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In the U.S. in 2015, the proportion of people dependent on opioids approached one percent, and opioid overdose rivaled auto accidents as the leading cause of accidental death. The literature suggests a credible link between increased opioid prescribing and increased opioid addiction. Accordingly, some have suggested that limiting the number of opioid prescriptions (and the number of doses per prescription) might be effective in reducing the number of opioid-related deaths. Toward this end, we designed and piloted an evidence-based quality-improvement project in four urgent care clinics. Results of the intervention were monitored with data from a state-sponsored prescription drug-monitoring program (PDMP) by comparing opioid prescribing before and after adoption of the guideline, and in this manner, a statistically significant (P < 0.05) decline in the rate of opioid prescribing was revealed. On average, 2.43 fewer opioid prescriptions were written, per provider, per week, in weeks five through eight after promulgation (5.21, SD =4.37) than in the eight weeks before promulgation (7.64, SD =7.73). Our results suggest that implementing a simple opioid-prescribing guideline, with monitoring, can reduce sub-optimal opioid prescribing, and therefore the volume of opioids available in the community for diversion, abuse, and addiction.

[Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

During an investigation of a novel interstitial lung disease in a cohort of nylon flock workers, a former worker was found to have developed bilateral synchronous pulmonary adenocarcinomas three decades after he quit smoking, suggesting that exposures in this industry might pose excessive risk of lung cancer. We conducted a retrospective cohort study of lung cancer incidence in the original study cohort (n=162) from August 15, 1998, to August 14, 2008. The Rhode Island Cancer Registry identified cohort members with lung cancer and provided age-gender-era-specific rates of lung cancer in Rhode Island. Five cases of lung cancer occurred among cohort members versus 1.61 cases expected for a standardized incidence ratio of 3.1 (95% CI, 1.01-7.23). The observed threefold increase in lung cancer incidence could not be readily ascribed to chance, study bias, or uncontrolled confounding. Workers in this industry should be notified of their potentially increased risk of lung cancer.

Study Objectives: Idiopathic diaphragm paralysis is probably more common and responsible for more morbidity than generally appreciated. Bell's palsy, or idiopathic paralysis of the seventh cranial nerve, may be seen as an analogous condition. The roles of zoster sine herpete and herpes simplex have increasingly been recognized in Bell's palsy, and there are some data to suggest that antiviral therapy is a useful adjunct to steroid therapy. Thus, we postulated that antiviral therapy might have a positive impact on the course of acute idiopathic diaphragm paralysis which is likely related to viral infection., Methods: Three consecutive patients with subacute onset of symptomatic idiopathic hemidiaphragm paralysis were empirically treated with valacyclovir, 1,000 mg twice daily for 1 week. Prior to therapy, diaphragmatic function was assessed via pulmonary function testing and two-dimensional B-mode ultrasound, with testing repeated 1 month later. Diaphragmatic function pre- and post-treatment was compared to that of a historical control group of 16 untreated patients., Results: All three subjects demonstrated ultrasound recovery of diaphragm function 4-6 weeks following treatment with valacyclovir. This recovery was accompanied by improvements in maximum inspiratory pressure (PI(max)) and vital capacity (VC). In contrast, in the untreated cohort, diaphragm recovery occurred in only 11 subjects, taking an average of 14.9 +/- 6.1 months (mean +/- SD)., Conclusions: The results of this small, preliminary study suggest that antiviral therapy with valacyclovir may be helpful in the treatment of idiopathic diaphragm paralysis induced by a viral infection.

Metformin, an antihyperglycemic, is widely used in the treatment of type 2 diabetes mellitus (DM). A rare, but important complication associated with this drug is the development of lactic acidosis: Overall mortality of lactic acidosis is approximately 50%. Certain subsets of patients taking metformin are at greater risk of developing lactic acidosis. This report discusses the development of metformin-associated lactic acidosis in four older adults admitted to an institution during a 2-month period, treatments, and outcomes. We recommend an aggressive treatment strategy of hemodialysis followed by peritoneal dialysis, continuous bicarbonate infusion, and tight glucose control. We review the cautions and contraindications of metformin use for the treatment of type 2 DM and report an educational plan for residents and staff instituted to improve drug complication awareness and reduce mortality.

Sexual misconduct with a patient violates the physician-patient relationship. Such behavior maybe an isolated event in the professional life of a physician, but more frequently is part of a pattern of predatory behavior. Such behavior on the part of any physician adversely affects all physicians and the public welfare.

Patients undergoing podiatric surgery should receive a thorough perioperative evaluation. Medical "clearance" is no longer sufficient; rather, formal risk assessment should be performed and risk-reducing strategies provided. A collaborative, multidisciplinary approach involving practitioners in internal medicine, anesthesiology, and podiatry is generally most appropriate. Unfortunately, expertise and training in this critical dimension of clinical practice are variable. Thus podiatric physicians should develop independent competence in perioperative evaluation in order to ensure optimal care for their patients. A general systematic approach is described that can be readily incorporated into clinical practice.

Renal failure is defined as a deterioration of kidney function that results in the retention of nitrogenous waste products. It is increasingly prevalent in older populations, individuals with diabetes or hypertension, and postoperative patients. Therefore, podiatric physicians caring for these populations can expect to encounter this condition frequently. This article describes the epidemiology, causes, complications, and appropriate evaluation of renal failure relevant to a practicing podiatric physician. Also highlighted are treatment considerations, renal dosing of medications, and prevention of contrast nephropathy.

Congress passed the Patient Self-Determination Act of 1990 to ensure that patients are informed of their rights to express healthcare preferences in advance of loss of capacity. Thus, a patient may elect to forgo cardiopulmonary resuscitation in favor of a treatment approach that favors comfort over survival. Do-not-resuscitate and stratification-of-care forms provide a means for expression of healthcare preferences in hospitals. These forms can often guide the important discussion of healthcare preferences. Unfortunately, no clear standard exists for what should be included in do-not-resuscitate or stratification-of-care forms that institutions seeking to improve in this vital area of practice could use for guidance. Existing forms in use at adult general hospitals throughout Rhode Island were reviewed.

Purpose: To characterize the thin-section computed tomographic (CT) features of flock worker's lung (FWL) and to determine whether these features may be used to distinguish workers with FWL from flock workers who do not fulfill diagnostic criteria for FWL., Materials and Methods: Thin-section CT images obtained in 43 flock workers (including 11 with FWL) were reviewed independently by radiologists blinded to occupational and clinical details. CT features recorded included ground-glass opacities, consolidation, micronodules, reticular abnormality, and septal thickening. Thirty-five of the CT scans (including nine obtained in patients with FWL) were also studied by using quantitative image analysis. The Student t test was used to compare mean lung attenuation between the workers with FWL and those without it., Results: Every patient with FWL and 19 (59%) of the 32 exposed flock workers who did not meet criteria for the disease had an abnormal thin-section CT scan. The most common findings in FWL were ground-glass opacities and micronodules. Quantitative analysis showed a mean lung attenuation of -736.4 HU in patients with FWL, compared with -775.0 HU in workers without the disease (P <.05)., Conclusion: While ground-glass opacities, micronodules, or both were found in all cases of FWL, these abnormalities were also present in a substantial proportion of symptomatic flock workers who did not satisfy current criteria for FWL. Although nonspecific, these findings should suggest the diagnosis of FWL in exposed individuals.

Here we report the case of a patient who presented with acute cardiac tamponade due to drug-induced systemic lupus erythematosus (SLE). The patient had been treated for a seizure disorder with carbamazepine, a drug that has previously been demonstrated to cause SLE-like syndromes. Further serologic analysis demonstrated the likelihood of drug-induced SLE in this patient, with the rare presentation of cardiac tamponade.

Laparoscopic surgical techniques are increasingly being applied to treat intraperitoneal abnormalities. These minimally invasive techniques potentially offer decreased operation time, decreased morbidity, and decreased length of hospitalization stays. These procedures, however are not without potential morbidity. Herein we describe two patients treated with laparoseopic cholecystectomy whose cases were complicated with subcutaneous emphysema and hyperearbia without pneumothorax. In each of these cases, carbon dioxide gas was used to induce pneumoperitoneum. In one of the cases, the hypercarbia was a late event occurring during the surgery, and in the second case, the first such description in the literature (to our knowledge), hypercarbia developed after termination of the induced pneumoperitoneum.

Background: Two young men working at a nylon flocking plant in Rhode Island developed interstitial lung disease of unknown cause. Similar clusters at the same company's Canadian plant were reported previously., Objective: To define the extent, clinicopathologic features, and potential causes of the apparent disease outbreak., Design: Case-finding survey and retrospective cohort study., Setting: Academic occupational medicine program., Patients: All workers employed at the Rhode Island plant on or after 15 June 1990., Measurements: Symptomatic employees had chest radiography, pulmonary function tests, high-resolution computed tomography, and serologic testing. Those with unexplained radiographic or pulmonary function abnormalities underwent bronchoalveolar lavage, lung biopsy, or both. The case definition of "flock worker's lung" required histologic evidence of interstitial lung disease (or lavage evidence of lung inflammation) not explained by another condition., Results: Eight cases of flock worker's lung were identified at the Rhode Island plant. Three cases were characterized by a high proportion of eosinophils (25% to 40%) in lavage fluid. Six of the seven patients who had biopsy had histologic findings of nonspecific interstitial pneumonia, and the seventh had bronchiolitis obliterans organizing pneumonia. All seven of these patients had peribronchovascular interstitial lymphoid nodules, usually with germinal centers, and most had lymphocytic bronchiolitis and interstitial fibrosis. All improved after leaving work. Review of the Canadian tissue specimens showed many similar histologic findings. Among the 165-member study cohort, a 48-fold or greater increase was seen in the sex-adjusted incidence rate of all interstitial lung disease., Conclusions: Work in the nylon flocking industry poses substantial risk for a previously unrecognized occupational interstitial lung disease. Nylon fiber is the suspected cause of this condition.