications. All rights reserved.)

Competing Interests: Conflicts of interest Author Feng has consulted for Cytrellis Biosystems, Inc and Soliton, Inc. Authors Beltrami, Hooper, Kodumudi, and Gronbeck have no conflicts of interest to declare.

Competing Interests: Conflicts of interest Dr Grant-Kels serves as Deputy Editor of Journal of the American Journal Academy of Dermatology; is Chief Medical Officer and member of the Board and stockholder of VeraDermics, Inc; and is a consultant and stock holder for DermaSensor, Inc. Dr Feng is a consultant for Cytrellis Biosystems, Inc and Soliton, Inc. Dr Kodumudi has no conflicts of interest to declare.

Competing Interests: Conflicts of interest Dr Feng is a consultant for Cytrellis Biosystems, Inc and Soliton, Inc. Authors Beltrami and Kodumudi and Dr Hooper do not have any conflicts of interest to disclose.

Competing Interests: Conflicts of interest Dr Feng is a consultant for Cytrellis Biosystems, Inc and Soliton, Inc. Drs Hooper and Gronbeck and Authors Beltrami and Kodumudi have no conflicts of interest to declare.

The management of connective tissue diseases is dramatically evolving with the advent of biologics and novel oral systemic therapeutics. Despite involvement in the care of these complex patients, there is a knowledge gap in the field of dermatology regarding these emerging agents. The second article in this continuing medical education series discusses new and emerging therapeutics for dermatomyositis and scleroderma that target cells, intracellular signaling pathways, and cytokines., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

There is a worldwide increase in food and nutrition-related contact dermatitis, including irritant contact dermatitis, allergic contact dermatitis, systemic contact dermatitis, protein contact dermatitis, and photocontact dermatitis. A wide range of patients is affected by this condition, from those who consume certain foods as part of their diet to workers who handle food occupationally. Patch testing, analytical chemistry, and reporting may help in timely recognition of contact allergens. Elimination of exposure to the known food or supplement is imperative for treatment. Currently, more research is needed in order to better define the role that nutrition plays in contact dermatitis., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Hidradenitis suppurativa (HS), a chronic, inflammatory, recurrent cutaneous disorder of the hair follicles, is debilitating and has substantial morbidity. Hidradenitis suppurativa-related pain has a profound effect on patient quality of life, yet at present, there are no established pain management algorithms. This comprehensive review provides an update on current treatment of HS-associated pain, including a summary of existing literature surrounding pharmacologic treatments of acute, perioperative, and chronic pain. Additionally, the epidemiology, pathophysiology, and clinical features of the disease are summarized.

Background: There is currently an uneven distribution of the Mohs surgery workforce, with a dearth in nonurban areas. The relationship between training and employment locations of Mohs surgeons has not been studied., Objective: To analyze the employment location of recent micrographic surgery and dermatologic oncology (MSDO) graduates in reference to residency and fellowship locations., Materials and Methods: Data collection of training and practice locations of 421 MSDO fellowship graduates from 2012 to 2017., Results: Thirty-two percent (n = 136) and 53% (n = 225) of MSDO fellowship graduates' first employment locations were located within 10 and 100 miles of either their residency or fellowship locations. Ninety-six percent of graduates were employed in a metropolitan location. Female graduates worked closer to training sites than male graduates, with 62% (n = 124) versus 46% (n = 102) working within 100 miles of either training site. Analysis by fellowship census region showed that graduates clustered around training sites in all regions, with 45% to 60% of graduates working within 100 miles of either training site., Conclusion: The majority of graduates chose to work in a metropolitan area. Training location strongly predicts employment location. More than 45% of graduates in any region worked within 100 miles of their residency or fellowship site, and a sizeable portion worked within 10 miles., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Pain management in dermatologic conditions can be complicated by the primary disease burden and associated decreased quality of life, disability, and psychosocial issues. This review focuses on pain management strategies in some of the more painful dermatologic conditions., Recent Findings: Pain management in painful dermatologic conditions such as pyoderma gangrenosum, postherpetic neuralgia, lower limb ulcers, and hidradenitis suppurativa revolves around treatment of the underlying disease process. Topical agents such as topical steroids and systemic immunosuppressants with over-the-counter analgesics usually suffice in mild to moderate pain. Severe pain may need neuropathic agents and referral to interventional pain physicians for consideration of advanced techniques such as epidural steroid injections and sympathetic nerve blocks. Part of the treatment process is for dermatologists to establish patient expectations and to treat pain within their scope of practice. More research is needed towards pain control in painful dermatologic conditions with elucidation of treatment algorithms unique to each condition.

Purpose of Review: Psoriasis and psoriatic arthropathy are inflammatory autoimmune conditions that can lead to profound emotional distress, social stigmatization, isolation, disfigurement, pain, disability, unemployment, and decreased quality of life. Thus, this disease has immense psychological, social, and economic implications as the pain experienced is closely associated with the primary disease burden. This review focuses on discussing the primary disease burden of psoriasis and psoriatic arthropathy, as well as management of different types of pain in these patients., Recent Findings: Pain affects over 40% of patients with psoriasis, ranging from neuropathic to nociceptive. Treatment of pain largely focuses on treating the underlying disease with mild topical steroids and non-steroidal medications including vitamin D analogs followed by systemic immunomodulatory agents for more severe disease. Interventional options such as corticosteroid injections are available for select cases (conditional recommendation). Psoriasis and psoriatic arthropathy have been associated with underreporting and resultant undertreatment of pain. Pain control in these conditions is complex and requires a multidisciplinary approach. More research and guidelines are needed in the areas of reporting of psoriatic disease, associated pain, psoriatic nociception, and optimal clinical management.

Calciphylaxis is a deadly, painful disease with a 1-year mortality of up to 50%. The disease is commonly associated with patients with end-stage kidney disease (ESKD), but it can manifest in non-uremic patients as well. In patients who are undergoing dialysis, the incidence of calciphylaxis can range from 0.04% to 4%. The progressive arterial calcification seen in calciphylaxis can affect multiple body organs, including the skin, brain, lungs, and muscle. In cutaneous calciphylaxis, painful and non-healing nodules, plaques, and ulcers may appear, increasing morbidity for patients. Diagnosis can be difficult, and the condition can clinically appear similar to other dermatological diseases, especially in non-uremic patients. Currently, skin biopsy with histological analysis is the most reliable method to help diagnose the condition. In certain cases, the use of medical imaging may be helpful. Treatment of pain in this condition can be difficult and should be multimodal and include wound care as well as modification of risk factors. Analgesic options include opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), as well as analgesic options that are targeted for specific patients. There are currently multiple clinical trials underway that are studying targeted therapies for this condition.

Purpose of Review: The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant., Recent Findings: The latest research has found that the development of standardized mechanisms and protocols to optimize the diagnosis, assessment, and management of pain in the critically ill can provide the best outcomes. The numerical rating scale, critical care pain observation criteria, and behavior pain scale has shown higher reliability to accurately assess pain in the critically ill. Most importantly, preemptive analgesia and the emphasis on early pain control-in the perioperative setting, ICU, and post-discharge-are crucial in minimizing chronic post-discharge pain. Finally, the multimodal approach is still found to be the most effective. This includes pharmacological treatments, regional nerve block, and epidural techniques, as well as alternative methods that are cheap, safe, and easily available. All these together have shown to help control pain, provide psychological support, and prevent long-term co-morbidities in the critically ill. Largely, pain in the critically ill patient is still a very complex issue that requires appropriate diagnosis, assessment, and management of the pain itself and treating all the underlying co-morbidities as well. Many different factors makes it challenging, especially the difficulty in communicating with an ICU patient. However, by looking at the patient as a whole, treating pain early with the multimodal approach, there seems to be some promising results in improving outcomes. It has shown that the improved outcomes in critically ill patients in the perioperative period seen with optimized pain management and ICU can shorten hospital stays, decreased inpatient costs, and limit the use of limited resources.

Purpose of Review: Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management., Recent Findings: Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.

Purpose of Review: The goal of this review is to evaluate the global supply and demand of opioids used for pain management and discuss how it relates to the utilization of opioids around the world. The purpose of the review is also to determine the factors that contribute to inappropriate pain management., Recent Findings: The total global production of opium for opioid manufacturing is enough to supply the growing global demands. However, licit opioids are only consumed by 20% of the world population. Most people throughout the world had no access to opioid analgesics for pain relief in case of need. Opioid misuse and abuse is not only a phenomena plague by the USA but globally across many countries. Many countries have a lack of availability of opioids, contributing factors being strict government regulations limiting access, lack of knowledge of the efficacy of opioid analgesics in treating acute and chronic pain and palliative care, and the stigma that opioids are highly addictive. For the countries in which opioids are readily available and prescribed heavily, diversion, misuse, abuse, and the resurgence of heroin have become problems leading to morbidity and mortality. It is pertinent to find a balance between having opioids accessible to patients in need, with ensuring that opioids are regulated along with other illicit drugs to decrease abuse potential.

Purpose of Review: In the present investigation, current literature on the relationship between substance abuse and pain is evaluated in order to improve clinical management and its implications on the increasingly challenging chronic pain and substance abuse epidemic. The relationship between substance abuse and chronic pain are evaluated, and this review provides recommendations on the management of this special patient population., Recent Findings: Currently, there are limited guidelines for prescribing opioids and other analgesics in the chronic pain population. As this field of practice continues to evolve, it is essential for clinicians to serve as the gatekeepers to monitor for misuse and safety. Multiple studies have indicated that illicit drug use and opioid abuse affect over 9% of patients. Although there are numerous reasons for seeking illicit drugs and abusing them, it is essential that clinicians identify factors which place certain patients at high risk and accordingly, to screen these patients in order to optimize their management. The high prevalence of patients with chronic pain who also screen positive for drug use emphasizes the importance and increasingly pressing need to evaluate and to manage chronic pain in this population.

Purpose of Review: The opioid crisis most likely is the most profound public health crisis our nation has faced. In 2015 alone, 52,000 people died of drug overdoses, with over 30,000 of those people dying from opioid drugs. A recent community forum led by the Cleveland Clinic contrasted this yearly death rate with the loss of 58,000 American lives in 4 years of the Vietnam War. The present review describes the origins of this opioid epidemic and provides context for our present circumstances., Recent Findings: Alarmingly, the overwhelming majority of opioid abusers begin their addiction with prescription medications, primarily for chronic pain. Chronic postoperative pain, which occurs in 10-50% of surgical patients, is a major concern in many types of surgery. Nationwide, the medical community has made it a priority to ensure that postsurgical analgesia is sufficient to control pain without increasing non-medically appropriate opioid use. The opioid epidemic remains a significant pressing issue and will not resolve easily. Numerous factors, including the inappropriate prescription of opioids, lack of understanding of the potential adverse effects of long-term therapy, opioid misuse, abuse, and dependence, have contributed to the current crisis.

Purpose of Review: Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction., Recent Findings: Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.

Ketamine an N-methyl-D-aspartate (NMDA) receptor blocking agent and a dissociative anesthetic with neurostimulatory side effects. In recent years, multiple research trials as well as systematic reviews and meta-analyses suggest the usefulness of ketamine as a strong analgesic used in subanesthetic intravenous doses, and also as a sedative. In addition, ketamine was noted to possess properties of anti-tolerance, anti-hyperalgesia and anti-allodynia most likely secondary to inhibition of the NMDA receptors. Tolerance, hyperalgesia and allodynia phenomena are the main components of opioid resistance, and pathological pain is often seen in the clinical conditions involving neuropathic pain, opioid-induced hyperalgesia, and central sensitization with allodynia or hyperalgesia. All these conditions are challenging to treat. In low doses, ketamine does not have major adverse dysphoric effects and also has the favorable effects of reduced incidence of opioid-induced nausea and vomiting. Therefore, ketamine can be a useful adjunct for pain control after surgery. Additional studies are required to determine the role of ketamine in the immediate postoperative period after surgical interventions known to produce severe pain and in the prevention and treatment of chronic pain., Competing Interests: Conflicts of Interest: None declared.

Background: Warfarin is the most widely prescribed oral anticoagulant frequently encountered in the patients presenting for both elective and emergent surgery. Maintaining therapeutic levels of warfarin therapy may increase the risk of blood loss and procedural complications, including complications from neuraxial and regional anesthetic techniques. However, in some vulnerable patient groups, discontinuing therapy may result in negative thromboembolic consequences., Objective: To review the published guidelines and supporting data from clinical studies addressing the safe and coordinated management of patients on warfarin therapy who present for perioperative care., Method: This review highlights the most up-to-date research from clinical trials as well as from retrospective studies in addition to multidisciplinary consensus guidelines regarding the safety of warfarin therapy and reversal in the perioperative period., Results: Based on the most up-to-date literature, certain patient groups may be more vulnerable to cessation of warfarin therapy before surgery and there exists a risk stratification algorithm. In many other cases, particularly emergent surgery, it may be necessary to reverse warfarin therapy preoperatively. There are anesthetic, surgical and safety implications in these clinical decision points., Conclusion: With the aging of the United States population, the prevalence of preoperative patients therapeutic on warfarin will continue to increase, necessitating the multidisciplinary and coordinated care of perioperative clinicians to ensure patient safety and optimize clinical outcomes.

Unlabelled: Regional anesthesia has increasingly expanded its role in the perioperative care of patients undergoing foot and ankle surgery. In addition to avoiding side effects associated with both general anesthesia and neuraxial anesthetic techniques, especially those related to cardiovascular and pulmonary systems, regional nerve blocks have been shown to improve postoperative pain and reduce hospital stay and associated expenses. The techniques utilized to achieve analgesia of the foot and ankle are diverse, multifaceted, and often incorporate ultrasound guidance. Given the aging of patient populations, and especially the growing incidence of cardiovascular-, pulmonary-, and obesity-related morbidity, the use of regional blocks is likely to expand in these surgical procedures. This review highlights some of the most current developments in the expanding role of regional anesthesia in foot and ankle surgery., Levels of Evidence: Therapeutic, Level II., (© 2015 The Author(s).)

Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings., (© 2014 World Institute of Pain.)

The majority of ophthalmic procedures are performed under regional anesthesia, but the proximity of important structures such as the blood vessels, optic nerve and the brainstem lead to increased risks associated with these blocks. The most serious of these complications is brainstem anesthesia. As the number of outpatient freestanding surgical centers increase, the significance of these potential complications is expected to increase from orbital blocks for ocular surgical procedures such as cataract removal and vitrectomy. An understanding of these complications, which may sometimes be life-threatening, are thus vital to the anesthesia practitioner. Procedural improvements include a close evaluation of the precise anatomy of the region, with particular attention to injection sites, depth of injection, position of the globe, and techniques to avoid nerve damage and accidental injection into surrounding structures, including blood vessels, globe and cerebrospinal fluid. This literature review emphasizes the importance of the prevention, recognition and management of these complications, which includes the extremely serious complication of brainstem anesthesia.

In the treatment of pain management, physicians employ a variety of drugs, ranging from low-impact to highly potent, and to maximize patient health, urine toxicology analyses can significantly improve the delivery of pain treatment. Drugs such as opioids that are used for pain management are peculiar in that they provide effective pain relief and have a high risk of addiction. The use of illicit drugs in the general population has been on the rise; however, self-reporting and close monitoring of patient behavior are insufficient means to detect drug abuse and confirm compliance. Therefore, in order to create more effective drug treatment plans, physicians must understand and account for the implications of patient drug use history. Urine toxicology analysis is an important tool for pain physicians because it is more sensitive than most alternative blood tests, more efficient and cost-effective. Urine testing in addition to improving patient pain management also has forensic and legal implications. There are however limitations to urine toxicology methods as they can produce false-positive and false-negative results and are prone to human error and sample contamination There is also a need for more specific and rapid urine drug testing. Healthcare professionals should therefore be familiar with the limitations of various urine drug testing methods, and possess skills necessary to properly interpret these results. This review suggests that the overall benefits incurred by both the patient's short-term and long-term health support the routine integration of urine toxicology analysis in routine clinical care. In addition to improving health care and patient health, it has a strong potential to improve patient-physician relationships and protects the interest of involved healthcare practitioners.