Therapeutics Commons^™

Use Of An Electronic Dynamometer Following Pitching To Identify Fatigue In Softball Pitchers, Bethany L. Hansberger, Peter Lisman

Clinical Practice in Athletic Training

This study used a case-series design to collect in-game fatigue measures for collegiate softball pitchers immediately after pitching during the competitive season. Five softball pitchers (age = 19.8 ± 1.5 years; height = 169.9±6.1 cm; body mass = 79.1±22.6 kg) from one Division I program were recruited. Isometric internal and external rotation, scaption, and grip strength measures were collected using an electronic dynamometer at the beginning and conclusion of the fall non-traditional season, and at the beginning of preseason in January. Strength measures were also obtained during the competitive season at the conclusion of pitching in a game and compared …

Concurrent Acl And Medial/Lateral Meniscal Repair In A Collegiate Soccer Player: Disablement Model Case Study, Rebecca L. Perry, Angelica Alicea, Jeanette Welch, Carl White, Emily E. Hildebrand, Peter Lisman

Clinical Practice in Athletic Training

This case examines a 19-year-old female Division I collegiate soccer player who underwent anterior cruciate ligament (ACL) reconstruction with medial and lateral meniscal repairs. Though meniscal tears often occur in conjunction with ACL injury, incidence of concurrent medial and lateral tears with presence of a displaced bucket-handle lesion is rare. This patient attempted to tackle an oncoming opponent in which contact caused forceful trunk rotation away from her planted right foot. Sideline evaluation revealed medial and posterior knee pain with active knee range of motion deficits. Further evaluation revealed apprehension and muscle guarding during Lachman’s, anterior drawer, and valgus stress …

Suturing Education For Athletic Trainers: An Evidence-To-Practice Review, Morgan K. Webb, Brett T. Heim, Allyson E. Ritchey, Kenya Moore, Zachary K. Winkelmann

Clinical Practice in Athletic Training

Teaching suturing skills to medical students is a critical component of their education. Implementing suturing into a comprehensive framework is developed from how professors teach the skill. Suturing is a required skill by the General Medical Council that all medical students must have, and how it is being introduced to new students is changing. This review aimed to summarize different educational interventions and determine the most efficient and cost-effective way to teach future suturing skills. The original systematic review included 25 articles in the final data synthesis. Fourteen studies were randomized control trials, six were quasi-experimental, and five were observational. …

Conservative Management Of Athletic Pubalgia In A Collegiate Beach Volleyball Athlete: A Case Study, Sydney F. Hendrick, Amy L. Fraley, Madison V. Kefferstan, Zachary K. Winkelmann

Clinical Practice in Athletic Training

A 24-year-old female collegiate beach volleyball athlete experienced sharp pain in the pubis symphysis region after turning and running to reach a ball hit over her right shoulder. The patient was unable to move her lower extremities without extreme pain and required help off the court. She was referred to the student health center, where no initial imaging was performed. Differential diagnoses included osteitis pubis, abdominal strain, and athletic pubalgia. Magnetic resonance imaging (MRI) showed a small partial sports hernia with the shearing of the aponeurotic plate. The team physician recommended conservative management. The patient requested a consultation with a …

Introducing Patient-Centered Outcomes To Preceptors In Caate-Approved Athletic Training Programs, K. Judge

Clinical Practice in Athletic Training

The 2020 standards set by the Commission on Accreditation of Athletic Training Education (CAATE) now require the incorporation of the International Classification of Function and Patient-Centered Outcomes into professional practice. These standards can be introduced initially through simulation, but to develop a competent and culturally aware professional, outcome measures should be completed during clinical experiences under the guidance of approved preceptors. As this is a relatively new standard, many preceptors did not receive this as part of their education and may be uncomfortable integrating outcomes into their practice. This lack of integration can negatively affect the learning opportunities of athletic …

Psychological And Psychosocial Effects Of Contemplative Practices In The Athletic Population: A Systematic Review, Victoria Baker, Emily Duckett, Alison Gardiner-Shires, Lindsey Keenan

Clinical Practice in Athletic Training

Mental health concerns in athletes are becoming a primary focus for institutions, companies, coaches, and more. An athlete carries an abundant load of stressors due to their lifestyle. The stressors can negatively impact an athlete by producing anxiety, depression, insomnia, and other mental health concerns. Previous studies have found a connection between the use of contemplative practices on psychological and psychosocial effects in athletes, creating an opportunity to evaluate the research of contemplative practices in the athletic population. 5, 7, 8, 13-16 A systematic review was conducted using nine electronic databases. Seven studies were included in this review, each assessing …

Neuromuscular Deficits Following An Isolated Pcl Tear In A Collegiate Lacrosse Player: A Case Study, Mckenna G. Witlin, Erin R. Mcmullan, Courtney M. Meyer, Amy L. Fraley

Clinical Practice in Athletic Training

This disablement model case study outlines a 21-year-old female collegiate lacrosse player attending a United States service academy who presented with a unique neuromuscular deficit following a conservative grade II PCL tear rehabilitation. Nearing the end of her rehabilitation protocol, she noticed difficulty with toe-off while running; however, she did not report to the athletic trainer due to the institution’s holiday break proximity. An unexpected transfer of care occurred when the patient returned after the holidays, and she was cleared for full participation upon return. Several days after the patient was cleared, she reported her ankle feeling “stuck.” Upon evaluation, …

Improving The Discussion Of Suicide Prevention: A Quality Improvement Project, Chelsea Reynolds, Alyssa Zeitouni, Kathryn Stephenson

Clinical Practice in Athletic Training

Suicide is currently the second leading cause of death among adolescents in the United States and the third leading cause of death in this age group worldwide.1,2 Suicide prevention is understandably a growing focus in pediatrics. Currently, at the Children’s Hospital Outpatient Clinic, that is staffed by pediatric resident physicians, suicidal ideation is screened for using a PHQ-9 screen. However, at the time this study was initiated and completed, the TEEN screen was utilized. After the screening is performed, regardless of type, it is up to the provider to address these findings in a safe and effective manner. The goal …

Oral Tranexamic Acid Use For Melasma Is Not Associated With Thromboembolism: Findings From A Multicenter Propensity Score–Matched Electronic Health Record Cohort, Tyler Hernandez, Kayla Penny, Nicholas Culotta

School of Medicine Faculty Publications

No abstract provided.

Permanent Visual Impairment Following A Behçet’S Disease Flare While On Calcitonin Gene-Related Peptide Receptor Antagonist Therapy: A Case Report, Fawad A. Khan, Alaa Malik, Evan Nelson, Kian Fahimdanesh, Karmveer Kaur, Jasmine Elison, Mohamed Sayed

School of Medicine Faculty Publications

Background: Behçet’s disease (BD) is a chronic, relapsing, systemic vasculitis that can involve both arteries and veins. Ocular involvement, including non-granulomatous panuveitis and occlusive retinal vasculitis, is common and a significant cause of morbidity. Erenumab is a monoclonal antibody targeting the calcitonin gene-related peptide (CGRP) receptor approved for migraine prevention Although it is generally well tolerated, recent concerns have emerged regarding its vasoconstrictive potential in patients with underlying vascular disorders. Case presentation: We report a case of a 44-year-old woman with a history of BD, well-managed with azathioprine and methotrexate, who developed painless, bilateral subacute visual loss eleven days after …

Rethinking Pain Relief After Surgery: What We Can Learn From Knee Replacements, Asim Trimzi

SKMC Student Presentations and Publications

This paper offers a clear, evidence-based look at how we can reduce opioid use after knee replacement surgery without sacrificing pain relief. This review focuses specifically on total knee arthroplasty (TKA)-one of the most commonly performed and most painful surgeries-and asks whether opioids are truly necessary. By analyzing results from 21 clinical trials, the paper shows that non-opioid medications like NSAIDs and gabapentinoids can provide similar pain control with fewer side effects, such as nausea, dizziness, constipation, and sedation. Lower risk of long-term use is an added benefit. A recent RCT found that after knee/shoulder arthroscopy, 72% of patients in …

Hospital And Temporal Variations In Limitations Of Care Among Hospitalized Patients With Covid-19: A Virus Registry Retrospective Cohort Study, Nathan Mesfin, Nitesh Kumar Jain, Anwar Khedr, Hisham Mushtaq, Abbas B. Jama, Noura Attallah, Esraa Hassan, Benjamin Langworthy, Nicholas Ingraham, Juan Pablo Domecq Garces, Thoyaja Koritala, Donna Lee Armaignac, Nicholas Eugene Perkins, Katherine Belden, Vishakha Kumar, Karen Boman, Devang K. Sanghavi, Vikas Bansal, Rahul Kashyap, Rodrigo Cartin-Ceba, Abigail La Nou, Allan J. Walkey, R. Adams Dudley, Syed Anjum Khan

Division of Infectious Diseases and Environmental Medicine Faculty Papers

INTRODUCTION: Life-support limits (i.e., code status), the first step in the continuum of palliation and end-of-life (EoL) care, stem from decisions made by patients and their providers to align care near the EoL with patients' wishes. The pandemic created health care strain that may have influenced life-support limitation practices among patients with serious COVID-19. In this study, we examine variations in life-support limitations (do-not-resuscitate, DNR; do-not-intubate, DNI) depending on the hospital and period of hospitalization.

METHODS: We included all adults admitted to a hospital in the United States with COVID-19 from January 2020 to December 2021 using the VIRUS registry. …

Trajectory Of Iron And Red Cell Parameters In Moderately Anemic Iron-Deficient Pregnant Women Receiving Daily Iron-Folic Acid Supplementation: A Prospective Cohort Study, J. P. Akshaykirthan, Manjunath S. Somannavar, S. Yogeshkumar, M. S. Deepthy, Umesh Charantimath, Amaresh Patil, Mrutyunjaya B. Bellad, Richard Derman, Shivaprasad S. Goudar

Global Health Articles

Background/Objectives: The objective is to study the trajectories of hematologic and biochemical markers in moderately anemic pregnant women receiving oral iron supplementation throughout pregnancy. Methods: This prospective cohort study was conducted from August 2021 to September 2023 involving 315 pregnant women from rural areas of Belgaum, Karnataka, India, with hemoglobin levels between 7.0 and 9.9 g/dL and serum ferritin < 30 ng/mL and/or TSAT < 20%. Participants received iron-folic acid supplementation (IFAS) as per Anaemia Mukt Bharat guidelines. Blood samples were collected to measure various hematologic and iron markers and compared across each visits. Results: We report a complete adherence rate of 95.3% for iron and 97.8% for folic acid supplementation throughout pregnancy and also observed significant improvements in hemoglobin (9.36 (8.55, 9.74) to 12.03 (11.49, 12.72)) g/dL, hematocrit (29.93 ± 2.87 to …

Synthetic Electrospun Fiber Matrix In The Management Of Acute Wounds Following Excision Of Hidradenitis Suppurativa Lesions: A Prospective Pilot Study, Michael Madueke, Frank Lau

School of Medicine Faculty Publications

Hurley Stage II or III hidradenitis suppurativa (HS) may necessitate surgical excision of diseased skin and subcutaneous fat for symptom control and disease management. These excisions result in open wounds in topographically challenging regions and typically cannot be primarily closed. This study evaluates the use of a synthetic electrospun fiber matrix (SEFM) as a post-resection regeneration template to accelerate re-granulation and improve subsequent skin graft incorporation. This prospective pilot study enrolled Hurley Stage II or III patients undergoing surgical resection of HS lesions. SEFM was applied to the resulting wounds in conjunction with negative pressure wound therapy (NPWT). Patients were …

“Not Today”: Overcoming Prep Hesitancy, Stigma, And Adherence Barriers With Lenacapavir, Margaret Conrad, Meredith Clement

School of Medicine Faculty Publications

No abstract provided.

Immunotherapy For Precision Medicine In Colorectal Cancer, Miao Cao, Michael Xu, Zinah Bairmani, Babar Bashir, Scott A. Waldman, Adam E. Snook

Department of Pharmacology, Physiology, and Cancer Biology Faculty Papers

INTRODUCTION: Colorectal cancer (CRC) is the fourth most common cancer and second leading cause of cancer-related death in the United States. The implementation of CRC screening has decreased CRC incidence in adults older than 65 years. However, among young adults who experience more aggressive disease progression, CRC incidence has been increasing for decades. Immunotherapy represents a collection of innovative and promising approaches with greater efficacy and safety. In this review, we discuss modalities and selected targets of immunotherapies for CRCs that are guided by precision medicine.

AREAS COVERED: The following review focuses on immunological approaches for CRCs, including therapeutic monoclonal …

Artificial Intelligence In The Management Of Leukemia, Stephanie Koo, Austin P. Runde, Melvin Speisman

School of Medicine

BACKGROUND: Recently, given the demonstrated ability of AI to accurately characterize complex pathologies, AI has been proposed to be of use in the diagnosis, treatment, and monitoring of leukemias given their genetic complexity and subtype heterogeneity, array of treatments, and need for relapse detection. AI has several potential applications in the management of leukemia. First, it can be used to detect leukemia; using AI to detect nuances in lab values can ensure these deadly cancers are never missed. Second, AI can be used to risk-stratify patients and personalize treatments; leukemias are among the most genetically complex cancers with well-characterized risk …

Implementing A Specific And Standardized Grading Scale For Therapeutic Injection Site Reactions To Improve Adverse Event Reporting, Priya Kale, Kavita Sarin

Research Colloquium

Up to 15.5% of patients taking biologic medication experience injection site reactions (ISRs) leading to morbidity, early discontinuation, and reduced treatment compliance. As biologic medications are increasingly used to treat chronic inflammatory conditions, including psoriasis and atopic dermatitis, there needs to be an improved understanding of ISRs. However, current methods of grading ISRs are nonspecific and unstandardized leading to a lack of understanding of medication-specific ISRs and ambiguity in perceptions of treatment tolerability. Here we aim to develop a standardized ISR grading scale for use in clinical trials. A scoping review was performed to evaluate current ISR grading scales and …

Rapid Mapping Of Spinal And Supraspinal Connectome Via Self-Targeting Glucose-Based Carbon Dots, Yasin B. Seven, Elif S. Seven, Emel Kirbas Cilingir, Komal Parikh, Mehmet Aydin, Edward K. Luca, Jayakrishnan Nair, Roger M. Leblanc

Department of Physical Therapy Faculty Papers

The spinal cord is a highly dynamic network, playing significant roles in the vital functions of the brain. Disorders of the spinal cord, such as spinal cord injury and amyotrophic lateral sclerosis (ALS), are associated with neurodegeneration, often resulting in morbidity and mortality. The blood-brain barrier (BBB) poses a major challenge to imaging and therapeutic agents because less than 2% of small-molecule drugs and almost no large-molecule drugs can cross the BBB. Furthermore, spatial spectroscopy studies have shown highly heterogeneous BBB crossing with significant accumulation at the unintended brain regions. Thus, targeting systems that can cross the BBB at the …

Early Definitive Fusion Versus Magnetic Growing Rods In "Tweeners": What Do Parents Prefer?, Sylvia Culpepper, Ravi Rajendra, Brett Lullo, Anthony A. Catanzano, Tyler C. Mcdonald, R Carter Clement

School of Medicine Faculty Publications

INTRODUCTION: In treating early-onset scoliosis (EOS), pediatric orthopaedic surgeons and families must often choose between growth-friendly interventions such as magnetically controlled growing rods (MCGR) and early definitive posterior spinal fusion (PSF). While each strategy has associated pros and cons, little is understood about the specific preferences of patients' families. Addressing potential nuances in these preferences is crucial for meaningful shared decision-making (SDM). To better understand the factors influencing family decisions, we conducted a choice-based conjoint (CBC) analysis to explore parents' preferences for PSF and MCGR as treatment options. METHODS: A survey was developed using Sawtooth Software (Lighthouse Studio version 9.2.0) …

Barriers To And Strategies For Improved Treatment Adherence In Vitiligo: A Systematic Review, Lauren Gawey, Aditya Joshi, Muhammad Rahman, Tyler Hernandez, Krishna Babaria, Roshni Sabhaya, Debbie Wang, Raveena Ghanshani, Jennifer L. Hsiao, Vivian Y. Shi

School of Medicine Faculty Publications

No abstract provided.

Metagenomic Characterization Of Gut Microbiota In Children With Autism Spectrum Disorder: Microbial Signatures And Modulation By Anti-Inflammatory Diet And Probiotics, Marysol Valencia-Buitrago, Rodrigo Dias Oliveira-Carvalho, Valbert Cardoso, Jessica Triviño-Valencia, Luisa Matilde Salamanca-Duque, Vanessa Martínez-Díaz, Jovanny Zabaleta, Narmer Fernando Galeano-Vanegas, Carlos Andrés Naranjo-Galvis

School of Medicine Faculty Publications

Background: Autism Spectrum Disorder (ASD) is increasingly associated with alterations in gut microbiota, intestinal permeability, and immune dysregulation. However, integrative studies exploring these mechanisms in Latin American populations are lacking. Objective: To characterize gut microbiota profiles in Colombian children with ASD and evaluate the effects of two microbiota-targeted interventions, an anti-inflammatory diet and a probiotic formulation, on microbial diversity and taxonomic composition. Methods: In a two-phase study, shotgun metagenomic sequencing was performed on fecal samples from 23 children with ASD and 7 typically developing (TD) controls. In the second phase, 17 children with ASD were randomized to receive a 12-week …

Distinct Transcriptional Regulation Of The Wnt And Tgfβ Signaling Families Associated With Wound Healing And Fibrotic Outcomes To Lens Injury, Catherine Lalman, Kylie R. Stabler, Joshua Disatham, Lisa A. Brennan, Marc Kantorow, Janice L. Walker

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

Posterior capsule opacification (PCO) is a fibrotic complication of cataract surgery caused by aberrant repair of residual lens cells. It remains unclear how the lens injury response shifts toward a pathological repair process. Here, we performed a transcriptional analysis of two major pro-fibrotic pathways, the TGF-β superfamily and Wnt signaling pathways to determine how they are differentially regulated during regenerative wound healing versus fibrosis in a lens injury model. For these studies, RNA sequencing was performed on an ex vivo lens explant system that models post-surgical healing within regenerative and fibrotic microenvironments, from 0 to 3 days post-injury. Fibrotic conditions …

Targeting Kinin B1r Attenuates Hypertension Through At1r-Dependent Mechanisms, Drew Theobald, Riley N. Bessetti, Yumei Feng Earley, Eric Lazartigues, Karen Litwa, Srinivas Sriramula

School of Medicine Faculty Publications

BACKGROUND: Neurogenic hypertension is chronically high blood pressure that is initiated and maintained through excessive sympathetic nervous system activity and has been associated with increased B1R (kinin B1 receptor) activation. We previously reported a central role for B1R in mediating inflammatory pathways in the development of deoxycorticosterone acetate salt hypertension. Additionally, we identified a causal relationship between B1R expression after Ang II (angiotensin II) stimulation, and that B1R can mediate the bidirectional interaction between neuroinflammation and oxidative stress. However, whether there are any interactions between AT1R (Ang II-type I receptor) and B1R, and if B1R can mediate the effects of …

Intelligence Architectures And Machine Learning Applications In Contemporary Spine Care, Rahul Kumar, Conor Dougherty, Kyle Sporn, Akshay Khanna, Puja Ravi, Pranay Prabhakar, Nasif Zaman

SKMC Student Presentations and Publications

The rapid evolution of artificial intelligence (AI) and machine learning (ML) technologies has initiated a paradigm shift in contemporary spine care. This narrative review synthesizes advances across imaging-based diagnostics, surgical planning, genomic risk stratification, and post-operative outcome prediction. We critically assess high-performing AI tools, such as convolutional neural networks for vertebral fracture detection, robotic guidance platforms like Mazor X and ExcelsiusGPS, and deep learning-based morphometric analysis systems. In parallel, we examine the emergence of ambient clinical intelligence and precision pharmacogenomics as enablers of personalized spine care. Notably, genome-wide association studies (GWAS) and polygenic risk scores are enabling a shift from …

Cardiomyocyte Regeneration Therapy And Its Effect On Lvef And Scar Size- A Systematic Review And Meta-Analysis, Mahnoor Mahnoor, Syed Irtaza Hassan, Muhammad Bakhtiar, Salal Sharjeel, Roha Daneyal, Muhammad Ibrahim, Raheel Iftikhar

Kimmel Cancer Center Faculty Papers

BACKGROUND: Myocardial infarction (MI) results in loss of cardiomyocytes leading to heart failure. Despite advancements in pharmacotherapy and interventions such as revascularization, ischemic heart failure remains a challenge. Recent advancements in stem cell therapies, genetic engineering and bioengineering have shown to improve cardiac function and quality of life.

METHODOLOGY: Following PRISMA guidelines, randomized controlled trials clinical trials from last 12 years were systematically reviewed. All the patients included in these studies had ischemic heart failure and were subjected to different types of stem cell therapies. Protocol for this meta-analysis is registered on PROSPERO (Registration no: CRD42023399263). Data extraction and Quality …

Comparison Of Crotalidae Immune F(Ab')2 (Equine) And Crotalidae Polyvalent Immune Fab (Ovine) At Establishing Control Of Initial Envenomation Symptoms In Louisiana Agkistrodon Envenomations, Taylor Sanders, Christine Murphy, Greggory Davis, Christina Aspinwall, Lauren Theriot, Christopher Mcvicker, Thomas Arnold

School of Medicine Faculty Publications

INTRODUCTION: Copperheads and cottonmouths are responsible for most snake envenomations in Louisiana. While the United States Food and Drug Administration has approved both Crotalidae polyvalent immune Fab (FabAV) and Crotalidae immune F(ab') (Fab2AV) for Agkistrodon envenomations, data is limited comparing their efficacies for this indication. METHODS: This is a retrospective study comparing FabAV to Fab2AV in the treatment of suspected Agkistrodon envenomations in Louisiana between April 2017 and October 2024. Cases identifying rattlesnakes were excluded. The primary outcome was the need for additional antivenom doses to achieve control after the initial antivenom dose. RESULTS: One hundred fifty-eight patients received FabAV …

Emerging Clinical Role Of Tavapadon, A Novel Dopamine Partial Agonist, In The Treatment Of Parkinson’S Disease, Alan D. Kaye, Bennett M. Ford, Brennan M. Abbott, Kalob M. Broocks, Sofia Novacic, Sahar Shekoohi

School of Medicine Faculty Publications

Tavapadon, a novel oral dopamine-D1R/D5R partial agonist, has been studied in recent years for the treatment of late-stage development Parkinson’s disease (PD). Levodopa, a dopamine precursor that currently remains the gold-standard first-line therapy for PD motor symptoms, serves as a benchmark against emerging dopaminergic agents. By selectively activating D1-family receptors on direct-pathway medium neurons, Tavapadon differs in that it delivers levodopa-level motor benefit while avoiding its many D2R/D3R-mediated adverse effects. In placebo-controlled trials, Tavapadon produced clear, clinically meaningful gains in motor function and day-to-day activities, as captured by the Unified Parkinson’s Disease Rating Scale (UPDRS). Recent late-stage results have revealed …

Determining Risk Factors And Rate Of Surgery After Collagenase Injections For Dupuytren Contracture, Ryan C. Cha, Juliet S. Chung, Sina Ramtin, Asif M. Ilyas

Department of Orthopaedic Surgery Faculty Papers

Purpose: Collagenase injections are a nonsurgical treatment for Dupuytren contracture, but their long-term effectiveness in preventing surgery remains unclear. This study aimed to evaluate the rate of surgical intervention following collagenase treatment and identify whether specific risk factors increase the likelihood of future surgical correction. Methods: This retrospective cohort study utilized the TriNetX US Collaborative network to identify patients diagnosed with Dupuytren contracture between January 2007 and September 2024. Patients initially treated with collagenase injections were identified using relevant current procedural terminology codes. Procedure-specific current procedural terminology codes were then used to determine which patients underwent a subsequent fasciectomy or …

Optimizing Pharmacologic Treatment For Neonatal Opioid Withdrawal Syndrome (Optimize Now): A Symptom-Based Dosing Approach Study Protocol For A Multi-Center, Cluster Crossover Design Randomized Controlled Trial, Leslie W. Young, Denise C. Babineau, Abhik Das, Sara Demauro, Walter K. Kraft, Scott Lorch, Michele C. Walsh, Stephanie Merhar, Lori A. Devlin

Department of Pharmacology, Physiology, and Cancer Biology Faculty Papers

BACKGROUND: Opioid use and misuse during pregnancy rose from 1.5 to 6.5 per 1000 deliveries between 1999 and 2014 and continues as a significant public health concern. A fivefold increase in neonatal opioid withdrawal syndrome (NOWS) has accompanied the increase in opioid use. The Eating, Sleeping, Consoling care approach (ESC) has been shown to improve outcomes for infants with NOWS and is quickly becoming the standard of care for infants affected by opioid use disorder. Quality improvement initiatives following the implementation of ESC provide some evidence to suggest that symptom-based (i.e., as needed, PRN, just in time) dosing of opioid …