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Baraa O Tayeb,1,2 Jennifer A Winegarden,3 Rawabi A Alashari,4,5 Moudi Alasmari,6,7 Jonathan Winegarden,8 Faisal Boker,9 Abdulaziz Halawi,2 Amy Lapidow,10 Ylisabyth S Bradshaw,11 Daniel B Carr11 1Department of Anesthesiology and Critical Care, King Abdulaziz University Faculty of Medicine, Jeddah, Saudi Arabia; 2King Abdulaziz University Hospital, Jeddah, Saudi Arabia; 3Department of Medicine, The Medical Team Hospice, Livonia, MI, USA; 4Department of Pharmacology, King Abdulaziz University, Faculty of Medicine, Jeddah, Saudi Arabia; 5Department of Pharmaceutical Science, MCPHS University, Boston, MA, USA; 6College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; 7King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia; 8Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA; 9Emergency Department, King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia; 10Tufts Hirsh Health Sciences Library, Boston, MA, USA; 11Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Baraa O TayebFaculty of Medicine, King Abdulaziz University, P.B. Box 80215, Jeddah, 21589, Saudi ArabiaTel +966-2-640-1000 (ext. 1-10199/10209)Fax +966-2-640-8335Email btayeb@kau.edu.saPurpose: Scoping reviews address the nature of the literature per se rather than inferring evidence-based treatment guidelines. Scoping reviews of the published literature are intended to describe the aggregated nature of the evidence surrounding some agent or intervention, in contrast to systematic reviews that seek when possible to guide clinical practice. We conducted a scoping review to identify reports of potential clinical utility of off-label topical analgesics and adjuvants when FDA-approved treatments have proven inadequate.Methods: We performed a comprehensive search of three databases (PubMed, Web of Science and Embase) for articles dating from 1947 to the present. Mindful that FDA-approved and WHO-recommended analgesic medications often prove inadequate for individual patients in extremis with palliative, hospice or cancer pain, we used broad, structured inclusion criteria to retrieve articles.Results: We retrieved 12,100 articles; after screening, we had 39 reports addressing 19 different topical agents out of the 32 chemical entities. Our scoping review disclosed evidence about agents that might not have met inclusion criteria for clinical practice guidelines.Discussion: Although generally considered lower quality evidence, case reports or series present suggestions for diverse topical medications to manage pain in challenging circumstances when high-quality evidence for agents and routes of administration is lacking.Conclusion: Patients with the greatest need for evidence to identify and guide lesser-used agents during aggressive pain management are the most difficult to enroll and follow in standardized, controlled and/or blinded clinical trials. This scoping review identifies medications, dosages, and routes of topical agents reported to be effective in these often-challenging circumstances. Until larger and higher quality studies are completed, we must rely on the best available evidence even if of lower quality.Keywords: topical medications, pain, analgesia, palliative care, hospice, cancer, evidence-based medicine, personalized medicine

Ronald Goldwater,1 William G Kramer,2 Douglas A Hamilton,3,4 Eric Lang,4,5 Jianyuan Wang,4 Donna E Madden,4 Peter G Lacouture,6,7 Atulkumar Ramaiya,8 Daniel B Carr4,9 1PAREXEL International, Baltimore, MD, 2Kramer Consulting, LLC, North Potomac, MD, 3New Biology Ventures, LLC, San Mateo, CA, 4Javelin Pharmaceuticals, Cambridge, MA (now Hospira, a Pfizer company, Lake Forest, IL, USA), 5Covance, Princeton, NJ, 6Magidom Discovery, LLC, Lindenhurst, IL, 7Brown University School of Medicine, Providence, RI, 8Global Medical Affairs, Hospira, a Pfizer company, Lake Forest, IL, 9Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA Purpose: The analgesic and opioid-sparing effects of nonsteroidal anti-inflammatory drugs can be beneficial in postoperative populations. Hydroxypropyl-β-cyclodextrin (HPβCD)-diclofenac is an injectable formulation of diclofenac solubilized with HPβCD that is administered as a low-volume intravenous bolus. This open-label, single-dose study examined the effects of age and weight on the pharmacokinetic (PK) profile of HPβCD-diclofenac. Methods: Eighty-eight adult volunteers were enrolled. An age-based cohort included 34 subjects 55–82 years old stratified into three groups and receiving HPβCD-diclofenac 18.75 mg. A weight-based cohort included 54 subjects stratified into five groups based on body weight and body mass index and receiving HPβCD-diclofenac 37.5 mg. PK analysis was performed on blood samples collected predosing and at predefined intervals (5, 10, 20, 30, and 45 minutes; 1, 1.5, 2, 2.5, 3, 4, 6, 8, 10, 12, and 18 hours) postdosing. Diclofenac PK parameters were examined in the individual cohorts, and regression analyses of the relationship between age, weight, and PK parameters were performed on pooled data from all enrolled subjects. Results: Examination of the age-based cohort revealed similar diclofenac PK parameters across age groups. PK parameters were likewise similar across weight groups in the weight-based cohort. Regression analysis on pooled data from the age- and weight-based cohorts revealed that increasing body weight was associated with a significant increase in diclofenac clearance (CL), suggesting decreased exposure in high-weight patients. Analysis of the pooled population also demonstrated an inverse relationship between age and elimination half-life (t1/2), likely due to a decrease in the volume of distribution (Vz) with increased age, not a change in CL. There were no deaths, serious adverse events, or adverse events that led to discontinuation. Conclusion: This study suggests that the CL of diclofenac is not dependent on age in elderly subjects receiving HPβCD-diclofenac but indicates that diclofenac CL increases with increasing body weight. Keywords: analgesia, pain control, pharmacokinetics, obesity, elderly, NSAID

Tong J Gan,1 Neil Singla,2 Stephen E Daniels,3 Douglas A Hamilton,4,5 Peter G Lacouture,6,7 Christian RD Reyes,8 Daniel B Carr4,9 1Department of Anesthesiology, Stony Brook University, NY, 2Lotus Clinical Research, LLC, Pasadena, CA, 3Premier Research, Austin, TX, 4Javelin Pharmaceuticals, Inc., Cambridge, MA, 5New Biology Ventures, LLC, San Mateo, CA, 6Magidom Discovery, LLC, St Augustine, FL, 7Department of Emergency Medicine, Brown University School of Medicine, Providence, RI, 8Hospira Inc., Lake Forest, IL, 9Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA Purpose: Use of nonopioid analgesics (including nonsteroidal anti-inflammatory drugs) for postoperative pain management can reduce opioid consumption and potentially prevent opioid-related adverse events. This study examined the postoperative opioid-sparing effect of repeated-dose injectable diclofenac formulated with hydroxypropyl-β-cyclodextrin (HPβCD)-diclofenac. Patients and methods: Pooled data from two double-blind, randomized, placebo- and active comparator-controlled Phase III trials were analyzed. Patients received HPβCD-diclofenac, placebo, or ketorolac by intravenous injection every 6 hours for up to 5 days following abdominal/pelvic or orthopedic surgery. Rescue opioid use was evaluated from the time of first study drug administration to up to 120 hours following the first dose in the overall study population and in subgroups defined by baseline pain severity, age, and HPβCD-diclofenac dose. Results: Overall, 608 patients received ≥1 dose of study medication and were included in the analysis. While 93.2% of patients receiving placebo required opioids, the proportion of patients requiring opioids was significantly lower for patients receiving HPβCD-diclofenac (18.75, 37.5, or 50 mg) or ketorolac (P

Aims/hypothesisIncreased intra-abdominal fat is associated with insulin resistance and an atherogenic lipoprotein profile. Circulating concentrations of adiponectin, an adipocyte-derived protein, are decreased with insulin resistance. We investigated the relationships between adiponectin and leptin, body fat distribution, insulin sensitivity and lipoproteins.MethodsWe measured plasma adiponectin, leptin and lipid concentrations, intra-abdominal and subcutaneous fat areas by CT scan, and insulin sensitivity index (S(I)) in 182 subjects (76 M/106F).ResultsAdiponectin concentrations were higher in women than in men (7.4+/-2.9 vs 5.4+/-2.3 micro g/ml, p

Background: Preterm birth is the leading cause of neonatal mortality and morbidity in developed countries. Whether continued tocolysis after 48 hours of rescue tocolysis improves neonatal outcome is unproven.Objectives: To evaluate the effectiveness of maintenance tocolytic therapy with oral nifedipine on the reduction of adverse neonatal outcomes and the prolongation of pregnancy by performing an individual patient data meta-analysis (IPDMA).Search Strategy: We searched PubMed, Embase, and Cochrane databases for randomised controlled trials of maintenance tocolysis therapy with nifedipine in preterm labour.Selection Criteria: We selected trials including pregnant women between 24 and 36(6/7)  weeks of gestation (gestational age, GA) with imminent preterm labour who had not delivered after 48 hours of initial tocolysis, and compared maintenance nifedipine tocolysis with placebo/no treatment.Data Collection and Analysis: The primary outcome was perinatal mortality. Secondary outcome measures were intraventricular haemorrhage (IVH), necrotising enterocolitis (NEC), infant respiratory distress syndrome (IRDS), prolongation of pregnancy, GA at delivery, birthweight, neonatal intensive care unit admission, and number of days on ventilation support. Pre-specified subgroup analyses were performed.Main Results: Six randomised controlled trials were included in this IPDMA, encompassing data from 787 patients (n = 390 for nifedipine; n = 397 for placebo/no treatment). There was no difference between the groups for the incidence of perinatal death (risk ratio, RR 1.36; 95% confidence interval, 95% CI 0.35-5.33), intraventricular haemorrhage (IVH) ≥ grade II (RR 0.65; 95% CI 0.16-2.67), necrotising enterocolitis (NEC) (RR 1.15; 95% CI 0.50-2.65), infant respiratory distress syndrome (IRDS) (RR 0.98; 95% CI 0.51-1.85), and prolongation of pregnancy (hazard ratio, HR 0.74; 95% CI 0.55-1.01).Conclusion: Maintenance tocolysis is not associated with improved perinatal outcome and is therefore not recommended for routine practice.Tweetable Abstract: Nifedipine maintenance tocolysis is not associated with improved perinatal outcome or pregnancy prolongation. [ABSTRACT FROM AUTHOR]

Although automobiles remain the transportation of choice for many older adults, late-life cognitive impairment and dementia often impair the ability to drive safely. However, there is no commonly used method of assessing dementia severity in relation to driving, no consensus on the assessment of older drivers with cognitive impairment, and no gold standard for determining driving fitness. Yet clinicians are called on by patients, their families, other health professionals, and often their state's Department of Motor Vehicles to assess their patients' fitness to drive and to make recommendations about driving privileges. This article describes the challenges of driving with cognitive impairment for both the patient and caregiver, summarizes the literature on dementia and driving, discusses evidence-based assessment of fitness to drive, and addresses important ethical and legal issues. It also describes the role of physician assessment, referral for neuropsychological testing, screening for functional ability, tools to assess dementia severity, driving evaluation clinics, and Department of Motor Vehicles referrals that may assist with evaluation. Lastly, it discusses mobility counseling (eg, exploration of transportation alternatives), because health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance patients' social connectedness and quality of life while meeting their psychological and medical needs and maintaining personal and public safety. [ABSTRACT FROM AUTHOR]

To characterize the driving and mobility status of older adults with dementia, a questionnaire was mailed to 527 informants; 119 were returned. The majority of patients were diagnosed with dementia of the Alzheimer type. Only 28% were actively driving at the time of survey. Informants rated 53% of current or recently retired drivers as potentially unsafe. Few informants reported using community/educational resources. Individuals with progressive dementia retire from driving for differing reasons, many subsequent to family recognition of impaired driving performance. Opportunities for education and supportive assistance exist but are underutilized. [ABSTRACT FROM AUTHOR]

Background and Objectives: Voltarol for injection (a diclofenac sodium formulation employing polyethylene glycol and benzyl alcohol [PG-BA] as excipients) is marketed in Europe but not in North America. A suspension, PG-BA diclofenac sodium, requires preparation for each patient and slow IV infusion to minimize venous irritation. Dyloject, a novel diclofenac formulation, employs hydroxypropyl beta-cyclodextrin (HPbetaCD) to solubilize diclofenac in a small volume. We compared the efficacy and safety of an IV HPbetaCD diclofenac sodium bolus, a 30-minute PG-BA diclofenac sodium infusion, and placebo in post-molar extraction pain.Methods: A total of 155 adult patients were randomized to receive HPbetaCD diclofenac sodium 75 mg, PG-BA diclofenac sodium 75 mg, or placebo. Primary endpoints were superiority of HPbetaCD diclofenac sodium to placebo and noninferiority of HPbetaCD diclofenac sodium to PG-BA diclofenac sodium with respect to total pain relief over 4 hours (TOTPAR4) on a 0 to 100-mm visual analog scale (VAS). Secondary endpoints included categorical TOTPAR4, VAS and categorical TOTPAR up to 8 hours, other measures of pain intensity and relief, patient global evaluation, and time to rescue medication.Results: HPbetaCD diclofenac sodium had efficacy superior to both placebo and PG-BA diclofenac sodium. At 15 minutes, more patients given HPbetaCD diclofenac sodium than PG-BA diclofenac sodium reported 30% reduction in pain intensity (52% vs. 21%, P = .0022). Both diclofenac products had a 6-hour duration of effect and were well tolerated. Patient global evaluations of HPbetaCD diclofenac sodium were high, superior to placebo, and similar to PG-BA diclofenac sodium. The adverse event (AE) incidence was similar for HPbetaCD diclofenac sodium and PG-BA diclofenac sodium, except that in the current trial and in integrated safety results from the present and prior studies, phlebitis was more common with PG-BA diclofenac sodium. No cardiac or renal AEs or gastrointestinal bleeding were reported or observed.Conclusions: IV bolus HPbetaCD diclofenac sodium produced analgesia more quickly than, and with equal duration as, the 30-minute PG-BA diclofenac sodium infusion. Pooled data on thrombophlebitis from the present investigation and our prior studies of the novel formulation indicate this adverse effect is less frequent and less severe with HPbetaCD diclofenac sodium than with PG-BA diclofenac sodium. [ABSTRACT FROM AUTHOR]

Objective: To determine whether deconditioned older adults referred from internal medicine units in an acute hospital setting benefited from inpatient rehabilitation services.Design: The design of this study was a retrospective review of consecutive admissions to a rehabilitation hospital.Setting: The rehabilitation setting was an 80-bed HealthSouth acute medical rehabilitation center adjacent to the Washington University Medical Center in mid-town St Louis, Mo, and affiliated with Barnes-Jewish Hospital.Patients: Participants were 88 patients aged 55 years and older, having a primary diagnosis of deconditioning or weakness admitted to an inpatient rehabilitation unit from February 2004 to February 2005.Main Outcome Measures: Medical diagnoses, laboratory data, medications prescribed, nutritional status, physical, occupational, and speech therapy interventions, and documentation of geriatric syndromes were obtained from the rehabilitation medical records. Outcomes measured were discharge disposition, the change in functional status as assessed by the Functional Independence Measure (FIM), and the FIM efficiency rating.Results: The majority of patients were referred from the hospital after an average length of stay of 9 days and stayed for an average of 12 days in the acute inpatient rehabilitation unit. The average FIM scores dramatically improved during inpatient rehabilitation (29.4 +/- 16.2), the FIM efficiency rating was 3.0 +/- 1.9, and 71% of patients were discharged home. Common geriatric syndromes in this sample included depression, cognitive impairment, pain, falls, and polypharmacy. When assessed, vitamin D deficiency/insufficiency was also common in this sample.Conclusions: An inpatient rehabilitation service, focused on the deconditioned older adult, was able to demonstrate significant improvement in FIM scores during an inpatient rehabilitation stay and the majority of these patients were discharged home. These outcomes occurred despite the presence of geriatric syndromes, comorbid illnesses, and a recent hospitalization for an acute medical illness. Further pilot studies on deconditioned patients who are admitted to inpatient rehabilitation service may confirm the need for trials that compare outcomes across other settings such as home and long-term care. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The relative roles of insulin resistance and beta-cell dysfunction in the pathogenesis of impaired glucose tolerance (IGT) and type 2 diabetes are debated. First-degree relatives of individuals with type 2 diabetes are at increased risk of developing hyperglycemia. RESEARCH DESIGN AND METHODS: We evaluated the evolution of insulin sensitivity, beta-cell function, glucose effectiveness, and glucose tolerance over 7 years in 33 nondiabetic, first-degree relatives of type 2 diabetic individuals using frequently sampled tolbutamide-modified intravenous and oral glucose tolerance tests. RESULTS: Subjects gained weight, and their waist circumference increased (P < 0.05). Insulin sensitivity, the acute insulin response to glucose, and glucose effectiveness did not change significantly. However, when we accounted for the modulating effect of insulin sensitivity on insulin release, beta-cell function determined as the disposition index decreased by 22% (P < 0.05). This decrease was associated with declines in intravenous and oral glucose tolerance (P < 0.05 and P < 0.001, respectively). Of the subjects with normal glucose tolerance at the first assessment, we compared those who progressed to IGT with those who did not. The disposition index was 50% lower in the progressors than in the nonprogressors at follow-up (P < 0.05). CONCLUSIONS: The decline in glucose tolerance over time in first-degree relatives of type 2 diabetic individuals is strongly related to the loss of beta-cell function. Thus, early interventions to slow the decline in beta-cell function should be considered in high-risk individuals. [ABSTRACT FROM AUTHOR]

As the number of drivers with cognitive impairment increases, family physicians are more likely to become involved in decisions about cessation of driving privileges in older patients. Physicians who care for cognitively impaired older adults should routinely ask about driving status. In patients who continue to drive, physicians should assess pertinent cognitive domains, determine the severity and etiology of the dementia, and screen for risky driving behaviors. Cognitive impairment detected by office-based tests may indicate that the patient is at risk of a motor vehicle crash. Referral for performance-based road testing may further clarify risk and assist in making driving recommendations. Physicians should assist families in the difficult process of driving cessation, including providing information about Web sites and other resources and clarifying the appropriate state regulations. Some states require reporting of specific medical conditions to their departments of motor vehicles. [ABSTRACT FROM AUTHOR]

Older adults rely mostly on driving to accomplish their transportation needs. With age-related functional limitations, most notably cognitive decline and dementia, vision impairment, and arthritis, driving may become more challenging. Seniors may need to find ways to maintain or enhance their driving ability or utilize alternate methods of transportation. Based on recent research and product development, a variety of resources are now available to assist rehabilitation specialists and related healthcare professionals in providing programs and information to their older patients. This article provides a comprehensive listing of programs, Web sites, and informational materials to assist older people in remaining safely mobile later in life. [ABSTRACT FROM AUTHOR]

National surveys continue to document the undertreatment of acute postoperative pain, despite the availability of evidence-based, clinical practice guidelines and the Joint Commission on Accreditation of Healthcare Organizations standards. This article surveys factors that contribute to persistent gaps during the acute pain management process, including deficiencies in providing continuous analgesia, disparities in access to medical care, the acute pain medicine culture itself, a lack of adequate pain assessment, health care provider biases, and limited health care resources. The role of technology in increasing patients' control over their own pain management and narrowing these gaps is discussed. Patient-controlled analgesia delivery systems are an example of such technology, and they play a key role in improving the quality of acute pain management and increasing the patient's involvement in this process. However, the use of these systems may be limited because of the amount of health care resources necessary for their administration and limitations in payment for professional services. Therefore, there exists a need for additional technologies that will simplify the pain management process and reduce the amount of health care resources necessary to provide patients with quality acute pain management. [ABSTRACT FROM AUTHOR]

Lifestyle modification reduces the risk of developing type 2 diabetes and may have its effect through improving insulin sensitivity, beta-cell function, or both. To determine whether diet and exercise improve insulin sensitivity and/or beta-cell function and to evaluate these effects over time, we quantified insulin sensitivity and the acute insulin response to glucose (AIRg) in 62 Japanese Americans (age 56.5 +/- 1.3 years; mean +/- SE) with impaired glucose tolerance (IGT) who were randomized to the American Heart Association (AHA) Step 2 diet plus endurance exercise (n = 30) versus the AHA Step 1 diet plus stretching (n = 32) for 24 months. beta-Cell function (disposition index [DI]) was calculated as S(i) x AIRg, where S(i) is the insulin sensitivity index. The incremental area under the curve for glucose (incAUCg) was calculated from a 75-g oral glucose tolerance test. Intra-abdominal fat (IAF) and subcutaneous fat (SCF) areas were measured by computed tomography. At 24 months, the Step 2/endurance group had lower weight (63.1 +/- 2.4 vs. 71.3 +/- 2.9 kg; P = 0.004) and IAF (75.0 +/- 7.9 vs. 112.7 +/- 10.4 cm(2); P = 0.03) and SCF (196.5 +/- 18.0 vs. 227.7 +/- 19.9 cm(2); P < 0.001) areas, greater S(i) (4.7 +/- 0.5 vs. 3.3 +/- 0.3 x 10(-5) min . pmol(-1) . l(-1); P = 0.01), and a trend toward lower AIRg (294.9 +/- 50.0 vs. 305.4 +/- 30.0 pmol/l; P = 0.06) and incAUCg (8,217.3 +/- 350.7 vs. 8,902.0 +/- 367.2 mg . dl(-1) . 2 h(-1); P = 0.08) compared with the Step 1/stretching group after adjusting for baseline values. There was no difference in the DI (P = 0.7) between the groups. S(i) was associated with changes in weight (r = -0.426, P = 0.001) and IAF (r = -0.395, P = 0.003) and SCF (r = -0.341, P = 0.01) areas. Thus, the lifestyle modifications decreased weight and central adiposity and improved insulin sensitivity in Japanese Americans with IGT. However, such changes did not improve beta-cell function, suggesting that this degree of lifestyle modifications may be limited in preventing type 2 diabetes over the long term. [ABSTRACT FROM AUTHOR]

Preexisting hypertension complicates 5% of all pregnancies. The objective of this study was to evaluate steady-state atenolol pharmacokinetics and pharmacodynamics (n = 17) during the second trimester (2nd T), third trimester (3rd T), and 3 months postpartum. Pregnancy as compared to 3 months postpartum (nonpregnant control) resulted in significant (P < .05) changes, including the following: 42% (2nd T) and 50% (3rd T) increase in creatinine clearance, 38% (2nd T) and 36% (3rd T) increase in atenolol renal clearance, 12% (2nd T) and 11% (3rd T) decrease in atenolol half-life, 20% (2nd T) and 28% (3rd T) increase in cardiac output, 15% (2nd T) and 23% (3rd T) increase in resting heart rate, and 22% (2nd T) and 21% (3rd T) decrease in total peripheral resistance in subjects on steady-state oral atenolol for treatment of hypertension in pregnancy. In conclusion, the renal clearance of atenolol along with creatinine clearance is increased during pregnancy. However, this does not translate into an increase in apparent oral clearance of atenolol, possibly related to the high variability in bioavailability. Atenolol administration did not appear to change the pattern of the increase in cardiac output and the decrease in total peripheral resistance, which normally occurs during pregnancy. [ABSTRACT FROM AUTHOR]

Older driver safety is a growing public health concern for which interventions are currently being sought. Statistics show that older drivers suffer a disproportionately high rate of motor vehicle fatalities compared with other adult drivers. This disproportion is due to two factors: an increased crash rate per vehicle mile driven and an increased risk of fatality in the event of a crash. Traditionally, traffic safety efforts for the older population have focused on methods to identify unsafe drivers to enforce driving cessation, but driving cessation deprives the majority of older Americans of their primary form of transportation and has been associated with an increase in depressive symptoms. In response to these concerns, the Older Drivers Project, created by the American Medical Association in partnership with the National Highway Traffic Safety Administration, describes and advocates a more acceptable approach to traffic safety. The primary objective of this approach involves helping older drivers stay on the road safely to preserve their mobility and independence. This can be accomplished through three methods: (1) optimizing the driver, (2) optimizing the driving environment, and (3) optimizing the vehicle. In this approach, driving cessation is recommended only after the safety of the driver cannot be secured through any other means. [ABSTRACT FROM AUTHOR]

Objective. To assess the reliability of an augmented SF-36 instrument, the Treatment Outcomes in Pain Survey (“TOPS”), in patients treated in two pain management programs, and present norms for initial values and treatment-related improvements. Design. Prospective case series at two sites with longitudinal follow-up. Setting. Multidisciplinary, comprehensive outpatient pain treatment centers in university hospitals in Salt Lake City and Boston. Patients. Nine hundred and forty seven adult outpatients with a range of socioeconomic, demographic, and ethnic characteristics, all referred for evaluation and treatment of chronic pain. Interventions. Usual practice multidisciplinary pain treatment. Outcomes Measures. TOPS prior to pain treatment and 5-week nominal follow-up. Means and standard deviations of baseline and follow-up results. Psychometric results for reliability (Cronbach alpha), validity (item discriminant validity, validity coefficients), and related statistical precision measures for group and individual designs. Results. Several measures were precise enough to permit following individual patients in standard clinic treatment, of which the Total Pain Experience dimension was the most powerful. Similar psychometrics were observed in the Boston and Salt Lake City sites. The Pain Symptom, Objective Family/Social Disability, Objective Work Disability, and Upper Body Functional Limitations scales were validated. Discussion. The TOPS was designed to satisfy several models of clinical pain treatment. It successfully monitored treatment based on those models. Not all patients improve with treatment, but most do. The TOPS can be administered in a variety of ways, but we found paper and pencil administration with computer scanning of results quick and efficient for making the data available to clinicians as part of treatment. Conclusions. The accuracy of the TOPS is sufficient to monitor the response of individual patients during multidisciplinary treatment of chronic pain. The TOPS provides needed documentation (e.g., to third-party payors) of the aggregate value of multidisciplinary outpatient treatment of chronic pain as well as its benefit for individual patients. [ABSTRACT FROM AUTHOR]

More adults aged 65 and older will be driving in the next few decades. Many older drivers are safe behind the wheel and do not need intensive testing for license renewal. Others, however, have physiologic or cognitive impairments that can affect their mobility and driving safety. When an older patient's driving competency is questioned, a comprehensive, step-by-step assessment is recommended. Many diseases that impair driving ability can be detected and treated effectively by family physicians. Physicians should take an active role in assessing and reducing the risk for injury in a motor vehicle and, when possible, prevent or delay driving cessation in their patients. Referral to other health care professionals, such as an occupational or physical therapist, may be helpful for evaluation and treatment. When an older patient is no longer permitted or able to drive, the physician should counsel the patient about using alternative methods of transportation. [ABSTRACT FROM AUTHOR]

Acute pain is a warning that something is wrong. The underlying condition requires treatment, but so does accompanying pain. Adequate pain relief is an essential part of emergency care. [ABSTRACT FROM AUTHOR]

At what point should curative cancer therapy stop and palliative care begin? What constitutes adequate palliation? Here are some up-to-date, authoritative solutions to these thorny questions. [ABSTRACT FROM AUTHOR]