West Palm Beach VA Medical Center

OBJECTIVE: To describe intracochlear insertion trauma caused by three perimodiolar cochlear implant electrodes. STUDY DESIGN: Descriptive histological study of 15 human cadaver temporal bones. METHODS: Fifteen cadaver temporal bones underwent surface preparation and were implanted with one of the following perimodiolar electrode arrays: Combi 40+PM (MedEl Corporation), HiFocus II (Advanced Bionics Corporation), or Contour (Cochlear Corporation). A cryosectioning technique was used to study horizontal sections at 200 microm intervals with the electrode in place. Image-enhanced videofluoroscopy and computer-assisted morphometrics were used to assess the mechanism of insertion trauma and to determine electrode position within the modiolus. RESULTS: Histological examination revealed varying degrees of damage to the spiral ligament, basilar membrane, and osseous spiral lamina. Using a novel grading system for electrode trauma, there was no statistically significant difference among the three electrodes. A literature search of histological studies of a commonly used "standard" electrode showed damage equal to or greater than that seen in the current study. CONCLUSIONS: Insertion trauma caused by periomodiolar electrodes occurs to an acceptable degree. Refinement of electrodes based on mechanisms of trauma may be able to further reduce damage.

A non-combustible nicotine inhaler, administered orally, has been developed for treatment of smokers. The inhaler allows weaning from nicotine while maintaining partial reinforcement of the ritual/sensory phenomena of smoking. Subjects were randomly assigned to active (n = 112) and placebo (n = 111) groups. Some behavioral intervention occurred as a function of participation. Strict abstinence (primary outcome criterion) was defined by CO < or = 8 ppm with no slips allowed at any time and cotinine values < or = 14 at 1 year. Survival analysis showed active inhaler was superior to placebo (p < 0.01). Active vs. placebo success rates were: 63% vs. 47% (day 3), 46% vs. 28% (week 1), 36% vs. 19% (week 2), 33% vs. 16% (week 3), 29% vs. 14% (week 6), 24% vs. 10% (3 months), 17% vs. 9% (6 months) and 13% vs. 8% (1 year). chi 2 analyses were significant through 3 months but not at 6 months (p < 0.08) or 1 year. Craving was relieved with active inhalers at day 3 and week 1. Subjects averaged six inhalers/day. Cotinine levels were 57-61% of smoking levels. Common side effects included throat/mouth irritation and coughing. Failure was predicted by early slips. The inhaler is clearly useful for short-term smoking cessation with potential for long-term efficacy. Extended access to the inhaler and relapse prevention training could improve success rates. Another promising approach would be to combine the inhaler with a nicotine patch.

The size and location of articular cartilage wear was assessed on 106 varus and 37 valgus osteoarthritic tibial plateaus resected during total knee arthroplasty. Anterior cruciate ligament integrity was assessed intraoperatively, and calibrated digital images were used to measure the wear patterns. Complete anterior cruciate ligament deficiency was seen in 25% of the varus and 24% of the valgus knees. Wear patterns on anterior cruciate ligament intact and attenuated varus tibial plateaus occurred in the middle to anterior aspect of the medial plateau. Anterior cruciate ligament deficient varus plateaus had significantly larger wear areas located more posterior on the medial plateau. In contrast, anterior cruciate ligament intact and deficient valgus tibial plateaus had wear located posterior to the center of the lateral plateau. Anterior cruciate ligament integrity is a discrete feature of advanced osteoarthritis that strongly influences the articular wear patterns. The anterior cruciate ligament deficient wear patterns show a wear mechanism that is consistent with the posterior femoral subluxation and posterior tibiofemoral contact observed after acute anterior cruciate ligament rupture. These observations provide insight into the altered knee mechanics that exist in osteoarthritic knees and the resulting mechanical factors that contribute to degenerative changes.

In Brief Patients with severe insulin resistance require >2 units/kg of body weight or 200 units/day of insulin. Yet, many patients do not achieve glycemic targets despite using very high doses of insulin. Insulin can cause weight gain, which further contributes to worsening insulin resistance. This article describes the pharmacological options for managing patients with severe insulin resistance, including the use of U-500 insulin and newer agents in combination with insulin.

Management of aggressive behavior has been identified as a concern for nursing staff who provide institutional care for cognitively impaired elderly. The Omnibus Reconciliation Act (OBRA '87) mandates a trial reduction in the use of chemical and physical restraints, and the development of nursing interventions for the management of behavioral disorders of institutionalized cognitively impaired elderly. Most skilled nursing facilities, however, are limited in their ability to provide environmental and behavioral programs to manage aggressive patient behavior. For the purposes of this study, physically aggressive behavior was identified as threatened or actual aggressive patient contact which has taken place between a patient and a member of the nursing staff. This study explored the nursing staff's responses to patient physical aggression and the effects that physical aggression had on them and on nursing practice from the perspective of the nursing staff. Nursing staff employed on one Dementia Special Care Unit (DSCU) were invited to participate. Interviews with nursing staff were analyzed using qualitative descriptive methods described by Miles and Huberman (1994). Nursing staff reported that they were subjected to aggressive patient behaviors ranging from verbal threats to actual physical violence. Nursing staff reported that showering a resident was the activity of daily living most likely to provoke patient to staff physical aggression. The findings revealed geropsychiatric nursing practices for the management of physically aggressive residents, and offered recommendations for improving the safety of nursing staff and residents on a secured DSCU.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematologic malignancy with historically poor outcomes and no worldwide consensus treatment approach. Unique among most hematologic malignancies for its frequent cutaneous involvement, BPDCN can also invade other extramedullary compartments, including the central nervous system. Generally affecting older adults, many patients are unfit to receive intensive chemotherapy, and although hematopoietic stem cell transplantation is preferred for younger, fit individuals, not all are eligible. One recent therapeutic breakthrough is that all BPDCNs express CD123 (IL3Rα) and that this accessible surface marker can be pharmacologically targeted. The first-in-class agent for BPDCN, tagraxofusp, which targets CD123, was approved in December 2018 in the United States for patients with BPDCN aged ≥2 years. Despite favorable response rates in the frontline setting, many patients still relapse in the setting of monotherapy, and outcomes in patients with relapsed/refractory BPDCN remain dismal. Therefore, novel approaches targeting both CD123 and other targets are actively being investigated. To begin to formally address the state of the field, we formed a new collaborative initiative, the North American BPDCN Consortium (NABC). This group of experts, which includes a multidisciplinary panel of hematologists/oncologists, hematopoietic stem cell transplant physicians, pathologists, dermatologists, and pediatric oncologists, was tasked with defining the current standard of care in the field and identifying the most important research questions and future directions in BPDCN. The position findings of the NABC's inaugural meetings are presented herein.

Recently created guidelines for the development of institutional antimicrobial stewardship programs recommend that a pharmacist with infectious diseases training be included as a core member of the antimicrobial stewardship team. However, training and certification requirements for infectious diseases-trained clinical pharmacists have not been established. Although pharmacists have nurtured their interest in infectious diseases by self-directed learning or on-the-job experiences, this mode of training is not considered feasible or sufficient for reliable training of future clinical specialists in infectious diseases. This document, therefore, is forward looking and provides overarching recommendations for future training and certification of pharmacists practicing, mentoring, and educating in infectious diseases pharmacotherapy, with the recognition that full implementation may take several years. We recommend that future pharmacists wishing to obtain a clinical position as an infectious diseases-trained pharmacist should complete a postgraduate year (PGY) 1 residency and a PGY2 residency in infectious diseases, that practitioners become board-certified pharmacotherapy specialists, that a certification examination in infectious diseases be developed, that practitioners maintain a portfolio of educational experiences to maintain qualifications, that current nonaccredited training programs seek accreditation, and that employers and academicians recognize the desirability of these qualifications in hiring decisions.

In the Balance1 May 2012Is Geriatric Medicine Terminally Ill?Adam G. Golden, MD, MBA, Michael A. Silverman, MD, MPH, CMD, and Michael J. Mintzer, MDAdam G. Golden, MD, MBAFrom the University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando; West Palm Beach Veterans Affairs Medical Center, West Palm Beach; and University of Miami Miller School of Medicine and the Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida., Michael A. Silverman, MD, MPH, CMDFrom the University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando; West Palm Beach Veterans Affairs Medical Center, West Palm Beach; and University of Miami Miller School of Medicine and the Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida., and Michael J. Mintzer, MDFrom the University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando; West Palm Beach Veterans Affairs Medical Center, West Palm Beach; and University of Miami Miller School of Medicine and the Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-156-9-201205010-00009 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Geriatric medicine was established as a discipline to care for the complex needs of elderly patients (1). After much pioneering work, the American Board of Internal Medicine and American Board of Family Medicine granted geriatric medicine a Certificate of Added Qualifications in 1988. Board eligibility required completion of an accredited 2-year fellowship or qualification under the "practice pathway" based on practice experience.Even with this recognition, geriatric medicine in the United States has struggled to clearly identify its clinical niche and to attract interest among physicians (2). After closure of the practice pathway in 1994, the number of physicians seeking ...References1. Libow LS. Geriatrics in the United States—baby boomers' boon? N Engl J Med. 2005;352:750-2. [PMID: 15728805] CrossrefMedlineGoogle Scholar2. Kane RL. The future history of geriatrics: geriatrics at the crossroads. J Gerontol A Biol Sci Med Sci. 2002;57:M803-5. [PMID: 12456740] CrossrefMedlineGoogle Scholar3. Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Pr; 2008. Google Scholar4. Warshaw GA, Bragg E. ADGAP National Survey of Geriatric Medicine Fellowship Program Directors. Cincinnati: Association of Directors of Geriatrics Academic Programs; 2011. Accessed at: www.adgapstudy.uc.edu/slides.cfm on 20 March 2012. Google Scholar5. Farber J, Siu A, Bloom P. How much time do physicians spend providing care outside of office visits? Ann Intern Med. 2007;147:693-8. [PMID: 18025445] LinkGoogle Scholar6. Warshaw GA, Bragg EJ, Fried LP, Hall WJ. Which patients benefit the most from a geriatrician's care? Consensus among directors of geriatrics academic programs. J Am Geriatr Soc. 2008;56:1796-801. [PMID: 19054198] CrossrefMedlineGoogle Scholar7. Caprio TV, Karuza J, Katz PR. Profile of physicians in the nursing home: time perception and barriers to optimal medical practice. J Am Med Dir Assoc. 2009;10:93-7. [PMID: 19187876] CrossrefMedlineGoogle Scholar8. Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med. 2009;169:1712-7. [PMID: 19822829] CrossrefMedlineGoogle Scholar9. Phelan EA, Genshaft S, Williams B, LoGerfo JP, Wagner EH. A comparison of how generalists and fellowship-trained geriatricians provide "geriatric" care. J Am Geriatr Soc. 2008;56:1807-11. [PMID: 19054199] CrossrefMedlineGoogle Scholar10. Torres C, Ciocon JO, Galindo D, Ciocon DG. Clinical approach to urinary incontinence: a comparison between internists and geriatricians. Int Urol Nephrol. 2001;33:549-52. [PMID: 12230293] CrossrefMedlineGoogle Scholar11. Chin MH, Wang JC, Zhang JX, Sachs GA, Lang RM. Differences among geriatricians, general internists, and cardiologists in the care of patients with heart failure: a cautionary tale of quality assessment. J Am Geriatr Soc. 1998;46:1349-54. [PMID: 9809755] CrossrefMedlineGoogle Scholar12. Phillips SL, Phillips JV, Branaman-Phillips J, Miller DJ. Geriatric versus non-geriatric approach of care to moderate Pra risk senior population. J Am Med Dir Assoc. 2005;6:396-9. [PMID: 16286061] CrossrefMedlineGoogle Scholar13. Vladeck BC. The continuing paradoxes of nursing home policy. JAMA. 2011;306:1802-3. [PMID: 21972271] CrossrefMedlineGoogle Scholar14. Leipzig RM, Granville L, Simpson D, Anderson MB, Sauvigné K, Soriano RP. Keeping granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical students. Acad Med. 2009;84:604-10. [PMID: 19704193] CrossrefMedlineGoogle Scholar15. Williams BC, Warshaw G, Fabiny AR, Lundebjerg N, Medina-Walpole A, Sauvigne K, et al. Medicine in the 21st century: recommended essential geriatrics competencies for internal medicine and family medicine residents. J Grad Med Educ. 2010;2:373-83. [PMID: 21976086] CrossrefMedlineGoogle Scholar16. Hazzard WR. General internal medicine and geriatrics: collaboration to address the aging imperative can't wait [Editorial]. Ann Intern Med. 2003;139:597-8. [PMID: 14530233] LinkGoogle Scholar17. Christmas C, Park E, Schmaltz H, Gozu A, Durso SC. A model intensive course in geriatric teaching for non-geriatrician educators. J Gen Intern Med. 2008;23:1048-52. [PMID: 18612742] CrossrefMedlineGoogle Scholar18. Eckstrom E, Desai SS, Hunter AJ, Allen E, Tanner CE, Lucas LM, et al. Aiming to improve care of older adults: an innovative faculty development workshop. J Gen Intern Med. 2008;23:1053-6. [PMID: 18612743] CrossrefMedlineGoogle Scholar19. Mazotti L, Moylan A, Murphy E, Harper GM, Johnston CB, Hauer KE. Advancing geriatrics education: an efficient faculty development program for academic hospitalists increases geriatric teaching. J Hosp Med. 2010;5:541-6. [PMID: 20717891] CrossrefMedlineGoogle Scholar20. Podrazik PM, Levine S, Smith S, Scott D, Dubeau CE, Baron A, et al. The Curriculum for the Hospitalized Aging Medical Patient program: a collaborative faculty development program for hospitalists, general internists, and geriatricians. J Hosp Med. 2008;3:384-93. [PMID: 18836989] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From the University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando; West Palm Beach Veterans Affairs Medical Center, West Palm Beach; and University of Miami Miller School of Medicine and the Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida.Acknowledgment: The authors thank S. Barry Issenberg for his editorial feedback of the manuscript and insights on medical education.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-3079.Corresponding Author: Adam G. Golden, MD, MBA, 5201 Raymond Street, CLC-136, Orlando, FL 32803; e-mail, adam.[email protected]edu.Current Author Addresses: Dr. Golden: 5201 Raymond Street, CLC-136, Orlando, FL 32803.Dr. Silverman: 7305 North Military Trail, Code 114; West Palm Beach, FL 33410.Dr. Mintzer: 1201 Northwest 16 Street, 11GRC, Miami, FL 33125.Author Contributions: Conception and design: A.G. Golden, M.A. Silverman, M.J. Mintzer.Analysis and interpretation of the data: A.G. Golden.Drafting of the article: A.G. Golden, M.A. Silverman, M.J. Mintzer.Critical revision of the article for important intellectual content: A.G. Golden, M.A. Silverman, M.J. Mintzer.Final approval of the article: A.G. Golden, M.A. Silverman.Provision of study materials or patients: A.G. Golden.Administrative, technical, or logistic support: A.G. Golden.Collection and assembly of data: A.G. Golden, M.J. Mintzer. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoTreating Our Societal Scotoma: The Case for Investing in Geriatrics, Our Nation's Future, and Our Patients Rosanne M. Leipzig , William J. Hall , and Linda P. Fried Dialogue on Geriatrics: How Should We Fix the Problem? John R. Burton and Samuel C. Durso Dialogue on Geriatrics: How Should We Fix the Problem? David Hamerman Dialogue on Geriatrics: How Should We Fix the Problem? Leslie S. Libow Dialogue on Geriatrics: How Should We Fix the Problem? Kenneth M. Madden and Kenneth Rockwood Dialogue on Geriatrics: How Should We Fix the Problem? T.S. Dharmarajan and Abishek Kumar Dialogue on Geriatrics: How Should We Fix the Problem? Hajime Ichiseki Dialogue on Geriatrics: How Should We Fix the Problem? Giuseppe Bellelli and Marco Trabucchi Dialogue on Geriatrics: How Should We Fix the Problem? Adam G. Golden , Michael A. Silverman , and Michael J. 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Durso, MD, MBADialogue on Geriatrics: How Should We Fix the Problem?David Hamerman, MDDialogue on Geriatrics: How Should We Fix the Problem?Leslie S. Libow, MDDialogue on Geriatrics: How Should We Fix the Problem?Kenneth M. Madden, MD, MSc and Kenneth Rockwood, MDDialogue on Geriatrics: How Should We Fix the Problem?T.S. Dharmarajan, MD and Abishek Kumar, MDDialogue on Geriatrics: How Should We Fix the Problem?Hajime Ichiseki, MD, PhDDialogue on Geriatrics: How Should We Fix the Problem?Adam G. Golden, MD, MBA, Michael A. Silverman, MD, MPH, CMD, and Michael J. Mintzer, MD 1 May 2012Volume 156, Issue 9Page: 654-656KeywordsAcademic medicineElderlyFellowshipsGeriatricsHealth careMedical educationMedicareMotivationNursesSub-specialty care ePublished: 1 May 2012 Issue Published: 1 May 2012 PDF downloadLoading ...

This paper represents the opinion of the Women's Health Practice and Research Network (PRN) of the American College of Clinical Pharmacy. It does not necessarily represent an official ACCP commentary, guideline, or statement of policy or position .

Dietary supplement use has increased during the past decade. Epidemiologic studies suggest that patients turn to dietary supplements because of a reluctance to take prescription medications or a lack of satisfaction with the results. They often perceive dietary supplements to be a safer or more natural alternative. Patients with mental health conditions, including depression, anxiety, and sleep disorders, are among those who use dietary supplements. St. John's Wort is used to treat depression. Clinical studies comparing dietary supplements with low-dose antidepressants (maprotiline, amitriptyline, or imipramine at 75 mg/day) or high-dose antidepressants (imipramine at 150 mg/day) find no significant difference between treatments. Kava kava is used to treat anxiety. Clinical trials demonstrate it to be superior to placebo, and roughly equivalent to oxazepam 15 mg/day or bromazepam 9 mg/day. Agents discussed for use in sleep disorders include melatonin, valerian, 5-hydroxytryptamine, catnip, chamomile, gotu kola, hops, L-tryptophan, lavender, passionflower, skullcap, and valerian. Familiarity with the evidence for use and the possible resulting risks can help health professionals to guide patient decisions regarding use of dietary supplements.

OBJECTIVE: To review pegaptanib, a novel aptamer for the treatment of age-related macular degeneration (AMD). DATA SOURCES: A literature search using MEDLINE (1980-January 2006) and the Cochrane Database of Systematic Reviews (1978-January 2006) for peer-reviewed, English-language publications was conducted. Abstracts from recent meetings, including the Association for Research in Vision and Ophthalmology and American Society of Retinal Specialists, were reviewed for relevant abstracts and poster presentations. STUDY SELECTION AND DATA EXTRACTION: Pharmacokinetic and pharmacology data were extracted from animal and human studies, and double-blind, randomized, controlled trials were included to describe the efficacy and adverse effects of pegaptanib. DATA SYNTHESIS: The efficacy of pegaptanib has been evaluated in 2 concurrent, prospective, randomized, double-blind trials. Patients with AMD were randomly assigned to receive placebo or pegaptanib intravitreous injection into 1 eye every 6 weeks for 48 weeks. The effectiveness of pegaptanib was realized as early as week 6 and continued through week 54. At week 54, 38% of patients receiving pegaptanib 0.3 mg were classified as legally blind versus 56% of those receiving the sham injection. CONCLUSIONS: Pegaptanib, a new inhibitor of ocular neovascularization, provides patients with an alternative to photodynamic therapy with verteporfin and offers a novel approach to future drug developments for AMD. Pegaptanib offers the advantage of not requiring photodynamic therapy in conjunction with drug delivery and may be a viable option for institutions where this service is not easily accessible. Results of clinical trials have shown that pegaptanib is effective in delaying progression of AMD.

Pharmacologic stress testing uses vasodilators to provide objective evidence of myocardial ischemia. Adenosine and dipyridamole are nonselective adenosine receptor agonists that have been associated with myocardial infarction (MI) during intravenous infusion. Mechanisms postulated for this effect include coronary steal, transmural steal, global hypotension, and direct vasoconstriction. Regadenoson, a direct A2A agonist, was approved for use in stress testing in 2008. We describe a 68-year-old man who presented to our institution with typical angina, relieved by nitroglycerin. He did not have electrocardiogram (ECG) changes suggestive of myocardial pathology, and laboratory testing did not reveal a significant rise in troponin-I levels. To further assess the etiology of his symptoms, he underwent a pharmacologic stress test with regadenoson followed by technetium 99 m sestamibi. Six minutes after regadenoson infusion, the patient developed severe retrosternal chest pain accompanied by ST elevations on ECG. Sublingual nitroglycerin was administered that resolved both the pain and ECG changes. The patient subsequently underwent urgent coronary angiography and was found to have a 95% critical stenosis involving the left anterior descending artery. We conclude this case represents a MI secondary to coronary steal phenomenon induced by regadenoson infusion. Clinicians should be aware this adverse effect can occur despite the improved side-effect profile of regadenoson. Continuous monitoring of vital signs and the ECG with regular assessment of symptoms is imperative to identify this rare but potentially devastating adverse event.

Objective To measure the association between race and head and neck cancer screening and education. Study Design Nationally representative survey. Setting US National Center for Health Statistics. Subjects and Methods Pooled data from the 2011-2014 National Health and Nutrition Examination Survey were used to examine disparities in head and neck cancer education and screening among US citizens aged ≥18 years. We measured the association between race and head and neck cancer education and screening, adjusting for age, sex, education, income, and health insurance. Subtype analyses were performed on ever smokers, a lifetime consumption of ≥100 cigarettes, and nonsmokers, a lifetime consumption of <100 cigarettes. Results Among smokers, only 20.2% were educated about the benefits of giving up cigarette smoking; 27.7% had ever received an oral cancer screening examination in which a doctor or dentist pulls on the tongue; and 24.8% had ever had a screening examination in which a doctor or dentist feels the neck. As compared with white smokers, nonwhite smokers were significantly less likely to receive an oral cancer screening examination in which the tongue was pulled (black smokers: odds ratio, 0.44; 95% CI, 0.31-0.63). Although 72.2% of screenings of white participants were performed by dentists, black participants were more often screened by a physician (36.4%) as compared with any other race. Conclusion This study highlights socioeconomic disparities in head and neck cancer screening and education. We advocate increased patient screening and education by primary care physicians, especially for nonwhite patients and patients with relevant risk factors.

The Ultraviolet Index was developed in the United States in 1994 following successful use of ultraviolet (UV) alerts in other countries. This daily National Weather Service prediction is a calculation which integrates five data elements to yield the amount of UV radiation impacting the surface (1m2) at solar noon in 58 of the largest US population centers. This simple numeric prediction is then categorized by the Environmental Protection Agency into five "exposure levels" with protective actions recommended for each level. This information is disseminated through the media. Daily reminders seem to affect awareness and behavior in Canada, but US surveys indicate the need for better understanding through educational graphics. Comparing the UV Index to a precipitation prediction has merit in that it links a familiar daily prediction with implied appropriate protective measures. Graphics link the ideas that "when it rains it pours and when it shines it radiates." Beginning in schools, camps, and dermatology meetings, using the rain/shine analogy, a wider exposure to the Ultraviolet Index is proposed.

Background: Palliative care (PC) teams increasingly care for patients with cancer into survivorship. Cancer survivorship transcends distinctions between acute, chronic, malignant, and nonmalignant pain. Partnering with oncologists, PC teams manage pain that persists after disease-directed treatment, evaluate changing symptoms as possible signs of cancer recurrence, taper opioids and mitigate risk of opioid misuse, and manage comorbid opioid use disorder (OUD). While interdisciplinary guidelines exist for pain management in survivorship, there is a need to develop a conceptual model that fully translates the biopsychosocial framework of PC into survivorship pain management. Objective: This review frames a model for pain management in cancer survivorship that balances analgesia with the imperative to minimize risk of OUD, recognizes signs of disease recurrence, and provides whole-person care. Methods: Comprehensive narrative review of the literature. Results: Little guidance exists for co-management of pain, psychological distress, and opioid misuse in survivorship. We identified themes for whole-person pain management in survivorship: use of opioids and coanalgesic medications to prevent recurrent pain from residual tissue damage following cancer treatment, opioid tapering to the lowest effective dose, utilization of nonpharmacologic psychological interventions shown to reduce pain, screening for and management of OUD in partnership with addiction medicine specialists, maintaining vigilance for disease recurrence, and engaging in shared medical decision making. Conclusions: The management of pain in cancer survivorship is complex and requires interdisciplinary care that balances analgesia with the imperative to reduce long-term inappropriate opioid use and manage OUD, while maintaining therapeutic presence with patients in the spirit of PC.

Warfarin-induced skin necrosis (WISN) is a disorder of unclear etiology that predominantly affects obese women. Although WISN typically occurs within the first 10 days of warfarin therapy, some patients develop the complication several years after warfarin exposure. We describe the case of a 43-year-old Caucasian woman with a history of recurrent thromboembolic disorders, protein S deficiency, and multiple exposures to warfarin who came to the emergency room with complaints of worsening dermatitis that had progressed over a 15-hour period. Examination revealed multiple, diffuse "lace-like" erythematous eruptions with superimposed lesions that were tender, ulcerated, and crusted. A biopsy was performed, and histopathologic findings were consistent with WISN. Based on the Naranjo adverse drug reaction probability scale, a probable causal relationship existed between warfarin and skin necrosis in this patient. Since treatment is generally supportive, prompt and prudent evaluation of suspicious skin lesions is necessary to prevent the serious sequelae associated with WISN.

STUDY OBJECTIVES: To review the effectiveness of interventions designed to improve antibiotic prescribing patterns in clinical practice and to draw inferences about the most practical methods for optimizing antibiotic utilization in hospital and ambulatory settings. METHODS: A literature search using online databases for the years 1975-2004 identified controlled trials of strategies for improving antibiotic utilization. Due to variation in study settings and design, quantitative meta-analysis was not feasible. Therefore, a qualitative literature review was conducted. RESULTS: Forty-one controlled trials met the search criteria. Interventions consisted of education, peer review and feedback, physician participation, rewards and penalties, administrative methods, and combined approaches. Social marketing directed at patients and prescribers was effective in varying contexts, as was implementation of practice guidelines. Authorization systems with structured order entry, formulary restriction, and mandatory consultation were also effective. Peer review and feedback were more effective when combined with dissemination of relevant information or social marketing than when used alone. CONCLUSIONS: Several practices were effective in improving antibiotic utilization: social marketing, practice guidelines, authorization systems, and peer review and feedback. Online systems providing clinical information, structured order entry, and decision support may be the most promising approach. Further studies, including economic analyses, are needed to confirm or refute this hypothesis.

Although traumatic brain injury (TBI) can happen to anyone at any time, the wars in Iraq and Afghanistan have brought it renewed attention. Fortunately, most cases of TBI from the recent conflicts are mild TBI (mTBI). Still, many physical, psychological, and social problems are associated with mTBI. Among the difficulties encountered are oculomotor and vision problems, many of which can impede daily activities such as reading. Therefore, correct diagnosis and treatment of these mTBI-related vision problems is an important part of patient recovery. Numerous eye care providers in the Department of Veterans Affairs, in military settings, and in civilian practices specialize and are proficient in examining patients who have a history of TBI. However, many do not have this level of experience working with and treating patients with mTBI. Recognizing this, we used a modified Delphi method to derive expert opinions from a panel of 16 optometrists concerning visual examination of the patient with mTBI. This process resulted in a clinical tool containing 17 history questions and 7 examination procedures. This tool provides a set of clinical guidelines that can be used as desired by any eye care provider either as a screening tool or adjunct to a full eye examination when seeing a patient with a history of mTBI. The goal of this process was to provide optimal and uniform vision care for the patient with mTBI.

Background: The optimal monitoring and follow-up strategy for long-term direct oral anticoagulant (DOAC) therapy has not been established. Historically, at our medical center, DOAC patients were referred to a clinical pharmacy specialist managed anticoagulation clinic (AC) for monitoring via regularly scheduled encounters (face-to-face or telephone). Objective: To determine if implementation of a DOAC Population Management Tool (PMT) designed to identify patients who most likely require clinical review and possibly intervention, would improve the efficacy (interventions per patient) and efficiency (time invested to generate an intervention) of monitoring over AC practices. Methods: The DOAC PMT group included patients flagged as potentially having a dosing issue or history of valve replacement. The AC group included patients who were scheduled for routine DOAC follow-up. The quantity and character of interventions made were prospectively recorded and compared. Results: A total of 399 patients were included. Data were collected for 131 patients identified by the DOAC PMT, resulting in a review of 170 flags with a total of 94 interventions or 0.55 interventions per flag reviewed. For the AC group, 268 patients were evaluated, leading to 53 interventions or 0.20 interventions per patient encounter ( P &lt; 0.001 for comparison). The time to generate an intervention was 16 minutes in the DOAC PMT versus 64 minutes for the AC group. Conclusion and Relevance: A population-based approach to DOAC monitoring represents a more effective and efficient strategy to reduce missed opportunities for interventions between follow-up appointments while also increasing clinic access, particularly for patients who require immediate attention.

STUDY OBJECTIVES: To evaluate the prevalence and magnitude of serum creatinine level elevations in patients receiving metformin who underwent radiologic procedures involving administration of intravenous contrast media, and to evaluate the efficacy of an electronic consultation in promoting timely evaluation of renal function after the procedure. DESIGN: Retrospective evaluation. SETTING: Veterans Affairs Medical Center. PATIENTS: Ninety-seven patients receiving metformin who underwent a radiologic procedure involving administration of intravenous contrast media over a 27-month period. MEASUREMENTS AND MAIN RESULTS: Ninety-seven patients underwent a total of 111 radiologic procedures with documented administration of intravenous contrast dye. Average time from procedure to laboratory follow-up, excluding one patient, was 2.62+/-1.56 days. Average serum creatinine levels before and after the procedure were 1.10+/-0.19 and 1.13+/-0.23 mg/dl, respectively (p>0.05). Four patients developed contrast material-associated nephropathy. An additional four patients with borderline serum creatinine levels at baseline (1.4 mg/dl) had a serum creatinine level of 1.5 mg/dl or greater after the procedure. CONCLUSION: Our results indicated that electronic consultations result in timely evaluation of serum creatinine levels in patients receiving metformin who undergo a radiologic procedure involving intravenous contrast material. Also, the study suggests that nearly 4% of patients with diabetes mellitus and normal renal function may develop contrast material-associated nephropathy [corrected] with nonionic contrast material. In addition, about 8% of patients with diabetes treated with metformin (with baseline serum creatinine levels < 1.5 mg/dl) who undergo a procedure with nonionic intravenous contrast material acquire an increased risk (serum creatinine > or = 1.5 mg/dl) of lactic acidosis. These findings support the recommendations of the Food and Drug Administration regarding metformin monitoring in patients undergoing radiologic procedures involving administration of intravenous contrast media.