Rollin M. Gallagher

Health Professional's Guide to Rehabilitation of the Patient with Osteoporosis

This guide is a summary reference on the rehabilitation principles that should be applied in the treatment and prevention of osteoporosis. As this guide addresses primarily rehabilitation issues required by osteoporotic fracture or low bone mass, the health professional is directed to the National Osteoporosis Foundation’s companion piece, Physician’s Guide to Prevention and Treatment of Osteoporosis (‘Physician’s Guide’), for other treatment approaches. Rehabilitation and exercise are often viewed as a means to improve function, such as activities of daily living (ADL) for patients. Psychosocial factors also impact strongly on functional ability and the general health of the osteoporotic patient. The information in this guide is based on scientific evidence from basic research, consensus from an expert panel convened by the National Osteoporosis Foundation (NOF), clinical studies, and randomized controlled clinical trials. The small number of randomized trials points to the need for more of them in the future. The majority of the studies on rehabilitation approaches and exercise recommendations related to osteoporosis are based on studies among white perimenopausal women. Clearly, osteoporosis affects men and non-white women as well. It can also affect younger as well as older individuals with certain chronic conditions and medication use. Until we have additional data, recommendations for these other populations should be on an individual basis. The committee believes that the guidelines have universal application in terms of recommending life-long, safe activities and exercises for all people. This guide’s recommendations are not intended as rigid standards of practice, but must be tailored for use by physicians in consultation with their patients. Executive Summary

Recommendations for a New Curriculum in Pain Medicine for Medical Students: Toward a Career Distinguished by Competence and Compassion

OBJECTIVEnThe education of physicians is a fundamental obligation within medicine that must remain closely aligned with clinical care. And although medical education in pain care is essential, the current state of medical education does not meet the needs of physicians, patients, or society. To address this, we convened a committee of pain specialist medical student educators.nnnMETHODSnTasked with creating systematically developed and valid recommendations for clinical education, we conducted a survey of pain medicine leadership within the American Academy of Pain Medicine (AAPM). The survey was conducted in two waves. We asked AAPM board members to rate 194 previously published pain medicine learning objectives for medical students; 79% of those eligible for participation responded.nnnRESULTSnThe Top 5 list included the awareness of acute and chronic pain, skillfulness in clinical appraisal, promotion of compassionate practices, displaying empathy toward the patient, and knowledge of terms and definitions for substance abuse. The Top 10 list included the major pharmacological classes as well as skills in examination, communication, prescribing, and interviewing. The Top 20 list included the pain care of cognitively impaired populations, those with comorbid illness, and older adults. With the survey results in consideration, the committee produced a new recommended topic list for curricula in pain medicine. We strongly recommend that adequate resources are devoted to fully integrated medical curricula in pain so that students will learn not only the necessary clinical knowledge but also be prepared to address the professional, personal, and ethical challenges that arise in caring for those with pain.nnnCONCLUSIONSnWe conclude that improved medical education in pain is essential to prepare providers who manifest both competence and compassion toward their patients.

Toward evidence-based prescribing at end of life: A comparative review of temazepam and zolpidem for the treatment of insomnia

A comparative review of temazepam and zolpidem use in managing insomnia in the hospice patient was undertaken to determine whether treatment with temazepam is a more cost-effective approach for this patient population. A MEDLINE search was conducted to identify pertinent literature, including clinical trials and reviews that involved temazepam or zolpidem. Published data was used as background information and provided in the discussion. This retrospective analysis, conducted from June 2002 through November 2002, focused on the prescribing patterns of temazepam and zolpidem in our hospice practice setting. We examined the reasons for discontinuation of each agent, along with the frequency of therapeutic change from temazepam to zolpidem. The top 10 ICD-9 codes associated with each treatment modality were investigated to determine any prescribing patterns. A total of 4,752 participants were prescribed either temazepam or zolpidem during this six-month period. Of the 4,065 patients prescribed temazepam 9.9 percent had the agent discontinued, whereas, 13.0 percent of those taking zolpidem (n = 687) terminated therapy. Reasons for discontinuation included change in dose, incomplete efficacy, change in patient status, adverse drug reaction, cultural/social issues and “other.” Analyses of prescribing patterns and the reasons for termination of each drug therapy were completed and compared with results found in the primary literature. Due to the limited financial resources available for hospice care, our goal is to provide the most clinically appropriate and cost-effective agents for hospice patients. With the lack of data pertaining to the hospice patient, physicians often are faced with challenges in deciding the most appropriate therapy. They may prefer one agent over another based on current medical opinion rather than sound clinical evidence. After review of the primary literature and the prescribing patterns in our setting, there is currently no evidence in our patient population to support that zolpidem is superior to benzodiazepines for the treatment of insomnia.