The opioid overdose epidemic is typically described as having occurred in three waves, with morbidity and mortality accruing over time principally from prescription opioids (1999-2010), heroin (2011-2013) and illicit fentanyl and other synthetic opioids (2014-present). However, the increasing presence of synthetic opioids mixed into the illicit drug supply, including with stimulants such as cocaine and methamphetamine, as well as rising stimulant-related deaths, reflects the rapidly evolving nature of the overdose epidemic posing urgent and novel public health challenges. We synthesize the evidence underlying these trends, consider key questions such as where and how concomitant exposure to fentanyl and stimulants is occurring, and identify actions for key stakeholders regarding how these emerging threats, and continued evolution of the overdose epidemic, can best be addressed.

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Purpose In light of highly publicized media coverage on breast implant recalls and Food and Drug Administration hearings on breast implant safety, online searches of these topics have surged. It is thus critical to determine whether such searches are providing meaningful information for those who use them. Patient/laywomen-directed online education materials on breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) must not only be comprehensible but also accurate, actionable, and culturally concordant, especially as more diverse populations turn to the internet for breast implant–related information. This study assessed the overall suitability of BIA-ALCL patient–directed educational text and video-based materials online. Methods This was a cross-sectional, multimetric investigation of online text– and video-based patient-directed educational materials for BIA-ALCL using multiple validated measures. Two reviewers assessed each resource. Kruskal-Wallis and Fisher exact analyses were used as appropriate to compare text- and video-based online resources. Results In total, 30 websites and 15 videos were evaluated, more than half (56%) of which were from academic/physician or governmental/nonprofit sources. Overall, website and video content, as well as quality, varied by source. Academic/physician or governmental/nonprofit sources tended to be more comprehensive and have higher-quality information than commercial/media outlet sources. Median actionability of websites was 38%, well below the threshold of 70% used in the literature to identify actionable resources. The median suitability score for BIA-ALCL websites was 57%, which is considered “adequate” based on published thresholds. The mean overall Cultural Sensitivity Assessment Tool score for websites was 2.4; Cultural Sensitivity Assessment Tool scores higher than 2.5 are generally regarded as culturally sensitive. In general, videos were more understandable than websites. Substantial interrater reliability across the validated tools used in this study was noted using Pearson correlation coefficients. Conclusions Online resources varied in content and quality by source. As BIA-ALCL becomes an increasingly salient topic among both providers and patients, it is important to empower women with accurate information about this implant-associated cancer. Of available resources, providers should refer patients or those seeking more information to websites from governmental/academic organizations (“.gov” or “.org” domains) and videos from academic/physician or governmental sources, given that among high-quality resources, these were most clear/comprehensible. Overall, there is a need for improved online content on this topic.

BackgroundA personal history of depression prior to breast cancer diagnosis and its effect on post-diagnosis quality of life (QOL) in women undergoing breast reconstruction is relatively unknown. We performed the current study to determine if depression alters QOL for patients who undergo breast reconstruction by assessing the pre-to-post-operative change in patient-reported BREAST-Q scores. MethodologyWe conducted a single-center, post-hoc analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction from November 2013 to November 2016 following a diagnosis of breast cancer. Patients completed the BREAST-Q at four time points: pre-operatively, six weeks following tissue expander (TE) insertion for patients undergoing staged reconstruction, and six and 12 months following the final reconstruction. Medical records were reviewed to identify patients who had a pre-cancer diagnosis of clinical depression and/or anti-depressant medication use. BREAST-Q scores were compared between groups and within groups. Groups compared were the depression (n = 50) and no depression (n = 250) patients, along with anti-depressant (n = 36) and no anti-depressant (n = 14) use in the depression group. ResultsWithin-group Sexual Well-being scores at the six-week post-TE follow-up for patients in the depression group (median = 37, interquartile range [IQR] = 25-47) were significantly lower (p < 0.01) than the scores for patients in the no depression group (median = 47, IQR = 39-60). There were no statistically significant differences in BREAST-Q scores in other domains. When compared to patients diagnosed with depression who were not taking anti-depressants, anti-depressant medication use did not result in statistically significant higher BREAST-Q scores, although Satisfaction With Breasts six months post-operatively, Psychosocial Well-being at six weeks post-TE, Sexual Well-being at six weeks post-TE and six months postoperatively were clinically higher in patients taking anti-depressants for depression. ConclusionsPatients with a diagnosis of depression prior to breast cancer had lower BREAST-Q Sexual Well-being scores in the six-week TE group with or without anti-depressant medication. Patients with a pre-cancer diagnosis of depression considering TEs may benefit from additional counseling prior to breast reconstruction or electing a different method of breast reconstruction. Anti-depressant medications may provide clinically higher BREAST-Q scores in patients with a pre-cancer diagnosis of depression. Adding an anti-depressant medication to a patient's treatment plan may provide additional benefits. Larger samples are required to properly determine the impact of anti-depressant medications on BREAST-Q scores in patients with a precancer diagnosis of depression.

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Introduction Effective management of chronic burn-induced neuropathy manifesting as pain and/or pruritus presents an ongoing challenge for clinicians. Standards of care are based on limited evidence and vary widely, especially for non-surgical neuropathies that are not associated with a specific nerve distribution. This study aims to quantify and qualify evidence for non-surgical treatments of chronic burn-induced neuropathy to define their efficacy. Methods PRISMA and Cochrane guidelines were implemented for review structure. PubMed, Science Direct, Embase, Cochrane Library, and Web of Science databases were searched for relevant studies. Inclusion criteria were patients age 18 years and older, with neuropathy lasting &gt;6 months following burn injury. Studies for inclusion were comparative intervention studies for treatments of chronic burn-induced neuropathies. Mean differences (MD) between interventions eligible for meta-analysis were analyzed for neuropathy outcomes. Results Seventeen randomized controlled trials (RCTs) were identified for inclusion with a mean post-burn follow-up of 20.8±39.3 months. Nine studies reported pain and sixteen reported pruritus using patient reported visual analogue scales for 601 and 975 patients, respectively. Pain interventions included transcranial direct current stimulation (tDCS), extracorporeal shockwave therapy (EWST), massage therapy, carbon dioxide (CO2) laser, silicone gel, and pressure therapy. Pruritus interventions included tDCS, ESWT, massage, herbal cream, doxepin cream, enzymatic moisturizer, CO2 laser, silicone gel, and pressure therapy. CO2 laser showed no improvement over standard care for the treatment of pain or pruritus associated with hypertrophic scarring (pain: MD 0.26, 95%CI -0.04, 0.57; p=0.09; pruritus: MD -0.07, 95%CI -0.44, 0.30; p=0.72). ESWT showed no statistically significant improvement over standard care for the treatment of pruritus (MD -2.69, 95%CI -5.42, 0.04; p=0.05). Massage therapy was associated with significantly greater improvements in pruritus than standard care (MD -1.64, 95%CI -2.10, -1.09; p&lt; 0.00001). Doxepin cream was not associated with greater improvements in pruritus than placebo or antihistamines (MD -0.84, 95%CI -3.61, 1.94; p=0.56). Conclusions Creative efforts have revealed massage therapy as a potential non-surgical intervention for treating chronic burn-induced neuropathy. Additional RCTs with innovative non-surgical interventions will provide further insights for this challenging condition.