Introduction:Much of the suffering and expense associated with treatment of persons with dementia (Major Neurocognitive Disorder) arises from associated noncognitive behavioral and psychological symptoms of dementia (BPSD). Although a consensus on the prevalence of BPSD is lacking, evidence suggests that most people with dementia will manifest one or more of these symptoms during the disorder's progression. BPSD raise the cost of care by leading to more frequent emergency room visits, more and longer hospitalizations, and earlier admission to long-term care facilities (LTCF). Treatment of BPSD presents a stressful challenge in LTCFs. We sought to investigate the care burden of BPSD in Delaware's LTCFs and to gather data that can inform management approaches.Methods:Using REDCap, we created an anonymous cross-sectional survey designed for completion by LTCF administrators. The Delaware Health Care Facilities Association (DHCFA) and Delaware's Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) encouraged participation. A link to the survey was emailed to the administrators of 81 facilities in Delaware. The resulting data were evaluated using descriptive statistics.Results:Forty-four of the 81 facilities surveyed opened the survey link. Thirty-eight facilities answered at least some of the questions, and 19 surveys were fully completed. The reported average prevalence of BPSD among Delaware LTCF residents with dementia was 49.3% (SD 28.9). The five most frequently reported BPSD symptoms were anxiety, agitation, wandering, dysphoria/depression, and appetite/eating abnormalities. All facilities reported employing a spectrum of pharmacologic and non-pharmacologic management strategies. Twenty-two of 24 respondents (91.7%) reported that behavioral health consultation was available at their facilities and 18 of 20 respondents (90.0%) indicated that they provided training on how to manage residents with BPSD.Conclusion:BPSD are a pervasive concern among Delaware's LTCFs. LTCFs may benefit from the development of training programs and dissemination of treatment guidelines incorporating evidence-based interventions and their implementation in managing BPSD to improve care, decrease stress on residents and caregivers, and reduce some avoidable health care costs.
BACKGROUNDAs patients with diabetes continue to have greater problems with obesity, the need for more medications and higher doses of insulin has increased. Some patients are so insulin resistant that they require U-500 insulin.QUESTIONS/PURPOSESAll insulins carry the risk of hypoglycemia. Despite being the most potent insulin available, the methodology for describing U-500 insulin administration varies. This paper examines the properties of U-500 insulin and suggests a unified method of defining how it is administered.METHODSA literature search for English language articles that reference U-500 insulin was performed. The 51 articles, and additional websites as applicable, were independently reviewed.RESULTSNow that U-500 insulin has a specific syringe and a pen, all patients who use this should be converted to one of these two devices. The insulin dose should be described as the number of units administered.CONCLUSIONU-500 insulin is a potent formulation and carries the risk of hypoglycemia. A unified method of administration is now available, and the description of its use should reflect the number of units administered.
Eluxadoline has emerged as an effective treatment option for patients with diarrhea- predominant irritable bowel syndrome (IBS-D). It was approved by the Food and Drug Administration (FDA) in May 2015 for treatment of IBS-D. It is a p-opioid receptor agonist and 6-receptor antagonist that acts locally in the gastrointestinal (GI) tract. In recently published phase IlIl IBS-3001 and IBS- 3002 trials, eight patients experienced abdominal pain due to sphincter of Oddi dysfunction (SOD), and one patient had acute pancreatitis, thought to be related to eluxadoline. Here, we describe a patient with eluxadoline- induced pancreatitis, the first case we know of to be reported outside of phase Ill clinical trials. Interestingly, only patients with prior cholecystectomy developed SOD and acute pancreatitis in the IBS 3001/3002 trials which also stands true with our patient. The enthusiasm with the efficacy of this drug should not have clinicians disregard the potential adverse effects, particularly serious ones, such as acute pancreatitis. We expect more cases of eluxadoline-induced pancreatitis and SOD to be reported, and future studies should focus on better understanding this association so as to guide treatment recommendations.
BACKGROUND:As patients with diabetes continue to have greater problems with obesity, the need for more medications and higher doses of insulin has increased. Some patients are so insulin resistant that they require U-500 insulin.QUESTIONS/PURPOSES:All insulins carry the risk of hypoglycemia. Despite being the most potent insulin available, the methodology for describing U-500 insulin administration varies. This paper examines the properties of U-500 insulin and suggests a unified method of defining how it is administered.METHODS:A literature search for English language articles that reference U-500 insulin was performed. The 51 articles, and additional websites as applicable, were independently reviewed.RESULTS:Now that U-500 insulin has a specific syringe and a pen, all patients who use this should be converted to one of these two devices. The insulin dose should be described as the number of units administered.CONCLUSION:U-500 insulin is a potent formulation and carries the risk of hypoglycemia. A unified method of administration is now available, and the description of its use should reflect the number of units administered.
Children lack the cognitive judgment and motor skills to safely operate all-terrain vehicles (ATVs) in all situations. The Trauma Team clinicians at Nemours Children's Health System/Alfred I. duPont Hospital for Children (N/AIDHC) were concerned about the severity of injuries sustained by children when they were either the driver or a passenger on an ATV. Although this subset of children within the trauma registry did not account for a high volume of trauma patients, these children sustained a higher proportion of severe injuries. In 2012, the Trauma Team at N/AIDHC partnered with Nemours Health & Prevention Services to form a broad-based statewide coalition in order to impact this alarming trend and to improve safety for those who ride ATVs. The coalition worked together to reach consensus and to successfully advocate for the passage of legislation requiring helmets and limiting passengers for recreational ATV riders under the age of 18. This legislation was signed into law in July 2015. Working with both ATV dealers and a national industry association, the coalition also has been successful in bringing to the State of Delaware, an ATV safety training course for riders in 2016. An evaluation of the impact of this new legislation using state trauma data will begin in 2017.
Diagnostic laparoscopy has been used in select patients with penetrating abdominal trauma. Here we present a case report where a midline surgical scar from a previous trauma laparotomy potentially prevented intra-abdominal injury. Furthermore, laparoscopy was used to exclude other intra-abdominal injuries and retrieve the projectile from within a hematoma cavity. This avoided the morbidity of a trauma laparotomy.
Renal cell carcinoma (RCC) is responsible for 80 to 85 percent of all primary renal malignancies. In the United State%, there are about 63,000 new cases and almost :14,000 deaths per year from RCC. Surgical resection of localized RCC can be curative but many patients eventually recur. Immunotherapy appears to be a promising new modality for many malignancies, including RCC. Nivolumab, a specific immunotherapy agent indicated for advanced RCC, may restore antitumor immunity and allow for greater progression-free survival by targeting proteins that negatively regulate T cell immunity. This case study aims to demonstrate the integration of nivolumab into the management of a patient with advanced RCC and provide a stimulus for further investigation and research into this treatment modality.
