Dexmedetomidine as Adjuvant Therapy for Acute Postoperative Neuropathic Pain Crisis

Background: Dexmedetomidine is a potent α2-adrenergic agonist U.S. Food and Drug Administration (FDA) approved for sedation. While its use as an analgesic has been described in the palliative medicine literature, its use for managing an acute neuropathic pain episode is less well known. Methods: Here we describe the use of adjuvant dexmedetomidine in a patient with metastatic sarcoma suffering from an acute postoperative neuropathic pain crisis. Conclusion: Among patients with acute neuropathic pain for whom additional opioids raises respiratory-related concerns, the use of dexmedetomidine should be considered as a viable treatment alternative.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140116/1/jpm.2013.0556.pd

Patient, Physician, and Community Demographics and Physicians' Perceptions of Patients, Their Practice, and the Management of Diabetes.

A growing body of health services research shows that African Americans, when compared to whites, are more likely to perceive discrimination in health care, be the target of negative stereotypes from health care providers, and receive lower quality of care for a broad range of services even after controlling for socioeconomic status. Less well documented are the physician- and setting-related factors that predict or protect against negative stereotypes and unequal treatment. Through a mail-based questionnaire administered to primary care physicians and endocrinologists in the greater-Southeast Michigan area, this research investigated these factors with the goal of improving our understanding of the intersections among race, place, socioeconomic status, and health care as it relates to the management of diabetes. Specifically, this dissertation explored physicians’ perceptions of patients, how these perceptions are associated with patients’ and physicians’ demographics, and how patients’ and physicians’ demographics are correlated with physicians’ decision making and strategies to manage diabetes. An overarching principle guiding this research is the notion that successful management of diabetes requires more than the provision of medical care; it requires balancing input from multiple influences across the ecological spectrum. Findings suggest that when physicians assess patients or when they make decisions on how to provide care they take into account not only information about patients’ illness or disease but are influenced by patients’ demographics, their own demographic and professional backgrounds, and the settings in which care is provided. After controlling for a broad set of covariates, physicians’ gender and training background proved to be the most salient predictors of physicians’ perceptions of patients, strategies to manage diabetes, and decision making style; results were not consistent with the notion that physicians respond more negatively or with biased attitudes when working with African American patients versus patients generally. Findings from this research indicate that (a) increasing physicians’ competency in social determinant of health, (b) promoting policies that finance patient centered medical homes, and (c) rewarding health systems that grow the primary care physician workforce in urban settings may help to improve the quality of diabetes care for the populations living in such areas.PHDHealth Services Organization & PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/96150/1/cshultz_1.pd

Family physician perceptions of the role and value of the clinical pharmacist in the management of patients with type 2 diabetes

PurposeClinical pharmacists can help primary care physicians (PCPs) manage medications for patients with poorly controlled type 2 diabetes. Studies have shown that clinical pharmacist involvement in care can improve outcomes such as glycosylated hemoglobin (A1C), blood pressure and lipid control, and decrease episodes of hypoglycemia. Despite these findings, some PCPs may be slow or disinclined to refer to clinical pharmacists when available. This study addressed PCP perceptions regarding referral to clinical pharmacists and endocrinologists for patients with poorly controlled type 2 diabetes.MethodsPhysicians from five family medicine sites were surveyed. Physicians were queried regarding their patterns for patient referral to endocrinologists and/or clinical pharmacists. Clinical contributions and importance of factors to consider when referring were compared between clinical pharmacists and endocrinologists using paired t tests.ResultsFifty physicians responded to the survey, resulting in a response rate of 73.5%. The majority of PCPs indicated that they have referred to endocrinologists (89.5%) and clinical pharmacists (93.5%) for specialty care. PCPs tended to refer to clinical pharmacists sooner and at lower A1C values than to endocrinologists. PCPs also considered multiple medical comorbidities, history of noncompliance with medical recommendations, low reading ability or math skills, complex psychosocial situations, fear of needles, or difficulty affording medications or supplies to be more important when referring patients to clinical pharmacists than endocrinologists.ConclusionWe hypothesized that referrals to a clinical pharmacist or endocrinologist are made with careful consideration of the patients’ needs. PCPs reported increased utilization of clinical pharmacists for patients with nonmedical needs, indicating that extra time, education, and psychosocial support provided by the clinical pharmacist is highly valued.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/153703/1/jac51114.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/153703/2/jac51114_am.pd

The Effect of Simulation based Training on Medical Students’ Perceptions, Knowledge, and Skill at Baseline and 6 month Follow up

The principal goal of most simulation-based learning is enhanced clinical skill, with the desired outcome being skill retention and improved performance over time. While evide nce supports simulation based training at the clerkship, graduate, and post graduate level, the evidence supporting its long term benefit at the pre clerkship level is less well established. Using quantitative methods, this research assessed the effect of skill based clinical simulation training on all second year medical students’ enrolled in two simulation courses at the University of Michigan during the 2013 2014 academic year (n=39). Pre course, post course, and 6 month follow up questionnaires were adm inistered, and analysis of variance was used to assess change in students\u27 knowledge, self reported confidence, and competency. Students in Course 1 (n=12) completed a post course and 6 month follow up skills test, and results were compared to faculty cont rols. Differences between groups were assessed using t tests. Odds ratios were calculated.Knowledge improved from pre course to post course; the gain was retained at follow up only for students in Course 1. Students perceived the courses as improving know ledge, confidence, and skill, though scores were significantly lower at follow up. For the subset of students participating in the skills test, the time to complete central line and thoracentesis at follow up did not significantly differ from post course; however, an increase was observed for lumbar puncture. Compared to faculty, students took significantly more time to complete the central line procedure. Outcomes for needle redirects and correct sequencing were mixed, with most procedures showing no signi ficant difference between measurement periods. Assessing students’ skill and the maintenance of that skill over time using objective and empirically derived measures can be challenging. The evaluation strategy described herein could be adapted to many proc edures commonly practiced within primary care and other medical specialties. Brief exposure to clinical simulation early in medical training and prior to clerkships can have a positive and lasting effecton medical students’ knowledge, confidence, and skil l for selected procedures

A Systems Approach to Improving Tdap Immunization Within 5 Community-Based Family Practice Settings: Working Differently (and Better) by Transforming the Structure and Process of Care.

OBJECTIVES: We examined how family medicine clinic physicians and staff worked in collaborative teams to implement an automated clinical reminder to improve tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine administration and documentation. METHODS: A clinical reminder was developed at 5 University of Michigan family medicine clinics to identify patients 11 to 64 years old who were in need of the Tdap booster vaccine. Quality improvement cycles were used to improve clinic care processes. Immunization rates from 2008 to 2011 were compared with rates at 4 primary care control clinics. RESULTS: Vaccination rates among eligible patients increased from 15.5% to 47.3% within the family medicine clinics and from 14.1% to 30.2% within the control clinics. After adjustment for covariates, family medicine patients had a higher probability of vaccination than control patients during each measurement period (0.17 vs 0.15 at baseline, 0.53 vs 0.22 during year 1, and 0.50 vs 0.30 during year 2). CONCLUSIONS: Automated clinical reminders, when designed and implemented via a consensus-based framework that addresses the process of care, can dramatically improve provision of preventive health care

Mechanosensitivity during lower extremity neurodynamic testing is diminished in individuals with Type 2 Diabetes Mellitus and peripheral neuropathy: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>Type 2 Diabetes Mellitus (T2DM) and diabetic symmetrical polyneuropathy (DSP) impact multiple modalities of sensation including light touch, temperature, position sense and vibration perception. No study to date has examined the mechanosensitivity of peripheral nerves during limb movement in this population. The objective was to determine the unique effects T2DM and DSP have on nerve mechanosensitivity in the lower extremity.</p> <p>Methods</p> <p>This cross-sectional study included 43 people with T2DM. Straight leg raise neurodynamic tests were performed with ankle plantar flexion (PF/SLR) and dorsiflexion (DF/SLR). Hip flexion range of motion (ROM), lower extremity muscle activity and symptom profile, intensity and location were measured at rest, first onset of symptoms (P1) and maximally tolerated symptoms (P2).</p> <p>Results</p> <p>The addition of ankle dorsiflexion during SLR testing reduced the hip flexion ROM by 4.3° ± 6.5° at P1 and by 5.4° ± 4.9° at P2. Individuals in the T2DM group with signs of severe DSP (n = 9) had no difference in hip flexion ROM between PF/SLR and DF/SLR at P1 (1.4° ± 4.2°; paired t-test p = 0.34) or P2 (0.9° ± 2.5°; paired t-test p = 0.31). Movement induced muscle activity was absent during SLR with the exception of the tibialis anterior during DF/SLR testing. Increases in symptom intensity during SLR testing were similar for both PF/SLR and DF/SLR. The addition of ankle dorsiflexion induced more frequent posterior leg symptoms when taken to P2.</p> <p>Conclusions</p> <p>Consistent with previous recommendations in the literature, P1 is an appropriate test end point for SLR neurodynamic testing in people with T2DM. However, our findings suggest that people with T2DM and severe DSP have limited responses to SLR neurodynamic testing, and thus may be at risk for harm from nerve overstretch and the information gathered will be of limited clinical value.</p

A Human Lung Xenograft Mouse Model of Nipah Virus Infection

Nipah virus (NiV) is a member of the genus Henipavirus (family Paramyxoviridae) that causes severe and often lethal respiratory illness and encephalitis in humans with high mortality rates (up to 92%). NiV can cause Acute Lung Injury (ALI) in humans, and human-to-human transmission has been observed in recent outbreaks of NiV. While the exact route of transmission to humans is not known, we have previously shown that NiV can efficiently infect human respiratory epithelial cells. The molecu

The importance of the altricial – precocial spectrum for social complexity in mammals and birds:A review

Various types of long-term stable relationships that individuals uphold, including cooperation and competition between group members, define social complexity in vertebrates. Numerous life history, physiological and cognitive traits have been shown to affect, or to be affected by, such social relationships. As such, differences in developmental modes, i.e. the ‘altricial-precocial’ spectrum, may play an important role in understanding the interspecific variation in occurrence of social interactions, but to what extent this is the case is unclear because the role of the developmental mode has not been studied directly in across-species studies of sociality. In other words, although there are studies on the effects of developmental mode on brain size, on the effects of brain size on cognition, and on the effects of cognition on social complexity, there are no studies directly investigating the link between developmental mode and social complexity. This is surprising because developmental differences play a significant role in the evolution of, for example, brain size, which is in turn considered an essential building block with respect to social complexity. Here, we compiled an overview of studies on various aspects of the complexity of social systems in altricial and precocial mammals and birds. Although systematic studies are scarce and do not allow for a quantitative comparison, we show that several forms of social relationships and cognitive abilities occur in species along the entire developmental spectrum. Based on the existing evidence it seems that differences in developmental modes play a minor role in whether or not individuals or species are able to meet the cognitive capabilities and requirements for maintaining complex social relationships. Given the scarcity of comparative studies and potential subtle differences, however, we suggest that future studies should consider developmental differences to determine whether our finding is general or whether some of the vast variation in social complexity across species can be explained by developmental mode. This would allow a more detailed assessment of the relative importance of developmental mode in the evolution of vertebrate social systems

Paralytic Shellfish Poisoning: A Case Series

We describe a case series of seven patients presenting to an emergency department with symptoms of paralytic shellfish poisoning. They developed varying degrees of nausea, vomiting, diarrhea, weakness, ataxia and paresthesias after eating mussels harvested from a beach near their resort. Four patients were admitted to the hospital, one due to increasing respiratory failure requiring endotracheal intubation and the remainder for respiratory monitoring. All patients made a full recovery, most within 24 hours. The ability to recognize and identify paralytic shellfish poisoning and manage its complications are important to providers of emergency medicine. [West J Emerg Med. 2014;15(4):378-381.

Paralytic Shellfish Poisoning: A Case Series

We describe a case series of seven patients presenting to an emergency department with symptoms of paralytic shellfish poisoning. They developed varying degrees of nausea, vomiting, diarrhea, weakness, ataxia and paresthesias after eating mussels harvested from a beach near their resort. Four patients were admitted to the hospital, one due to increasing respiratory failure requiring endotracheal intubation and the remainder for respiratory monitoring. All patients made a full recovery, most within 24 hours. The ability to recognize and identify paralytic shellfish poisoning and manage its complications are important to providers of emergency medicine. [West J Emerg Med. 2014;15(4):378-381.