Successful interventions in decreasing oxycodone CR prescriptions within an underserved population.

OBJECTIVE: To use fundamental population health and Patient Centered Medical Home guidelines to create an effective intervention that would decrease the quantity of inappropriate oxycodone controlled release (CR) prescriptions within an uninsured population. DESIGN: This was a prospective interventional study. PATIENTS, PARTICIPANTS: Patients seen in the newly formed University of Florida Community Health and Family Medicine Department Total Care Clinic, for chronic nonmalignant pain. This clinic was designed to serve the uninsured patients of Jacksonville, FL. INTERVENTIONS: A structured, step-wise pain management protocol was introduced and implemented, and an improved Controlled Substance User Agreement was created and implemented. Pharmacists and primary care providers collaborated on care. MAIN OUTCOME MEASURE(S): The primary study outcome measures were the number of oxycodone CR prescriptions over an 8-month period. RESULTS: At the initiation of the program, the authors averaged over 40 oxycodone CR prescriptions per month. After 3 months, the number of prescriptions dropped to an average of 10 per month, a 75 percent decrease. More importantly, the number of oxycodone CR tablets saw a corresponding 75 percent drop from over 2,500 tablets per month to approximately 600 per month. Of course, the authors were concerned that the reduction of oxycodone CR may lead to increases in the use of other opioids. However, trends for hydrocodone/acetaminophen also showed a reduction in total usage as well as all other long-acting opioids. In addition, patient satisfaction did not change significantly, and no significant complaints from patients regarding this specific change were received. CONCLUSIONS: By implementing criteria for oxycodone CR prescribing in an innovative, comprehensive, and unified patient-centered practice model, the authors saw a significant decrease in the number of oxycodone CR tablets prescribed per month and also a decrease in total prescriptions per month.

A rare urinary bladder tumour.

This case report describes a 54-year-old man who presented to his primary care physician with low back pain. During his workup, an incidental finding of a bladder mass was diagnosed. He underwent transurethral resection of the bladder tumour and the resulting pathology was consistent with extra nodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). Presentation of MALT lymphoma in the urinary bladder is rare. This malignancy is more commonly found in the stomach. The prognosis for this rare tumour is excellent. Our patient showed no sign of recurrence with transurethral excision and radiation alone.

Cutaneous horn: get to the bottom of it.

A 62-year-old man presented to our family practice office with a skin lesion that developed over 8-10 months. Over the past 2-3 months the lesion grew more quickly. A 2-3 cm, hard brown projection was noted on the dorsal aspect of his hand. A decision was made to excise the lesion and send it for pathological evaluation. The lesion was found to be a cutaneous horn with invasive squamous cell carcinoma at the base. The margins of the sample were free of cancer cells. Cutaneous horns are raised skin lesions made of dead keratin derived from base keratinocytes. They are frequently found in areas of the body that have had solar exposure. There are a wide variety of histopathological findings at the base of these lesions. They range from benign to premalignant to malignant. Cutaneous horns should be completely excised and sent for pathological evaluation.

Capillary haemangioma in a 13-year-old boy.

This case presents a 13-year-old boy who developed an unusual skin lesion on his chest that occurred after 2-3 weeks following a traumatic injury. The lesion was raised and bled easily. It was surgically removed via shave excision and treated with electrocautery. The patient healed with no recurrence and minimal scarring. Pathology determined the skin lesion to be a capillary haemangioma.

Laughter-induced syncope.

This case report describes a 58-year-old man who is otherwise healthy but has periodic episodes of syncope which only happen when he laughs vigorously. This occurs suddenly with no prodrome, so the patient has no time to react and is unable to brace himself when he falls. The case is one of the very few described in the medical literature, most of which have similar presentations and findings on subsequent investigation. Recognition of the typical presentation, in the absence of more serious causes of syncope, may avoid extensive and expensive evaluation.