Clinical Pharmacy Specialist, St. Elizabeth Youngstown Hospital, Youngstown
Clinical Associate Professor of Pharmacy Practice, Northeast Ohio Medical University, Rootstown, Ohio
You have the power not only to advocate for children asthma symptoms dog dander cheap 5mg montelukast amex, but to consolidate the message of their families into a cohesive advocacy voice asthma treatment drug types generic 4 mg montelukast with mastercard. You Have Passion: Advocacy allows you to dig deeper into your interests and touches on why you originally became a health care professional asthma definition american thoracic society montelukast 10mg lowest price. Through advocacy asthmatic bronchitis 101 purchase montelukast 10 mg without a prescription, you can channel your passion for health and well-being into meaningful and lasting change asthma symptoms when sick generic 4mg montelukast mastercard. Advocacy allows you to help improve the lives of children while simultaneously strengthening the role of your profession within the community asthma breathing exercises quality 4 mg montelukast. You Have Well-Suited Skills: Health care professionals already have the skill set of an advocate. The same skills you use every day to establish trust, develop relationships, and develop solutions with your patients can be applied in your community advocacy work. Through advocacy, you can convey both the personal and factual importance of the environmental factors that influence childhood obesity. Advocacy brings about changes to benefit the health of children in your community. Quick Tip Advocacy means speaking on behalf of a group of people within the public sphere around a particular issue. As we move from the center of the grid, to its furthest ring, the opportunities for change move from an individual to a systems and policy focus. The following policy priorities as reported by the Robert Wood Johnson Foundation have been identified as demonstrating the greatest and longest-lasting impact on children and their families:2 1. Ensure that all foods and beverages served and sold in schools meet or exceed the most recent dietary guidelines for Americans. Increase access to high-quality, affordable foods through new or improved grocery stores and healthier corner stores and bodegas. Increase the time, intensity and duration of physical activity during the school day and out-of-school programs. Use pricing strategies - both incentives and disincentives - to promote the purchase of healthier foods. Reduce youth exposure to unhealthy food marketing through regulation, policy and effective industry self-regulation. The table below provides an overview of the types of community advocacy activities physicians and other health care professionals can engage in based on their time availability. It is in the aggregate that we can make significant changes, changes that will make a difference. Activity Vote Call, email or write a letter to a decision-maker addressing your advocacy issue. Contribute to a nonprofit advocacy organization that focuses on your advocacy issue. Patronize businesses that donate a percentage of their profits to health issues related to preventing overweight and obesity in children. Cultivate long-term relationships with a public official or other decision-maker in your community who can impact your advocacy issue. Talk to other health care professionals and parents you come into contact with about the advocacy issue you care about. Attend community forums and events sponsored by decision makers who may have a say on your advocacy issue. Testify before the state legislature or participate in community forums about your advocacy issue. Set up a booth in your professional setting that explains the issue you are working on and provides information and resources for getting involved. Serve as a spokesperson for a local or community-based organization that is also addressing your advocacy issue. Volunteer as a board member of a health organization that is supportive of your advocacy issue. The initiative provides health care professionals with training on community collaboration, nutrition messages, and advocacy techniques to promote healthy eating and active living throughout California. To join the Health Care Professionals for Healthy Communities Initiative, please fill out and submit the subsequent form. Health Care Professionals for Healthy Communities An Initiative of the California Medical Association Foundation 30. There are two kinds of Fact Sheets available: State Factsheets and County Fact Sheets (categorized by state). Whatever your level of time commitment, know that every effort you make is improving the health and well-being of children and families in your local area. Hold a training to get other health care professionals involved in advocating for community change to promote the reversal of childhood obesity. Through training others and building a coalition, your voice to advocate for children can be strengthened. Some have dedicated months and years while others could only spare a few hours; each has changed behavior to break the cycle of childhood obesity by empowering patients to take control of their health. Initiative the Health Care Professionals for Healthy Communities Initiative provides training on community collaboration, nutrition messages, and advocacy techniques to promote healthy eating and active living throughout California. The initiative promotes important policy and environmental changes in schools and neighborhoods to counteract the obesity epidemic and support improved access to healthy food and opportunities to be physically active. This tool provides actionable policy strategies and associated resources to prevent obesity. Specific strategies and resources are presented for implementation at the practice, community, school, state and federal levels. Healthcare providers and their staff will understand the coding procedures related to obesity prevention coding and coding for co-morbidities. Chapter 8 Billing and Coding Obesity Coding Fact Sheet: American Academy of Pediatrics Expert Panel Recommendation Stages Prevention: 1. Revisit yearly the services provided during the Prevention Stage are included in the annual well visit (99381-99385 for new patient, 99391-99395 for established patient). However, if a significant, separately identifiable service is performed, an Office or Other Outpatient Service evaluation and management (E/M) code (99201-99215) is reported in addition to the well visit. Develop plan for balanced macronutrient intake with emphasis on portion size of high energy dense foods 2. Reassess in 3-6 months proceed to step 3 prn this service is performed during a visit separate from the well visit. Health and Behavior Assessment/Intervention 96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Step 1 Prevention Plus: Primary Care Office 1. Revisit weekly, reassess in 6-12 months, if no progress consider step 4 the Medical Team Conference codes (99366-99368) are reported for these services. Medical team conferences include face-to-face participation by a minimum of three qualified health care professionals from different specialties or disciplines, with or without the presence of the patient, family member(s), community agencies, surrogate decision makers. In addition, you will report the Inpatient Hospital Care codes (99221-99223 for initial and 99231-99233 for subsequent). Initial Hospital Care 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: Step 3 Comprehensive Multidisciplinary Intervention, Specialized Program 1. Therefore, coding for obesity services is fundamentally a two-tiered system, where the first tier requires that the health care provider submit claims using appropriate codes and the second tier involves the practice-level issues of denial management and contract negotiation. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320 96150 Health and behavior assessment. Chapter 8: Billing and Coding 119 Medical Nutrition Therapy Codes 4 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (2 or more individual(s)), each 30 minutes Physician Educational Services 99078 Physician educational services rendered to patients in a group setting. The new rule does not apply to "grandfathered" individual health insurance policies. A grandfathered individual health insurance policy is a policy that is purchased by an individual directly from the insurer on or before the rule went into effect on March 23, 2010. Until then, obesity related services may not be covered or considered part of a disease management program, i. Disease management agreements are generally closed to a single or small number of providers in a given area. Nonetheless, physicians may want to investigate the possibility of providing disease management services as a new source of revenue. American Academy of Pediatrics - Prevention of Pediatric Overweight & Obesity: Practice Management Resources. All Rights Reserved 124 Chapter 8: Billing and Coding 125 Chapter 8: Billing and Coding 128 Chapter 8: Billing and Coding Chapter 8: Billing and Coding 131 140 Chapter 8: Billing and Coding End Notes 1. This service would be included in the examination component of the evaluation and management (E/M) code reported. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. For medical nutrition therapy assessment and/or intervention performed by a physician, see Evaluation and Management or Preventive Medicine service codes. Obesity and Related Co-Morbidities Coding Fact Sheet for Primary Care Pediatricians, American Academy of Pediatrics, 2006. This will be a fairly rare occurrence among hospital inpatients, but will be relatively more common among hospital outpatients and patients of family practitioners, health clinics, etc. Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some current illness or injury classifiable to categories 001-999" "In the latter circumstances the V code should be used only as a supplementary code and should not be the one selected for use in primary, single cause tabulations. Examples of these circumstances are a personal history of certain diseases, or a person with an artificial heart valve in situ. Data analysis provided by the Child and Adolescent Health Measurement Initiative, Data Resource Center. The 2007 definition defines 100% of poverty as $20,650 per year for a family of four. Disparity Ratios estimate the magnitude of differences between rates of overweight/obesity for any two groups of children within each state. They are calculated by dividing the rate for the more vulnerable/minority group by the rate for the less vulnerable/majority group. States are ranked by lowest to highest disparity ratios, such that a lower number ranking indicates a lower level of disparity between the groups in that state. Estimates with a relative standard error greater than 30%, or based on an un-weighted sample of fewer than 25 children, are considered unreliable and are not reported. State rankings on disparity ratios include only those states with reliable estimates for both groups. Hispanic here is defined as ethnicity and compares those who self-identify as Hispanic with all individuals who do not self-identify as Hispanic A Self-Love = Healthy-Love! Circle the number beside the question according to how you think and feel about the question. Adolescent is at a pivotal point in their development of positive or negative body image, possibly establishing an unhealthy perception of self-image. Should be immediately referred to services highlighted by assessment self-disclosure. Peer edutainment programs, self-esteem building programs, would be very advisable. Play close attention to the questions answered in the negative to see exactly where the adolescent is expressing concern and give pointed suggestions for proper attention. Care Health Plan Blue Shield of California Molina Healthcare of California Partner Plan, Inc. I display pictures, posters, artwork and other decor that reflect the cultures and ethnic backgrounds of clients served by my program or agency. I ensure that magazines, brochures, and other printed materials in reception areas are of interest to and reflect the different cultures and languages of individuals and families served by my program or agency. When using videos, films or other media resources for health education, treatment or other interventions, I ensure that they reflect the culture and ethnic backgrounds of individuals and families served by my program or agency. I ensure that printed information disseminated by my agency or program takes into account the average literacy levels of individuals and families receiving services. When interacting with individuals and families who have limited English proficiency I always keep in mind that: * limitations in English proficiency are in no way a reflection of their level of intellectual functioning. I use bilingual/bicultural or multilingual/multicultural staff, and/or personnel and volunteers who are skilled or certified in the provision of medical interpretation services during treatment, interventions, meetings or other events for individuals and families who need or prefer this level of assistance. For individuals and families who speak languages or dialects other than English, I attempt to learn and use key words so that I am better able to communicate with them during assessment, treatment or other interventions. I attempt to determine any familial colloquialisms used by individuals or families that may impact on assessment, treatment, health promotion and education or other interventions. I understand that it may be necessary to use alternatives to written communications for some individuals and families, as word of mouth may be a preferred method of receiving information. I understand the principles and practices of linguistic competency and: * apply them within my program or agency. I understand the implications of health literacy within the context of my roles and responsibilities. I use alternative formats and varied approaches to communicate and share information with individuals and/or their family members who experience disability. Goode National Center for Cultural Competence Georgetown University Center for Child & Human Development University Center for Excellence in Developmental Disabilities, Education, Research & Service Adapted Promoting Cultural Competence and Cultural Diversity for Personnel Providing Services and Supports to Children with Special Health Care Needs and their Families June 1989 (Revised 2009).
The epithelial-mesenchymal transition generates cells with properties of stem cells asthma symptoms in children under 2 buy montelukast 5mg fast delivery. Gene expression profiles identify epithelialto-mesenchymal transition and activation of nuclear factor-kappaB signaling as characteristics of a high-risk head and neck squamous cell carcinoma asthma definition 71 generic montelukast 4mg otc. Epigenetic events of disease progression in head and neck squamous cell carcinoma asthmatic bronchitis 8 month order 5mg montelukast visa. Integrating radiotherapy with epidermal growth factor receptor antagonists and other molecular therapeutics for the treatment of head and neck cancer asthma definition racism order montelukast 5 mg without prescription. Differences in expression of oncogenes and tumor suppressor genes in different sites of head and neck squamous cell asthma doctor specialist purchase 10mg montelukast free shipping. Impact of epidermal growth factor receptor expression on survival and pattern of relapse in patients with advanced head and neck carcinoma asthma definition spirometry cheap montelukast 4 mg online. Emerging perspectives in epidermal growth factor receptor targeting in head and neck cancer. Therapies directed against epidermal growth factor receptor in aerodigestive carcinomas. Inverse relationship between epidermal growth factor receptor expression and radiocurability of murine carcinomas. The prognostic value of epidermal growth factor receptor is related to tumor differentiation and the overall treatment time of radiotherapy in squamous cell carcinomas of the head and neck. Epidermal growth factor receptor expression in pretreatment biopsies from head and neck squamous cell carcinoma as a predictive factor for a benefit from accelerated radiation therapy in a randomized controlled trial. The effects of insulin-like growth factors on tumorigenesis and neoplastic growth. The role of insulin-like growth factors and their binding proteins in tumor hypoglycemia. The insulin-like growth factor I receptor protects tumor cells from apoptosis in vivo. Insulin-like growth factor I receptor is required for the mitogenic and transforming activities of the platelet-derived growth factor receptor. Effect of a null mutation of the insulin-like growth factor I receptor gene on growth and transformation of mouse embryo fibroblasts. Insulin-like growth factor-1 and its receptor mediate the autocrine proliferation of human ovarian carcinoma cell lines. Simian virus 40 large tumor antigen is unable to transform mouse embryonic fibroblasts lacking type 1 insulin-like growth factor receptor. Impact of insulin-like growth factor receptor-I function on angiogenesis, growth, and metastasis of colon cancer. Growth factor-induced epidermal invasion of the dermis in human skin organ culture: expression and role of matrix metalloproteinases. Beta1A integrin expression is required for type 1 insulin-like growth factor receptor mitogenic and transforming activities and localization to focal contacts. Increased expression of insulin-like growth factor I is associated with Ara-C resistance in leukemia. Insulin-like growth factor-I receptor signaling in tamoxifen-resistant breast cancer: a supporting role to the epidermal growth factor receptor. Expression and distribution of insulin-like growth factor-1 receptor in human carcinomas. Potential crosstalk between insulin-like growth factor receptor type 1 and epidermal growth factor receptor in progression and metastasis of pancreatic cancer. Insulin-like growth factor receptor I mediates resistance to anti-epidermal growth factor receptor therapy in primary human glioblastoma cells through continued activation of phosphoinositide 3-kinase signaling. Mechanisms of disease: signaling of the insulinlike growth factor 1 receptor pathway-therapeutic perspectives in cancer. Insulin-like growth factor receptor as a therapeutic target in head and neck cancer. Insulin-like growth factor-1 receptor and ligand targeting in head and neck squamous cell carcinoma. Vascular endothelial growth factor family members are differentially regulated by c-erbB signaling in head and neck squamous carcinoma cells. Dissecting the Akt/mammalian target of rapamycin signaling network: emerging results from the head and neck cancer tissue array initiative. Mammalian target of rapamycin, a molecular target in squamous cell carcinomas of the head and neck. Mammalian target of rapamycin inhibitors as possible adjuvant therapy for microscopic residual disease in head and neck squamous cell cancer. The host environment promotes the constitutive activation of nuclear factor-kappaB and proinflammatory cytokine expression during metastatic tumor progression of murine squamous cell carcinoma. Nuclear factor-kappaB is an important modulator of the altered gene expression profile and malignant phenotype in squamous cell carcinoma. Expression of proinflammatory and proangiogenic cytokines in patients with head and neck cancer. Overexpression of phosphorylated nuclear factor-kappa B in tonsillar squamous cell carcinoma and high-grade dysplasia is associated with poor prognosis. Expression of a dominant-negative mutant inhibitor-kappaBalpha of nuclear factor-kappaB in human head and neck squamous cell carcinoma inhibits survival, proinflammatory cytokine expression, and tumor growth in vivo. Inhibition of nuclear factor-kappaB and target genes during combined therapy with proteasome inhibitor bortezomib and reirradiation in patients with recurrent head-and-neck squamous cell carcinoma. Cigarette smoke condensate activates nuclear transcription factor-kappaB through phosphorylation and 1124 Stadler et al 161. Role of activated nuclear factor-kappaB in the pathogenesis and therapy of squamous cell carcinoma of the head and neck. The heat-shock response: regulation and function of heat-shock proteins and molecular chaperones. Drug-mediated targeted disruption of multiple protein activities through functional inhibition of the Hsp90 chaperone complex. Potent activity of a novel dimeric heat shock protein 90 inhibitor against head and neck squamous cell carcinoma in vitro and in vivo. An expression profile for diagnosis of lymph node metastases from primary head and neck squamous cell carcinomas. Molecular predictors of clinical outcome in patients with head and neck squamous cell carcinoma. Molecular classification of head and neck squamous cell carcinomas using patterns of gene expression. The development of drugs to combat these conditions is particularly challenging for several reasons. Knowledge gaps about the causes and clinical progression of a given rare disease make it difficult to determine the best strategy for targeting the condition and compound the inherent complexities of developing medicines. For example, clinical trials are an important part of the drug development process, but a lack of understanding of a disease can make it difficult to design and conduct clinical trials. Furthermore, the small patient populations in rare diseases often make it difficult to recruit a sufficient number of patients to participate in clinical trials and gain statistically significant results. This issue is particularly problematic when trying to address rare diseases that have a significant impact on children given that children comprise an even smaller percentage of the overall population. The Orphan Drug Act, first passed in 1983, has proven instrumental in this progress and continues to provide important incentives for the research and development of innovative new treatments for rare diseases (See sidebar: the Orphan Drug Act). Many of these medicines are transforming the treatment of diseases where few or no treatment options existed previously. A major area of this research targets rare cancers, accounting for more than one-third of all rare disease medicines in development. Other top research areas for rare diseases include genetic disorders, neurological conditions, infectious diseases, and autoimmune disorders. This report seeks to highlight the significant progress made over the past decade in a broad range of disease areas, representing conditions that vary widely in terms of prevalence, availability of treatment options, and patient populations affected. In addition, the report spotlights several rare diseases where major milestones have transformed treatment for patients. The O r phan D r ug Ac t: C r ucial Incen t i ve s for Con t in ued Ad vance s again s t R ar e Disea ses Biopharmaceutical research companies, academic researchers, patient groups, and others are applying the growing understanding of the causes of rare diseases to speed the development of new treatments for patients. The Orphan Drug Act of 1983 has been and continues to be an important force in driving treatment innovation for rare diseases. The Orphan Drug Act created economic incentives to promote the development of new treatments for rare diseases, defined generally as those conditions affecting fewer than 200,000 people in the United States. The incentives include 7 years of market exclusivity, tax incentives for certain R&D costs, and user fee waivers. This abnormality is caused when portions of chromosomes 9 and 22 break off and trade places. Once researchers understood this biological pathway, they were able to develop a targeted treatment to inhibit the tyrosine kinase protein and stop the proliferation of leukemia cells. Imatinib demonstrated that if researchers could understand the biological mechanisms contributing to cancer, then medicines could be specifically designed and targeted to interfere with these mechanisms. Ultimately, this meant that medicines could be targeted to treat cancer without harming healthy cells and thereby minimizing side effects. In cancer, where chemotherapy had been the primary mode of treatment, this was truly game-changing for patients. However, there still remained a need for additional treatment options as imatinib did not work for everyone and in some cases, patients who may have responded initially to the drug developed resistance later on. The decade that followed, however, led to the development of medicines able to challenge genetic mutations and resistance to previous therapies, offering further survival gains for patients. And still other patients, after initially responding to imatinib, developed resistance later on. For these patients there remained a substantial need for additional treatment options. Lymphocytes are white blood cells that play an important role in helping the immune system fight infection. Although chemotherapy is effective for many patients, it can result in a variety of potential side effects, including suppression of the immune system. The drug has been shown to improve endurance, mobility, and overall quality of life for patients with the disease. These advances were primarily based on a greater understanding of the underlying biology of the disease, which enabled researchers to explore new areas beyond chemotherapy, including use of monoclonal antibodies (mAbs), tyrosine kinase inhibitors (like imatinib), and other targeted therapies, as well as other forms of treatment. These new agents are going to raise a lot of interesting questions about potential combinations that in the long run may get us away from the use of cytotoxic chemotherapy entirely. For patients with immune systems unable to tolerate chemotherapy, additional treatment options with fewer side effects were very much needed. This makes it difficult for blood to flow, which increases pressure in the blood vessels and causes the heart to work harder. This eventually weakens the muscles in the heart and, in some cases, may lead to heart failure. Because of these changes, patients have difficulty breathing and maintaining normal activity levels. Oxygen therapy and diuretics provided some 10 A Decade of Innovation in Rare Diseases short-term relief by reducing shortness of breath and fluid build-up. However, these medicines did not fully address the root causes of the condition or extend the lives of patients. For some patients, the route of administration was challenging, had a negative impact on quality of life, and was sometimes associated with potential life-threatening complications such as sepsis and blood clots. The condition is rare, but extremely lifethreatening for the few that inherit the disorder because it often leads to heart attack and death by age 30. In combination with diet and other lipid-lowering treatments, both of these medicines have been found to significantly reduce bad cholesterol levels by as much as 50%. These important advances reduce mortality and improve overall health by allowing patients to better manage their cholesterol levels. Continuing research and development has delivered several new medications, offering patients a variety of safer, more effective, and more convenient treatment options. As a result, blood pressure decreases, making it safer for patients to exercise and resume normal day-to-day activity. Patients were required to limit physical activity to reduce their chances of a heart event. Patients were anxious of experiencing heart events or complications due to the lack of convenient and effective medications. As the condition is very rare, affecting 1 in 10,000 to 50,000 people, it is often underor mis-diagnosed. Most attacks occur spontaneously, meaning there is no trigger, although some may be triggered by factors such as anxiety, stress, dental procedures, or infections. Gastrointestinal edema can cause excruciating abdominal pain, nausea, vomiting, and diarrhea. Because of the limited number of treatment options, severe symptoms, including attacks, frequently led to hospitalizations, creating a significant physical, emotional, and economic burden on patients and their loved ones. Although available treatments do not cure this dangerous disorder, medicines provide important options to patients for reducing the severity of acute attacks. In the lungs, this mucus blocks airways and results in a persistent cycle of inflammation, chronic bacterial infection, severe lung damage, and sometimes respiratory failure. In the pancreas, this mucus obstructs the movement of digestive enzymes that are important for helping the body break down food and absorb nutrients. S po t ligh t: G aucher Disea se Gaucher disease is a genetic disorder that affects organs and tissue throughout the body.
No patient with a diagnosis of depression who was treated only in primary care and who did not receive antidepressant medication died by suicide asm 024 asthma buy cheap montelukast 4mg line. Thus asthmatic bronchitis nursing care plan purchase montelukast 5 mg with mastercard, the rate of suicidality is increased in individuals with prior inpatient treatment asthmatic bronchitis fatigue order 5 mg montelukast visa, although it is not clear whether the rate is higher because the patients have more severe illnesses (and are deemed to be at increased risk for suicide) or because hospitalization increases suicide risk by increasing emotional or psychosocial distress asthmatic bronchitis acute buy generic montelukast 4mg on line. Temporally asthma obesity montelukast 4 mg without a prescription, the risk for suicide appears to be greatest after changes in treatment setting or intensity (304) asthma yawning purchase 10mg montelukast overnight delivery. Rates decline with time since discharge but may remain high for as long as several years (91, 306, 309). For example, Pirkis and Burgess (309) systematically reviewed the literature on suicide and health care contacts and found that up to 41% of those in the general population who die by suicide may have had psychiatric inpatient care in the year before death, with up to 9% dying by suicide within 1 day of discharge. Assessment and Treatment of Patients With Suicidal Behaviors 109 Copyright 2010, American Psychiatric Association. Ninety-nine percent of all premature deaths occurred during the initial 2 years after discharge, with the risk for premature death being greatest among women and the young. Over the initial 2-year period, 29% of deaths were by suicide and suicide occurred at a rate that was more than 50 times the expected rate for the group as a whole. Roy (96) compared 90 psychiatric patients who had attempted suicide (53 male patients and 37 female patients) to a group of 90 matched control subjects who had not attempted suicide. Of the 75 patients who had died by suicide as outpatients, 58% had seen a psychiatrist within the previous week, 81% had been admitted in their last episode of contact, and 44% of those who had been inpatients attempted suicide within 1 month of discharge. Of these, 358 (16%) were psychiatric inpatients at the time of death, and one-fifth of those patients were being monitored with special observation procedures. An additional 519 suicides (24%) occurred within 3 months of hospital discharge, with the highest number occurring in the first week. Rossau and Mortensen (95) found that 508 suicides occurred among 9,156 patients who were admitted to psychiatric hospitals in Denmark between 1970 and 1987 and who received a diagnosis of schizophrenia for the first time. Suicide risk was particularly high during the first 5 days after discharge, and risk was also increased in individuals with multiple admissions during the prior year. Similar findings have been reported for suicide attempts, which are also more frequent in the period following hospitalization. Given that the intensity of past treatment is associated with risk for suicide and suicide attempts, the treatment history is an important part of the assessment process. In addition, these observations suggest specific points in the course of treatment. Awareness of these factors will allow the psychiatrist to take them into consideration in developing a plan of treatment with the patient. Multiple studies have shown that suicidality tends to occur early in the course of affective disorder, often before diagnosis or before treatment has begun (310, 719). These observations emphasize the importance of early identification of these disorders and early implementation of effective interventions. Bradvik and Berglund (317) followed 1,206 inpatients who had received a discharge diagnosis of severe depression/melancholia between 1956 and 1969. At the time of the initial follow-up in 1984, 22% had died by suicide, whereas by the second follow-up in 1998, an additional 4% had died by suicide. Suicide has been noted to be more likely early in the illness course in individuals with schizophrenia. Suicides were present throughout the course of schizophrenia in the National Suicide Prevention Project in Finland (100). In contrast, in individuals with schizophrenia, low levels of negative symptoms have been associated with increased suicide risk (93). It is also important to recognize that other factors such as age modulate the effects of symptom severity on risk. With older adults, for example, milder symptoms may be associated with greater risk than moderate symptoms in younger adults (66). However, those who had attempted suicide reported higher levels of subjective depression and suicidal ideation and fewer reasons for living. That the risk for suicidality may be associated with symptom or illness severity suggests that it is important to determine the magnitude and not simply the presence of risk factors as part of the assessment process. In addition, when estimating risk and implementing a plan of treatment to address risk, variations in risk with illness course may need to be considered in the context of other patient-specific factors. Assessment and Treatment of Patients With Suicidal Behaviors 111 Copyright 2010, American Psychiatric Association. Physical illness Considerable evidence derived from a variety of sources supports a link between physical illness and suicide (Table 7). Methods used to establish this relationship have included record linkage and prospective cohort studies of clinical samples with specific physical illnesses, as well as retrospective examinations of the prevalence of specific physical illnesses in samples of individuals who took their own lives. Harris and Barraclough (25) conducted a comprehensive, systematic literature review and meta-analysis to determine the suicide risk associated with 63 specific physical disorders that had been posited to influence this risk. They did not include reports of epilepsy, conceding that the evidence base was already strong for its association with suicide. Surprising findings included the association of amyotrophic lateral sclerosis, blindness, stroke, diabetes mellitus, rheumatoid arthritis, and hypertension with only average risk that was no greater than that in the general population. Pregnancy and the puerperium were associated with a statistically reduced risk for suicide. Although the authors were unable to examine the influence of mental disorders or other mediating or moderating effects, many of the disorders associated with increased risk are also associated with mental disorders. Therefore, when the influence of comorbid psychiatric illness is accounted for, the independent risk associated with physical illness may be less. Quan and colleagues (337) reported results of a record linkage study conducted in Alberta, Canada, that was designed to establish whether specific illnesses distinguish persons who died by suicide from comparison subjects who died in accidents. In univariate statistical analyses comparing 822 persons age 55 years and older who died by suicide with 944 subjects of similar age who died in motor vehicle accidents, those who died by suicide were more likely to have had malignant neoplasm, arteriosclerotic heart disease, chronic obstructive pulmonary disease, peptic ulcer disease, prostate disorders, depression, and other psychiatric diagnoses. In multivariate analyses in which the effects of demographic and health characteristics were controlled, arteriosclerotic heart disease and peptic ulcer disease did not differentiate the groups. Among the physical illnesses, only malignant neoplasm and prostate disorders (excluding prostate cancer) remained significant predictors, along with chronic obstructive pulmonary disease in married (but not single) men. Grabbe and colleagues (338) used data from the National Mortality Followback Survey to identify health status variables related to suicide in older persons, compared with natural deaths and deaths from injury. In comparing suicides with injury deaths, they found that malignant neoplasm, but not lung conditions, was associated with increased risk. Other studies have also specifically looked for associations between suicide and central nervous system disorders that are known to increase the rates of depressive syndromes. In general, risk for suicide was higher in women than in men and in age groups under age 60 years, compared to older adults. The group at highest risk was women under age 50 with a stroke, who had a risk for suicide almost 14 times greater than that for women of similar age in the general population. These data provide additional support for an association between suicide and cerebrovascular disease, particularly among younger and middle-aged stroke patients. Stenager and Stenager (323) examined all published reports concerning the link between suicide and neurologic disorders in order to critically evaluate the strength of the evidence. They identified a variety of common methodologic problems in this body of research, including sources of bias in selection of cases, inadequate definition of control samples, imprecise definitions of disease, inadequate sample sizes, absent or imprecise definitions of suicidal behavior, and inadequate follow-up intervals. Nonetheless, they concluded that sufficiently rigorous studies of patients with multiple sclerosis, patients with spinal cord injury, and selected groups of patients with epilepsy did establish increased risk in these conditions. The most rigorous studies examining risk associated with epilepsy were conducted by White and colleagues in 1979 (324). They followed 2,099 patients with epilepsy who had been committed for institutional care and treatment and compared their risk for suicide with that in an age- and sex-standardized control population. Among men, the relative risk of dying by suicide was almost six times the expected risk in the general population, and the rates of death from accidents, poisoning, and violence were about three times the expected rates. In a comparison of 26 individuals who died by suicide and 23 individuals suspected of having died by suicide with 171 living control subjects, individuals with an onset of epilepsy before age 18 had a higher risk for suicide than those with comorbid psychiatric diagnoses or those treated with antipsychotics. However, unlike other studies, this study did not find a specific association with particular types of epilepsy, including temporal lobe seizures. Suicide attempts also appear to be increased in frequency among patients with epilepsy, compared to the general population. Rates of depression were similarly increased among the patients with epilepsy (55%, compared with 30% of the control subjects). Brown and colleagues (721) found that 34 of 44 terminally ill patients receiving palliative care had never wished for an early death. All of the 10 patients who had wished for an early death were found to have clinical depressive illness, but only three reported suicidal ideation. Chochinov and colleagues (342) interviewed 200 patients who had terminal cancer to determine their psychiatric status and whether they had thoughts of death. Predictors of desire for death included pain, a low level of family support, and clinically significant depression. Diagnosable depressive illness was found in almost 60% of those with a desire to die and in 8% of those without a desire to die. Assessment and Treatment of Patients With Suicidal Behaviors 113 Copyright 2010, American Psychiatric Association. Other features of physical illness that may augment the likelihood of suicidal ideation or suicide include functional impairments (338), pain (340, 341), disfigurement, increased dependence on others, and decreases in sight and hearing (321, 333). In addition to neurological disorders and malignant disease, which were associated with three- to fourfold increases in suicide risk, visual impairment and serious physical illness of any type were also associated with increased risk, with odds ratios of 7. Although the number of women in the sample was small, the risk appeared to be greater among men, particularly in those with a high burden of physical illness. They compared 196 patients age 60 years and older from a group practice of general internal medicine (N=115) or family medicine (N=81) to 42 individuals age 60 years and older who had visited a primary care provider and who died by suicide within 30 days of their visit. Those who died by suicide were significantly more likely than control subjects to have had a depressive illness, greater functional impairment, or a larger burden of physical illness. Although the evidence is less compelling, indications are that a range of other conditions may also be associated with suicide and suicidal behaviors. However, further study is needed to determine the role of social and psychological factors as mediators or moderators of the relationship between physical illness and suicide. As a result, in assessing suicide risk among individuals with physical illness, consideration should be given to the presence of comorbid mood symptoms as well as to the functional effects of the illness. Family history Findings from at least three types of studies suggests that risk for suicide has a familial and probably genetic contribution. These familial associations appear to be accounted for only partly by familial risks for major affective illness or other clinical risk factors for suicide. The pooled overall relative risk of suicidal behavior in first-degree relatives of suicidal probands compared to control or population risks, weighted by the number of subjects in each study, was 4. Across studies, reported estimates of relative risk for suicidal behavior within families vary greatly, depending in part on the types of behavior included (suicide, suicide attempts of varying lethality, or both) and their defining criteria, the prevalence of psychiatric risk factors for suicide among the control subjects, the closeness of kinship (first-degree relatives, including parents and siblings, with or without second-degree relatives), and differences in sample size. Such studies, while demonstrating a powerful association, do not prove genetic risk nor rule out shared environmental factors. Moreover, it remains to be proved that the relationship for suicide is separable from the well-known heritability of leading risk factors for suicide, including major affective illness. Nevertheless, the findings from pooled family studies strongly support the conclusion that overall risk for suicidal behavior is at least four times greater among close relatives of suicidal persons than among unrelated persons. Risks for dizygotic twins should be similar to those found among other first-degree family members in family studies. None of the studies involved samples of twins raised separately from early life, and, thus, the confounding effects of shared environments were possible. Moreover, the size and statistical power of these studies varied markedly, from an analysis of a single monozygotic twin-pair (373) to a study of an entire Australian national twin registry involving more than 1,500 monozygotic and nearly 1,200 dizygotic twin-pairs (375). When the data from all seven twin studies were pooled, the overall concordance rate for suicide or suicide attempts, weighted for the numbers of subjects involved, was 23. Given the low frequency of suicidal behavior found among fraternal co-twins, this relative risk is likely to be a quantitatively unstable estimate. Nevertheless, its magnitude strongly supports a genetic contribution to suicidal behavior. A highly significant fourfold excess of risk in identical twins remained, even after statistical corrections for depressive and other psychiatric morbidity associated with suicide (375). Therefore, twin studies add Assessment and Treatment of Patients With Suicidal Behaviors 115 Copyright 2010, American Psychiatric Association. When data for suicide were pooled across all studies, to include affectively as well as psychotically ill probands (376, 378), there was an approximately fivefold greater risk among biological than among adoptive relatives (20 of 543 subjects [3. Later, the same American and Danish collaborators (378) compared all adoptees identified as having an affective spectrum disorder (N=71) with matched control adoptees without such disorders (N=71). In relatives of affectively ill adopted probands, there was a significant, approximately sevenfold greater risk for suicide in biological relatives, compared with adopted relatives (15 of 387 subjects [3. Further analysis of the suicide rate for biological relatives, compared with control subjects, also yielded a highly significant 13. In striking contrast, however, when suicide attempts were considered separately, there was a 1. A similar comparison of the rate of suicide attempts in biological relatives of adopted probands and in matched but not affectively ill control subjects showed a modest 2. Among relatives of index adoptees with a diagnosis of schizophrenia, there was a nonsignificant 2. Matched comparison of 57 early-adopted individuals who died by suicide with other adoptees lacking evidence of suicide or psychiatric illnesses also showed a great excess risk of suicide in biological over adoptive relatives (12 of 269 subjects [4.
Accordingly asthma definition symptoms treatment montelukast 5mg generic, Review Committees are now meeting and reviewing annual accreditation data based on these requirements asthma worse at night buy 10 mg montelukast with visa, and will be issuing citations where violations of the 80-hour limit are identified asthma definition and implications for treatment buy generic montelukast 4mg on-line. David Ouyang and his colleagues conducted a retrospective cohort study to determine whether housestaff working more than 80 hours per week had an impact on patient care in an inpatient general medicine service asthma treatment mechanism discount montelukast 10mg with visa. Of the 4 asthmatic bronchitis 20 buy cheap montelukast 5mg on line,767 hospitalizations reviewed asthma treatment for babies order 4 mg montelukast with visa, 41 percent were cared for by housestaff who worked more than 80 hours per week. There was no association between hours worked with in-hospital mortality or 30-day readmission rates. It is interesting to note that the interns in the flexible hours programs were less satisfied with their educational experience (includes educational quality and overall wellbeing), but their program directors were more satisfied with overall educational quality, including having time for bedside teaching. Mandatory Time Free of Clinical Work and Education Background and Intent: While it is expected that resident schedules will be structured to ensure that residents are provided with a minimum of eight hours off between scheduled work periods, it is recognized that residents may choose to remain beyond their scheduled time, or return to the clinical site during this time-off period, to care for a patient. This must occur within the context of the 80hour and the one-day-off-in-seven requirements. The Background and Intent section related to this requirement underwent extensive discussion by the Common Program Requirements Task Force. There were often conflicting impacts of this requirement on patient safety, clinical care, and continuity of care by resident teams, and resident learning found in the literature. Finally, the Task Force heard a uniform request by the specialty societies, certifying boards, membership societies and organizations, and senior residents to repeal this requirement. The graduate medical education community uniformly requested that the Task Force remove this requirement. The Task Force examined the impact of the request to consider 16-consecutive-hour limits for all residents, and rejected the proposition. It found that model incompatible with the actual practice of medicine and surgery in many specialties, excessively limiting in configuration of clinical services in many disciplines, and potentially disruptive of the inculcation of responsibility and professional commitment to altruism and placing the needs of patients above those of the physician. Clinical and Educational Work Hour Exceptions these exceptions are intended to provide residents with some control over their schedules by providing the flexibility to voluntarily remain beyond the scheduled responsibilities under the circumstances described above. The provision for exceptions for up to 88 hours per week has been modified to specify that exceptions may be granted for specific rotations if the program can justify the increase based on criteria specified by the Review Committee. The underlying philosophy for this requirement is that while it is expected that all residents should be able to train within an 80-hour work week, it is recognized that some programs may include rotations with alternate structures based on the nature of the specialty. One of the most common misconceptions regarding this requirement is that residents and fellows are required to record every single minute they are spending on home call answering phone calls, and providing documentation. However, program directors must ensure that time spent on home call is reasonable. A Literature Review on Topics Related to Diversity and Inclusion Table of Contents Systematic Reviews. The bibliography seeks to offer a broad view across different segments of individuals in medical education and medicine or are viewed, or who view themselves, as minorities. This includes racial and ethnic minorities, sex/gender minorities, and women in some contexts. The organization of the bibliography is intended to highlight the different dimensions of this sizable body of literature. Sections are arrayed in reverse chronological order, with the newest articles first, to show the historical evolution of these topics. The bibliography opens with a section on meta-analyses, and systematic and narrative reviews on all topics in the remainder of the compilation. Bolding of selected text in the abstracts was added by the curator to emphasize important findings. For the sections on affirmative action, representation of minority individuals in medical education, the experience of the minority physicians in the medical environment, and efforts to promote diversity and inclusion in medical education and in teaching settings, the bibliography is comprehensive and encompasses all published original research, policy discussions, and descriptions of programs. Whites comprise greater proportions of medical students, residents, and faculty than African Americans and Latino Americans, respectively. African American males are particularly underrepresented in medicine, when compared to African American females and other minority groups. In addressing this disparity in education, a challenge is the medical education "pipeline," with minority individuals, particularly African American men accounting for a disproportionately smaller percentage of individuals enrolled in and completing postsecondary education. In addition, minorities have higher attrition rates in all phases of medical education, with attrition rates of 5 to 6. As a consequence, minority representation in some areas in medicine is unchanged of the past four decades. Studies of barriers to pursuit of a medical career by women and underrepresented minorities have found that aspects of the basic science curriculum, particularly chemistry, are perceived barriers for this population. Another barrier at all levels of medical education is the lack of race- and/or gender-congruent mentors and role models. Minority learners and residents also are at higher risk for adverse academic status events, as well as adverse life events that may affect their education. Another common theme in the literature includes the generally lower standardized test scores and general academic achievement for minority learners. Experience of Women and Minority Learners and Faculty Regardless of the type of minority status, including racial/ethnic and sex/gender, members of minorities report "microaggressions" (low-level, covert acts of aggression), "microinsults," and "microinvalidations. Recent studies still who a considerable degree of gender identity concealment for sexual and gender minority students and residents. Although women now make up a sizable proportion of medical students, female students learn how to confront and respond to inappropriate behavior from male patients. However, these students do not feel equipped to respond to the unprofessional behavior of male supervisors, resulting in feelings of guilt and resignation over time that such events would be a part of their professional identity. While women currently make up one-half of medical school graduates, women, along with individuals of color, continue to be underrepresented in leadership positions, with one consequence a lack of leadership role models for women and minority individuals. When women and minority faculty are given leadership positions, these frequently are "minorityfocused," "nurturing" or "advocacy" roles Studies overall have found a lower prevalence of burn out and depressive symptoms in minority students, although minority students are more likely to report that a race-related incident adversely affected their medical school experience, and to cite this as a cause for burn out and low-quality of life. In some studies, minority medical students report a lower sense of personal accomplishment. Minority Physician Contributions to Addressing Health Disparities A constant argument for diversity and inclusion is that healthcare workforce diversity enhances access for minority patients and populations, and that cultural competence is importance to allowing physicians to provide culturally sensitive and appropriate care to all patients, regardless of their minority status. The literature consistently showed a greater contribution by minority physicians to the care of minority patients, and across race and ethnicity, to the care of patients facing challenges with access to care. An interesting sub-theme is whether it is ethical to expect this contribution to the care of underserved patients of this group of physicians. Bias in the Learning and Working Environment There is significant implicit and some explicit bias in the learning environment, which is expressed in implicit white-favoring bias on objectives tests; bias in assessment of women and minority learners; and norming of male stereotypes in the "ideal" learner in some specialties such as emergency medicine. There also is an overrepresentation of minorities in clinical questions in standardized tests to assess medical knowledge, with minority status used as a proxy for genetics, social class or life style factors, which contributes to bias in learners taking these tests. Finally, research shows both attentional blindness to minority members, and implicit bias in children and adults regarding minority individuals perceptions of pain, which extends to health professionals. Articles were reviewed and selected per study eligibility criteria and summarized to answer study research questions. Eight (50%) programs reported longitudinal training; seven (44%) reported block experiences, while one (6. Four (25%) programs required residents to develop and complete a research project, and six (37. Programs vary in curricular elements, using a wide variety of training aims, learner competencies, learning activities, and evaluation methods. This review highlights the need for published reports of educational programs aimed at training residents in health disparities and underserved medicine to include the evidence for effectiveness of various training models. While much has been written, there has not been a systematic review published on this topic. The same criteria were applied to extract evidence-based observations of problems in recruitment and retention for minority faculty. Faculty development programs in 15 different institutions showed mentoring and faculty development for minority faculty could increase retention, academic productivity, and promotion rates for this group. Overall evidence is strong that faculty development programs and mentoring programs increase retention, productivity, and promotion for this group of medical faculty. This paper is a call to action for more faculty development and mentorship programs to reduce the disparities that exist between minority faculty and all other faculty members. Mentoring programs for underrepresented minority faculty in academic medical centers: a systematic review of the literature. Abstract reviews led to retrieval of 38 full-text articles for assessment; 18 articles describing 13 programs were selected for review. Most evaluated programs on the basis of the number of grant applications and manuscripts produced or satisfaction with program content. Programs offered a variety of training experiences, and adoption was relatively high, with minor changes made for implementing the intended content. Program sustainability was a concern because programs were supported through external funds, with minimal institutional support. Despite this need, relatively few publications exist to document mentoring programs for this population. Perceptions Revisited: Pediatric Chief Resident views on Minority Housestaff Recruitment and Retention in Pediatric Residency Programs. Sixty-seven percent stated that their resident selection committees do not have defined recruitment goals, 6% indicated that their committees have specifically defined recruitment goals, and 27% were not sure. As individuals involved with both medical training and hospital hierarchy, they are uniquely positioned to influence and carry out program goals and objectives. Disparities in access to care persist despite efforts to improve care for underserved patients: racial and ethnic minorities, the uninsured, the poor, Medicaid recipients, and non-English speakers. A shortage of physicians practicing in communities where disadvantaged patients live is a major contributor. While the Patient Protection and Affordable Care Act will expand insurance coverage for lowincome, uninsured individuals, concern remains about the supply of physicians to care for these newly insured populations. If nonwhite physicians care for a large proportion of the underserved, then increasing the racial and ethnic diversity of the physician workforce may help. Given the demographic changes and impending implementation of the Patient Protection and Affordable Care Act, this question has renewed relevance. Dimensions of Diversity and Perception of Having Learned From Individuals From Different Backgrounds: the Particular Importance of Racial Diversity. The authors thus investigate whether, among medical students, the association between racial diversity (as distinct from other forms of diversity) and learning from individuals from different backgrounds is unique. They modeled the association between each of the school-level dimensions of diversity and the student-level responses to having learned from others with different backgrounds, and they assessed whether associations vary across different groups of students. The association between racial/ethnic diversity and student perceptions of having learned from others who are different is especially strong for members of historically underrepresented minority groups. This association is of particular relevance to admissions and diversity policies in an era of strict scrutiny of these policies. Some authors credit the "minority tax"-the burden of extra responsibilities placed on minority faculty in the name of diversity. This tax is in reality very complex, and a major source of inequity in academic medicine. This disparity is evident in many areas: diversity efforts, racism, isolation, mentorship, clinical responsibilities, and promotion. However, owing to their foreign citizenship, these students have visa requirements for post-graduate training that may adversely impact their candidacy for residency placement. They focus on students pursuing surgical specialties and ask whether diversity concerns are more prominent among applicants to surgical programs than among applicants to nonsurgical programs. Nineteen residency programs, amounting to 1,657 residency interviewees, participated. However, perceived program diversity is an important factor that positively influences the program ranking decision for women and minorities pursuing surgical training. Promoting women and minorities within programs and connecting women and minority applicants to outreach programs and mentors is pertinent to the recruitment of these traditionally under-represented groups to surgical programs. Understanding of the factors that protect against burnout is needed to guide student wellness programs. The surveys included standardized instruments to evaluate burnout, quality of life, fatigue and stress. Additional items explored social support, learning climate, life events, employment status and demographics. Similarly, the differences between those who recovered and those who were chronically burned out were also compared in students with burnout at the first time-point. Logistic regression modelling was employed to evaluate associations between the independent variables and resiliency to and recovery from burnout. No differences in demographic characteristics were observed between resilient (290/792 [36. Resilient students were less likely to experience depression, had a higher quality of life, were less likely to be employed, had experienced fewer stressful life events, reported higher levels of social support, perceived their learning climate more positively and experienced less stress and fatigue (all p < 0. On multivariable analysis, perceiving student education as a priority for faculty staff, experiencing less stress, not being employed and being a minority were factors independently associated with recovery from burnout. Students were also asked about the impact of race/ethnicity on their training experience. Prevalence of depressive symptoms was similar regardless of minority status, but more nonminority students had burnout (39% vs 33%; P <. Minority students were more likely to report that their race/ethnicity had adversely affected their medical school experience (11% vs 2%; P <. While minorities appear to be at lower risk for burnout than nonminority students, race does contribute to the distress minority students do experience. Additional studies are needed to define the causes of these perceptions and to improve the learning climate for all students.
