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Ryans CP, Brooks BM, Tower DE, Robbins JM, Butterworth ML, Stapp MD, Nettles AM, Brooks BM. Evidence-Based Opioid Education That Reduces Prescribing: The 10 Principles of Opioid Prescribing in Foot and Ankle Surgery. J Foot Ankle Surg 2024; 63:214-219. [PMID: 37981027 DOI: 10.1053/j.jfas.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/30/2023] [Accepted: 11/04/2023] [Indexed: 11/21/2023]
Abstract
Over half of opioid misusers last obtained access to opioids via a friend or relative, a problematic reflection of the opioid reservoir phenomenon, which results from an unused backlog of excess prescription opioids that are typically stored in the American home. We aim to determine if a voluntary educational intervention containing standard opioid and nonopioid analgesic prescribing ranges for common surgeries is effective in altering postoperative prescribing practice. We utilized a mixed methods approach and sent out a questionnaire to American podiatric physicians, including residents (baseline group A), via email in early 2020 for baseline data; then, we interviewed foot and ankle surgeons and the primary themes of these semistructured interviews informed us to target residents for an educational intervention. We repeated the survey 3 years later in summer 2022 (preintervention group B). We created an opioid guide and emailed it to residents in fall 2022. Another repeat survey was done in spring 2023 (postintervention group C). We used the Mann-Whitney U test to examine differences between the groups among their reported postoperative opioid quantities for a first metatarsal osteotomy surgical scenario. Groups A, B, and C had 60, 100, and 99 residents, respectively. There was no significant difference (p = .9873) between baseline group A and preintervention group B. There was a difference (p < .0001; -5 median) between preintervention group B and postintervention group C (same residency year). In postintervention group C, a majority (91/99) reported viewing the guide at least once, and the number of residents that reported supplementing with NSAIDs also doubled compared to preintervention group B. This novel opioid educational intervention resulted in meaningful change in self-reported postoperative prescribing behavior among residents.
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Affiliation(s)
| | - Bradley M Brooks
- University of South Alabama Health, Department of Psychiatry, AL
| | - Dyane E Tower
- The American Podiatric Medical Association, Bethesda, MD
| | - Jeffrey M Robbins
- Department of Veterans Affairs Central Office Services, Cleveland, OH
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Benedict K, Gold JAW, Jones CT, Tushla LA, Lipner SR, Joseph WS, Tower DE, Elewski B, Pappas PG. Concerning rates of laboratory-confirmed antifungal-resistant onychomycosis and tinea pedis: An online survey of podiatrists, United States. Health Sci Rep 2023; 6:e1694. [PMID: 38028688 PMCID: PMC10667959 DOI: 10.1002/hsr2.1694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Kaitlin Benedict
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental DiseasesCenters for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Carolynn T. Jones
- Mycoses Study Group Education and Research ConsortiumBirminghamAlabamaUSA
- College of NursingThe Ohio State UniversityColumbusOhioUSA
| | | | - Shari R. Lipner
- Department of DermatologyWeill Cornell MedicineNew YorkNew YorkUSA
| | - Warren S. Joseph
- Arizona College of Podiatric MedicineMidwestern UniversityGlendaleArizonaUSA
| | - Dyane E. Tower
- American Podiatric Medical AssociationBethesdaMarylandUSA
| | - Boni Elewski
- Department of DermatologyUniversity of BirminghamBirminghamAlabamaUSA
| | - Peter G. Pappas
- Department of Medicine, Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Brooks BM, Bratches RWR, Wolff KB, Stapp MD, Bruce KW, Tower DE. Opioid-Prescribing Approaches-One-Size-Fits-All versus Patient-Centric and Procedure-Focused-Among Podiatric Physicians: A Cross-Sectional Study. J Am Podiatr Med Assoc 2023; 113:21-246. [PMID: 37717232 DOI: 10.7547/21-246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND More than half of opioid misusers last obtained opioids from a friend or relative, a problematic reflection of the commonly known opioid reservoir maintained by variable prescription rates and, notably, excessive postoperative prescription. We examined the postoperative opioid-prescribing approaches among podiatric physicians. METHODS We administered a scenario-based, anonymous, online questionnaire via an online survey platform. The questionnaire consisted of five patient-foot surgery scenarios aimed at discerning opioid-prescribing approaches. Respondents were asked how many opioid "pills" (dosage units) that they would prescribe at the time of surgery. We divided respondents into two opioid-prescribing approach groups: one-size-fits-all (prescribed the same dosage units regardless of the scenario) and patient-centric and procedure-focused (prescribed varied amounts of opioid dosage units based on the patient's opioid history and the procedure provided in each scenario). We used the Mann-Whitney U test to determine the difference between the opioid dosage units prescribed at the time of surgery by the two groups. RESULTS Approximately half of the respondents used a one-size-fits-all postoperative opioid-prescribing approach. Podiatric physicians who used a patient-centric and procedure-focused approach reported prescribing significantly fewer opioid dosage units in scenarios 1 (partial toe amputation; -9.1; P = .0087) and 2 (incision and drainage with partial fifth-ray resection; -12.3; P = .0024), which represented minor procedures with opioid-naive patients. CONCLUSIONS Podiatric physicians who used a one-size-fits-all opioid-prescribing approach prescribed more postoperative opioid dosage units regardless of the scenario. Given that the patient population requiring foot surgery is diverse and may have multiple comorbidities, the management of postoperative pain, likewise, should be diverse and nuanced. The patient-centric and procedure-focused approach is suited to limit excess prescribing while defending the physician-patient relationship.
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Affiliation(s)
- Brandon M Brooks
- *The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
- †Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC
| | - Reed W R Bratches
- *The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Kristina B Wolff
- *The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | | | | | - Dyane E Tower
- ‖American Podiatric Medical Association, Bethesda, MD
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Brooks BM, Shih CD, Brooks BM, Tower DE, Tran TT, Simon JE, Armstrong DG. The Diabetic Foot-Pain-Depression Cycle. J Am Podiatr Med Assoc 2023; 113:22-126. [PMID: 37463195 DOI: 10.7547/22-126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND More than 86,000 Americans with type 2 diabetes mellitus (T2DM) undergo nontraumatic lower-extremity amputations annually. The opioid-prescribing practice of podiatric surgeons remains understudied. We hypothesized that patients with T2DM who undergo any forefoot amputation while using antidepressant medication will have reduced odds of using opioids beyond 7 days. METHODS We completed a retrospective cohort study examining patients with T2DM who underwent forefoot amputation (toe, ray, transmetatarsal). Data were restricted to patients with a hemoglobin A1c level less than 8.0% and an ankle-brachial index greater than 0.8. The outcome was use of postoperative opioids beyond 7 days. Patients received an initial opioid prescription of 7 days or less. We developed simple logistic regression models to identify the odds of a patient using opioids beyond 7 days by patient variables: age, race, sex, amputation level, body mass index, antidepressant medication use, and marital status. Variables with P < .1 in the univariate analysis were included in the multiple logistic regression model. RESULTS Fifty patients met the inclusion criteria. Antidepressant use and marital status were the only statistically significant variables. Adjusting for marital status, patients with antidepressant use had decreased odds (odds ratio, 0.018; 95% confidence interval, 0.001-0.229; P = .002) of using opioids beyond 7 days after a diabetic forefoot amputation. CONCLUSIONS Patients with T2DM who used antidepressants had significantly reduced odds of using opioids beyond 1 week after forefoot amputations compared with those without antidepressant use. We proposed an underlying diabetic foot-pain-depression cycle. To break the cycle, podiatric surgeons should screen this population for depression preoperatively and postoperatively and not hesitate to make a mental health referral if warranted. Nontraumatic amputations can be a traumatic experience for patients; psychiatrists and other mental health providers should be members of limb preservation teams.
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Affiliation(s)
- Brandon M Brooks
- *The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH; Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC
| | - Chia-Ding Shih
- †California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
| | | | - Dyane E Tower
- §American Podiatric Medical Association, Bethesda, MD
| | - Tiffany T Tran
- †California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
| | | | - David G Armstrong
- ¶Keck School of Medicine of University of Southern California, Los Angeles, CA
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Saini K, Tran T, Khosravi M, Krishnan J, Tower DE, Shih CD. Toenail Dust as a Potential Occupational Hazard in Podiatric Medicine: A Comprehensive Literature Review. J Am Podiatr Med Assoc 2022; 112:20-197. [PMID: 36251593 DOI: 10.7547/20-197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Debridement of toenails is a common procedure that leads to the production of nail dust aerosols in the work environment. Previous studies indicate that inhaled nail dust can cause respiratory distress and eye irritation. This comprehensive review aimed to assess the available literature on the effect of nail dust exposure and to evaluate nail dust as a potential occupational hazard for podiatric physicians. METHODS A comprehensive literature search was conducted via PubMed, Google Scholar, CINAHL, Cochrane Library, and ClinicalTrials.gov. Risks of bias of the collected studies were evaluated using various assessment tools to match the type of study design. A qualitative analysis of the included studies was performed, from which primary and secondary outcome measures were extracted: prevalence of symptoms and specific microorganisms in nail dust. RESULTS Of 403 articles screened, eight met the inclusion criteria. The primary outcome measure resulted in a pooled prevalence of eye-related symptoms being the most consistent symptom reported (41%-48%). The secondary outcome measure resulted in a pooled prevalence of Trichophyton rubrum (9.52%-38%) and Aspergillus (11.11%-35.48%) as the most common microorganisms present in nail dust. CONCLUSIONS From the included eight articles, we found that nail dust is a potential occupational hazard, especially for those exposed more often. Aspergillus and T rubrum are most commonly associated with nail dust leading to development of respiratory illness. It is important to take preventive measures in podiatric medical clinics by using improved and efficient personal protective equipment for workers exposed to nail dust. Detailed health safety guidelines can be developed to decrease respiratory symptoms and diseases from nail dust exposure.
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Affiliation(s)
- Komal Saini
- *California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
| | - Tiffany Tran
- *California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
| | - Melody Khosravi
- *California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
| | - Jannani Krishnan
- *California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
| | - Dyane E Tower
- †Clinical Affairs, American Podiatric Medical Association, Bethesda, MD
| | - Chia-Ding Shih
- *California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
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Abstract
Acral fibrokeratoma is a rare soft-tissue mass, more commonly found on the hands and rarely on the feet. This case report of a 40-year-old Hispanic man highlights an unusually located acral fibrokeratoma on the second toe, describes the clinical presentation and microscopic and pathologic findings, discusses differential diagnoses, and presents treatment options.
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Tower DE, Wood RW, Vaardahl MD. Talocalcaneal Joint Middle Facet Coalition Resection With Interposition of a Juvenile Hyaline Cartilage Graft. J Foot Ankle Surg 2015; 54:1178-82. [PMID: 25922335 DOI: 10.1053/j.jfas.2015.02.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Indexed: 02/03/2023]
Abstract
Talocalcaneal joint middle facet coalition is the most common tarsal coalition, occurring in ≤2% of the population. Fewer than 50% of involved feet obtain lasting relief of symptoms after nonoperative treatment, and surgical intervention is commonly used to relieve symptoms, increase the range of motion, improve function, reconstruct concomitant pes planovalgus, and prevent future arthrosis from occurring at the surrounding joints. Several approaches to surgical intervention are available for patients with middle facet coalitions, ranging from resection to hindfoot arthrodesis. We present a series of 4 cases, in 3 adolescent patients, of talocalcaneal joint middle facet coalition resection with interposition of a particulate juvenile hyaline cartilaginous allograft (DeNovo(®) NT Natural Tissue Graft, Zimmer, Inc., Warsaw, IN). With a mean follow-up period of 42.8 ± 2.9 (range 41 to 47) months, the 3 adolescent patients in the present series were doing well with improved subtalar joint motion and decreased pain, and 1 foot showed no bony regrowth on a follow-up computed tomography scan. The use of a particulate juvenile hyaline cartilaginous allograft as interposition material after talocalcaneal middle facet coalition resection combined with adjunct procedures to address concomitant pes planovalgus resulted in good short-term outcomes in 4 feet in 3 adolescent patients.
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Affiliation(s)
- Dyane E Tower
- Podiatrist, Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Assistant Professor of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Ryan W Wood
- Podiatrist, Coachella Valley Foot and Ankle, Rancho Mirage, CA
| | - Michael D Vaardahl
- Podiatrist, Foot and Ankle Center of Northern Colorado, Greeley, CO; Residency Director, North Colorado Medical Center, Greeley, CO
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Warner CJ, Richey EA, Tower DE, Condino AE, Tapp SJ, Tosteson AN, Walsh DB. Inferior vena cava filter retrieval provides no advantage in the average patient. J Vasc Surg Venous Lymphat Disord 2015; 3:142-6. [DOI: 10.1016/j.jvsv.2014.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 12/30/2014] [Indexed: 11/30/2022]
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Warner CJ, Condino AE, Richey EA, Tower DE, Tapp SJ, Tosteson AN, Walsh DB. Leave ‘Em or Retrieve ‘Em? Management of Inferior Vena Cava Filters†. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Warner CJ, Condino AE, Richey EA, Tower DE, Tapp SJ, Tosteson AN, Walsh DB. PS178. Leave ‘Em or Retrieve’ Em? Management of Inferior Vena Cava Filters. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.03.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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