Underused Treatment Research Articles

Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal

Buprenorphine is an effective yet underused treatment for opioid use disorder (OUD). To evaluate the feasibility (acceptability, tolerability, and safety) of 7-day injectable extended-release buprenorphine in patients with minimal to mild opioid withdrawal. This nonrandomized trial comprising 4 emergency departments in the Northeast, mid-Atlantic, and Pacific geographic areas of the US included adults aged 18 years or older with moderate to severe OUD and Clinical Opiate Withdrawal Scale (COWS) scores less than 8 (minimal to mild), in which scores range from 0 to 7, with higher scores indicating increasing withdrawal. Exclusion criteria included methadone-positive urine, pregnancy, overdose, or required admission. Outcomes were assessed at baseline, daily for 7 days by telephone surveys, and in person at 7 days. Patient recruitment occurred between July 13, 2020, and May 25, 2023. Injection of a 24-mg dose of a weekly extended-release formulation of buprenorphine (CAM2038) and referral for ongoing OUD care. Primary feasibility outcomes included the number of patients who (1) experienced a 5-point or greater increase in the COWS score or (2) transitioned to moderate or greater withdrawal (COWS score ≥13) within 4 hours of extended-release buprenorphine or (3) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. Secondary outcomes included injection pain, satisfaction, craving, use of nonprescribed opioids, adverse events, and engagement in OUD treatment. A total of 100 adult patients were enrolled (mean [SD] age, 36.5 [8.7] years; 72% male). Among the patients, 10 (10.0% [95% CI, 4.9%-17.6%]) experienced a 5-point or greater increase in COWS and 7 (7.0% [95% CI, 2.9%-13.9%]) transitioned to moderate or greater withdrawal within 4 hours, and 2 (2.0% [95% CI, 0.2%-7.0%]) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. A total of 7 patients (7.0% [95% CI, 2.9%-13.9%]) experienced precipitated withdrawal within 4 hours of extended-release buprenorphine, which included 2 of 63 (3.2%) with a COWS score of 4 to 7 and 5 of 37 (13.5%) with a COWS score of 0 to 3. Site pain scores (based on a total pain score of 10, in which 0 indicated no pain and 10 was the worst possible pain) after injection were low immediately (median, 2.0; range, 0-10.0) and after 4 hours (median, 0; range, 0-10.0). On any given day among those who responded, between 29 (33%) and 31 (43%) patients reported no cravings and between 59 (78%) and 75 (85%) reported no use of opioids; 57 patients (60%) reported no days of opioid use. Improving privacy (62%) and not requiring daily medication (67%) were deemed extremely important. Seventy-three patients (73%) were engaged in OUD treatment on day 7. Five serious adverse events occurred that required hospitalization, of which 2 were associated with medication. This nonrandomized trial of the feasibility of a 7-day buprenorphine injectable in patients with minimal to mild opioid withdrawal (COWS scores, 0-7) found the formulation to be acceptable, well tolerated, and safe in those with COWS scores of 4 to 7. This new medication formulation could substantially increase the number of patients with OUD receiving buprenorphine. ClinicalTrials.gov Identifier: NCT04225598.

Adherence to clinical practice guidelines for using electroconvulsive therapy in elderly depressive patients

ObjectivesElectroconvulsive therapy (ECT) is one of the most effective treatments in mood disorders, mainly in major depressive episode (MDE) in the context of either unipolar (MDD) or bipolar disorder (BD). However, ECT remains a neglected and underused treatment. Older people are at high risk patients for the development of adverse drug reactions. In this context, we sought to determine the duration of MDEs and the number of lines of treatment before the initiation of ECT in patients aged 65 years or over according to the presence or absence of first-line indications for using ECT from international guidelines.MethodsIn this multicenter, retrospective study including patients aged 65 years or over with MDEs in MDD or BD who have been treated with ECT for MDEs, data on the duration of MDEs and the number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests.ResultsWe identified 335 patients. The mean duration of MDEs before ECT was about 9 months. It was significantly shorter in BD than in MDD- about 7 and 10 months, respectively. The co-occurrence of chronic medical disease increased the duration before ECT in the MDD group. The presence of first-line indications for using ECT from guidelines did not reduce the duration of MDEs before ECT, except where there was a previous response to ECT. The first-line indications reduced the number of lines of treatment before starting ECT.ConclusionEven if ECT seems to be a key treatment in the elderly population due to its efficacity and safety for MDEs, the delay before this treatment is still too long.

Maintenance electroconvulsive therapy: An effective yet underused treatment modality in psychiatry: A case series

Maintenance Electroconvulsive Therapy (M-ECT) refers to ECTs administered beyond 6 months after the remission of illness. Maintenance electroconvulsive therapy (M-ECT) can be used to reduce the risk for relapse and recurrence of illness in patients who fare poorly with standard medication regimens. There is improvement in the relapse rate of major psychiatric disorders when continuation or maintenance (C or M-ECT) are used with psychotropics. These are single-center, retrospective case studies of patients diagnosed with major psychiatric disorders (as per International Classification of Diseases, 11th edition) who are receiving M-ECT in Department of Psychiatry, B.J. Government Medical College and Sassoon Hospital, Pune. We included 12 patients- 8 males and 4 females in this study. 4 cases were of patients suffering from schizophrenia, 3 cases were of patients suffering from depression, 1 case of bipolar affective disorder and 4 cases of patients of intellectual disability with psychosis. There was a reduction in hospitalization rate for acute exacerbation and significant improvement in the patients’ overall functioning on standardized rating scales without any significant adverse effects. Maintenance ECT is an underused treatment option that can substantially reduce risks of relapse in patients with major depressive disorder, bipolar disorder and schizophrenia as well. Despite the potential value of these ECT schedules, these are relatively neglected in clinical practice. This article aims to explore the clinical utility of maintenance ECTs and emphasizes the use of maintenance ECTs in routine psychiatric care.

Metabolic Bariatric Surgery—A Vastly Underused Treatment

This Viewpoint discusses the disease of obesity: treatment options, disease management, and the need for legislation for obesity-related discrimination.

“You Do More Difficult Things Than This”: A National Study of Nurse Practitioner Buprenorphine Prescribing

Nearly 300 Americans die every day from unintentional drug overdoses, most involving opioids. Buprenorphine is an effective but underused treatment for opioid use disorder. This quantitative, descriptive study used data from a national survey to explore nurse practitioner buprenorphine prescribing. The study finds associations between full practice authority environments and buprenorphine prescribing propensity. The study also finds stigma and medication misconceptions may inhibit prescribing. To increase access to this lifesaving medication, policymakers, patient advocates, educators, and clinicians should focus on reducing state scope of practice barriers while advocating for education to address stigma and medication misperceptions.

Prescriptions for Buprenorphine in Michigan Following an Education Intervention

Buprenorphine is an underused treatment for opioid use disorder (OUD) that can be prescribed in general medical settings. Founded in 2017, the Michigan Opioid Collaborative (MOC) is an outreach and educational program that aims to address clinician and community barriers to buprenorphine access; however, the association between the MOC and buprenorphine treatment is unknown. To evaluate the association between MOC service use and county-level temporal trends of density of buprenorphine prescribers and patients receiving buprenorphine. This cohort study exploited staggered implementation of MOC services across all Michigan counties. Difference-in-difference analyses were conducted by applying linear fixed-effects regression across all counties to estimate the overall association of MOC engagement with outcomes and linear regression for each MOC-engaged county separately to infer county-specific results using data from May 2015 to August 2020. Analyses were conducted from September 2021 to November 2023. MOC engagement. County-level monthly numbers of buprenorphine prescribers and patients receiving buprenorphine (per 100 000 population). Among 83 total counties, 57 counties (68.7%) in Michigan were engaged by MOC by 2020, with 3 (3.6%) initiating engagement in 2017, 19 (22.9%) in 2018, 27 (32.5%) in 2019, and 8 (9.6%) in 2020. Michigan is made up of 83 counties with a total population size of 9 990 000. A total of 5 070 000 (50.8%) were female, 1 410 000 (14.1%) were African American or Black, 530 000 (5.3%) were Hispanic or Latino, and 7 470 000 (74.7%) were non-Hispanic White. The mean (SD) value of median age across counties was 44.8 (6.4). The monthly increases in buprenorphine prescriber numbers in the preengagement (including all time points for nonengaged counties) and postengagement periods were 0.07 and 0.39 per 100 000 population, respectively, with the absolute difference being 0.33 (95% CI, 0.12-0.53) prescribers per 100 000 population (P = .002). The numbers of patients receiving buprenorphine increased by an average of 0.6 and 7.15 per 100 000 population per month in preengagement and postengagement periods, respectively, indicating an estimated additional 6.56 (95% CI, 2.09-11.02) patients receiving buprenorphine per 100 000 population (P = .004) monthly increase after engagement compared with before. In this cohort study measuring buprenorphine prescriptions in Michigan over time, counties' engagement in OUD-focused outreach and clinician education services delivered by a multidisciplinary team was associated with a temporal increase in buprenorphine prescribers and patients receiving buprenorphine.

The IMPACT (Infection Management Plus Addiction Care Together) Pilot: A Case Series of Combined Contingency Management for Substance Use Disorders and Antibiotic Adherence in the Hospital Setting.

Psychostimulant-related mortality is rising alongside increasing substance use-related hospitalizations, which are commonly complicated by patient-directed (or "against medical advice") discharges. Contingency management (CM) is an underused evidence-based treatment for substance use disorders with proven efficacy to support medication adherence. Our objective was to describe feasibility and preliminary effectiveness of a novel CM intervention incentivizing both drug use reduction and antibiotic adherence in the hospital setting. We conducted a pilot intervention of twice weekly CM for stimulant and/or opioid use disorder and antibiotic adherence conducted on inpatient wards and/or an embedded skilled nursing facility in an urban public hospital. Based on point-of-care urine drug test results and objective antibiotic adherence review, participants earned increasing opportunities to receive incentives. We measured feasibility via number of visits attempted and cost of gift cards dispensed. We evaluated effectiveness via antibiotic completion, discharge type, and participant perception of intervention effectiveness collected via structured survey. Of 13 participants enrolled, most had opioid use disorder (fentanyl in 10/13) and stimulant use disorder (methamphetamine in 7/13). Almost all were receiving treatment for osteomyelitis and/or endocarditis (12/13). Feasibility challenges included competing demands of acute care with variable range of completed visits per participant (1-12 visits). Despite this, antibiotic completion was high (92%, 12/13 participants) with only two patient-directed discharges. Participants described CM as very effective in aiding infection treatment but had greater variability in beliefs regarding CM facilitation of reduced drug use. Providing CM in the hospital setting may represent an effective approach to improving health outcomes by increasing antibiotic adherence and addressing substance use.

Readability and content gaps in online epilepsy surgery materials as potential health literacy and shared-decision-making barriers.

Epilepsy surgery is an effective albeit underused treatment for refractory epilepsy, and online materials are vital to patient understanding of the complex process. Our goal is to analyze the readability and content inclusion of online patient health education materials designed for epilepsy surgery. A private browser setting was used on Google and Bing to identify the top 100 search results for the terms "epilepsy+surgery". Scientific papers, insurance pages, pay-wall access sites, and non-text content were excluded. The website text was reformatted to exclude graphics, contact information, links, and headers. Readability metrics were calculated using an online tool. Text content was analyzed for inclusion of important concepts (pre-surgical evaluation, complications, risks of continued seizures, types of surgery, complimentary diagrams/audiovisual material). Comparison of readability and content inclusion was performed as a function of organization types (epilepsy center, community health organization, pediatric-specific) and location (region, country). Browser search yielded 82 distinct websites with information regarding epilepsy surgery, with 98.7% of websites exceeding the recommended 6th-grade reading level for health information. Epilepsy centers had significantly worse readability (Flesch-Kincaid Grade Level (FKGL) P < 0.01 and Flesch Reading Ease (FRE) P < 0.05). Content analysis showed that only 37% of websites discuss surgical side effects and only 23% mention the risks of continued seizures. Epilepsy centers were less likely to report information on surgical side effects (P < 0.001). UK-based websites had better readability (FKGL P < 0.01 and FRE P < 0.01) and were more likely to discuss side effects (P = 0.01) compared to US-based websites. The majority of online health content is overly complex and relatively incomplete in multiple key areas important to health literacy and understanding of surgical candidacy. Our findings suggest academic organizations, including level 4 epilepsy centers, need to simplify and broaden online education resources. More comprehensive, publicly accessible, and readable information may lead to better-shared decision-making.

Placebos in pediatrics: A cross-sectional survey investigating physicians' perspectives

ObjectivePlacebo responses are significantly higher in children than in adults, suggesting a potential underused treatment option in pediatric care. To facilitate the clinical translation of these beneficial effects, we explored physicians' current practice, opinions, knowledge, and likelihood of recommending placebos in the future. MethodsA cross-sectional web-based survey administered by REDCap was conducted at Boston Children's Hospital between October 2021 and March 2022. Physicians (n = 1157) were invited to participate through an email containing a link to a 23-item survey designed to assess physicians' attitudes and perceptions towards the clinical use of placebo in pediatrics. ResultsFrom 207 (18%) returned surveys, 109 (9%) were fully completed. Most respondents (79%) believed that enhancing the therapeutic components that contribute to the placebo response may be a way of improving pediatric care. However, whereas most (62%) found placebo treatments permissible, only one-third reported recommending them. In pediatrics, placebos are typically introduced as a medicine that “might help” (43%). The most common treatments recommended to enhance placebo effects are physical therapy, vitamins, and over-the-counter analgesics. Physicians most frequently recommend placebos for occasional pain, headaches, and anxiety disorders. Finally, the great majority of physicians (87%) stated they would be more likely to recommend placebo treatments if there were safety and ethical guidelines for open-label placebos. ConclusionsPlacebo treatments seem permissible to physicians in pediatric care, but the development of safety and ethical guidelines may be necessary before physicians systematically incorporate the benefits of the placebo effect in pediatrics.

A Potential Systematic Barrier to Community Health Literacy about Epilepsy Surgery: A Preliminary Readability Analysis of Online Health Education Materials in the United States (P6-1.006)

<h3>Objective:</h3> Analyze readability of online health education materials designed to provide epilepsy surgery information to patients. <h3>Background:</h3> Epilepsy surgery is an effective albeit underused treatment for refractory epilepsy. The workup and procedure explanations are complex and further compounded by the cognitive difficulties many people with epilepsy face. A previous United Kingdom study showed poor readability of online resources used for epilepsy surgery. However, there is still much to explore regarding the readability of resources in the United States, and what kinds of sites are associated with better readability. <h3>Design/Methods:</h3> A private browser was used to search Google for the top 100 search results for the terms “epilepsy+surgery”. Scientific papers, insurance pages, pay-wall access sites, and non-text content were excluded. The website text was re-formatted to exclude graphics, contact information, links, and headers. Readability metrics were calculated using an online readability tool (Datayze Readability Analyzer). Analysis was done through R using the Kruskal-Wallis test, and statistical assumptions were assessed. <h3>Results:</h3> Here we present the preliminary analysis of the top 100 items from a Google search yielding 76 websites and 24 exclusions. Websites were categorized as US based organizations or non-US, content from level 4 epilepsy centers, and if the sources were community health websites not associated with academic institutions. The Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) showed significantly better readability in community health websites (FRE p=.03, FKGL p=.03), non-level 4 epilepsy centers (FRE p=.002, FKGL p=.002), and international websites (FRE p=.02, FKGL =.03). <h3>Conclusions:</h3> Health information source characteristics associated with better readability levels included non-academic centers, non-level 4 epilepsy centers and community health information websites. This analysis suggests that academic centers, especially level 4 epilepsy centers, should consider involving community members, advocacy organizations and non-medical writers in the designing of online epilepsy surgery health education materials. <b>Disclosure:</b> Mr. Seneviratne has nothing to disclose. Ms. Ho has nothing to disclose. Dr. Correa has received personal compensation in the range of $0-$499 for serving as a Consultant for Independent Medical Consultants. Dr. Correa has received personal compensation in the range of $0-$499 for serving as a Consultant for Atheneum Partners. Dr. Correa has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Academy of Neurology. Dr. Correa has stock in Aidin Inc. Dr. Correa has received research support from Genentech. Dr. Correa has received research support from Psi Upsilon Foundation Inc.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers.

Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States. The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing. Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming. Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

Comparing the clinical and cost-effectiveness of remote (telehealth and online) cognitive behavioral therapy-based treatments for high-impact chronic pain relative to usual care: study protocol for the RESOLVE multisite randomized control trial

BackgroundCognitive behavioral therapy for chronic pain (CBT-CP) is an effective but underused treatment for high-impact chronic pain. Increased access to CBT-CP services for pain is of critical public health importance, particularly for rural and medically underserved populations who have limited access due to these services being concentrated in urban and high income areas. Making CBT-CP widely available and more affordable could reduce barriers to CBT-CP use.MethodsAs part of the National Institutes of Health Helping to End Addiction Long-term® (NIH HEAL) initiative, we designed and implemented a comparative effectiveness, 3-arm randomized control trial comparing remotely delivered telephonic/video and online CBT-CP-based services to usual care for patients with high-impact chronic pain. The RESOLVE trial is being conducted in 4 large integrated healthcare systems located in Minnesota, Georgia, Oregon, and Washington state and includes demographically diverse populations residing in urban and rural areas. The trial compares (1) an 8-session, one-on-one, professionally delivered telephonic/video CBT-CP program; and (2) a previously developed and tested 8-session online CBT-CP-based program (painTRAINER) to (3) usual care augmented by a written guide for chronic pain management. Participants are followed for 1 year post-allocation and are assessed at baseline, and 3, 6, and 12 months post-allocation. The primary outcome is minimal clinically important difference (MCID; ≥ 30% reduction) in pain severity (composite of pain intensity and pain-related interference) assessed by a modified 11-item version of the Brief Pain Inventory-Short Form at 3 months. Secondary outcomes include pain severity, pain intensity, and pain-related interference scores, quality of life measures, and patient global impression of change at 3, 6, and 12 months. Cost-effectiveness is assessed by incremental cost per additional patient with MCID in primary outcome and by cost per quality-adjusted life year achieved. Outcome assessment is blinded to group assignment.DiscussionThis large-scale trial provides a unique opportunity to rigorously evaluate and compare the clinical and cost-effectiveness of 2 relatively low-cost and scalable modalities for providing CBT-CP-based treatments to persons with high-impact chronic pain, including those residing in rural and other medically underserved areas with limited access to these services.Trial registrationClinicalTrials.gov NCT04523714. This trial was registered on 24 August 2020.

Is Intravenous Immunoglobulin Therapy for Chronic Pain Conditions an Underused Treatment Option?

Is Intravenous Immunoglobulin Therapy for Chronic Pain Conditions an Underused Treatment Option?

Does Electroconvulsive Therapy for Patients with Mood Disorders Extend Hospital Length of Stays and Increase Inpatient Costs?

Although randomized trials have shown that electroconvulsive therapy (ECT) is an effective and underused treatment for mood disorders, its impact on inpatient length of stay (LOS) and hospital costs are not fully understood. We analyzed private insurance claims of patients hospitalized for mood disorders who had continuous insurance for three months prior to an index hospitalization and six months after discharge (N = 24,249). Propensity score weighted linear models were used to examine the association of any ECT use, the number of ECT treatments, and time to first ECT treatment, with LOS and hospital costs adjusting for potential confounders. Three months prior to the index hospitalization, patients who subsequently received ECT had more than double the total healthcare costs and bed days ($12,669 vs. $6,333 and 4.5 vs. 0.92days, p < .001) of the other group. During their index admission, patients receiving ECT had longer LOS (16.1 vs. 5.8days, p < .001) and three times greater hospital costs ($28,607 vs. $8,708, p < .001). Analyses adjusted for other group differences showed a dose-response relationship between the number of ECT treatments and LOS and hospital costs. Receipt of ECT was associated with increased LOS by 4 to 29days depending on the number of ECT treatments and increasing total hospital costs from $5,767 to $52,717. Receipt of any ECT and the number of treatments during hospitalization were associated with markedly increased LOS, hospital admission costs, and post-discharge costs. Cost-effectiveness of ECT may be enhanced by shifting treatments to outpatient settings when possible.

Slowing the Flow: Management of Benign Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB), specifically heavy menstrual bleeding, is a common condition that can significantly affect women’s lives. AUB can impact women’s health, finances, social engagement, and overall quality of life. Potential causes of AUB can be assessed using a standard mnemonic to identify the origin as structural or nonstructural. The PALM-COEIN mnemonic stands for polyps, adenomyosis, leiomyoma, malignancy, hyperplasia, coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic causes, and those not yet classified that are rare or not clearly defined. Treatment options include medical therapies, procedures, or surgical interventions. Nurse practitioners should partner with patients to individualize their plan of care based on best practices, beginning with the least invasive method. This case challenge highlights an underused treatment option for premenopausal women with heavy menstrual bleeding.

Beyond border health: Infrastructural violence and the health of border abolition

Most existing approaches to border health focus on identifying the social determinants that produce ill health and health disparities among migrants, including language barriers, documentation status, and trauma associated with migration. Attention to these kinds of problems can lead to policy and clinical changes that indeed help improve quantitatively measurable outcomes for patients. However, these approaches usually ignore the larger historical and political framework that determines the determinants – the underlying infrastructure of ill health, or what we term the infrastructural determinants of health. In this paper, we outline specific infrastructures involving race, political economy, history, and most importantly, borders themselves, that lay the foundations for border illness. We examine the plans, histories, policies, and peoples involved in building the conditions for migration, particularly out of the Northern Triangle, including forces of colonialism, US imperialism, neoliberalism, and border militarization. In place of a tacit acceptance of the modern system of borders, we argue for border abolition as a vital but underused treatment in the repertoire of medical intervention. Outlining the rights of people to stay and to move, and drawing on lessons from the prison abolition movement, we offer policies and practices towards a ‘no borders’ system that privileges liberatory solidarity with migrants by explicitly challenging global infrastructures that drive displacement. In doing so, we offer an emergent framework for a medical border abolition that treats both the causes and symptoms of a widespread global sickness.

Nitroglycerin, or Not, When Treating Impending Filler Necrosis.

Dermal necrosis is a rare yet serious risk associated with cosmetic filler injections, and although current consensus recommends the use of hyaluronidase injections in cases of hyaluronic acid filler, the efficacy of topical nitroglycerin as a treatment has not yet been fully investigated. To review the literature on tissue necrosis resulting from soft tissue augmentation and to highlight the use of topical nitroglycerin as a first-line treatment. A review of the literature was performed with no time limitations resulting in 35 articles and 66 patients who experienced tissue necrosis secondary to injectable fillers. Articles were reviewed for pertinent information and presented. Only 7 of the 66 reported cases (10%) used topical nitroglycerin as a treatment. Six of 7 (85%) were successful in halting the impending necrosis. Fifty-nine patients received alternative treatments, with hyaluronidase injection being the most common. Few reports of novel treatments for necrosis included the use of topical growth factors and injection of adipose-derived stem cells. Topical nitroglycerin is a potentially effective and underused treatment for tissue necrosis from soft tissue augmentation, but because data are very limited, topical nitroglycerin should be used in conjunction with hyaluronidase injections in cases of hyaluronic acid filler dermal necrosis.

Apomorphine therapy: alternative initiation for patients with complex Parkinson's disease presentation

The apomorphine challenge test can be a distressing experience for some patients and, if they are not experienced, a discouraging option for some healthcare professionals (HCPs). The test is repeated exposure to bolus-dose injection of the medication to assess response and patient-specific dose before embarking on apomorphine therapy. Recent changes in prescribing of the anti-emetic domperidone (limited use because of QT prolongation), a drug which is a prerequisite for most patients embarking on therapy, has also added a possible complication. While recognising the value of the apomorphine challenge test, the author suggests an alternative approach of establishing apomorphine by subcutaneous infusion pump (SCAI) without the challenge test. This approach makes it more ‘user friendly’ for people with complex Parkinson's disease (PwPd) and their HCPs, and can eliminate the need for preloading with domperidone or other anti-emetic (if one is available in the country of practice). It is a viable option in acute situations, such as nil by mouth, surgery and oral dopamine agonist withdrawal, because of the associated harmful impulsive behaviour. Starting immediately with SCAI without the challenge test has proven both helpful and beneficial in clinical practice, especially in PwPd who have potential to abuse the intermittent injection, have complicated regimens and are vulnerable to drug-induced adverse effects. Some patients only need nocturnal infusions; injections during the night are difficult to administer and miss the objective of better sleep. Facilitating the process of initiation with the SCAI could improve uptake of this underused treatment through easier use and positive experience, and overcome the need for short- and longer-term domperidone use.

67.4 WHEN DO I GET TO TOUCH THE DIRTY TOILET SEAT AND OTHER FUN EXPOSURES: TIPS FOR CLINICIANS

Clinical experience teaches that few, if any, children presenting with OCD or any anxiety disorder enter therapy eagerly wishing to confront their fears. Young patients rarely ask questions like, “When do I get to touch the dirty toilet seat?” Instead, they demonstrate expected levels of avoidance. Research on inhibitory learning indicates that the key elements in successful exposure are decreasing emotionally driven behaviors such as avoidance, as well as reinforcing new approach behaviors that enable greater tolerance for anxiety. A previous study noted that the key element in psychotherapy is engaging patients’ willingness to change. Gamelike and fun exposures increase treatment engagement, propel motivation, and consequently foster greater willingness. Humor, fun, and silliness when implementing exposures make the tasks more appealing. Exposure therapy is a powerful yet underused treatment method. Some research indicates that the utilization rate of exposure matches or is less than the use of nonevidence-based, questionable clinical practices in treatment-as-usual community settings. This presentation aims to increase child psychiatrists’ skills in crafting fun and engaging exposures with children and adolescents. Accordingly, the session is entirely consistent with the conference themes emphasizing translational science to enhance the quality of patient care and training and build excellent service delivery systems.

Barriers to Neoadjuvant Chemotherapy before Radical Cystectomy at a Single Referral Center in South Florida.

We investigated barriers to the receipt of neoadjuvant chemotherapy by patients undergoing radical cystectomy. After institutional review board approval we performed a retrospective chart review from January 1, 2012 to March 1, 2018 of cases of radical cystectomy with urinary diversion for bladder cancer. Patients were placed in 1 of 3 groups according to eligibility to receive neoadjuvant chemotherapy before undergoing cystectomy, as "NAC" if they received neoadjuvant chemotherapy, "No NAC - Declined" if they were eligible but declined neoadjuvant chemotherapy and "No NAC - Ineligible" if they were clinically ineligible to receive neoadjuvant chemotherapy. We performed univariate and multivariate analyses on social and pathological factors in these 3 categories. Of 268 patients identified 209 were eligible to be included in this study. On univariate analysis statistical differences were noted according to age and distance from treatment center. On pathological analysis stage was statistically different between the cohorts. A multivariate analysis revealed that single patients were more likely to decline neoadjuvant chemotherapy as opposed to married patients. Neoadjuvant chemotherapy before radical cystectomy for muscle invasive bladder cancer continues to be an underused treatment modality in South Florida. Age, marital status and distance from treatment center all appear to have an impact on patient acceptance of or referring doctor recommendations for neoadjuvant chemotherapy. We suggest larger multi-institutional studies to further assess this issue.