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Assess your knowledge, prep for the boards, and earn CME credits and MOC points with the best self-assessment program. Editorial note: ACP InternistWeekly will not be published next week due to the Thanksgiving holiday. Two major health insurance groups announced last week that they will provide coverage for all Americans, if the government mandates that everyone purchase health insurance.
Under the proposal, the members of America's Health Insurance Plans (AHIP) and the BlueCross BlueShield Association would no longer reject applicants based on their health status or exclude pre-existing conditions from coverage. Mandatory coverage, a controversial issue in the recent presidential election, was not a component of President-elect Barack Obama's health reform plan.
Ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals. Ginkgo biloba doesn't reduce the incidence of dementia or Alzheimer's in elderly individuals with normal cognition or mild cognitive impairment, a recent study found. The authors noted that the formulation of Ginkgo biloba used in the study is the one for which most data are available. Editor's Note: Thanks to all our readers who wrote us and said they wanted to see the critiques posted with the questions. A 32-year-old woman is evaluated for a 5-month history of pain and swelling of her hands and progressive weakness.
Almost a third of adults who had been diagnosed with asthma turned out not to have the disease, according to a Canadian study. Researchers randomly recruited 540 Canadian adults (half of whom were obese) who had been diagnosed with asthma by a physician. Patients found not to have asthma stopped medications, and 65.5% of them didn't need or asthma-related drugs or health care during the next six months. Researchers concluded that in developed countries such as Canada asthma may be overdiagnosed, explaining recent increases in asthma rates.
Spirometry is also crucial to a diagnosis of asthma, wrote the researchers and the author of an accompanying editorial. A review spells out which factors to consider when deciding whether to recommend implantable cardioverter-defibrillators (ICDs) as primary prevention in high-risk patients who have had myocardial infarction.
ICDs are an established device as secondary prevention for patients who have survived a life-threatening ventricular arrhythmia.
When selecting primary prevention patients for ICD, physicians should start by assessing ejection fraction (EF), then consider other factors, the reviewer said. Patients with none of the above factors can defer ICD implementation, especially if their EF is between 30%-35%. Three brands of 10% benzoyl peroxide acne cream are being recalled because samples of the products contained Burkholderia cepacia, an FDA alert and manufacturer's press release said. The affected one-ounce tubes are "DG Maximum Strength Acne Medicated Gel" (Dollar General), "Kroger Acne Gel 10% Benzoyl Peroxide Acne Medication" (Kroger) and "Equate: Medicated Acne Gel" (Wal-Mart).
The products may carry a heightened risk of infections in people with cuts, scrapes, rashes and other skin conditions, as well as in those with weakened immune systems. New educational tools for physicians’ offices and patients aimed at helping Spanish-speakers over age 50 keep track of recommended screening tests are now available from the Agency for Healthcare Research and Quality (AHRQ).
Checklists for male and female Spanish speakers list evidence-based recommendations from the U.S. AHRQ cited statistics showing that Hispanic adults are more likely than whites to be hospitalized for preventable conditions, such as complications of uncontrolled diabetes, congestive heart failure, hypertension and angina. English-language versions of the checklists for men and women as well as the wall chart are also available through AHRQ’s Web site. A new training manual on medication-assisted treatment for opioid addition is available free from the Substance Abuse and Mental Health Services Administration (SAMHSA). The latest issue of ACP Advocate features a look at Senate Finance Committee Chairman Max Baucus' white paper on health care reform, which proposes increases in Medicare payment rates for primary care physicians and expansion of the Patient Centered Medical Home. The ACP Board of Regents has approved and signed the Joint Statement of Medical Societies Regarding Vaccination by Physicians. The joint statement is the collaborative effort of several medical societies, including ACP and the Infectious Diseases Society of America, to emphasize the importance of adult vaccination and the critical roles that primary care and subspecialty physicians play in patients’ vaccination status. The statement’s release coincides with a growing emphasis on adult vaccination, which has been bolstered by increased consumer demand for quality care as well as CDC recommendations. ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. This issue's winning cartoon caption was submitted by Leslie Thompson Harris, ACP Associate Member, an internal medicine PGY-1 resident at Gundersen Lutheran Medical Center, La Crosse, Wis. December's Grand Prize cartoon contest will pit the three top vote getters from 2008 head-to-head, with one lucky voter winning a $100 gift certificate. This patient most likely has polymyositis, which may be associated with elevated antinuclear antibody titers and a normal or elevated erythrocyte sedimentation rate. This patient's only finding consistent with systemic lupus erythematosus is antinuclear antibody positivity. Manifestations of inflammatory myositis may include elevated antinuclear antibody titers and creatine kinase levels, abnormal electromyography findings, proximal muscle weakness, interstitial lung disease, arthritis, and skin rashes. To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.
ACP offers different categories of membership depending on your career stage and professional status. Ensure you're board-exam ready with ACP's Board Prep Ace - a multifaceted, self-study program that prepares you to pass the ABIM Certification Exam in internal medicine. Ji Linong, president of the Chinese Diabetes Society under the Chinese Medical Association, made the remarks at an event on Tuesday to mark World Diabetes Day, which falls on Nov 14 every year. According to Ji, the number of diabetes patients on the mainland has doubled over the past decade, and about 9.7 percent of the population aged 20 and older suffer from the chronic disease related to a high-fat diet and sedentary lifestyle. Diabetics who do not receive early treatment could suffer a heart attack, kidney failure or serious complications that result in amputation, he said. A nurse shows a diabetic where on her body to inject insulin, at the Xiangyang No 1 People’s Hospital in Hubei province in November 2011. Ji attributed the low diagnosis rate to limited access to early screening services and poor public awareness. Statistics from the ministry showed that more than 5 percent of China’s total health expenditures went to diabetes treatment. Roughly 60 percent of Chinese patients take an oral medication and the rest a combination of insulin injections and oral medications, statistics from the Chinese Diabetes Society showed. According to Ji, 80 percent of the mainland’s annual diabetes treatment costs are for complications, which involve a lot of inpatient care.

Less than half of diabetics manage to keep their blood-sugar levels under control, he added.
Kong said health authorities will enhance diabetes control efforts, particularly at grassroots-level health facilities. By 2030, China will have 40 million new diabetes cases on the mainland, and the treatment cost for all patients will reach about $28 billion annually, the International Diabetes Federation estimated. Among residents between the ages of 18 and 29, the diabetes prevalence is 1.3 percent, which is the lowest of all age groups. In addition to the variety of services for the effective treatment and management of Diabetes, the center offers self-management educational programs and research opportunities.
Individuals with diabetes are at risk for a variety of serious health complications that require specialty care.
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Around 35,000 nurses and midwives have completed revalidation in the first three months since it was introduced in April, but more than 3,000 have left the register in that time, data from the Nursing and Midwifery Council has shown.
I was invited recently to present my PhD research project on dementia to a patient and public involvement (PPI) group.
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Knowing how to control wound pain effectively is an important aspect of wound care, since poorly managed pain can significantly impede the healing process. Many patients with wounds suffer from pain that is often underestimated or poorly managed, due to nurses focusing on the wound itself rather than the whole person (Johnson, 2009; Scheinfeld, 2005).
Non-verbal cues, such as grimacing, guarding the area and restricted movement should also be noted (Brown, 2014). There are several types of pain, which fall broadly into two main categories: nociceptive and neuropathic. Differentiating between nociceptive and neuropathic wound pain can be difficult, but is important if the pain is to be managed effectively. Pain is complex and is influenced by many factors, such as emotion, social background and what the meaning of the pain is to the patient. Worrying about the cause of the pain is common and when pain is not managed effectively, such as in the case of chronic wounds, patients may become depressed, experience difficulties with concentration or have a poor sleeping pattern (Mason, 2009); these responses adversely affect the healing process (Eagle, 2009). Use adhesive removal products such as Appeel (CliniMed) to assist in removing adhesive products. Health professionals may find it useful to use pain assessment tools, such as numerical or visual rating scales that patients complete themselves.
When analgesia is used to treat wound pain, its effectiveness must be reassessed frequently.
Instead of administering analgesia when the pain starts, analgesia must be given regularly and at the appropriate dose, particularly in chronic pain, to ensure continuous pain relief. In addition to analgesia, there are many non-pharmacological treatments that can help to reduce wound pain. Assessing pain should be the first priority in managing wounds and should not be a one-off process. The next article in this series discusses the importance of clear and accurate documentation for wound management. Nursing Times subscribers can now access the latest news affecting the nursing profession on the go with the Nursing Times app. Search for Nursing Times on your Apple or Android device and log in using the same details you use on the website. Bennett M (2001) The LANSS pain scale: the Leeds assessment of neuropathic symptoms and signs.
Bethell E (2003) Why gauze dressings should not be the first choice to manage most acute surgical cavity wounds.
Callister LC (2001) Culturally competent care of women and newborns: knowledge, attitude, and skills. Howarth A (2002) Will aromatherapy be a useful treatment strategy for people with multiple sclerosis who experience pain?
Mason V (2009) Psychological factors of pain perception, communication and responses to treatment. Price PE et al (2008) Dressing-related pain in patients with chronic wounds: an international perspective. Stephenson N L et al (2000) The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Walsh D, Radcliffe J (2002) Pain beliefs and perceived physical disability of patients with chronic low back pain. Williams A, Irurita V (2004) Therapeutic and non-therapeutic interpersonal interactions: the patient’s perspective. Wounds International (2004) Principles of best practice: minimising pain at wound dressing-related procedures. Their proposal is contingent on Congress enacting an enforceable individual coverage mandate.
Based on these results, they concluded that Gingko biloba should not be used for preventing dementia. There are scaly, rough, dry, darkened, cracked horizontal lines on the palmar and lateral aspects of her fingers.
Electromyogram reveals spontaneous fibrillations, repetitive discharges, and positive sharp waves. The study found that 44 of those patients did not have current asthma, determined by the fact that they had no evidence of acute worsening of symptoms, reversible airflow obstruction or bronchial hyperresponsiveness despite being weaned off asthma medications. Only 7.7% required an unscheduled evaluation by a health care provider because of respiratory symptoms. They did not find any difference in overdiagnosis between obese and nonobese patients, however, indicating that asthma actually is more prevalent in the obese population.
Major trials also suggest a benefit to ICD use in high-risk patients in whom life-threatening arrhythmias haven't yet occurred, but the studies' limitations make the picture less clear, the reviewer said in the Nov.
Generally, those with an EF of 25% or less after MI are candidates, while those with higher than 35% EF aren't, the reviewer said. Those with symptomatic heart failure or a history of heart failure seem more likely to benefit from an ICD, particularly in the 26%-30% group.
Doctors should take into account a prolonged duration of the QRS interval (120 milliseconds or more), which studies have associated with a benefit from ICDs in the 26%-35% EF group.

Ambient nonsustained VT or VT induced by programmed electrical stimulation increase the indication for ICD in those with 26% to 35% EF. In addition, ICD isn't appropriate for patients with serious comorbidities and expected survival of one year or less. Preventive Services Task Force on screening tests, preventive medicines and healthy lifestyle behaviors.
AHRQ also reported that nearly 67% of Hispanics age 50 or older have never had a screening colonoscopy compared with 46% of whites. All of the above resources also can be ordered by calling AHRQ’s Publications Clearinghouse at 800-358-9295 or by e-mail. The statement stresses the potential role of subspecialists, in particular, to serve as a source of vaccination administration or referral, as they are the primary source of care for many patients with chronic disease. This week's contest was a squeaker, with the winning entry tied or leading with less than a handful of votes all week. She will receive a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history. Her symptom complex, including proximal muscle weakness, elevated creatine kinase levels, abnormal electromyography findings, interstitial lung disease, and “mechanic's hands,” is particularly consistent with the antisynthetase (anti–Jo-1 antibody) syndrome.
Patients with mixed connective tissue disease typically present with clinical features associated with rheumatoid arthritis, scleroderma, lupus, and myositis and have very high titers of antiribonucleoprotein antibodies. It is automatically sent to all College members who have an e-mail address on file with ACP.
Two weeks ago, she was in a car accident, and an incidental pituitary adenoma was found on a cervical spine CT scan. As an on-going condition, continued education is critical to the successful management of the disease. Our diabetes experts make it as convenient for patients to receive coordinated care from a multi-disciplinary team of specialists. Select 10+ subscriptions Our package is designed for organisations who want to purchase access and benefit from a group saving. Pain management should form the first part of the assessment and is an ongoing process; effective pain management requires assessment of the cause, nature, frequency, timing, site and severity of the pain and how it is affecting the patient’s life (Keast, 2009). Acute nociceptive pain is the first sensation felt as a result of tissue damage and usually passes quickly. A patient experiencing pain as a result of cancer will perceive their pain differently from a woman with labour pain (Callister, 2001).
Patients who have experienced a painful procedure before, such as a dressing change, will remember this and become tense and anxious, anticipating the pain again; this may result in increased pain (Brown, 2014).
These can be used to determine whether the interventions and treatments being used are effective, and should be performed at each dressing change until the pain is being managed effectively.
Several types of analgesia can be used to manage wound pain and selection should be based on the type of wound, whether it is acute or chronic, and the level of pain the patient is experiencing.
Non-steroidal inflammatory drugs (NSAIDs), such as aspirin, ibuprofen or diclofenac, are particularly useful for managing pain as they dampen down the inflammatory response.
These range from simple distraction techniques, such as listening to music or watching TV, to alternative therapies that work holistically and induce a state of relaxation (Table 3, attached).
Regular reassessment and adjustment of analgesia regimens are essential until the pain is under control. The 3,069 community volunteers age 75 years or older began the study with normal cognition (n=2,587) or mild cognitive impairment (n=482) and were given a dementia assessment every six months, according to the study published in the Nov. Antinuclear antibody titer is 1:160, and assays for anti–double-stranded DNA, Smith, and ribonucleoprotein antibodies are negative. The study authors suggested that when trying to exclude a diagnosis of asthma, physicians should assess patients after their anti-inflammatory medications have been stopped. For patients with EF between 25% and 35%, studies suggest those at the lower end see more benefit than those near the top; thus additional factors in this 25%-35% EF group can tip the balance. If a patient's EF is on the borderline, a heart failure history adds support for ICD therapy. Some research suggests people age 75-plus years are just as likely to benefit as younger patients, but these patients should be in reasonably good shape both physically and mentally to be considered for ICD, the reviewer said. Patients can take the checklists with them to medical appointments to help them keep track of their screening test history and plan follow-up medical appointments.
Scleroderma may be excluded because this patient does not have thickening of the skin, which is a hallmark of this condition.
Urgent care is offered to patients with complications so they may be seen in a timely manner, avoiding emergency room visits. This article describes the different types of pain and the psychological aspects of pain that should be taken into account when deciding on a wound-management strategy.
Neuropathic pain is caused by an abnormally strong response by the nervous system and may be caused by trauma, infection, a metabolic disorder or cancer (Wounds International, 2004). Age can be a factor, as many older patients believe pain in old age is normal and will decline analgesia (Price, 2006; Price et al, 2008). Uncontrolled pain can have a considerable effect on the patient’s wellbeing and may delay the healing process.
Musculoskeletal examination shows proximal muscle weakness in the upper and lower extremities, as well as neck flexor weakness. Typically, skin thickening in scleroderma initially affects the hands with sclerodactyly, which may be preceded by puffiness in the fingers. Following a physical exam and laboratory studies, a pituitary MRI shows a 7-mm adenoma in the anterior sella.
It discusses assessment tools, along with pharmacological and non-pharmacological interventions for pain management. Senecal (1999) produced an adapted version of the World Health Organization cancer analgesia ladder, to aid selection of analgesia for wound pain (Fig 1, attached). Health professionals should consider combining different strategies to reduce pain, particularly for patients who may be reluctant to take medication on a long-term basis. It is important to determine which type of pain the patient is experiencing as they need different treatment approaches (Table 2, attached). Nurses need to be aware of these factors and, together with the patient, develop a pain-management strategy that may involve pharmacological and non-pharmacological interventions acceptable to the patient (Callister, 2003). A variety of techniques can be used by health professionals to improve its assessment and managementUsing negative pressure therapy in wound healing31 August, 2012Complex wounds may benefit from negative pressure therapy.

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