Outcomes and Issues Addressed by Palliative Care in the Neurology Clinic.

Patients with neurological illnesses have many palliative care needs that need to be addressed in the outpatient clinical setting. This review discusses existing models of care delivery, including services delivered by neurology teams, palliative care specialists, telehealth, and home-based programs. We review the existing literature that supports these services and ongoing limitations that continue to create barriers to necessary clinical care for this vulnerable patient population.

Toward safer opioid prescribing: effects of the TOWER intervention on HIV care providers.

ABSTRACTRates of opioid use disorder and associated deaths remain alarmingly high. Measures to address the epidemic have included reductions in opioid prescribing, in part guided by the Centers for Disease Control Opioid Prescribing Guideline (CDCG). While reductions in over-prescribing have occurred, these measures have also resulted in decreased access and adverse outcomes for some stable opioid-treated chronic pain patients. The TOWard SafER Opioid Prescribing (TOWER) intervention was designed to support HIV primary care providers in use of the CDCG and in decision-making and patient-provider communication regarding safe opioid prescribing. Eleven HIV primary care providers and 40 of their patients were randomized into intervention and control groups. Transcripts from 21 patient visits were analyzed, focusing on opioid and pain-related communications. Findings from this research indicate greater alignment with the CDCG among visits carried out with providers in the TOWER intervention group. However, control group visits were notably consistent with guideline recommendations in several key areas. Differences observed between the intervention and control group visits demonstrate intervention strengths, as well as areas where additional work needs to be done to ensure prescribing and communication consistent with the CDCG.

Baseline Characteristics and Readmissions after Cerebral Venous Sinus Thrombosis in a Nationally Representative Database.

BACKGROUND: There are limited epidemiologic data on cerebral venous sinus thrombosis (CVST). We aim to summarize baseline characteristics and outcomes using a large nationally representative administrative database. METHODS: Using the 2013 Nationwide Readmissions Database, we used validated International Classification of Disease, Ninth Revision codes to identify baseline characteristics of patients admitted with CVST. We calculated readmission rates (per 100,000 index hospitalizations) for neurological complications. Multivariable Poisson regression yielded rate ratios (RR) of associations between index admission variables and all-cause readmission up to 1 year. RESULTS: Among 2,105 patients with index admission for CVST, mean age was 46.8 (SD 18.4); 65.2% were female, and 6.1% were pregnant. Hemorrhagic stroke (15.6%) was more common than ischemic stroke (10.7%), seizure occurred in 16.3, and 3.7% of patients died during index hospitalization. The 90-day readmission rate (per 100,000 index CVST hospitalizations) was the highest for CVST (1,447) and ischemic stroke (755). Diabetes (RR 1.10, 95% CI 1.002-1.22), cancer (1.23, 1.09-1.39), insurance status (0.92, 0.83-0.97 for Medicare/private insurance vs. others), and discharge home (RR 0.89, 95% CI 0.85-0.99) were associated with increased readmission rate. CONCLUSIONS: We provide baseline characteristics and readmission rates after CVST over a 1-year period. In-hospital mortality rate and association with pregnancy were lower than previously observed.

Assessment of Chicken-Egg Membrane as a Dressing for Wound Healing.

OBJECTIVES: To examine the efficacy of the folk remedy of chicken-egg membrane dressing on wound healing. DESIGN: Full-thickness excisional wounds were created on 14 male Sprague-Dawley rats in 2 separate trials. Each animal received 2 wounds on the upper back. One wound was untreated, and the other was dressed with chicken-egg membrane to assess its impact on wound healing. Half of the rats received egg membrane treatment on the inferior wound, whereas the other half received egg membrane treatment on the superior wound. Membrane replacement, wound debridement, and imaging were done on days 5, 8, and 10 and then imaging continued on days 12, 14, 16, 18, and 20 of the experiment. Healing rate was measured based on the wound area over the 20 days of the experiment. RESULTS: The wounds dressed with chicken-egg membrane had a significantly (P < .01) faster rate of healing compared with the control at the early stages of healing between days 0 and 5. This group healed 21% faster during this early phase, compared with the control group. Overall, however, wound healing rates were indistinguishable from days 5 to 20. CONCLUSION: Chicken-egg membrane dressing significantly improves healing of cutaneous wounds in the early stages of wound healing.

The role of the capsaicin 8% patch in the treatment of painful diabetic peripheral neuropathy.

Treatment of painful diabetic peripheral neuropathy (PDPN) is challenging and often limited by drug tolerability and adverse effects. This review article focuses on the high-dose (8%) capsaicin patch that allows for improved efficacy and reduced application frequency in comparison to low-dose capsaicin formulations. Systemic absorption is minimal resulting in fewer systemic side effects than first-line oral medications. There is evidence that capsaicin patch treatment is well-tolerated, safe and provides effective pain relief maintained for several weeks; well-powered studies are needed to confirm these findings. The capsaicin 8% patch may benefit patients at high risk for adverse effects from oral medication, polypharmacy or inadequate pain relief from first-line therapies.

Treatment of nerve pain in the feet and other regions due to nerve damage from diabetes is challenging, often due to the unwanted side effects of medications. This review article focuses on the high-dose (8%) capsaicin patch, which can be applied directly to the feet. It is more potent than the low-dose formulations, allowing patients to apply it less often while also working more effectively compared with low-dose capsaicin creams. Because it acts directly on the skin, there are fewer systemic side effects such as drowsiness or urinary retention. There is evidence that capsaicin patch treatment is safe and provides pain relief for several weeks. More large studies are needed to confirm these findings. The capsaicin 8% patch may benefit patients at high risk for side effects from oral medications or inadequate pain relief from first-line medications.

Paraproteinemias and Peripheral Nerve Disease.

This article provides an overview of the clinical features, diagnosis, and treatment of the major paraprotein-related peripheral neuropathies, including monoclonal gammopathy of undetermined significance, Waldenström macroglobulinemia, POEMS syndrome, multiple myeloma, transthyretin amyloidosis, and light chain amyloidosis. For each paraprotein neuropathy, the epidemiology, demographics, systemic findings, and electrophysiologic features are presented. Pharmacologic treatment of transthyretin amyloid polyneuropathy also is reviewed.