Physicians have difficulty detecting when patients are lying or deceiving them. A literature review found that standardized patients, or actors trained to mimic real patients, were correctly identified as fake by physicians only about 10% of the time during office visits. Some real patients were even mistakenly identified as standardized patients. Deception is challenging for physicians given their tendency to assume patients are being truthful. The legal risks of prescribing opioids when deceived mean doctors must take precautions to minimize risks of abuse or diversion, but allowance must be made for the fact that honest physicians can still be misled by deceptive patients.
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
The document summarizes a study that reviewed charts of 86 patients discharged from an Opioid Renewal Clinic (ORC) over 22 months to examine outcomes two years after discharge. The most common reason for discharge was recurrent positive urine drug screens for illicit substances (47%). Only 17% received addiction treatment in the two years after discharge. 41% were prescribed opioids within two years of discharge, and those prescribed opioids tended to have longer stays in the ORC and more primary care visits after discharge. The outcomes reveal a need to improve addiction management for this patient population.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
Palliative care could help improve the quality of life for Parkinson’s diseas...Δρ. Γιώργος K. Κασάπης
A small study of individuals with Parkinson’s disease finds that adding palliative care to standard care may help raise their quality of life. Half the patients in a 210-person trial were assigned to visit physicians as usual, while the others also received palliative care — a team of a social worker, nurse, palliative medicine specialist, and chaplain visited the patient at home or via telemedicine to discuss symptoms and difficult emotions and offer support to caregivers. Patients in the combination care group had more improvement in their quality of life score (as measured by a survey that assesses physical and mental health).
These patients also scored higher on quality of life measures when their caregivers were surveyed in their stead.
This study examined whether a psychological opioid-risk evaluation influenced physicians' opioid prescribing decisions for 151 chronic pain patients being considered for chronic opioid therapy. Patients underwent an evaluation that assigned them an opioid-risk level of low, moderate, or high. The evaluation report was made available to physicians before their follow-up appointment where prescribing decisions were made. Results found that risk level significantly predicted opioid prescribing, with lower risk patients more likely to be prescribed opioids. A history of substance abuse also predicted less likely opioid prescribing. Demographic factors did not significantly influence prescribing contrary to some previous research. This suggests providing additional information about patients' abuse risk aids prescribing decisions and may reduce bias.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
The document summarizes a study that reviewed charts of 86 patients discharged from an Opioid Renewal Clinic (ORC) over 22 months to examine outcomes two years after discharge. The most common reason for discharge was recurrent positive urine drug screens for illicit substances (47%). Only 17% received addiction treatment in the two years after discharge. 41% were prescribed opioids within two years of discharge, and those prescribed opioids tended to have longer stays in the ORC and more primary care visits after discharge. The outcomes reveal a need to improve addiction management for this patient population.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
Palliative care could help improve the quality of life for Parkinson’s diseas...Δρ. Γιώργος K. Κασάπης
A small study of individuals with Parkinson’s disease finds that adding palliative care to standard care may help raise their quality of life. Half the patients in a 210-person trial were assigned to visit physicians as usual, while the others also received palliative care — a team of a social worker, nurse, palliative medicine specialist, and chaplain visited the patient at home or via telemedicine to discuss symptoms and difficult emotions and offer support to caregivers. Patients in the combination care group had more improvement in their quality of life score (as measured by a survey that assesses physical and mental health).
These patients also scored higher on quality of life measures when their caregivers were surveyed in their stead.
This study examined whether a psychological opioid-risk evaluation influenced physicians' opioid prescribing decisions for 151 chronic pain patients being considered for chronic opioid therapy. Patients underwent an evaluation that assigned them an opioid-risk level of low, moderate, or high. The evaluation report was made available to physicians before their follow-up appointment where prescribing decisions were made. Results found that risk level significantly predicted opioid prescribing, with lower risk patients more likely to be prescribed opioids. A history of substance abuse also predicted less likely opioid prescribing. Demographic factors did not significantly influence prescribing contrary to some previous research. This suggests providing additional information about patients' abuse risk aids prescribing decisions and may reduce bias.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
Tingkat Kepuasan Pasien dalam Pelayanan Konseling Kefarmasian Berbasis Al-Qur...Aji Wibowo
This study examined the satisfaction levels of hypertensive patients with two types of pharmacy counseling - usual care counseling and counseling with Al-Quran recitation - at a pharmacy in Indonesia. A survey found that most patients were satisfied with both types of counseling and there was no significant difference in satisfaction levels between the two groups. Both counseling methods can be applied to improve patient satisfaction with pharmacy services.
This randomized clinical trial tested the effectiveness of stellate ganglion block (SGB) treatment compared to a sham procedure for reducing posttraumatic stress disorder (PTSD) symptoms over 8 weeks. 113 active-duty service members with PTSD symptoms were randomly assigned to receive either 2 SGB treatments 2 weeks apart or a sham procedure. The primary outcome was change in PTSD symptom severity scores measured by the CAPS-5 scale from baseline to 8 weeks. Participants receiving SGB had a greater reduction in symptoms scores compared to the sham group, with adjusted mean decreases of 12.6 vs 6.1 points respectively, indicating SGB treatment may help reduce PTSD symptoms.
Homeopathic treatment of elderly patients - a prospective observational study...home
The severity of disease showed marked and sustained improvements under homeopathic treatment,
but this did not lead to an improvement of quality of life. Our findings might indicate that homeopathic medical
therapy may play a beneficial role in the long-term care of older adults with chronic diseases and studies on
comparative effectiveness are needed to evaluate this hypothesis.
This study surveyed behavioral health clinicians with experience using stellate ganglion block (SGB) as an adjunct treatment for trauma-related disorders like PTSD. Of the 23 respondents, 95% would recommend SGB to colleagues. Respondents rated SGB as at least as useful as the highest rated standard PTSD interventions. SGB was seen as most helpful for reducing arousal/reactivity symptoms. The majority would refer patients for SGB at any stage of therapy, including before starting other treatments.
Disorganized Diseases: Are they a Simple Explosion of Random Energy and there...asclepiuspdfs
Objective: The study has two objectives: (1) To determine the prevailing characteristics of a given set of patients with “disorganized disease” and (2) to determinate the prevailing outcomes for these patients in family medicine to assess their implications for decision-making. Participants and Methods: A qualitative, longitudinal, and retrospective cases series study based on a single cohort was carried out. Analyses based on a retrospective study of case records from June to October 2017, in a family medicine office in the Health Center Santa Maria de Benquerencia, Toledo, Spain. A convenience sample was selected consisting of patients who consulted during that period and who met the criteria for entering the study. These cases were considered in the epidemiological term as index cases, which means that beyond these the study should be expanded. Hence, in addition, using a technique of snowball “mental” or “astute clinical observation” others patients attended previously were included until the saturation of the data. The cases were described in short case reports. An analysis of the content of these reports was carried out, defining categories of qualitative data. The results were interpreted, and a generalization was drawn from these cases.
This document discusses drug risk assessment and pharmacoepidemiology. It notes that clinical trials prior to drug approval are limited in detecting uncommon or long-term side effects. Observational studies using large patient populations are needed to further evaluate drug safety issues and understand rare or long-term side effects. The document compares different pharmacoepidemiological study designs like cohort studies and case-control studies that can be used to investigate drug safety questions following a drug's approval and entry into widespread use.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise is the only therapy strongly recommended based on meta-analyses showing benefit for pain, sleep, and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies.
- If non-response, further therapies such as psychological therapies, pharmacotherapy, or rehabilitation may be tailored to the individual. However, meta-analyses only found weak evidence for all potential pharmacological therapies.
- Most treatments show relatively modest effects. Future research priorities are identifying who benefits from specific interventions,
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
This document summarizes a study on the predictive characteristics of users of alternative medicine. The study found that 6.6% of patients surveyed had visited an alternative practitioner in the previous year. These patients tended to be of middle age, have chronic conditions, have a lower quality of life, greater anxiety and depression, and were heavier users of primary and secondary healthcare. Three factors - self-care and visiting specialists, changing primary doctors, and younger age - explained 66.2% of the variance in alternative medicine use. The conclusions indicate that seeking alternative medicine seems driven by patient characteristics but was not due to dissatisfaction with their primary doctor.
Diagnoses from an on-line expert system for chronic pain confirmed by intra-o...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com is an on-line expert system, which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. To further confirm the accuracy of the Diagnostic Paradigm, a professor of neurosurgery from the University of Rome found 100% of the time, his intra-operative findings confirmed the diagnoses of the Diagnostic Paradigm. The Diagnostic Paradigm can be used to get pre-authorization for surgery from insurance companies, since it documents medical necessity
Comparative evaluation of 2g single dose versus conventional dose azithromycin in uncomplicated skin and skin structure infections. Indian Journal Of Pharmacology. August 2015;Vol. 47; Issue 4
Are Primary Care Clinicians Serving Low-Income Patients More Likely to Screen...asclepiuspdfs
Background: Women of all income levels experience domestic violence (DV). Primary health-care providers are able to screen women early and provide services or referrals; however, regular DV screening rarely occurs in the US. We investigated whether implicit bias based on patient population income level could be influencing provider practices in California. Methods: Data for this study were drawn from a self-administered survey conducted from October 2013 to March 2014. Providers (n = 152) were included if they worked in primary care and provided information on the predominant income of their patients. The survey included questions on provider demographics, screening practices, and number of female victims identified. Results: Providers serving low-income patient populations (LIPPs) or higher-income patient populations had equivalent training and knowledge about DV. However, DV screening practices (e.g., screening more often, at a younger age, and giving a screening question for DV) and outcomes (DV victims identified) varied significantly by patient population income level (P < 0.01). Working with low-income patients and engaging in universal screening practices both predicted more victim identification (P < 0.01). Conclusions: Implicit bias appears to influence clinicians’ screening practices, with those serving LIPPs being more likely to screen regardless of training or knowledge. If DV screening in primary care occurred more regularly, it would yield more detection of victims at all income levels. Training and self-reflection could combat implicit bias, as well as written policies and standardized procedures to encourage universal screening practices by clinicians irrespective of the income level of their patient populations.
This document provides instructions for calculating the volume of a cylinder. It defines the formulas for calculating the curved surface area, base area, and volume of a cylinder. It then works through an example problem to find the volume of a cylinder with a radius of 4 cm and a height of 10 cm, applying the volume formula of πr2h and solving for 502.4 cm3.
José Arnulfo Castorena es un medallista paralímpico mexicano que ha tenido que superar grandes adversidades en su vida. Nació huérfano y con una discapacidad congénita. Vivió en la pobreza y tuvo que trabajar desde muy joven para sobrevivir. A pesar de esto, se ha dedicado al deporte y ha logrado importantes victorias y récords a nivel mundial en natación. Gracias a su esfuerzo y perseverancia, ha podido salir adelante y ahora es un ejemplo para otros.
Diagnosing & Treating MSK Pain Based Upon Underlying MechanismsPaul Coelho, MD
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Tingkat Kepuasan Pasien dalam Pelayanan Konseling Kefarmasian Berbasis Al-Qur...Aji Wibowo
This study examined the satisfaction levels of hypertensive patients with two types of pharmacy counseling - usual care counseling and counseling with Al-Quran recitation - at a pharmacy in Indonesia. A survey found that most patients were satisfied with both types of counseling and there was no significant difference in satisfaction levels between the two groups. Both counseling methods can be applied to improve patient satisfaction with pharmacy services.
This randomized clinical trial tested the effectiveness of stellate ganglion block (SGB) treatment compared to a sham procedure for reducing posttraumatic stress disorder (PTSD) symptoms over 8 weeks. 113 active-duty service members with PTSD symptoms were randomly assigned to receive either 2 SGB treatments 2 weeks apart or a sham procedure. The primary outcome was change in PTSD symptom severity scores measured by the CAPS-5 scale from baseline to 8 weeks. Participants receiving SGB had a greater reduction in symptoms scores compared to the sham group, with adjusted mean decreases of 12.6 vs 6.1 points respectively, indicating SGB treatment may help reduce PTSD symptoms.
Homeopathic treatment of elderly patients - a prospective observational study...home
The severity of disease showed marked and sustained improvements under homeopathic treatment,
but this did not lead to an improvement of quality of life. Our findings might indicate that homeopathic medical
therapy may play a beneficial role in the long-term care of older adults with chronic diseases and studies on
comparative effectiveness are needed to evaluate this hypothesis.
This study surveyed behavioral health clinicians with experience using stellate ganglion block (SGB) as an adjunct treatment for trauma-related disorders like PTSD. Of the 23 respondents, 95% would recommend SGB to colleagues. Respondents rated SGB as at least as useful as the highest rated standard PTSD interventions. SGB was seen as most helpful for reducing arousal/reactivity symptoms. The majority would refer patients for SGB at any stage of therapy, including before starting other treatments.
Disorganized Diseases: Are they a Simple Explosion of Random Energy and there...asclepiuspdfs
Objective: The study has two objectives: (1) To determine the prevailing characteristics of a given set of patients with “disorganized disease” and (2) to determinate the prevailing outcomes for these patients in family medicine to assess their implications for decision-making. Participants and Methods: A qualitative, longitudinal, and retrospective cases series study based on a single cohort was carried out. Analyses based on a retrospective study of case records from June to October 2017, in a family medicine office in the Health Center Santa Maria de Benquerencia, Toledo, Spain. A convenience sample was selected consisting of patients who consulted during that period and who met the criteria for entering the study. These cases were considered in the epidemiological term as index cases, which means that beyond these the study should be expanded. Hence, in addition, using a technique of snowball “mental” or “astute clinical observation” others patients attended previously were included until the saturation of the data. The cases were described in short case reports. An analysis of the content of these reports was carried out, defining categories of qualitative data. The results were interpreted, and a generalization was drawn from these cases.
This document discusses drug risk assessment and pharmacoepidemiology. It notes that clinical trials prior to drug approval are limited in detecting uncommon or long-term side effects. Observational studies using large patient populations are needed to further evaluate drug safety issues and understand rare or long-term side effects. The document compares different pharmacoepidemiological study designs like cohort studies and case-control studies that can be used to investigate drug safety questions following a drug's approval and entry into widespread use.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise is the only therapy strongly recommended based on meta-analyses showing benefit for pain, sleep, and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies.
- If non-response, further therapies such as psychological therapies, pharmacotherapy, or rehabilitation may be tailored to the individual. However, meta-analyses only found weak evidence for all potential pharmacological therapies.
- Most treatments show relatively modest effects. Future research priorities are identifying who benefits from specific interventions,
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
This document summarizes a study on the predictive characteristics of users of alternative medicine. The study found that 6.6% of patients surveyed had visited an alternative practitioner in the previous year. These patients tended to be of middle age, have chronic conditions, have a lower quality of life, greater anxiety and depression, and were heavier users of primary and secondary healthcare. Three factors - self-care and visiting specialists, changing primary doctors, and younger age - explained 66.2% of the variance in alternative medicine use. The conclusions indicate that seeking alternative medicine seems driven by patient characteristics but was not due to dissatisfaction with their primary doctor.
Diagnoses from an on-line expert system for chronic pain confirmed by intra-o...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com is an on-line expert system, which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. To further confirm the accuracy of the Diagnostic Paradigm, a professor of neurosurgery from the University of Rome found 100% of the time, his intra-operative findings confirmed the diagnoses of the Diagnostic Paradigm. The Diagnostic Paradigm can be used to get pre-authorization for surgery from insurance companies, since it documents medical necessity
Comparative evaluation of 2g single dose versus conventional dose azithromycin in uncomplicated skin and skin structure infections. Indian Journal Of Pharmacology. August 2015;Vol. 47; Issue 4
Are Primary Care Clinicians Serving Low-Income Patients More Likely to Screen...asclepiuspdfs
Background: Women of all income levels experience domestic violence (DV). Primary health-care providers are able to screen women early and provide services or referrals; however, regular DV screening rarely occurs in the US. We investigated whether implicit bias based on patient population income level could be influencing provider practices in California. Methods: Data for this study were drawn from a self-administered survey conducted from October 2013 to March 2014. Providers (n = 152) were included if they worked in primary care and provided information on the predominant income of their patients. The survey included questions on provider demographics, screening practices, and number of female victims identified. Results: Providers serving low-income patient populations (LIPPs) or higher-income patient populations had equivalent training and knowledge about DV. However, DV screening practices (e.g., screening more often, at a younger age, and giving a screening question for DV) and outcomes (DV victims identified) varied significantly by patient population income level (P < 0.01). Working with low-income patients and engaging in universal screening practices both predicted more victim identification (P < 0.01). Conclusions: Implicit bias appears to influence clinicians’ screening practices, with those serving LIPPs being more likely to screen regardless of training or knowledge. If DV screening in primary care occurred more regularly, it would yield more detection of victims at all income levels. Training and self-reflection could combat implicit bias, as well as written policies and standardized procedures to encourage universal screening practices by clinicians irrespective of the income level of their patient populations.
This document provides instructions for calculating the volume of a cylinder. It defines the formulas for calculating the curved surface area, base area, and volume of a cylinder. It then works through an example problem to find the volume of a cylinder with a radius of 4 cm and a height of 10 cm, applying the volume formula of πr2h and solving for 502.4 cm3.
José Arnulfo Castorena es un medallista paralímpico mexicano que ha tenido que superar grandes adversidades en su vida. Nació huérfano y con una discapacidad congénita. Vivió en la pobreza y tuvo que trabajar desde muy joven para sobrevivir. A pesar de esto, se ha dedicado al deporte y ha logrado importantes victorias y récords a nivel mundial en natación. Gracias a su esfuerzo y perseverancia, ha podido salir adelante y ahora es un ejemplo para otros.
Diagnosing & Treating MSK Pain Based Upon Underlying MechanismsPaul Coelho, MD
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
The target audience for this media product would be 16-year-old Jamal. Jamal enjoys hanging out with friends, listening to rap music from artists like 50 Cent and 67, watching gangster films, playing and watching football, and boxing. He dresses in tracksuits and listens to rap/hip-hop music that inspires and motivates him. The proposed film would appeal to Jamal as it has similar violent and criminal themes to the films he enjoys, as well as a main character that dresses like Jamal.
Taller: "Web 2.0 para dinamizar tu presencia online: segunda parte"Eclectica DV
Este documento proporciona información sobre el marketing por correo electrónico. Explica las ventajas del marketing por correo electrónico como costos limitados e inmediatez de resultados. También discute temas como el diseño de correos electrónicos, el calendario de envío, los programas de correo electrónico de código abierto como PHPlist versus programas de pago como MailChimp, y la importación y exportación de listas de contactos.
This document discusses Munchausen by Internet, which is when someone intentionally exaggerates or induces health problems online to gain attention. It includes multiple pages from a research paper on the topic, with citations and sections of text cut out discussing factitious disorders and how some individuals intentionally misrepresent their health online. The document encourages readers to add comments and discuss publications with authors.
Taller: "Televisión online" - primera parteEclectica DV
El documento describe un taller sobre el uso de la plataforma de transmisión en vivo Livestream. El taller cubre cómo iniciar sesión en Livestream con una cuenta existente, visitar el enlace público de un canal, usar el estudio de mezcla para transmitir en vivo, preparar una cámara web, importar clips de YouTube y transmitirlos en vivo, y configurar un nuevo canal.
Kedacom has release an Intelligent Tracking System to facilitate smart city and safe city initiatives for governments and corporations to enhance their security programs. The system has built-in artificial intelligence algorithms and performs some human cognitive functions. This leads to an increase in Return on Investment and also reduces dependence on manpower and human-related operational errors. Kedacom also ensures that the system is always up to date with timely software releases and technical support.
The document discusses global health security and threats. It highlights Ebola as a recent health threat and lessons learned from it. It also discusses antimicrobial resistance as an ongoing threat. The document examines progress on building core health security capacities as outlined in the International Health Regulations and potential future steps like an EU Medical Corps.
An Internet questionnaire to identify Drug seeking behavior in a patient in t...Nelson Hendler
Drug seeking behavior in patients with little or no real pain, has led to the opioid crisis. Until now, there was no reliable method for detecting drug seeking behavior. The Pain Validity Test from www.MarylandClinicalDiagnostics.com can predict with 95% accuracy who will have medical test abnormalities, i.e. who has a valid complaint of pain, and predicts with 85%-100% accuracy who will not have any medical test abnormalities, i.e. who is faking and drug seeking. The Pain Validity Test has been admitted as evidence in over 30 legal cases in 8 states.
Pain Validity Test to detect drug seeking behaviorNelson Hendler
The Pain Validity Test predicts which patient will have medical test abnormalities with 95% accuracy, thereby validating their complaint of pain. The Pain Validity Test also predicts with 85%-100% accuracy who will not have medical test abnormalities, thereby detecting drug seeking behavior, faking and malingering.
1) The study surveyed 298 patients visiting family doctors for acute sore throat pain to understand their reasons for visiting and expectations.
2) The top three reasons patients visited were to establish the cause of symptoms, get pain relief, and learn about the illness course. Hopes for antibiotics ranked 11th out of 13 items.
3) Patients hoping for antibiotics valued pain relief more and felt less well than others. They had more faith in antibiotics and were less convinced sore throat is self-limiting.
4) The desire for pain relief strongly predicted hoping to get an antibiotic prescription, even after adjusting for other factors. This suggests patients wanting antibiotics may believe it is the best pain treatment.
This case study describes a 24-year-old woman who presented with exacerbated chronic knee pain and demanded specific opioid medications. Her past history included heroin addiction but reported being sober for 4 years. On examination, her knee showed no changes but she displayed atypical irritable behavior. The physician suspected drug seeking behavior and refused to prescribe opioids given concerns about relapse of addiction. This case highlights the importance of thoroughly evaluating the potential causes of aberrant behavior before making assumptions about addiction or misuse.
- A study compared rates of preventable adverse drug events (ADEs) in intensive care units (ICUs) vs. non-ICUs at two hospitals over 6 months.
- The unadjusted ADE rate was twice as high in ICUs, but when adjusted for number of drugs, there was no difference between ICUs and non-ICUs.
- Preventable ADEs occurred due to normal systems failures like poor communication rather than overworked individuals, showing the need for systems solutions over blaming individuals.
Incident opioid abuse and dependence sullivan 2014Paul Coelho, MD
This study investigated the association between prescription opioid exposure and risk of opioid use disorder (OUD) among individuals with chronic noncancer pain (CNCP). The study used claims data from 2000-2005 for over 500,000 individuals with a new CNCP diagnosis and no recent opioid use or OUD. The results showed significantly higher rates of OUD among those prescribed opioids compared to those not prescribed opioids. Risk increased with longer duration of therapy and higher daily doses. Chronic opioid therapy, even at low doses, was associated with substantially increased risk of OUD compared to acute therapy or no opioids. Duration of opioid therapy was more important than daily dose in determining OUD risk.
Incident opioid abuse and dependence sullivan 2014 (2)Paul Coelho, MD
This study investigated the association between opioid prescription and subsequent opioid use disorder (OUD) diagnoses among 568,640 individuals with chronic noncancer pain. The results showed that prescription opioid exposure significantly increased the risk of OUD compared to no opioid exposure. The risk was highest with longer duration of therapy (chronic vs acute) rather than daily dose. Specifically, the odds of OUD were over 100 times higher for those receiving high-dose opioids chronically compared to no opioid exposure. Duration of opioid therapy was more important than daily dose in determining OUD risk.
An observational study of medicationadministration errors in.docxdaniahendric
An observational study of medication
administration errors in old-age
psychiatric inpatients
CAMILLA HAW, JEAN STUBBS AND GEOFF DICKENS
St. Andrew’s Hospital, Billing Road, Northampton, NN1 5DG, United Kingdom.
Abstract
Background. Relatively little is known about medication administration errors in mental health settings.
Objective. To investigate the frequency and nature of medication administration errors in old-age psychiatry. To assess the
acceptability of the observational technique to nurse participants.
Method. Cross-sectional study technique using (i) direct observation, (ii) medication chart review and (iii) incident reports.
Setting. Two elderly long-stay wards in an independent UK psychiatric hospital.
Participants. Nine nurses administering medication at routine medication rounds.
Main outcome measures. Frequency, type and severity of directly observed medication administration errors compared with
errors detected by retrospective chart review and incident reports.
Results. Using direct observation 369 errors in 1423 opportunities for errors (25.9%) were detected vs. chart review detected
148 errors and incident reports none. Most errors were of doubtful or minor severity. The pharmacist intervened on four
occasions to prevent an error causing patient harm. The commonest errors observed were unauthorized tablet crushing or
capsule opening (111/369, 30.1%), omission without a valid reason (100/369, 27.1%) and failure to record administration
(87/369, 23.6%). Among the nurses observed, the error rate varied widely from no errors to one error in every two doses
administered. Of the seven nurses who completed the post-observation questionnaire, all said they would be willing to be
observed again.
Conclusion. Medication administration errors are common and mostly minor. Direct observation is a useful, sensitive
method for detecting medication administration errors in psychiatry and detects many more errors than chart review or inci-
dent reports. The technique appeared to be acceptable to most of the nursing staff that were observed.
Keywords: administration, adverse drug events, elderly, medication errors, mental health, observation, psychiatry
Medication errors (prescribing, transcribing, dispensing and
administration errors) are an important cause of patient mor-
bidity and mortality [1]. Medication administration errors are
a common sub-type of medication errors and accounted for
34% of errors in one large USA study conducted in medical
and surgical units [2]. Observational studies in general hospi-
tals have yielded error rates varying between 3.5 and 27% of
doses [3–8]. Direct observation detects medication adminis-
tration errors at a much higher rate than chart review or inci-
dent report review [9]. The observational method has been
demonstrated to be valid and reliable [10].
Less research on medication errors has been conducted
in mental health settings, and little is known about the
incidence of medication admi ...
An observational study of medicationadministration errors in.docxamrit47
An observational study of medication
administration errors in old-age
psychiatric inpatients
CAMILLA HAW, JEAN STUBBS AND GEOFF DICKENS
St. Andrew’s Hospital, Billing Road, Northampton, NN1 5DG, United Kingdom.
Abstract
Background. Relatively little is known about medication administration errors in mental health settings.
Objective. To investigate the frequency and nature of medication administration errors in old-age psychiatry. To assess the
acceptability of the observational technique to nurse participants.
Method. Cross-sectional study technique using (i) direct observation, (ii) medication chart review and (iii) incident reports.
Setting. Two elderly long-stay wards in an independent UK psychiatric hospital.
Participants. Nine nurses administering medication at routine medication rounds.
Main outcome measures. Frequency, type and severity of directly observed medication administration errors compared with
errors detected by retrospective chart review and incident reports.
Results. Using direct observation 369 errors in 1423 opportunities for errors (25.9%) were detected vs. chart review detected
148 errors and incident reports none. Most errors were of doubtful or minor severity. The pharmacist intervened on four
occasions to prevent an error causing patient harm. The commonest errors observed were unauthorized tablet crushing or
capsule opening (111/369, 30.1%), omission without a valid reason (100/369, 27.1%) and failure to record administration
(87/369, 23.6%). Among the nurses observed, the error rate varied widely from no errors to one error in every two doses
administered. Of the seven nurses who completed the post-observation questionnaire, all said they would be willing to be
observed again.
Conclusion. Medication administration errors are common and mostly minor. Direct observation is a useful, sensitive
method for detecting medication administration errors in psychiatry and detects many more errors than chart review or inci-
dent reports. The technique appeared to be acceptable to most of the nursing staff that were observed.
Keywords: administration, adverse drug events, elderly, medication errors, mental health, observation, psychiatry
Medication errors (prescribing, transcribing, dispensing and
administration errors) are an important cause of patient mor-
bidity and mortality [1]. Medication administration errors are
a common sub-type of medication errors and accounted for
34% of errors in one large USA study conducted in medical
and surgical units [2]. Observational studies in general hospi-
tals have yielded error rates varying between 3.5 and 27% of
doses [3–8]. Direct observation detects medication adminis-
tration errors at a much higher rate than chart review or inci-
dent report review [9]. The observational method has been
demonstrated to be valid and reliable [10].
Less research on medication errors has been conducted
in mental health settings, and little is known about the
incidence of medication admi.
An observational study of medicationadministration errors in.docxgreg1eden90113
An observational study was conducted to investigate medication administration errors in two long-stay psychiatric wards for elderly patients in the UK. Direct observation of nurses administering medication detected 369 errors in 1423 doses administered, representing an error rate of 25.9%. The most common errors were unauthorized crushing of tablets, omission of doses without reason, and failure to record administration. Most errors were considered minor in severity. Direct observation detected substantially more errors than retrospective chart review or incident reports. Nurses found the observational technique acceptable.
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
This study analyzed results from over 900,000 urine drug tests conducted between 2006-2009 on patients prescribed chronic opioids. The results showed:
- 11% tested positive for illicit drugs
- 29% tested positive for non-prescribed medications
- 38% did not detect the prescribed medication
- 15% had lower than expected levels of the prescribed medication
- 27% had higher than expected levels of the prescribed medication
These high rates of potential issues like non-compliance, abuse or diversion demonstrate the importance of periodic urine drug screening for patients on long-term opioid therapy to identify problems and ensure appropriate use of medications.
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Critical Appraisal Tools Worksheet
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Evaluation Table
Use this document to complete the evaluation table requirement of the Module 4 Assessment,Evidence-Based Project, Part 4A: Critical Appraisal of Research
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Article #1
Article #2
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Article #4
Ashcroft, D., Lewis, P., Tully, M., Farragher, T., Taylor, D., & Wass, V., Williams, S. D., & Dornan, T. (2015). Prevalence, Nature, Severity and Risk Factors for Prescribing Errors in Hospital Inpatients: Prospective Study in 20 UK Hospitals. Drug Safety, 38(9), 833-843. DOI: 10.1007/s40264-015-0320-x
Carayon, P., Wetterneck, T., Cartmill, R., Blosky, M., Brown, R., & Kim, R., Kukreja, S., Johnson, M., Paris, B., Wood, K. E., & Walker, J. (2014). Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. BMJ Quality & Safety, 23(1), 56-65. DOI: 10.1136/bmjqs-2013-001828
Hines, S., Kynoch, K., & Khalil, H. (2018). Effectiveness of interventions to prevent medication errors. JBI Database Of Systematic Reviews And Implementation Reports, 16(2), 291-296. DOI: 10.11124/jbisrir-2017-003481
Khalil, H., Chambers, H., Sheikh, A., Bell, B., & Avery, A. (2017). Professional, structural and organisational interventions in primary care for reducing medication errors. Cochrane Database System Review, 10 (CD003942). DOI: 10.1002/14651858.CD003942.pub3.
Conceptual Framework
Describe the theoretical basis for the study
The study deduced the reasoning that doctors during their first year of post-graduate training are prone to making disproportionate errors in their prescription.
Safety during medication is a significant issue in healthcare more so in intensive care units (ICUs). Therefore, the complexity of the medication management process is reflected on the convolution of evaluating medication errors and adverse drug events in ICUs.
This study seeks to assess the effectiveness of interventions developed to avert medication error during administration of medication, medication-related death, and medication-related harms among acute care patients.
During primary care, there are adverse events associated with medication and they represent a significant cause of hospital admission and mortality and these events could be as a result of patient going through adverse drug reactions or medication errors and the latter is preventable.
Design/Method Describe the design and how the study
was carried out
The study used pharmacists as their subjects across 20 health facilities over 7 selected days and the data was collected based on the number of checked medication orders, details of the prescribing errors, and the prescriber’s grade.
As part of the study’s methodology, the research has assessed the effect of electronic medical record on the safety and quality across ICUs by having cross-sectional study which has reported on the medication safety before EHR was used in two ICU facilities ...
The role of illness perceptions and medicine beliefs in adherence to chronic ...epicyclops
Presentation given by Dr Leanne Ramsay & Dr Martin Dunbar to the West of Scotland Pain Group on 7th October 2008 at the Royal College of Physicians and Surgeons of Glasgow.
This document summarizes the results of moderator analyses from a large randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) for chronic pain from osteoarthritis. The trial compared 10 sessions of Pain Coping Skills Training (PCST), a form of CBT, delivered by nurse practitioners to a usual care control group. Several demographic and clinical variables were examined as potential moderators of treatment response. The analyses found that patients' pain coping style, expectations for treatment, disease severity, age, and education level significantly moderated outcomes, with some subgroups showing stronger responses to PCST. Sex, race, BMI, and depression did not impact treatment response. Specifically, patients with interpersonal pain coping problems did not benefit much from
This document discusses adopting a "universal precautions" approach to assessing and managing chronic pain patients to improve care and reduce risks. It notes that while some chronic pain patients have substance use disorders, there is no reliable way to identify those individuals in advance. It recommends thoroughly assessing all patients for present and past substance use, including illicit drugs and alcohol, to better understand risks. A universal precautions approach allows for formulating individualized treatment plans based on mutual trust and honesty while improving care, reducing stigma, and containing overall risks.
This article reviews literature on primary non-adherence of prescribed pharmaceutical treatments. It identified 53 studies, including 16 on cost-related non-adherence. Commonly cited factors for non-adherence included age, gender, race, mental health, comorbidities, polypharmacy, medication beliefs, side effects, affordability, education, healthcare utilization, patient-physician relationship, prescriber traits, and forgetfulness. Issues related to affordability were the most frequently cited factor. The relevance of predictors and causes varied between studies. The review aims to inform future research by compiling known factors associated with primary non-adherence.
This study examined health insurance claims data from over 10 million patients who were prescribed opioids to evaluate how opioid receipt differed based on preexisting psychiatric conditions and medications. The study found that patients with a variety of psychiatric conditions and those prescribed various psychoactive medications were more likely to receive opioids, particularly long-term opioid therapy. The increased risk for long-term opioid therapy ranged from 1.5 times higher for those previously prescribed ADHD medications, to over 8 times higher for those with prior opioid use disorder diagnoses. The results provide evidence that commercially insured patients with psychiatric conditions receive opioids more than those without such conditions.
This research paper summarizes a randomized controlled trial that studied the effect of pharmacist counseling on preventing adverse drug events (ADEs) after hospital discharge. 178 patients were randomly assigned to an intervention group that received pharmacist counseling at discharge and a follow-up phone call 3-5 days later, or a control group that received usual care. The intervention focused on clarifying medications, reviewing instructions and side effects. At 30 days post-discharge, preventable ADEs occurred in 1 patient in the intervention group versus 8 in the control group, showing pharmacist counseling can significantly reduce preventable ADEs and medication-related emergency visits or readmissions after hospitalization.
Johns Hopkins Hospital doctors report that 40%-80% of chronic pain patient are misdiagnosed, and that MRIs and CTs miss pathology 56%-78% of the time, Therefore, during extensive chart reviews of current medical data will produce a classic case of GIGO-garbage in giving garbage out. The need for accurate diagnoses and testing is critical for AI to work.
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
Labeling Woefulness: The Social Construction of FibromyalgiaPaul Coelho, MD
This document discusses the social construction of fibromyalgia and how it has been established as a legitimate disease label despite a lack of clear biological or clinical evidence. It argues that fibromyalgia serves social and economic purposes for various groups, including patients, doctors, pharmaceutical companies, and the media, but poses risks by medicalizing psychosocial problems. The document proposes that widespread pain is a normal human experience for some that is best addressed by exploring psychosocial factors rather than believing the solution lies in neurobiology. Examining fibromyalgia as a social construct may be more helpful for patients than continuing to medicalize their experiences.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
This document appears to be a questionnaire assessing symptoms of widespread pain and calculating a WPI (Widespread Pain Index) score and SS (Symptom Severity) score. It asks the respondent to indicate areas of pain on a diagram and rate the severity of symptoms like fatigue, thinking difficulties, and unrefreshed sleep. It also inquires about additional symptoms like abdominal pain, depression, and headaches. The final section rates pain-related worry and fear on a scale. Additional questions determine if the respondent has a workers compensation or disability claim related to their pain complaint.
Fibromyalgia is a condition that causes chronic aches and pains all over the body, fatigue, and often a sleep disorder. The doctor diagnosed the patient with fibromyalgia based on a score of 13 or more on the fibromyalgia questionnaire from the American College of Rheumatology, which is consistent with the syndrome. By focusing on and managing the diagnosis of fibromyalgia, the patient's other pain symptoms can decrease.
This document contains two studies related to psychological treatments for chronic conditions:
1) A study of chronic fatigue syndrome patients found that poorer outcomes were predicted by membership in a self-help group, receiving sickness benefits, and symptoms of dysphoria. Severity and duration of symptoms did not predict response.
2) A randomized controlled trial of 125 fibromyalgia patients compared operant behavioral therapy, cognitive behavioral therapy, and attention placebo. Both behavioral therapies significantly reduced pain intensity while cognitive therapy improved cognitive and affective variables and operant therapy improved physical functioning and behaviors. The attention placebo resulted in no improvement or deterioration.
This document summarizes three studies on the risks and efficacy of opioids for chronic non-cancer pain (CNP). The first study finds that while opioids were associated with small improvements in pain and physical functioning compared to placebo, they also increased the risk of vomiting. Comparisons to other medications found similar benefits to pain and functioning. The second study finds no difference in pain-related function between opioid and non-opioid groups over 12 months, and higher rates of adverse effects and pain intensity in the opioid group. The third study finds limited effectiveness of opioids for CNP, as opioid users did not report improvements in outcomes after 2 years. Regarding risks, higher opioid doses are associated with increased overdose risk across several patient groups in
Mortality quadrupled among opioid-driven hospitalizations notably within lowe...Paul Coelho, MD
This study analyzed national hospitalization data from 1993-2014 to examine trends in mortality and characteristics of hospitalizations related to opioids compared to other drug and non-drug hospitalizations. The key findings were:
1) Mortality among opioid-related hospitalizations quadrupled from 0.43% before 2000 to 2.02% in 2014, increasing 0.12 percentage points per year relative to other drug hospitalizations.
2) While total opioid-related hospitalizations remained stable, diagnoses shifted from opioid dependence/abuse to opioid/heroin poisoning, which have higher mortality rates. Hospitalizations for poisoning grew by 0.01 per 1,000 people annually after 2000.
3) Patients hospitalized for opioid/
Prescriptions filled following an opioid-related hospitalization.Paul Coelho, MD
This study analyzed prescription drug fills within 30 days of discharge for 36,719 patients hospitalized for opioid misuse. Only 16.7% received medications approved for opioid dependence, while 40.3% filled antidepressant prescriptions and 22.4% filled opioid pain medication prescriptions. Concurrently, 13.9% filled benzodiazepine prescriptions and 7.4% filled both benzodiazepine and opioid prescriptions, indicating a need for improved education on risks. Overall, more effort is required to ensure patients receive recommended post-hospitalization treatment and support services.
This study examined the risk of psychiatric hospitalization in the offspring (second generation) of Finns who were evacuated to Sweden without parents during World War II (first generation), compared to offspring of Finns who were not evacuated. The study found that daughters of mothers who were evacuated during childhood had an elevated risk of psychiatric hospitalization, especially for mood disorders. However, there was no increased risk found for offspring of evacuated fathers or for male offspring of evacuated mothers. This suggests that early childhood adversity experienced by the first generation, such as war-related trauma, may be associated with mental health problems that persist into the second generation.
Correlation of opioid mortality with prescriptions and social determinants -a...Paul Coelho, MD
This study analyzed Medicare Part D data from 2013-2014 to examine the relationship between opioid prescription rates, socioeconomic factors, and opioid-related mortality rates at the county level in the United States. The results showed that higher county-level opioid prescription rates, especially those from emergency medicine, family medicine, internal medicine, and physician assistants, were associated with higher opioid-related mortality rates. Higher poverty levels and proportions of white populations in counties also correlated with increased mortality. Additionally, prescribers in the highest quartile of opioid prescription rates had a disproportionate impact on mortality compared to the remaining 75% of prescribers.
This report examines CMS's oversight of Medicare Part D beneficiaries who receive opioid prescriptions and providers who prescribe opioids to these beneficiaries. It finds that while CMS provides guidance to Part D plan sponsors on monitoring beneficiaries at high risk of opioid overuse, it lacks complete data on the full population of beneficiaries at risk. It also finds that CMS oversees prescribing through its contractor NBI MEDIC but does not specifically analyze opioid prescription data or require reporting on actions taken regarding inappropriate opioid prescribing. The report concludes that CMS needs more comprehensive oversight to reduce the risks of opioid misuse, overdose, and inappropriate prescribing among Medicare beneficiaries.
This study analyzed opioid prescription trends among medical specialties in the U.S. from 2007-2012 using a national prescription database. The key findings were:
- Primary care specialties (family practice, internal medicine, general practice) accounted for nearly half of all dispensed opioid prescriptions in 2012.
- Specialties treating pain conditions like pain medicine, surgery, and physical medicine had the highest rates of opioid prescribing.
- Overall opioid prescribing rates increased from 2007-2010 but stabilized from 2010-2012 as most specialties reduced rates.
- The greatest increase in opioid prescribing was among physical medicine specialists, while the largest decreases were in emergency medicine and dentistry.
The place-of-antipsychotics-in-the-therapy-of-anxiety-disorders-and-obsessive...Paul Coelho, MD
This document summarizes a research article about the use of antipsychotic drugs in the treatment of anxiety disorders and obsessive-compulsive disorders. The review finds evidence that certain second-generation antipsychotics (SGAPs), like quetiapine, risperidone, and aripiprazole, can be effective for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD). Quetiapine in particular receives a recommendation as a first-line treatment for GAD. However, the review finds insufficient evidence for SGAPs in the treatment of social anxiety disorder and panic disorder. First-generation antipsychotics are not recommended for any anxiety disorders based on their side effect profiles
Structured opioid refill clinic epic smartphrases Paul Coelho, MD
#*** I explained to the patient the risks of combining opioids and benzodiazepines based on medical literature. We agreed to slowly taper the patient off benzodiazepines and trial safer alternatives for sleep and anxiety issues.
#*** I showed the patient their fibromyalgia screening questionnaire results, which were consistent with a fibromyalgia diagnosis. Fibromyalgia can amplify other painful conditions and is often the primary source of morbidity when present with other chronic pain diagnoses.
#*** We discussed the patient's high risk opioid regimen based on their dose exceeding CDC guidelines. While willing to work on a harm reduction plan, it will require a taper or switching to buprenorphine due to safety concerns.
Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, an...Paul Coelho, MD
This document summarizes the key issues regarding the use of opioids for chronic pain treatment:
1) An overreliance on opioids to treat chronic pain has contributed to the prescription opioid abuse epidemic in the US, as outpatient use allows for abuse and diversion of these addictive drugs.
2) While clinical trials show opioids effectively treat acute pain and are initially effective for chronic pain, real-world use reveals increased risks of abuse, addiction, and poor functional outcomes over the long-term.
3) The evidence supporting chronic opioid therapy was limited and observational in nature, yet convinced the medical community until larger population studies showed increased abuse rates contrary to initial assumptions.
The potential adverse influence of physicians’ words.Paul Coelho, MD
The physician's words can inadvertently amplify patients' symptoms and increase somatic distress if not carefully considered. Learning about potential side effects from medications, procedures, or test results can lead patients to experience and report those effects more frequently through psychological mechanisms like misattribution and increased attention to bodily sensations. Discussing concepts like nocebo and viscerosomatic amplification with patients can help provide reassuring explanations for symptoms and make them feel less intrusive. Physicians should thoughtfully consider their word choices and focus on benefits as well as side effects to minimize undue distress.
This document is an evidence report published by the Institute for Clinical and Economic Review (ICER) that evaluates the comparative clinical effectiveness and value of cognitive and mind-body therapies for chronic low back and neck pain. It was authored by Jeffrey Tice and others from ICER. The report assesses the clinical evidence on therapies such as cognitive behavioral therapy and mindfulness-based stress reduction and presents economic analyses of the long-term cost-effectiveness and potential budget impact of these therapies. It also incorporates input from clinical experts and stakeholders.
The conundrum of opioid tapering in long term opioid therapy for chronic pain...Paul Coelho, MD
The document discusses the challenges clinicians face when tapering patients off long-term opioid therapy for chronic pain. It explains that opioid dependence can cause worsening pain, psychiatric symptoms, and functioning during tapering due to neuroplastic changes. While tapering seems logical to address risks of high-dose opioids, it may paradoxically make a patient's issues worse due to protracted abstinence syndrome. The document provides guidance for managing these complex patients focused on both pain and opioid dependence.
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Emphysema is a disease condition of respiratory system.
Emphysema is an abnormal permanent enlargement of the air spaces distal to terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
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The facial nerve, also known as cranial nerve VII, is one of the 12 cranial nerves originating from the brain. It's a mixed nerve, meaning it contains both sensory and motor fibres, and it plays a crucial role in controlling various facial muscles, as well as conveying sensory information from the taste buds on the anterior two-thirds of the tongue.
End-tidal carbon dioxide (ETCO2) is the level of carbon dioxide that is released at the end of an exhaled breath. ETCO2 levels reflect the adequacy with which carbon dioxide (CO2) is carried in the blood back to the lungs and exhaled.
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Sidestream devices can monitor both intubated and non-intubated patients, while mainstream devices are most often limited to intubated patients.
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This particular slides consist of- what is Pneumothorax,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is a summary of Pneumothorax:
Pneumothorax, also known as a collapsed lung, is a condition that occurs when air leaks into the space between the lung and chest wall. This air buildup puts pressure on the lung, preventing it from expanding fully when you breathe. A pneumothorax can cause a complete or partial collapse of the lung.
2. 434 Jung and Reidenberg
patients. For this reason, we focused on the spe-
cific problems of being deceived by patients who
say they are in pain.
Physicians operate with what Burgoon et al.
[14] call a truth bias. That is, they presume that
patients’ presentations of themselves are true,
complete, and accurate. Their assessment of
patients’ pain complaints are based both on cur-
rent information (obtained in the interview and
physical examination) and on the starting point,
or anchoring point [15] for the assessment. Doc-
tors assume that patients come to see them
because they have a problem for which they want
treatment.
Law enforcement personnel appear to have a
different assumption when they interview some
people. Yet, in a study of police, judges, and federal
law enforcement personnel,* only the Secret Ser-
vice agents were better than chance at detecting
lying [16]. Thus, law enforcement personnel who
presume physicians can discern lies cannot recog-
nize lies themselves.
Can physicians tell when patients lie? Studies
with standardized patients can address this ques-
tion. Standardized patients are individuals (includ-
ing actual patients) who have been trained to
present accurate, reproducible history and physi-
cal examination findings of a particular clinical
problem. They are increasingly used in teaching
[17], evaluation [18–22], and research [23,24].
They have been used since 1998 to evaluate for-
eign medical graduates applying for American
medical licenses and, since 2004, as part of the US
medical licensing examination [25,26]. They per-
mit assessment of skills and behaviors essential to
medical practice but which are poorly measured
by paper-and-pencil tests.
Standardized patients provide a new way to
consider the question of deceiving doctors by
patients not telling the truth. Standardized
patients have been used in the community to study
resource utilization [24], risk factor determination
and counseling [22,23], and diagnosis, recognition
and management [18,19,27]. All studies involved
training individuals to present an overall scenario
(history, physical examination findings, responses
to physicians’ questions, expressing pain) consis-
tent with a disease or condition. For these studies,
the individuals would then go to the doctor
*Federal law enforcement personnel included Central
Intelligence Agency, Federal Bureau of Investigation,
Secret Service, Drug Enforcement Agency, etc.
pretending to be a real patient and right after the
visit, accurately record the physician’s questions
and interventions. The standardized patients were
trained in how to present themselves to office staff,
and to handle payment for the visit in order not
to be perceived as standardized patients. All phy-
sicians tested with standardized patients had vol-
unteered to be studied in this way, and were asked
to report any patient visit they believed was made
by a standardized patient. Six studies reported on
the rate at which physicians detected standardized
patients when they appeared for their office
appointment.
The first [18] was a study of how well Austra-
lian general practitioners managed depression.
Twenty-five physicians were each visited by two
standardized patients. None of these were identi-
fied as such by the physicians.
The second study was used to evaluate and
develop the methodology of standardized patients
for evaluating primary care [28]. Eight different
standardized patients visited 11 doctors. The stan-
dardized patient was detected seven times (13%)
and was suspected of being the standardized
patient eight times (15%) in the 55 visits in non-
painful illness. The actor portraying a patient with
vascular headache was detected twice (18%) and
suspected once (9%).
Another study included pain (headache for one
case and back pain for another) as the presenting
symptom in two of 10 scenarios. Twenty-six of 263
visits by standardized patients were detected as
such. The frequency of detection of each scenario
was not reported [21].
In a study of 59 doctors visited by an older
woman for a periodic health exam she was
detected as the standardized patient by two doc-
tors [22]. In another study of 51 other doctors
visited by a woman in her 50s for a periodic health
exam only two doctors detected her as the
standardized patient [23]. A study to evaluate
nonsteroidal anti-inflammatory drug (NSAID)
therapeutics by family and internal medicine prac-
titioners had standardized patients portray chronic
hip pain of osteoarthritis and epigastric pain of
NSAID gastropathy. Thirty-six of the 312 visits
(12%) were identified as being the standardized
patients [24,29].
In one study, two real patients were identified
as fakes [24,29] and another article indicated some
real patients were considered imposters but no
numbers were presented [28]. There was no men-
tion of assessing “false positive” identification in
any of the other articles.
byguestonMay30,2016http://painmedicine.oxfordjournals.org/Downloadedfrom
3. Physicians Being Deceived 435
When a patient complains of pain, doctors
apply their experience of how people with pain
appear and respond. Often, different people assess
the same patient’s pain intensity differently [30].
The correlation between subjective pain intensity
and facial pain expression is not strong and differs
between men and women [31]. In a study of decep-
tion in pain expressions, Poole and Craig [15] per-
formed experiments on 104 college students. The
students observed videotapes of facial expressions
of people in pain or faking pain. The observers
thought the fakers were in more pain than the true
sufferers. When the observer was warned about
possible deception, the observer estimated lower
pain intensity in subjects with both genuine and
faked pain. Thus, a faked facial expression of pain
can easily deceive an observer.
Both deception and fear of deception have con-
sequences. Patients can get too much medical care
when the doctor is deceived (as in Munchausen’s
syndrome) or insufficient medical care when the
doctor fears deception (disbelieving reports of
pain when it exists). These consequences affect
both the individual patient and society.
The experience with standardized patients
shows deception is difficult to detect. In the natu-
ralistic setting of an office encounter, genuine
patients can be mistaken for fake patients as well
as fake patients accepted as real ones. In the cur-
rent legal climate surrounding prescribing opioids,
accepting patients’ reports of pain can have signif-
icant legal consequences for the doctor. These
consequences must be addressed to improve the
treatment of patients with chronic pain.
What should a conscientious doctor do that is
reasonable to avoid being deceived? The Model
Policy for the Use of Controlled Substances for
the Treatment of Pain by the Federation of State
Medical Boards of the United States says, “physi-
cians (should) incorporate safeguards into their
practices to minimize the potential for abuse and
diversion of controlled substances” [32]. First, “a
physician-patient relationship must exist and the
prescribing should be based on a diagnosis and
documentation of unrelieved pain.” Suggestions
for documenting in the medical record were pre-
sented in [1] and include: history and physical
findings supporting the diagnosis of a painful con-
dition requiring opioid therapy, laboratory and/or
imaging studies as needed to confirm the diagno-
sis, a treatment plan and consultations for addi-
tional evaluations and treatments as indicated.
Regular follow-up visits with documentation are
also required [1]. When more than one doctor is
treating a patient, the one prescribing controlled
substances must keep the other doctors informed
about the regimen and any other medical matters
coming to the prescribing doctor’s attention. The
other doctors certainly should reciprocate so all
are on the same team.
Assuming this is present, what additional issues
should be considered?
One issue is identifying patients with a sub-
stance abuse disorder and differentiating them
from those diverting prescription drugs to the
illicit market. Much of the attention in the Opioid
Guidelines in the Management of Chronic Non-
cancer Pain by the American Society of Interven-
tional Pain Physicians is devoted to detecting
illicit drug use [33]. The purpose of random drug
screening appears to be the detection of unpre-
scribed central nervous system active drugs in the
urine of the patients. This can certainly identify a
patient as a potential substance abuser but does
not necessarily identify diverters. The American
Pain Society, in its the Use of Opioids for Treat-
ment of Chronic Pain [34], states that “known
addicts can benefit from the carefully supervised
judicious use of opioids for the treatment of pain
from cancer, surgery, or recurrent painful illnesses
such as sickle cell disease.” An estimated 9% of the
US population over age 12 years has used cannab-
inoids within the past year [35]. The National
Institute of Drug Abuse (N.I.D.A.) has estimated
that 46% of the US high school seniors had tried
marijuana at some time and that 20% were current
users [36]. Thus, the clinical significance of 18%
or 11% prevalence of marijuana use detected in
urine test of 500 chronic pain patients [37,38] is
not completely clear. N.I.D.A. estimated that 19.1
million Americans, or 7.9% of the US population,
were classified as illicit drug users; 7.1 million of
these were classified as substance abusers or sub-
stance dependant in 2004 [39]. Thus, interpreta-
tion of the 16% or 22% detection of illicit drugs
in the urine of a group of chronic pain patients in
two different studies [37] is also complex, as all of
these people are not necessarily dependent or
abusers of the detected drugs. Certainly, substance
abuse problems present in chronic pain patients
should be addressed. This is needed for proper
medical care.
In conclusion, we agree with the Model Policy
that safeguards to minimize abuse of prescribed
drugs and diversion of them [32] should be part of
medical practice. Determining if a current or prior
substance abuse problem exists is an important
part of the history. It suggests that the patient is
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4. 436 Jung and Reidenberg
at risk of recurrence and this should be addressed.
Portenoy and Payne [40] have prepared a table of
aberrant drug behaviors that are suggestive of a
drug problem, and behaviors of pain patients that
are “less suggestive” of a drug problem. Some sug-
gestive patient behaviors are: multiple dose esca-
lations, other noncompliance with therapy despite
warnings, multiple episodes of prescription “loss,”
seeking prescriptions from multiple sources, and
deterioration in functioning. Patient behaviors less
suggestive of a drug problem in a chronic pain
patient include aggressive complaining about the
need for more drug, drug hoarding during periods
of reduced symptoms, requesting specific drugs,
and occasional nonsanctioned dose escalation [40].
Obtaining a urine test for illicit drug use is appro-
priate for a chronic pain patient with these or
other suggestive behaviors. It may indicate a sub-
stance abuse or dependence problem that should
be confirmed and addressed, as would any other
confounding medical problem.
Building trust between doctor and patient is
an important part of the management of chronic
pain patients. Victor and Richeimer point out
the importance of the patient’s demonstrating
responsibility in the relationship by following
through on the patient’s part of the management
plan [41] and not trying to conceal deviations from
the physician.
Patients who are diverters, on the other hand,
cannot be treated as other chronic disease patients.
Behaviors suggestive of a drug problem can also
indicate a possible diversion problem. Additional
suggestive behaviors in the Portenoy and Payne
article include prescription forgery, stealing or
“borrowing” drugs from others, and learning that
the patient is selling drugs (p. 40). Our review of
prosecutions of doctors for prescribing opioids
[42] found that often it was other parties and not
the doctor that discovered the acts of diversion.
The doctor had been deceived.
We have presented the data on how easily a
doctor can be deceived by a standardized patient
into thinking the standardized patient was a bona
fide patient. We have noted that Munchausen syn-
drome is another example of the ease with which
doctors can be deceived. It should not be surpris-
ing that undercover agents can also deceive con-
scientious doctors. When portions of the medical
press describe cases of physicians accused of
diverting controlled substances because they were
deceived, suspicion of patients with chronic pain
complaints increases. Unscrupulous doctors exist
and they can be clever in masking what they are
actually doing under the guise of practicing med-
icine. They should be caught and dealt with. But
our data show that conscientious doctors can be
deceived. Therefore, while doctors must make
every reasonable effort to confirm the diagnosis
and need for opioid therapy, allowance must be
made for the fact that conscientious doctors can
be deceived.
Acknowledgments
Supported in part by a grant from the charitable founda-
tion of Marilyn Spinoza Weinberg and Robert F. Wein-
berg. Dr. Reidenberg is a member of the Weill Cornell
CERT.
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