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Heavy societal stigma of certain conditions has created an environment where individuals may be hesitant to seek professional care. Urology is a specialized field that focuses on many of these conditions that society has deemed taboo to discuss. In this review, we address barriers that have prevented patients from seeking urologic care in order to better understand and elucidate important concerns within development of the physician-patient relationship. Recognizing these concerns can also assist in public health outreach approaches to motivate patients for seeking urologic care. The scope of this review was limited to three highly prevalent conditions affecting both men and women, including urinary incontinence, erectile dysfunction, and genitourinary syndrome of menopause.

Lower Urinary Tract Symptoms (LUTS) are frequently present in the general population as patients age with approximately a third of individuals experiencing LUTS during their lifetime. LUTS can be further defined as having any of the following symptoms: urinary hesitancy, straining, nocturia, increased urination frequency, and dysuria. LUTS has the potential for patients to contribute their symptoms to what can normally occur as we age. This can lead to a decrease in patients seeking care and could negatively impact patients’ health-related quality of life (HRQL). In conjunction with LUTS, we obtained from our analysis that LUTS and depression are closely related and worsening depressive symptoms may increase the severity of LUTS. We also discerned three categories of factors that can yield major depression namely adversity, internalizing, and externalizing factors. Within these categories, trauma, social support, genetic factors, and minimal education appeared to increase the risk of depression in patients. With the recent increase in mental health awareness and more access to mental health care amid the COVID-19 Pandemic, further screening, and collaboration between providers to treat both urological and psychiatric symptoms could improve patient outcomes. It is important for providers to have an increased understanding of the mental and physical impact both LUTS and depression can have on patients’ wellbeing. This has the potential to help patients be more open about their symptoms with the aim of better addressing LUTS and depression to positively impact their HRQL.

Numerous complications are associated with central venous catheters. Among them, cardiac tamponade is a rare but well-documented catastrophic complication. A 22-year-old healthy male presented with Code 1 trauma resulting from gunshot wounds in the abdomen. Upon examination, he was found to have a large pericardial fluid collection, a large right supraclavicular hematoma, and significant amount of bilateral pleural effusions secondary to extraluminal placement of the right internal jugular central line during resuscitation. After repairing the internal jugular injury and draining the pericardial fluid, the patient was transferred from the intensive care unit to the regular hospital floor. However, 15 days later, imaging revealed re-accumulation of a large pericardial effusion, which was eventually treated with a pericardial window operation. This case report explores potential complications that could arise from central line placement and the anesthetic considerations in a patient with cardiac tamponade from extraluminal central line placement.

With the ongoing opioid epidemic in the United States there has been a strong transition towards utilizing multi-modal analgesia, interventional procedures, and non-opioid medications when managing acute and chronic pain. There has also been an increased interest in utilizing buprenorphine. Buprenorphine is a novel long-acting analgesic with partial mu-opioid agonist activity that can be utilized for analgesia as well as opioid use disorder. Buprenorphine also has a unique set of side effects as well pharmacodynamic and pharmacokinetic properties that require special attention, especially if these patients require future surgical interventions. Given the increased interest in this medication we believe that there needs to be increased education and awareness regarding this medication amongst physicians, specifically pain management physicians and trainees.

# Purpose of Review Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB). # Recent Findings PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches. # Summary In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

Burning mouth syndrome is a condition characterized by a painful burning sensation in the oral mucosa lasting at least 3-6 months with no definitive etiology. The pathophysiology is not well understood, though there appears to be a connection with other neuropsychiatric conditions such as depression, anxiety, and mood disorders. We briefly discuss our experience with a patient who suffered from this conidtion and how it was treated with mandibular and maxillary nerve blocks after failing more conservative pharmacological options.

The present investigation summarizes relevant symptoms, differential diagnosis, imaging, and treatment options of Eagle Syndrome. A comprehensive literature review of peer-reviewed literature was employed utilizing most relevant databases. The diagnoses of Eagle Syndrome have recently increased because of increased awareness of physicians of Eagle Syndrome and the earlier identification of the cardinal symptoms of the disease. The most important symptoms are dysphagia in the setting of cervical neck pain, but there is a wide variety of symptomatology that make Eagle Syndrome a challenge to recognize and diagnose clinically. CT scan continues to be the standard of care for diagnosing Eagle Syndrome and CT Angiography has an important role in aiding diagnosis as well. Medical treatment options include steroids, antidepressants, and anticonvulsants however not all cases of Eagle Syndrome can be managed medically. Surgical approaches are varied but typically are either extraoral or transoral. This report aims to update providers on the important diagnostic criteria of Eagle Syndrome and how physicians can develop a treatment plan that addresses all the symptoms of patients with Eagle Syndrome because it can be treated safely and appropriately.

# Purpose of Review The present investigation is a comprehensive review regarding the use of Suvorexant for insomnia treatment. It covers the background, pathophysiology, and significance of addressing insomnia, the pharmaceutical details of Suvorexant, and its safety, efficacy, and implications in treating insomnia. We further discuss Suvorexant's role in targeting insomnia with other comorbidities. # Recent Findings Insomnia refers to poor quality and/or quantity of sleep. While there are many existing treatments such as benzodiazepines, melatonin agonists, TCAs, and atypical antipsychotics used to target various receptors involved in normal induction and maintenance of sleep, Suvorexant is an antagonist that specifically targets orexin receptors. Recent clinical studies suggest that Suvorexant is both clinically safe and effective. Quantity and quality of sleep are measured in various ways, yet the consensus points towards Suvorexant's effectiveness in improving sleep time, onset, latency, and quality compared to placebo. In addition to helping improve isolated insomnia, Suvorexant helps improve sleep in patients that have other comorbidities such as obstructive sleep apnea, Alzheimer's disease, dementia, acute stroke, and delirium. While Suvorexant is safe, there are still adverse effects associated with the drug that needs to be considered. The most common adverse effects include dizziness, somnolence, headaches, and cognitive impairment. # Summary Insomnia is a major public health concern that affects many people worldwide and has been linked to many adverse health outcomes. While there are existing treatments that target different receptors and pathways of normal sleep induction and maintenance, Suvorexant is a novel drug that targets dual orexin receptors. Its safety and efficacy, mechanism of action, pharmacokinetic parameters, and relative lack of rebound and withdrawal effects render suvorexant a reliable choice for the treatment of insomnia.

This is a review of the latest and seminal evidence in pediatric migraine. It covers the etiology and pathophysiology known today, and then will review treatment options, efficacy and safety, quality of data and indications. Though migraine is usually regarded as an infliction in adults, it is not uncommon in the pediatric population and affects up to 8% of children. Children may experience migraine differently than adults, and present not only with headache but also frequent gastrointestinal symptoms. They are frequently shorter in duration than in adults. Traditional migraine treatment in adults is less effective in children. In this population, adjunct therapies -- such as interventional techniques -- should be considered when traditional treatment fails, including Botulinum Toxin A (BTA) injections, peripheral nerve and ganglion blocks. BTA injections are FDA approved for migraine prophylaxis in adults, but currently not in children; however, recent evidence shows efficacy and safety in pediatric migraine management. Nerve blocks stop nociceptive afferent fibers through injection of local anesthetics, and it may be associated with the local injection of corticosteroids. Although more common in adults, recent data suggests they are safe and effective in children and adolescents. Blocking the sphenopalatine ganglion can be achieved through nasal approach, and achieves a similar action by blocking the entire ganglion. Interventional techniques may provide a key component in the alleviation of this otherwise debilitating chronic migraine pain. Though most studies have been performed in adults, new studies provide encouraging results for treatment in children.

# Background Depression is a common disorder that affects millions globally and is linked to reduced quality of life and mortality. Its pathophysiology is complex and there are several forms of treatment proposed in the literature with differing side effect profiles. Many patients do not respond to treatment which warrants augmentation with other treatments and the investigation of novel treatments. One of these treatments includes testosterone therapy which evidence suggests might improve depressed mood in older patients with low levels of testosterone and helps restore physical impairments caused by age-related hormonal changes. # Objective The objective of this review is to synthesize information regarding clinical depression, its treatment options, and the efficacy and safety of testosterone treatment for the treatment of depression. # Methods This review utilized comprehensive secondary and tertiary data analysis across many academic databases and published work pertaining to the topic of interest. # Results Within some subpopulations such as men with dysthymic disorder, treatment resistant depression, or low testosterone levels, testosterone administration yielded positive results in the treatment of depression. Additionally, rodent models have shown that administering testosterone to gonadectomized male animals reduces symptoms of depression. Conversely, some studies have found no difference in depressive symptoms after treatment with testosterone when compared with placebo. It was also noted that over administration of testosterone is associated with multiple adverse effects and complications. # Conclusion The current evidence provides mixed conclusions on the effectiveness of testosterone therapy for treating depression. More research is needed in adult men to see if declining testosterone levels directly influence the development of depression.

Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it. More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.

Management of mental health illnesses and needs are important in fostering psychosocial support, interprofessional coordination, and greater adherence to treatment protocols in the field of urology. This can be especially true for mental health conditions that may greatly impact the presentation of a patient in the healthcare setting with urologic symptoms. This review describes the history, epidemiology, pathophysiology, clinical presentation, and treatment of somatic symptom disorder, illness anxiety disorder, compulsive sexual behavior/hypersexuality, factitious disorder, malingering symptoms, and conversion disorder in the realm of urology. Given the newly updated psychiatric diagnoses in the *Diagnostic and Statistical Manual of Mental Disorders*, fifth edition, there has been a lack of studies reviewing how these illnesses may present in a urology patient encounter. Additionally, as these mental health illnesses may carry a rare incidence compared to other well-known mental health illness such as generalized depression or generalized anxiety disorder, we have found that the lack of provisions and recognition of the diseases can prolong the timeline for diagnosis and lead to an increased cost in both healthcare and quality of life of patients with these mental health illnesses. This review provides awareness on these mental health conditions which may greatly impact patient history and presentation within the field of urology. Additionally, urologic care providers may have an improved understanding of interdisciplinary management of such illnesses and the common symptoms patients may present with such diseases.

This article is a literature review of mental health concerns in non-oncologic urology patients. Pathologies represented in this review include Peyronie's Disease (PD), erectile dysfunction (ED), urinary incontinence and urinary tract infections (UTI), infertility, benign prostatic hyperplasia (BPH), kidney stones, and urinary retention. While there has been great interventional focus as of late for urogenitary malignancies (i.e. prostate cancer awareness with the Movember campaign), literature studies and intervention focused on non-oncologic urology patients has been limited. As such, we conducted a review on urology patients with non-oncologic pathologies as an effort to increase clinician awareness of mental health concerns among such patients, increase the comfort level for clinician communication on socially sensitive topics surrounding pathologies, and review ongoing interventions conducted within these pathologies. We outlined different ongoing Mental Health Illness (MHI) needs and treatments for various pathologies. Patients with non-cancerous urologic pathologies had lower quality of life and higher incidence of MHI than the general population. As such, in line with the American Urological Association recommendations, psychological and social support from peers, therapists, and healthcare providers further prove to be crucial for some subpopulations. The review also yielded pathology specific interventions such as group therapy for ED patients. Given the higher incidence of MHI in the patient population after the Covid-19 pandemic, MHI awareness in the sphere of non-oncologic urology treatment continues to be crucial when creating a collaborative treatment platform for patients.

Gender dysphoria is defined by severe or persistent distress associated with an incongruence between one's gender identity and biological sex. It is estimated that 1.4 million Americans and 25 million people worldwide identify as transgender and that 0.6% of Americans experience gender dysphoria. The pathophysiology of gender dysphoria is multifactorial and incompletely understood. Genetics, androgen exposure, neuroanatomy, brain connectivity, history of trauma, parents with psychological disorders, and being raised by less than two parents are associated with gender dysphoria. Gender dysphoria most frequently presents in early teenage years but can present earlier or later. Anxiety and depression are the two most common comorbid diagnoses and may be the reason for presentation to medical care. Diagnosis is established through history and or validated questionnaires. Treatment includes psychosocial therapy, pharmacotherapy for underlying depression and/or anxiety, hormonal therapy, non-genital and/or genital feminization or masculinization operations. The frequency and severity of treatment related morbidity increases progressively as treatments go from conservative to more invasive. Gender dysphoria and its treatment is individualized and not completely understood.

Urologic procedures (both open and minimally invasive) can cause pain due to the surgery itself, devices placed, and post-operative issues. Thus, pain management is important for every post-procedure recovery period. Opioid use post-surgery is common and often over-prescribed contributing to persistent use by patients. In this article, we review the extent of opioid use in pediatric urologic procedures, vasectomy, endourologic procedures, penile implantation, urogynecologic procedures, prostatectomy, nephrectomy, cystectomy, and scrotal/testicular cancer surgery. Generally, we have found that institutions do not have a standardized protocol with a set regimen to prescribe opioids, resulting in more opioids being prescribed than needed and patients not properly disposing of their unused prescriptions. However, many institutions recognize their opioid overuse and are implementing new multimodal opioid-sparing analgesics methods such as non-opioid peri-operative medications, minimally invasive robotic surgery, and nerve blocks or local anesthetics with varying degrees of success. By shedding light on these opioid-free methods and prescription protocols, along with improved patient education and counselling, we hope to bring awareness to institutions and decrease unnecessary opioid use.

Ketamine is a common medical anesthetic and analgesic but is becoming more widely used as a recreational drug. Significant side effects on the urinary tract are associated with frequent recreational ketamine use most notably ketamine-induced cystitis (KIC). Regular ketamine consumption has been shown to increase the risk of cystitis symptoms by 3- to 4-fold, and cessation of ketamine use is usually associated with improvement of symptoms. Common KIC-related problems are urinary pain and discomfort, bladder epithelial barrier damage, reduced bladder storage and increased pressure, ureter stenosis, and kidney failure, all of which significantly impact patients' quality of life. Furthermore, it becomes a vicious cycle when KIC patients attempt to manage their urinary pain with increased ketamine use. The precise pathophysiology of KIC is still unknown but several theories exist, most of which highlight the inflammatory signaling pathways leading to bladder epithelium damage due to presence of ketamine in the urine. Empirical treatment options for KIC are available and consist of ketamine cessation, noninvasive therapies, and surgery, and should be decided upon based on the time course and severity of the disease. Of note, cessation of use is strongly recommended for all KIC patients, and should be supplemented with motivational interviews and psychological and social support. It is crucial for clinicians to be familiar with KIC diagnosis and treatment, and to be prepared to have informed discussions with ketamine-using patients about the potential health consequences of ketamine.

# Background Vasectomy is a procedure that results in permanent yet reversible sterility and remains a great contraceptive option for many. Previous research studies have highlighted frequency of vasectomy utilization, defining characteristics of individuals who opt for this method, various surgical techniques, and the risks and benefits associated with the procedure. What remains to be defined is why or why not individuals may experience post-vasectomy regret and whether the previous characteristics correlate. # Objective The objective of this review is to synthesize information regarding reasons individuals may regret their vasectomy and seek reversal, what options exist for accomplishing the reversal, and patients' fertility prognosis post-vasovasostomy. # Methods This review utilized a combination of secondary and tertiary data analysis across a wide scope of academic databases pertaining to the topic of interest. # Results Typically, most males who have sought a vasectomy are satisfied with their decision, however, approximately 6% of this population seeks reversal. Key factors influencing vasectomy regret include age at the time of vasectomy, parental status, pre- and post-operative relationship status, unresolved physical and psychosexual problems, and development of chronic scrotal pain following the procedure. Few options exist for vasectomy reversal including microsurgical reconstructive vasectomy reversal (VR) and sperm extraction for in vitro fertilization. There is no guarantee that fertility will be restored in any case but a major predictive factor for success is the time interval prior to reversal. # Conclusion Vasectomy is intended to be a permanent form of contraception; however, a minor chance remains that individuals may experience post-operative regret due to various factors. This warrants proper comprehensive counseling by the patient's provider regarding benefits and risks, procedural outcomes, opportunities for reversal, and fertility prognosis.

COVID-19 caused a drastic change in clinical medicine around the globe. In the United States, telemedicine was rapidly adopted on a wide scale to minimize direct patient interaction and to reduce the spread of the COVID-19 virus. Telemedicine also went hand in hand with the rapid movement of working remotely. This has provided several challenges to chronic pain management clinics along with other subspecialties. Telemedicine has also opened opportunities for providing valuable care for patients with significant barriers to healthcare professionals. Given the benefits and downfalls of telemedicine, it is ultimately up to the provider who has an established patient-physician relationship and best understands the patient's limitations and healthcare needs who can best determine which patient population telemedicine is appropriate for and how frequently it can be utilized for each individual patient.

Male sexual dysfunction is a series of conditions, most notably including erectile dysfunction (ED), Peyronie's disease (PD), and premature ejaculation (PE), defined by impaired sexual functioning. The prevalence of male sexual dysfunction increases with age and is relatively high with greater than 50% of men aged 40 to 70 describing some degree of erectile dysfunction. Risk factors for male sexual dysfunction include age, diabetes mellitus (DM), cancer, stroke, hypertension, penile trauma, depression, anxiety, and disturbance in central serotonin neurotransmission and 5-HT postsynaptic receptor functioning. Sexual questionnaires including the International Index of Erectile Dysfunction, Sexual Health Inventory for Men, and the Premature Ejaculation Diagnostic Tool are useful in screening for these disorders. Focused history and physical can establish diagnoses. For a condition to be diagnosed as male sexual dysfunction, the patient or their partner must view their sexual functioning as impaired. Treatment of male sexual dysfunction is etiology dependent. For ED, first-line therapy is a phosphodiesterase-5 inhibitor or mental health care for psychogenic ED. More complicated cases may be treated with injections, surgery, or shockwave therapy. PD is either treated with medications for pain management, collagenase clostridium histolyticum injection, corpoplasty, plication, or shockwave therapy. PE may be treated behaviorally or with SSRIs as first line medication.

This article is a systematic review of mental health in urologic oncology patients with prostate cancer (PCa), bladder cancer (BC), renal cell carcinoma (RCC), testicular cancer (TC), or penile cancer (PeCa). For all pathologies, a focus on increasing quality of life post-treatment demonstrated a positive impact in reducing Mental Health Illness (MHI) prevalence. Cancer specific mental health care may be given to patients to reduce suicide risk in BC patients and sexual identify and masculinity counseling may improve mental health for TC or PeCa patients. In order to better accommodate patient’s mental health needs when undergoing GU cancer treatment, we recommend incorporation of mental health metrics such as questionnaires to assess early treatment of MHI, a greater emphasis on psychosocial support with the patient’s loved ones, peers, and healthcare team, alongside advising healthy habits such as exercise which has been shown to drastically reduce MHI incidence across all pathologies. We hope that these measures conducted by urologists and oncologists, alongside possible coordination with psychiatrists and psychologists for psychotherapy, psychopharmacology, and neuro-stimulation treatment modems may be helpful in the long term to reduce MHI incidence in urology oncology patients. Given the higher incidence of MHI in oncology patients and in the patient population after the Covid-19 pandemic, MHI awareness in the sphere of urologic oncologic treatment continues to be crucial when creating a collaborative treatment platform for patients.

Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.

# Purpose of Review Chronic pain continues to be one of the leading healthcare cost burdens in the United States and is typically defined as ongoing pain, lasting longer than six months. Various treatment options exist for chronic pain, including physical therapy, medical management, pain psychology, and interventional therapies. Pain medications have been the mainstay of treatment for chronic pain conditions with an increasing use of membrane stabilizers and antidepressants to treat neuropathic pain conditions. Specifically, serotonin noradrenaline reuptake inhibitors (SNRIs) have been used to treat a range of pain conditions expanding from everyday use for depressive disorders. # Recent Findings SNRIs, including duloxetine, venlafaxine, and milnacipran, have demonstrated efficacy in reducing pain in musculoskeletal pain (chronic low back pain and osteoarthritis), fibromyalgia, and neuropathic pain conditions (peripheral diabetic neuropathy). # Summary The article describes the function, role, and use of SNRIs to treat chronic and neuropathic pain by altering the noradrenergic descending inhibitory pathways.

Abstract Acupuncture is a form of traditional Chinese medicine that is performed by placing needles or pressure in specific locations on a patient’s skin to achieve a therapeutic effect. Although used to treat a variety of disorders, one of the most common applications of acupuncture is to treat chronic pain, especially headache and migraine pain. Migraines are difficult to treat, and pharmacotherapies are often the first line of treatment, although these options have many unwanted side effects, such as exacerbation of headache pain in those with chronic migraine. Many complimentary and integrative therapies are available to treat migraine (including nutraceuticals, yoga, tai chi, and biofeedback), among which acupuncture as a treatment is gaining increasing attention. In this review, we provide an overview of the current understanding of both acupuncture and migraine and of current research investigating the effectiveness of acupuncture in treating migraine and chronic migraine.

Abstract Occipital neuralgia (ON) is unilateral or bilateral neuralgia in the dermatomal nerve distribution of the greater, lesser or third occipital nerves and is a very common presentation of neuropathic pain. ON, although common and well defined, is still a poorly understood pain syndrome. It often requires invasive treatment for long term and significant pain alleviation; however, the evidence supporting different options is still limited. Several minimally invasive techniques have proven to be efficacious and safe, and the selection depends mostly on response to nerve blocks, patient choice and provider preference. This is a comprehensive review of the latest and seminal literature available about occipital neuralgia and currently available minimally invasive treatment options. It covers the anatomical and physiologic biology at the base of neuralgia, the presentation and diagnostic process. It then reviews the available literature to provide description and comparison of the available methods for alleviation.

Aim: This study examined the incidence, demographic predictors, and map patterns of dog bites to humans in unincorporated Harris County, Texas, USA. Materials and Methods: Dog bites reported to Harris County Veterinary Public Health (HCVPH) between January 1, 2013, and December 31, 2016, were analyzed in this retrospective cohort study. Canine and victim characteristics and bite circumstances were evaluated to establish risk factors for bites. Geographic location was used to produce choropleth maps. Results: There were 6683 dog bites reported to HCVPH between the years of 2013 and 2016, with stable incidence rates over time. The incidence was highest for both children and older adults. Dogs with the primary breed of Pit Bull had the greatest frequency of bites (25.07%), with the second highest breed being Labrador Retrievers (13.72%). Bites were more common from intact dogs of both genders, especially from intact males. Persons aged 70+ had the greatest incidence of severe injury (14.09/100,000). A strong correlation between dog bite incidences and stray dogs was found after controlling for the human population and income. Conclusion: Dog bites remain a largely preventable issue, and risk factors identified in this study can help direct preventative efforts to reduce the incidence of dog bites.

Regional anesthesia is an important aspect of the overall anesthetic plan for patients. It has the potential to offer superior benefits compared to opioid-based treatment and is an important component of Enhanced Recovery after Surgery (ERAS) protocols. The use of the pectoral type I (PECS I) and pectoral type II blocks (PECS II) has been shown to reduce postoperative pain and opioid consumption in patients undergoing complete mastectomy and breast surgery. We describe the use of dexamethasone and dexmedetomidine to prolong the analgesic effects of these regional blocks in a patient undergoing total mastectomy with lymph node dissection.

With the ongoing public health crisis with prescription opioids, there is a need for safer alternatives for medication management in chronic pain patients. Buprenorphine is a partial mu-opioid agonist which is commonly utilized to treat patients with opioid-use disorders. The purpose of this review is to discuss the potential use of this medication for the treatment of chronic pain instead of resorting to more traditional Schedule II opioids. Buprenorphine offers a safer alternative for patients who require opioids to manage chronic pain, given the unique pharmacological properties that allow it to provide adequate analgesia with less abuse potential.

# Purpose of review This is a comprehensive review of the literature regarding the use of ketamine as a treatment for treatment-resistant depression (TRD). It covers the epidemiology, risk factors, pathophysiology, and current treatment modalities regarding Major Depressive Disorder (MDD) and TRD. It provides background on the mechanism of action of ketamine, its history, current approved and off-label indications in the field of psychiatry, and then provides an overview of the existing evidence for the use of ketamine in the treatment of TRD. # Recent findings MDD is a mental illness that puts an enormous strain on the affected and a high socio-economic burden on society. The illness is complex and combines genetic, pathophysiologic, and environmental factors that combine to negatively affect neurotransmitter balance in the brain. Additional evidence suggests dysregulation of the hypothalamic-pituitary (HPA) axis, brain-derived neurotrophic factor (BDNF), vitamin D levels, and involvement of pro-inflammatory markers. Core symptoms include depressed mood or anhedonia, combined with neurovegetative symptoms such as sleep impairment, changes in appetite, feelings of worthlessness and guilt, and psychomotor retardation. Current first-line treatment options are antidepressants of the selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) class. Failure to respond to two adequate trials of treatment meets the criteria for TRD. Esketamine (Spravato) is an NMDA-receptor antagonist with additional AMPA-receptor agonist properties, which the FDA approved in 2019 to treat adult TRD in conjunction with an oral antidepressant. It can be administered intranasally, providing a rapid response and proven effective and safe. Additional research suggests that oral ketamine might be effective for PTSD and anxiety disorders. Intravenous administration of ketamine has also shown benefits for acute suicidal ideation and depression and substance use to reduce relapse rates. # Summary TRD is associated with huge costs on individual and societal levels. Underlying disease processes are multifactorial and not well understood. Adjunctive therapies for TRD with proven benefits exist, but acutely depressed and suicidal patients often require prolonged inpatient stabilization. Intranasal esketamine is a new FDA-approved alternative with rapid benefit for TRD, which has also shown a rapid reduction in suicidal ideation while maintaining a favorable side-effect profile. Additional potential off-label uses for ketamine in psychiatric disorders have been studied, including PTSD, anxiety disorders, bipolar depression, and substance use disorders.

Opiates are routinely used for chronic pain patients, and up to 44% of them will have a prescription for an opiate medication for pain alleviation. However, of the 76 million adults prescribed opiates for pain management, about 12% report misuse, and a large number of these may find themselves addicted to opioid medications. Opioid addiction is an ongoing epidemic, costing many lives. Withdrawal is very difficult. This requires providers to consider alternative analgesic plans and minimize opiate use. Here we report the use of a dexamethasone-dexmedetomidine combination for a regional nerve block in an elderly woman chronically treated with opiate medications who had previously failed opiate weaning. Following her nerve block, she was able to completely wean off of opioids and continues having good pain control with an opioid-free regimen.

Tarlov cysts are an uncommon and often incidentally noted source of low back pain in women. Because these cysts can be asymptomatic, they can be overlooked on radiological imaging. This case is of a 49-year-old woman who presented with a chronic history of low back pain and bilateral radiculopathy who on magnetic resonance imaging (MRI) was found to have multiple Tarlov cysts. This case illustrates the need for large observational studies to show the incidence of Tarlov cysts as a cause of low back pain in women.

Chronic pruritus affects up to 20% of the population; about 8% of patients suffer from neurogenic pruritus, including notalgia paresthetica (NP). This is a syndrome of benign, chronic itch of the unilateral medial border of the scapula of unknown etiology and limited treatment efficacy.Here we report the background on NP, followed by a classic case presentation of a 63-year-old woman. We report on difficulty in her diagnosis and numerous failed lines of treatment, until initiation of treatment with duloxetine, which provided her with long-lasting benefit for the first time.Delay in diagnosis is common for NP, and though there are many options for treatment, evidence is lacking to support their efficacy. Finding an effective, well-tolerated regimen to alleviate long-term suffering brought on by this syndrome is heavily dependent on early identification. Our case provides anecdotal evidence for both treatment efficacy as well as the etiology of this poorly understood phenomenon. Keywords: Notalgia Paresthetica, Pruritus, Duloxetine, Neurogenic itch

Tarlov cysts are extradural meningeal cysts with collections of cerebrospinal fluid within the nerve sheath. These cysts are uncommon but tend to present more often in women. Symptomatic Tarlov cysts can lead to a variety of neurologic symptoms and painful conditions, including chronic pelvic pain. There is no consensus regarding the best treatment for symptomatic cysts. Surgical management has high rates of complication, including chronic pain, but better long-term results for symptom and cyst resolution. We describe a patient who developed worsening pelvic pain and lumbar radiculopathy after surgical management of her Tarlov cysts. Medication failed to relieve the pain, as did a variety of other procedures, before the patient ultimately received significant pain relief from high-frequency spinal cord stimulation. This case may provide guidance for physicians when managing patients suffering from symptomatic Tarlov cysts, or worsening pain symptoms after surgical management of these cysts. Keywords: Pelvic pain, Chronic pain, Tarlov cyst, Spinal cord stimulator

Traumatic brain injuries (TBI) and chronic post-traumatic headaches (PTH) have affected many military personnel. The increasing use of improvised explosive devices have made blast- and explosive-related head injuries more common than in previous wars [1, 2]. Data from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn demonstrate that a significant portion of military TBIs are caused by blast-related injuries [3, 4]. From 2000 to 2016 more than 350,000 military service members were diagnosed with a TBI [4]. Military troops are at greater risk of developing PTH from head injuries that arise during deployment to combat zones. These patients can be extremely challenging because they often suffer from comorbid conditions including depression and post-traumatic stress disorder (PTSD). Additionally, there is a lack of high-quality studies on the treatment of PTH [5]. This brief report describes a patient who suffered from chronic PTH after sustaining a mild TBI, and our results with greater occipital and auriculotemporal nerve blocks.

Brachioradial pruritus is a specific subtype of neuropathic pruritus that commonly presents in women. This condition is a type of neurological itch that mostly involves the dorsal forearm. It is more common in fair-skinned females, is exacerbated by exposure to bright sunlight or ultraviolet radiation (UVR), and is associated with degenerative changes in the cervical spine. Diagnosis is difficult, and is usually delayed for 2–3 years. We describe a patient who suffered brachioradial pruritus for many years and was misdiagnosed by multiple specialists until she presented to our pain clinic. The patient had undergone invasive diagnostic testing by previous specialists but this had not led to diagnosis. After a thorough history and exam, the diagnosis of brachioradial pruritus was considered and the patient was treated with anticonvulsant medications, as these have been shown to be effective in this condition. This case is of interest to all physicians treating female patients as consideration of this diagnosis can avoid unnecessary invasive diagnostic testing. Keywords: Brachioradial pruritus, Pruritis, Pain

In this work an efficient method for hiding a speech in audio is proposed. The features of secret speech is extracted with LPC (Linear Predictive Coding), and these parameters embedded in audio in chaotic order. Discrete Wavelet Transform (DWT) is applied on audio frames to split the signal in high and low frequencies. The embedding parameters are embedded in high frequency. The stego audio is perceptually indistinguishable from the equivalent cover audio. The proposed method allows hiding a same duration of speech (secret) and audio (cover). The stego audio is subjected to objective tests such signal to noise ratio (SNR), signal to noise ratio segmental (SNRseg), Segmental Spectral SNR, Log Likelihood Ratio (LLR) and Correlation (Rxy) to determine the similarity with original audio.