Neuropathic opioid refractory phantom limb pain (PLP) following amputation can be a life long deb... more Neuropathic opioid refractory phantom limb pain (PLP) following amputation can be a life long debilitating chronic pain syndrome capable of completely destroying a patient’s life. The pain, its associated depression and sleep deprivation can make many patients suicidal. Ever changing and relentless, it is notoriously unresponsive to traditional cocktails of strong opioids, adjuvant pain medications, antidepressants, local anaesthetics, nerve stimulators, hypnotics and psychotropics. Drug effects are seldom more effective than placebo. We describe a successful sustained rescue of a difficult 2-year-long PLP case with sublingual buprenorphine/naloxone using the drug’s potent multimodal mechanisms of action: potent long-acting mu agonist/antagonist, kapa receptor antagonist, delta receptor antagonist and novel opioid receptor-like 1 (OR-L1) agonist effects. Traditional escalating pure mu-opioid receptor agonists and adjuvant neuropathic pain cocktails often have disappointing efficacy ...
Background The management of penetrating thoracoabdominal trauma can be a vexing surgical challen... more Background The management of penetrating thoracoabdominal trauma can be a vexing surgical challenge. Patients with penetrating thoracoabdominal injuries and hypovolemic shock usually warrant immediate surgical intervention. However, in selected hemodynamically stable patients with isolated right sided thoracoabdominal wounds, interventional radiologic angio-embolization may provide a non-operative alternative. Methods We present a 19 year old man who sustained two gun shot wounds (GSW): A through and through injury to the right thoracoabdominal region two inches lateral and below the nipple and a second to the left lower extremity. On arrival to the emergency department (ED) he was normotensive, but tachycardic to 106 bpm. On physical exam, he had decreased breath sounds on the right and a right thoracostomy was performed.Left lower extremity pulses were present Initial hemoglobin was 12.0 mg/dL followed 11.3 mg/dL and 10.1 mg/dL. Focus sonography for trauma (FAST) scan demonstrated a small amount of free fluid in the abdomen. Computed tomography (CT) showed a Grade III-IV liver laceration involving the anterior and posterior segments of the right lobe of the liver with an area of active extravasation. CT clearly demonstrated that the missile trajectory only involved the liver.The patient was the taken to IR for hepatic arteriogram and embolization. Results Arteriogram revealed active extravasation from a tertiary branch of the right hepatic artery, which was succesfully embolized Conclusion Arteriogram also showed disruption of the left popliteal artery which was repaired surgically. The patient had an uneventful post procedure course and was discharged to home on hospital day four. Conclusion This case illustrates the widening multi-disciplinary approach to the non-operative management of penetrating right sided thoracoabdominal injuries. In this case surgical intervention was avoided resulting in a decreased length of stay and decreased morbidity related to laparotomy and hepatorrhaphy.
Background For over 30 years, syringe services programs (SSPs) have served as an efficacious inte... more Background For over 30 years, syringe services programs (SSPs) have served as an efficacious intervention for the prevention of HIV and Hepatitis C transmission among persons who use drugs. Despite a strong body of evidence for the effectiveness of SSPs as a preventative public health measure, numerous local and state governments in the United States continue to resist the establishment of new SSPs and aggressively pursue the closure of those already in operation. Commentary In Orange County, California, local officials have repeatedly mobilized in opposition of the establishment of syringe access – thereby hindering access to healthcare for thousands of predominantly unhoused individuals. The county was previously served by the Orange County Needle Exchange Program from 2016 until 2018 when a civil suit brought by the Orange County Board of Supervisors resulted in the closure of the program. For more than 2 years, persons who inject drugs in Orange County lacked reliable access to ...
Alcohol abuse is recognized as a significant contributor to injury. It is therefore essential tha... more Alcohol abuse is recognized as a significant contributor to injury. It is therefore essential that trauma centers implement screening and brief intervention (SBI) to identify patients who are problem drinkers. Although, the utility of SBI in identifying at-risk drinkers have been widely studied in level 1 trauma centers, few studies have been done in level 2 centers. This study evaluates the usefulness of SBI in identifying at-risk drinkers and to investigate the pattern of alcohol drinking among level 2 trauma patients. This is a retrospective study of a convenience sample of trauma patients participating in computerized alcohol screening, brief intervention, and referral to treatment (CASI) in an academic level 1 trauma center and a nearby suburban community hospital level 2 trauma center. CASI utilized Alcohol Use Disorders Identification Test (AUDIT) to screen patients. We compared the pattern of alcohol drinking, demographic factors, and readiness-to-change scores between those...
Objective: The Alcohol Use and Disorders Test (AUDIT) result is a composite score of three domain... more Objective: The Alcohol Use and Disorders Test (AUDIT) result is a composite score of three domains of alcohol use: frequency, dependency, and harmful drinking patterns. Studies have analyzed these domains to validate AUDIT as a screening tool, but few have investigated their association with patient demographics. Methods: This retrospective study analyzed AUDIT domain scores in association with age, sex, language, education level, and readiness-to-change scores from adult emergency and trauma patients at a tertiary university hospital between January 2011 and December 2013. We analyzed data from 761 hazardous drinkers using one-way ANOVA testing, two-sample T-tests, and linear regression. Results: In linear regression, adjusted for: age, sex, language, and education level, age and sex were associated with drinking frequency, with 18-20 year-olds and females scoring significantly less than other groups. The dependency domain was associated with education, age, and language. Individua...
The aim of this study was to determine factors that predict mortality in patients with traumatic ... more The aim of this study was to determine factors that predict mortality in patients with traumatic inferior vena cava (IVC) injuries and to review the current management of this lethal injury. A 7-year retrospective review of all trauma patients with IVC injuries was performed. Factors associated with mortality were assessed by univariate analysis. Significant variables were included in a multivariate regression analysis model to determine independent predictors of mortality. Statistical significance was determined at P < or = 0.05. A literature review of traumatic IVC injuries was performed and compared with our institutional experience. Thirty-six IVC injuries were identified (mortality, 56%; mechanisms of injury, 28% blunt and 72% penetrating). There was no difference in mortality based on mechanism of injury. Injuries with closer proximity to the heart were associated with increased mortality (P < 0.001). Univariate analysis demonstrated that nonsurvivors had a higher injury...
Neuropathic opioid refractory phantom limb pain (PLP) following amputation can be a life long deb... more Neuropathic opioid refractory phantom limb pain (PLP) following amputation can be a life long debilitating chronic pain syndrome capable of completely destroying a patient’s life. The pain, its associated depression and sleep deprivation can make many patients suicidal. Ever changing and relentless, it is notoriously unresponsive to traditional cocktails of strong opioids, adjuvant pain medications, antidepressants, local anaesthetics, nerve stimulators, hypnotics and psychotropics. Drug effects are seldom more effective than placebo. We describe a successful sustained rescue of a difficult 2-year-long PLP case with sublingual buprenorphine/naloxone using the drug’s potent multimodal mechanisms of action: potent long-acting mu agonist/antagonist, kapa receptor antagonist, delta receptor antagonist and novel opioid receptor-like 1 (OR-L1) agonist effects. Traditional escalating pure mu-opioid receptor agonists and adjuvant neuropathic pain cocktails often have disappointing efficacy ...
Background The management of penetrating thoracoabdominal trauma can be a vexing surgical challen... more Background The management of penetrating thoracoabdominal trauma can be a vexing surgical challenge. Patients with penetrating thoracoabdominal injuries and hypovolemic shock usually warrant immediate surgical intervention. However, in selected hemodynamically stable patients with isolated right sided thoracoabdominal wounds, interventional radiologic angio-embolization may provide a non-operative alternative. Methods We present a 19 year old man who sustained two gun shot wounds (GSW): A through and through injury to the right thoracoabdominal region two inches lateral and below the nipple and a second to the left lower extremity. On arrival to the emergency department (ED) he was normotensive, but tachycardic to 106 bpm. On physical exam, he had decreased breath sounds on the right and a right thoracostomy was performed.Left lower extremity pulses were present Initial hemoglobin was 12.0 mg/dL followed 11.3 mg/dL and 10.1 mg/dL. Focus sonography for trauma (FAST) scan demonstrated a small amount of free fluid in the abdomen. Computed tomography (CT) showed a Grade III-IV liver laceration involving the anterior and posterior segments of the right lobe of the liver with an area of active extravasation. CT clearly demonstrated that the missile trajectory only involved the liver.The patient was the taken to IR for hepatic arteriogram and embolization. Results Arteriogram revealed active extravasation from a tertiary branch of the right hepatic artery, which was succesfully embolized Conclusion Arteriogram also showed disruption of the left popliteal artery which was repaired surgically. The patient had an uneventful post procedure course and was discharged to home on hospital day four. Conclusion This case illustrates the widening multi-disciplinary approach to the non-operative management of penetrating right sided thoracoabdominal injuries. In this case surgical intervention was avoided resulting in a decreased length of stay and decreased morbidity related to laparotomy and hepatorrhaphy.
Background For over 30 years, syringe services programs (SSPs) have served as an efficacious inte... more Background For over 30 years, syringe services programs (SSPs) have served as an efficacious intervention for the prevention of HIV and Hepatitis C transmission among persons who use drugs. Despite a strong body of evidence for the effectiveness of SSPs as a preventative public health measure, numerous local and state governments in the United States continue to resist the establishment of new SSPs and aggressively pursue the closure of those already in operation. Commentary In Orange County, California, local officials have repeatedly mobilized in opposition of the establishment of syringe access – thereby hindering access to healthcare for thousands of predominantly unhoused individuals. The county was previously served by the Orange County Needle Exchange Program from 2016 until 2018 when a civil suit brought by the Orange County Board of Supervisors resulted in the closure of the program. For more than 2 years, persons who inject drugs in Orange County lacked reliable access to ...
Alcohol abuse is recognized as a significant contributor to injury. It is therefore essential tha... more Alcohol abuse is recognized as a significant contributor to injury. It is therefore essential that trauma centers implement screening and brief intervention (SBI) to identify patients who are problem drinkers. Although, the utility of SBI in identifying at-risk drinkers have been widely studied in level 1 trauma centers, few studies have been done in level 2 centers. This study evaluates the usefulness of SBI in identifying at-risk drinkers and to investigate the pattern of alcohol drinking among level 2 trauma patients. This is a retrospective study of a convenience sample of trauma patients participating in computerized alcohol screening, brief intervention, and referral to treatment (CASI) in an academic level 1 trauma center and a nearby suburban community hospital level 2 trauma center. CASI utilized Alcohol Use Disorders Identification Test (AUDIT) to screen patients. We compared the pattern of alcohol drinking, demographic factors, and readiness-to-change scores between those...
Objective: The Alcohol Use and Disorders Test (AUDIT) result is a composite score of three domain... more Objective: The Alcohol Use and Disorders Test (AUDIT) result is a composite score of three domains of alcohol use: frequency, dependency, and harmful drinking patterns. Studies have analyzed these domains to validate AUDIT as a screening tool, but few have investigated their association with patient demographics. Methods: This retrospective study analyzed AUDIT domain scores in association with age, sex, language, education level, and readiness-to-change scores from adult emergency and trauma patients at a tertiary university hospital between January 2011 and December 2013. We analyzed data from 761 hazardous drinkers using one-way ANOVA testing, two-sample T-tests, and linear regression. Results: In linear regression, adjusted for: age, sex, language, and education level, age and sex were associated with drinking frequency, with 18-20 year-olds and females scoring significantly less than other groups. The dependency domain was associated with education, age, and language. Individua...
The aim of this study was to determine factors that predict mortality in patients with traumatic ... more The aim of this study was to determine factors that predict mortality in patients with traumatic inferior vena cava (IVC) injuries and to review the current management of this lethal injury. A 7-year retrospective review of all trauma patients with IVC injuries was performed. Factors associated with mortality were assessed by univariate analysis. Significant variables were included in a multivariate regression analysis model to determine independent predictors of mortality. Statistical significance was determined at P < or = 0.05. A literature review of traumatic IVC injuries was performed and compared with our institutional experience. Thirty-six IVC injuries were identified (mortality, 56%; mechanisms of injury, 28% blunt and 72% penetrating). There was no difference in mortality based on mechanism of injury. Injuries with closer proximity to the heart were associated with increased mortality (P < 0.001). Univariate analysis demonstrated that nonsurvivors had a higher injury...
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