James D. Stoehr

Norovirus Outbreaks Among Colorado River Rafters in the Grand Canyon, Summer 2012

OBJECTIVE To investigate the incidence and causative agent of the recurrent outbreaks of acute gastrointestinal illness (AGI) among different rafting groups on the Colorado River in the Grand Canyon National Park during the 2012 summer season. METHODS Confidential illness reports were completed by all individuals with symptoms of AGI, and samples of fecal matter and vomitus, surface swabs of rafting equipment, and environmental swabs at stops along the hiking corridor were collected and tested for the presence of norovirus using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). RESULTS During the active outbreak period between May 9 and July 9, 2012, 97 rafters (1.4%) from 10 trips (2.9% of all trips) declared AGI symptoms. AGI incidence within the 10 infected trips varied from 6% to 88%. Outbreaks occurred in 3 distinct temporal clusters that involved 2 different genogroups of norovirus. All available toilet fecal samples (5 samples) were positive for norovirus RNA: 1 with genogroup I (GI) and 4 with GII. The vomitus sample tested positive for GI. None of the fomite samples from rafting equipment or from the hiking corridors were confirmed for norovirus. CONCLUSIONS The results suggest that norovirus may have been introduced by ill or asymptomatic individuals actively shedding the virus in their vomitus or feces, and spread within, or between, river trips by different modes of transmission. This study reinforces the importance of appropriate guidance and practice regarding norovirus prevention and the necessity of postoutbreak containment in relatively isolated groups of individuals.

The risk of tramadol abuse and dependence: findings in two patients.

CASE 1 After suffering a seizure, a 38-year-old male who used tramadol frequently was still in denial about his dependence. He experienced brief, intermittent periods of abstinence, then relapsed, and 1 year later had a second seizure. This seizure prompted the man to admit his dependence on tramadol and express a desire to seek treatment. At the peak of his addiction, he was taking 27 tablets (50 mg per tablet) of tramadol daily. The patient began using tramadol for daily headaches approximately 4 years earlier. He used hydrocodone and oxycodone preparations intermittently but preferred tramadol because of the euphoria and increased energy level he experienced after taking that drug. The patient, who was a physician, obtained the medication through drug samples and Internet purchasing. He attempted to stop the medication several times but ran into difficulty when he experienced physical manifestations, such as rebound headache and mood changes. His medical history was significant for the two seizures and untreated depression. He did not use tobacco products or alcohol. His family history was positive for drug use/abuse. He had no history of physical or sexual abuse. Following completion of a 6-week inpatient detoxification and residential treatment program, the patient presented to the addiction medicine physician for follow-up care. The management plan Because the patient was employed as a physician, his management plan included a voluntary 5-year monitoring program that involved monthly office visits with an addictionist, random urine drug screens (approximately two per month), bimonthly group counseling sessions, and documented participation in 12-step meetings. Medical management included trazodone at bedtime for sleep. The patient was encouraged to seek treatment for depression and daily headaches. Outcome The patient is under the care of an internist, neurologist, and addictionists. His daily headaches are well-controlled with modifications to diet, exercise, and asneeded use of sumatriptan and NSAIDs. He has been abstinent for 25 months. He has good family support and involvement in his sobriety, has maintained employment, and is active in the recovery process, which includes 12step participation, frequent interaction with his sponsor, and bibliotherapy.

Is black cohosh a safe and effective substitute for hormone replacement therapy

A50-year-old woman is seeking advice from her primary care PA regarding her progressively worsening hot flashes associated with menopause. The patient reports an average of eight hot flashes per day for the past 7 days; she has difficulty sleeping and is concerned about her loss of interest in sexual activities. She is the mother of two teenagers, so maintaining her emotional stability and energy are important to her. The patient eats a healthy diet, exercises daily, denies tobacco use, and drinks a glass of red wine nightly with dinner. She takes daily vitamins and is more accepting of holistic remedies than prescription medications. She has been researching various herbal products advertised to alleviate the vasomotor symptoms associated with menopause and would like to utilize black cohosh as an alternative to hormone replacement therapy (HRT).

Incorporation of the Competencies for the Physician Assistant Profession into Physician Assistant Education

&NA; The Competencies for the Physician Assistant Profession (Competencies) were developed and disseminated in 2006 by the American Academy of Physician Assistants (AAPA), the Physician Assistant Education Association (PAEA), the Accreditation Review Commission on Education for the Physician Assistant (ARC‐PA), and the National Commission on Certification of Physician Assistants (NCCPA). They are based on the competencies endorsed by the Accreditation Council for Graduate Medical Education (ACGME). This NCCPA Foundation‐funded project describes (1) the integration of the Competencies within PA education, (2) obstacles to incorporating the Competencies, and (3) methods used to assess students based on the Competencies. A survey was developed based on a document developed by ARC‐PA: “Comparison of ARC‐PA Accreditation Standards for Physician Assistant Education, 3rd edition (2006), to the Competencies for the Physician Assistant Profession (2005).” The majority of program respondents (97.1%) reported being familiar with the Competencies and most programs (84.5%) are currently incorporating, or have successfully incorporated, the Competencies into their curricula. The two most frequent obstacles to incorporating the Competencies were reported as limited or lack of time, and difficulty identifying successful methods of assessment. Multiple‐choice testing and the clinical preceptors evaluation of the student were the two most common methods used to assess the Competencies. These baseline data may help identify common obstacles and new challenges faced by PA programs, as well as provide representative organizations with information needed to help PA programs incorporate the Competencies into their curricula.

Does the use of episiotomy protect against postpartum incontinence

A26-year-old woman presents for a routine prenatal visit. She is a primigravida, 34 weeks pregnant, and has been healthy throughout her pregnancy. She has never smoked and stopped social alcohol use before conception. The patient is currently taking prenatal vitamins. She has no known allergies. Her vital signs are within normal limits, and her physical examination findings are all normal. The patient is concerned about shortterm maternal complications associated with delivery, specifically urinary incontinence. In conversations with friends, she learned that some received episiotomies and some did not; all experienced variable impacts on their continence status. The patient is having trouble finding helpful patient education material and would like your guidance on whether an episiotomy would offer protection from urinary incontinence.

Perceptions and Usage of Glucosamine in Osteoarthritis Management

Glucosamine is a pop u lar al ter na tive treat merit for osteo -arthritis. Cur rent be liefs and prac tices among pri mary care med i cal prac-ti tio ners re gard ing the use of oral glucosamine for osteoarthritis (OA) man age ment were in ves ti gated by survey. A ques tion naire mailed to 600 ran domly se lected Ar i zona phy si cians and Phy si cian As sis tants yielded 195 re sponses. Sev enty-nine per cent rec om mended glucosamine to patients with osteoarthritis, and over half of the re spon dents be lieved that glucosamine has an al ge sic ben e fits and/or ac tiv ity against car ti lage deg ra-da tion. Only 16% of prac ti tio ners be lieved that glucosamine has ad verse effects, and 8% had re ceived ad verse re ports from pa tients. Fifty-six percent ofrespondentsfeltthatsufficientempiricalevidenceexiststosupport the use of glucosamine for 0 A. There fore, it ap pears that a con sid er able por tion of pri mary care pro vid ers in Ar i zona per ceive glucosamine as a safe and beneficial treat merit for 0 A.