Opioid Use Disorder and Assessment of Patient Interactions Among Family Medicine Residents, Medical Students, and Physician Assistant Students.

Introduction: In light of the opioid overdose epidemic in the US and the necessity of developing training to conduct difficult conversations around opioid dependence, three case-based videos were created to demonstrate providers using motivational interviewing (MI) with patients who have opioid use disorder (OUD). These vignettes displayed a primary care provider interacting with a patient seeking opioids. Methods: Learners-including third-year medical and physician assistant (PA) students, and family medicine residents-viewed three videos set in a family medicine clinic and assessed clinician use of MI when interacting with patients with OUD. The patients were at different levels of acknowledging their need to change their opioid use behaviors and/or pursue treatment. Learners rated each video with an MI rating scale, and a facilitator debriefed strengths, weaknesses, and omissions regarding MI. Results: Medical and PA students, and resident family physicians provided 572 ratings. Analysis of variance of mean percent incorrect was lower in residents than in all groups combined, but failed to reach statistical significance (47% + 12.0 vs 53% + 15.0, p = .43). Discussion: These case-based videos with MI ratings afforded students and residents the opportunity to assess clinician use of MI techniques with patients with OUD. The MI rating scale had clinical significance (residents scored +5 points and had more training) despite lacking statistical significance. These scenarios allowed learners to recognize how to use MI when having a difficult conversation with patients who misuse opioids. We envision individual use or use for group discussion.

Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review.

IntroductionFemoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention.ProblemThe purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects. METHODS: A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK). RESULTS: Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported. Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays. CONCLUSIONS AND RELEVANCE: The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids. HardsM, BrewerA, BessantG, LahiriS. Efficacy of prehospital analgesia with Fascia Iliaca Compartment Block for femoral bone fractures: a systematic review. Prehosp Disaster Med. 2018;33(3):299-307.

Overview of a pharmacist anticoagulation certificate program.

BACKGROUND AND PURPOSE: To describe the design of an ongoing anticoagulation certificate program and annual renewal update for pharmacists. EDUCATIONAL ACTIVITY AND SETTING: Components of the anticoagulation certificate program include home study, pre- and posttest, live sessions, case discussions with evaluation and presentation, an implementation plan, and survey information (program evaluation and use in practice). Clinical reasoning skills were assessed through case work-up and evaluation prior to live presentation. An annual renewal program requires pharmacists to complete home study and case evaluations. FINDINGS: A total of 361 pharmacists completed the anticoagulation certificate program between 2002 and 2015. Most (62%) practiced in ambulatory care and 38% in inpatient care settings (8% in both). In the past four years, 71% were working in or starting anticoagulation clinics in ambulatory and inpatient settings. In their evaluations of the program, an average of 90% of participants agreed or strongly agreed the lecture material was relevant and objectives were met. SUMMARY: Pharmacists are able to apply knowledge and skills in management of anticoagulation. This structured practice-based continuing education program was intended to enhance pharmacy practice and has achieved that goal. The certificate program in anticoagulation was relevant to pharmacists who attended the program.

Continuing warfarin therapy does not increased risk of bleeding for patients undergoing minor dental procedures.

DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, International Association for Dental Research abstracts and reference lists of retrieved articles were searched, and contact made with content experts. STUDY SELECTION: Studies were selected independently by two reviewers. Randomised controlled trials (RCT) were selected if: they compared the effects of continuing a regular dose of warfarin with the effects of discontinuing (or modifying) the dose on the incidence of bleeding; the study group participants were people undergoing dental procedures who also had thromboembolism (arterial or venous); and the outcome assessed was postoperative bleeding (major, clinically significant nonmajor, or minor). Study quality was assessed using the Jadad scale. DATA EXTRACTION AND SYNTHESIS: Data extraction was carried out by three reviewers independently. Meta-analysis was conducted using a random-effects model. RESULTS: Five RCT (553 patients) met the inclusion criteria. Compared with interrupting warfarin therapy (either partial or complete), peri-operative continuation of warfarin at the patient's usual dose was not associated with an increased risk for clinically significant nonmajor bleeding [relative risk (RR), 0.71; 95% confidence interval (CI), 0.39-1.28; P 0.65; I(2) 0%) or an increased risk for minor bleeding (RR, 1.19; 95% CI, 0.90-1.58; P 0.22; I(2) 0%). CONCLUSIONS: Continuing the regular dose of warfarin therapy does not seem to confer an increased risk of bleeding compared with discontinuing or modifying the warfarin dose in people undergoing minor dental procedures.