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Thrush J, Simonds R, Antony A, Vidimos A, Lucas J. Acetaminophen and warfarin: A recipe for supratherapeutic international normalized ratio with postoperative bleeding risk. JAAD Case Rep 2024; 43:51-52. [PMID: 38204883 PMCID: PMC10776374 DOI: 10.1016/j.jdcr.2023.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Justin Thrush
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Robert Simonds
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Ashley Antony
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Allison Vidimos
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Lucas
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
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2
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Warner NS, Tung EE, DeMartino ES, Kissoon NR. Ethics of neuromodulation in adults with cognitive impairment and chronic pain. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:S3-S5. [PMID: 37833043 PMCID: PMC10575752 DOI: 10.1093/pm/pnad110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Nafisseh S Warner
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Ericka E Tung
- Department of Community Internal Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Erin S DeMartino
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Narayan R Kissoon
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, United States
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3
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Nugent ST, Veerabagu SA, Madden M, Yanes AF, Etzkorn JR, Miller CJ, Sobanko JF, Shin TM, Higgins HW, McMurray SL, Walker JL, Zhang J, Giordano CN. Patient Preferences for Pain Control After Mohs Micrographic Surgery: A Single-Center Discrete Choice Experiment. JAMA Dermatol 2023; 159:848-853. [PMID: 37405725 PMCID: PMC10323759 DOI: 10.1001/jamadermatol.2023.1899] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/05/2023] [Indexed: 07/06/2023]
Abstract
Importance Patient preferences for pain medications after Mohs micrographic surgery are important to understand and have not been fully studied. Objective To evaluate patient preferences for pain management with only over-the-counter medications (OTCs) or OTCs plus opioids after Mohs micrographic surgery given varying levels of theoretical pain and opioid addiction risk. Design, Setting, and Participants This prospective discrete choice experiment was conducted in a single academic medical center from August 2021 to April 2022 among patients undergoing Mohs surgery and their accompanying support persons (≥18 years). A prospective survey was administered to all participants using the Conjointly platform. Data were analyzed from May 2022 to February 2023. Main outcome and measure The primary outcome was the pain level at which half of the respondents chose OTCs plus opioids equally to only OTCs for pain management. This pain threshold was determined for varying opioid addiction risk profiles (low, 0%; low-moderate, 2%; moderate-high, 6%; high, 12%) and measured via a discrete choice experiment and linear interpolation of associated parameters (pain levels and risk of addiction). Results Of the 295 respondents (mean [SD] age, 64.6 [13.1] years; 174 [59%] were female; race and ethnicity were not considered) who completed the discrete choice experiment, 101 (34%) stated that they would never consider opioids for pain management regardless of the pain level experienced, and 147 (50%) expressed concern regarding possible opioid addiction. Across all scenarios, 224 respondents (76%) preferred only OTCs vs OTCs plus opioids after Mohs surgery for pain control. When the theoretical risk of addiction was low (0%), half of the respondents expressed a preference for OTCs plus opioids given pain levels of 6.5 on a 10-point scale (90% CI, 5.7-7.5). At higher opioid addiction risk profiles (2%, 6%, 12%), an equal preference for OTCs plus opioids and only OTCs was not achieved. In these scenarios, patients favored only OTCs despite experiencing high levels of pain. Conclusion and relevance The findings of this prospective discrete choice experiment indicate that the perceived risk of opioid addiction affects the patient's choice of pain medications after Mohs surgery. It is important to engage patients undergoing Mohs surgery in shared decision-making discussions to determine the optimal pain control plan for each individual. These findings may encourage future research on the risks associated with long-term opioid use after Mohs surgery.
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Affiliation(s)
- Shannon T. Nugent
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Arianna F. Yanes
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jeremy R. Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | | | - Joseph F. Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Thuzar M. Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - H. William Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Stacy L. McMurray
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Joanna L. Walker
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Junqian Zhang
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Cerrene N. Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
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4
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Hayoun-Vigouroux M, Misery L. Dermatological Conditions Inducing Acute and Chronic Pain. Acta Derm Venereol 2022; 102:adv00742. [DOI: 10.2340/actadv.v102.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pain is a common condition in dermatology. The aim of this review is to analyse the characteristics of pain in dermatology. Some skin diseases are conventionally known to cause pain; e.g. ulcers, pyoderma gangrenosum and herpes zoster. Common dermatoses, such as psoriasis or atopic dermatitis, can also cause significant pain. Some conditions are characterized by neuropathic pain and/or pruritus, without visible primary lesions: e.g. the neurocutaneous diseases, including small fibre neuropathies. Patients often fear pain in skin surgery; however, surgical procedures are rather well tolerated and any pain is mainly due to administration of local anaesthetic. Some therapies may also be uncomfortable for the patient, such as photodynamic therapy or aesthetic procedures. Thus, pain in dermatology is common, and its aetiology and characteristics are very varied. Knowledge of the different situations that cause pain will enable dermatologists to propose suitable analgesic solutions.
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Veerabagu SA, Cheng B, Wang S, Etzkorn JR, Kilaru AS, Noe MH, Miller CJ, Sobanko JF, Shin TM, Higgins HW, McMurray SL, Krausz AE, Walker JL, Giordano CN. Rates of Opioid Prescriptions Obtained After Mohs Surgery: A Claims Database Analysis From 2009 to 2020. JAMA Dermatol 2021; 157:1299-1305. [PMID: 34550299 DOI: 10.1001/jamadermatol.2021.3468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance To curtail the opioid epidemic, physicians have been advised to limit opioid prescriptions. Objective To characterize the frequency and changes over time (2009-2020) of opioid prescriptions following Mohs micrographic surgery. Design, Setting, and Participants This cross-sectional study using Optum Clinformatics DataMart (Optum CDM), a nationally representative insurance claims database, included patients aged 18 years and older who had Mohs micrographic surgery insurance claims in the Optum CDM database from 2009 to 2020. Data were analyzed from November 11, 2020, to March 30, 2021. Exposures Opioid prescription following Mohs surgery. Main Outcomes and Measures The primary outcome was the proportion of patients who underwent Mohs surgery and obtained an opioid prescription within 2 days of surgery. Secondary outcomes included type and opioid quantity prescribed. Results Among 358 012 patients with Mohs micrographic surgery claims (mean [SD] age, 69 [13] years; 205 609 [57.4%] were men), the proportion of patients obtaining an opioid prescription after Mohs micrographic surgery increased from 2009 (34.6%) to 2011 (39.6%). This proportion then declined each year, reaching a low of 11.7% in 2020 (27.9% absolute decrease from 2011 to 2020). Hydrocodone, codeine, oxycodone, and tramadol were the 4 most commonly prescribed opioids. By 2020, hydrocodone was obtained less (2009: 47.5%; 2011: 67.1%; 2020: 45.4%; 21.7% absolute decrease from 2011 to 2020) and tramadol was obtained more (2009: 1.6%; 2020: 27.9%; 26.3% absolute increase from 2009 to 2020). Conclusions and Relevance In this cross-sectional study of Mohs micrographic surgery claims, patients obtained fewer postsurgery opioid prescriptions over the study period, suggesting responsiveness of patients and dermatologic surgeons to public health concerns regarding the opioid epidemic. During this decline, prescriptions for hydrocodone decreased and tramadol increased.
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Affiliation(s)
| | - Brian Cheng
- University of South Carolina School of Medicine, Columbia
| | - Sonia Wang
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Austin S Kilaru
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Megan H Noe
- Department of Dermatology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - H William Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Stacy L McMurray
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Aimee E Krausz
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Joanna L Walker
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Cerrene N Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
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Anne S, Mims JW, Tunkel DE, Rosenfeld RM, Boisoneau DS, Brenner MJ, Cramer JD, Dickerson D, Finestone SA, Folbe AJ, Galaiya DJ, Messner AH, Paisley A, Sedaghat AR, Stenson KM, Sturm AK, Lambie EM, Dhepyasuwan N, Monjur TM. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngol Head Neck Surg 2021; 164:S1-S42. [PMID: 33822668 DOI: 10.1177/0194599821996297] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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Affiliation(s)
| | - James Whit Mims
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - John D Cramer
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Dickerson
- NorthShore University Health System, Evanston, Illinois, USA.,University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Adam J Folbe
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Deepa J Galaiya
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna H Messner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Allison Paisley
- University of Pennsylvania Otorhinolaryngology, Philadelphia, Pennsylvania, USA
| | - Ahmad R Sedaghat
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Angela K Sturm
- Angela Sturm, MD, PLLC, Houston, Texas, USA.,University of Texas Medical Branch, Galveston, Texas, USA
| | - Erin M Lambie
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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7
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Jenkins LE, Cole EF, Blalock TW. Do Patients Fill Their Postoperative Opioid Prescription After Mohs Surgery? A Retrospective Study. Dermatol Surg 2021; 47:822-823. [PMID: 32897940 DOI: 10.1097/dss.0000000000002745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Lauren E Jenkins
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Emily F Cole
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Travis W Blalock
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute of Emory University School of Medicine, Atlanta, Georgia
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8
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Winsett F, Gleghorn K, Croley J, Wagner RF. Managing pain associated with dermatologic procedures. Int J Dermatol 2021; 60:e480-e485. [PMID: 33739460 DOI: 10.1111/ijd.15540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/15/2021] [Accepted: 02/26/2021] [Indexed: 11/30/2022]
Abstract
Dermatologists are faced with an aging population, accompanied by an increase in the incidence of skin cancer, especially nonmelanoma skin cancer. With this increase in cutaneous malignancy comes an increase in the number of dermatologic procedures being performed. A common concern of dermatologists and dermatology patients is the attenuation and management of pain associated with dermatologic procedures. Fortunately, there are several techniques that may be used in the preoperative, intraoperative, and postoperative periods to manage patient anxiety, minimize injection pain, and safely and effectively treat postoperative pain.
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Affiliation(s)
- Frank Winsett
- Department of Dermatology, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Kristyna Gleghorn
- Department of Dermatology, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Julie Croley
- Department of Dermatology, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Richard F Wagner
- Department of Dermatology, The University of Texas Medical Branch, Galveston, Texas, USA
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Strickler AG, Shah P, Bajaj S, Mizuguchi R, Nijhawan RI, Odueyungbo M, Rossi A, Ratner D. Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns. J Am Acad Dermatol 2021; 84:895-903. [PMID: 33493570 DOI: 10.1016/j.jaad.2021.01.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 12/17/2022]
Abstract
The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.
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Affiliation(s)
- Allen G Strickler
- Department of Dermatology, Geisinger Medical Center of Geisinger Commonwealth School of Medicine, Danville, Pennsylvania; Department of Laboratory Medicine, Geisinger Medical Center of Geisinger Commonwealth School of Medicine, Danville, Pennsylvania.
| | - Payal Shah
- School of Medicine, New York University Langone Health, New York, New York
| | - Shirin Bajaj
- Department of Dermatology, New York University Langone Health, New York, New York
| | - Richard Mizuguchi
- Department of Dermatology, Mount Sinai Medical School, New York, New York
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Anthony Rossi
- Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Désirée Ratner
- Department of Dermatology, New York University Langone Health, New York, New York
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10
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McLawhorn JM, Stephany MP, Bruhn WE, Crow LD, Coldiron BM, Hruza GJ, Leach BC, Soon SL, Friedmann DP, Stebbins WG, Blalock TW, Graves MS, Billingsley EM, Knackstedt TJ, Miller SJ, Yob EH, Albertini JG, Zeitouni N, Krathen RA, Bichakjian CK, Jellinek NJ, Hanke CW, Samie FH, Mann MW, Carucci JA, Kakar R, Saylor DK, Fosko SW, Ortiz AE, Henghold WB, Jennings TA, Davis DS, Maloney ME, Curcio NM, Behshad R, Tope WD, McCoppin H, Levin JI, Collins L, Stasko T. An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures. J Am Acad Dermatol 2020; 82:700-708. [DOI: 10.1016/j.jaad.2019.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
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11
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Saco M, Golda N. Optimal timing of postoperative pharmacologic pain control in Mohs micrographic surgery: A prospective cohort study. J Am Acad Dermatol 2020; 82:495-497. [DOI: 10.1016/j.jaad.2019.07.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/12/2019] [Accepted: 07/24/2019] [Indexed: 11/30/2022]
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