Skin Tear Management: A Multidisciplinary Education Project.

OBJECTIVE: To identify the number of skin tears present at the authors' facility and evaluate a multidisciplinary educational intervention to support treatment of skin tears. METHODS: The authors determined the prevalence of skin tears from an analysis of a wound audit dataset at Baycrest Health Sciences and compared it with the literature to inform the aims of the educational intervention. They developed an educational module and presented it to physicians and students at separate in-person sessions and to clinical care staff at a virtual session. Participants completed an evaluation survey after the education sessions to assess their knowledge and confidence with skin tear management and obtain their feedback about the session. RESULTS: The prevalence of skin tears at Baycrest hospital was 5.6%, which was low compared with the values reported in the literature. For the 10 studies reviewed, the median prevalence was 8.8% (range, 3.0%-22.1%). A total of 7 physicians, 12 students, and 7 clinical care staff completed the evaluation survey. All of the physicians (100%), 43% of students, and 57% of clinical care staff could classify an image of a skin tear; 86% of physicians, 33% of students, and 43% of clinical care staff identified the correct skin tear complications; and 71% of physicians, 0% of the students, and 29% of clinical care staff selected the appropriate dressing. Participants reported moderate to considerable increases in knowledge and confidence in skin tear management. CONCLUSIONS: This method of multidisciplinary teaching on skin tears was well received and useful in enhancing knowledge and confidence in identifying and treating skin tears.

Understanding the role of community pharmacies in current medication for opioid use disorder care practices.

BACKGROUND: Many barriers for patient access to medications for opioid use disorder (MOUD) exist in current care practices. Previous literature has evaluated subsets of pharmacists, patients, and prescribers; however, few have collectively evaluated the perspectives of all 3 groups. OBJECTIVE: The objective of the study was to identify barriers, facilitators, and opportunities for improvement in Indiana community pharmacy MOUD care practices from the perspectives of peer recovery coaches, community pharmacists, and prescribers to optimize patient care. METHODS: Individual semistructured interviews were conducted with each participant. Interviews explored stakeholders' perspectives on their current role in MOUD care practices and how current pharmacy practices could be improved. Data were analyzed using preconceived deductive and iterative inductive codes. The first author analyzed all transcripts, of which 3 were also analyzed separately by the last author to confirm consistent utilization of codes. All transcripts were coded once, followed by a second coding to ensure inductive codes were thoroughly applied. RESULTS: Ten peer recovery coaches, 10 pharmacists, and 6 prescribers were included. Interviews identified barriers, facilitators, and opportunities for improvement in current MOUD care practices. Stigma was a major barrier identified by all groups. Other barriers identified included limited patient engagement at pharmacies and lack of access to patient-specific health information in community pharmacy settings. Pharmacists also identified additional barriers including Drug Enforcement Administration regulations and difficulties balancing patient care with external factors like insurance and legal policies. Positive prescriber/pharmacist relationships were identified as a facilitator of care. Opportunities for improvement included having community MOUD resource information available at pharmacies, further education on MOUD for pharmacists, and increased collaboration between pharmacists and prescribers. CONCLUSION: Many barriers exist in current MOUD care practices. Additional pharmacist MOUD education and intentional collaboration between pharmacists, peer recovery coaches, and prescribers would facilitate better care and leverage the accessibility of pharmacists within their communities.

Community pharmacist-provided opioid intervention frequencies and barriers.

BACKGROUND: Community pharmacists are well-positioned to engage in opioid-related harm reduction activities (i.e., opioid interventions). However, several barriers to providing these interventions have been identified. Comparing the frequencies of opioid interventions and identifying which barriers are perceived to have the highest impact in providing interventions will yield valuable information for increasing opioid use disorder (OUD) care access within pharmacies. OBJECTIVES: To (1) characterize the frequency of 9 opioid interventions in community practice settings and (2) assess community pharmacists' perceptions of what impact 15 key barriers have on providing opioid interventions. METHODS: This was a multi-state, cross-sectional, and descriptive survey study. Opioid interventions evaluated included prevention (e.g., OUD screening) and treatment (e.g., OUD resource referral); barriers encompassed confidence and knowledge, work environment, provider interactions, and patient interactions. Respondents were recruited from 3 community pharmacy practice-based research networks in the Midwest and South regions of the US. Recruitment and telephone survey administration occurred between December 2021 and March 2022. Descriptive statistics were computed and open-ended items were reviewed to identify common themes. RESULTS: Sixty-nine of 559 pharmacists contacted (12.3%) completed the survey. All opioid interventions were reported to be provided less frequently than indicated in practice. Screening and referral interventions were provided least frequently, at 1.2 and 1.6 times on average, respectively, to the last 10 patients for which respondents felt each intervention was needed. Patient refusal, minimal or no reimbursement, inadequate staffing and time, and negative patient reactions were identified as the highest-impact barriers to providing opioid interventions. Approximately 26% of respondents agreed or strongly agreed that pharmacy school adequately prepared them to provide opioid interventions in practice. CONCLUSION: Prioritizing the resolution of pharmacy work environment barriers will support pharmacists in routinely providing opioid interventions. Changes in Doctor of Pharmacy curricula and continuing education are also indicated to further prepare pharmacists to engage in opioid-related harm reduction.

Use of Project ECHO to promote evidence based care for justice involved adults with opioid use disorder.

Background: People with opioid use disorders (OUDs) are at heightened risk for involvement with the criminal justice system. Growing evidence supports the safety and effectiveness of providing empirically supported treatments for OUD, such as medications for OUD (M-OUD), to people with criminal justice involvement including during incarceration or upon reentry into the community. However, several barriers limit availability and accessibility of these treatment options for people with OUDs, including a shortage of healthcare and justice professionals trained in how to implement them. This study evaluated a novel education program, the Indiana Jail OUD Treatment ECHO, designed to disseminate specialty knowledge and improve attitudes about providing M-OUD in justice settings. Methods: Through didactic presentations and case-based learning (10 bimonthly, 90-min sessions), a multidisciplinary panel of specialists interacted with a diverse group of community-based participants from healthcare, criminal justice, law enforcement, and related fields. Participants completed standardized surveys about OUD knowledge and attitudes about delivering M-OUD in correctional settings. Thematic analysis of case presentations was conducted. Results: Among 43 participants with pre- and post-series evaluation data, knowledge about OUD increased and treatment was viewed as more practical after the ECHO series compared to before. Cases presented during the program typically involved complicated medical and psychiatric comorbidities, and recommendations addressed several themes including harm reduction, post-release supports, and integration of M-OUD and non-pharmacological interventions. Conclusions: Evaluation of future iterations of this innovative program should address attendance and provider behavior change as well as patient and community outcomes associated with ECHO participation.

The Effect of a PTSD Service Dog on Military Veterans' Medication Regimens: A Cross-Sectional Pilot Study.

Recent research suggests that service dogs may have clinically-relevant benefits for military veterans with posttraumatic stress disorder (PTSD). However, the effects of PTSD service dogs on veterans' medication use has been largely unexplored. The objective of this study was to quantify the effect of PTSD service dogs on medication use among a population of military veterans with PTSD. In a cross-sectional design, United States post-9/11 military veterans with PTSD were recruited from a single service dog provider including veterans living with a PTSD service dog (n = 52) and veterans on the waitlist (n = 44). Both populations of veterans received treatment as usual. Participants completed an online survey of self-reported medication regimens and medication changes. Regression models quantified the effect of having a service dog on physical health, mental health, pain, and sleep medications while controlling for confounding variables (age, sex, relationship status, traumatic brain injuries, and physical health). Results indicated that there were no significant effects of having a service dog on overall self-reported medication use nor any specific medication category (p's > 0.06). However, veterans with a service dog were more likely than those on the waitlist to report that their doctor had decreased dosage or removed medications since getting their service dog. The results of this preliminary cross-sectional research should be interpreted with caution, as future within-subject and pharmacy-verified research is necessary to understand the causality of these findings.

Esketamine: A Novel Option for Treatment-Resistant Depression.

Objective:To review the pharmacology, pharmacokinetics, efficacy, safety, use requirements, and place in therapy of esketamine for treatment-resistant depression (TRD). Data Sources: A comprehensive PubMed search (1966 to October 2019) was conducted using the search terms depression, treatment-resistant, suicide, intranasal, esketamine, and JNJ-54135419. Additional data were obtained from references of identified articles, governmental sources, manufacturer product labeling, and Clinicaltrials.gov . Study Selection and Data Extraction: All English-language trials evaluating intranasal esketamine for TRD were included and discussed. Data Synthesis: Intranasal esketamine was approved by the US Food and Drug Administration, in conjunction with an oral antidepressant, for treating TRD in adults. Two short-term trials (TRANSFORM-1 and -2) found statistically significant reduction in the Montgomery-Asberg Depression Rating Scale score at day 28 for the fixed 56-mg dose (-4.1; 95% CI = -7.69 to -0.49; P = 0.027 [exploratory]) and flexible-dosed arms (-4.0; 95% CI = -7.31 to -0.64; P = 0.02), though the fixed-dose 84-mg arm (-3.2; 95% CI = -6.88 to 0.45; P = 0.088) of TRANSFORM-1 and TRANSFORM-3 did not (-3.6; 95% CI = -7.2 to 0.07; P = 0.059). Two long-term trials (SUSTAIN-1 and -2) suggested maintenance of response with continued use. Esketamine's adverse effects include dizziness, dysgeusia, somnolence, dissociation, suicidal thoughts and behaviors, and increased heart rate and blood pressure. Relevance to Patient Care and Clinical Practice: Although providing a novel antidepressant mechanism and formulation for TRD, esketamine's role in treatment will likely be limited by cost, administration, and diversion concerns. Conclusion: Intranasal esketamine significantly reduced depression symptoms in TRD, though with tolerability issues.

The evolving role of the pharmacist for individuals with serious mental illness.

Adults with serious mental illness such as schizophrenia, bipolar disorder, or severe depression encounter many barriers in receiving appropriate health care services and are at a markedly increased risk of premature mortality. A range of clinical pharmacist roles in community mental health may help offset the increasing issues related to access to care and contribute to recovery-oriented systems of care for individuals with serious mental illness. In this commentary, we offer a description of one such model operationalized within a large community mental health center. Clinical pharmacists provide substantial contributions toward optimizing care for individuals with serious mental illness through medication therapy management, cardiovascular risk reduction, and various other interventions to help positively impact the health disparity these individuals face.

Medical staff perceptions of medication-assisted treatment in a federally qualified health center.

OBJECTIVES: To describe medical staff attitudes and perceived behaviors toward medication-assisted treatment (MAT) in a federally qualified health center (FQHC). The secondary objective was to identify the staff's perceptions of using pharmacists during MAT. DESIGN: A cross-sectional, descriptive study using a 26-item Web-based survey was developed using the theory of planned behavior (TPB) and consisted of Likert scale and multiple-select options. SETTING AND PARTICIPANTS: Medical staff located at an FQHC in northwest Indiana were eligible to participate if they were 18 years or older. Corporate and administrative staff were not eligible to participate. OUTCOME MEASURES: Perceptions were measured using the 4 constructs of the TPB: attitude, perceived behavioral control, subjective norm, and intent. The data were analyzed using descriptive statistics. RESULTS: Of the 240 eligible respondents, 104 employees completed the survey, yielding a 43.3% response rate. The providers generally believed they had the knowledge (83.9% agree or strongly agree) to diagnose patients with opioid use disorder (OUD). From the perceived behavioral control construct, staff were confident of their ability to identify patients for MAT (65.2%); however, most believed they needed additional training on MAT (75%) from the attitude construct. From the subjective norm construct, more than half of the respondents believed that their employer wanted them to be involved in the treatment of a patient with OUD (60.7%). Commonly, from the intent construct, the staff favored adding pharmacists to the care team when managing patients with MAT (57.7%). CONCLUSION: The staff expressed the need for additional training to provide MAT services and believed this would enable them to become an important part of the MAT team. Adding a trained pharmacist to the care team when managing patients with MAT was favored by the staff. The study showed that health professionals would be more comfortable if a pharmacist were available for MAT consultation.

Monitoring and Treating Metabolic Abnormalities in Patients with Early Psychosis Initiated on Antipsychotic Medications.

Antipsychotic medications carry an established lifetime risk of metabolic syndrome. This retrospective chart review evaluated feasibility of a metabolic monitoring clinical decision support tool (CDST) for weight, lipid, blood glucose, and blood pressure management of 163 clients in an early psychosis outpatient clinic over 2 years. Each parameter had at least 98 (60.1%) clients with a recorded value, the most being documented for weight with 112 (68.7%) clients. CDST adherence ranged from at least 54.3-100% for non-pharmacologic interventions (e.g. clinic counseling, referral to health program or primary care) and at least 33.3-100% for pharmacologic interventions (e.g. metformin). Though no baseline cardiometabolic abnormalities were identified, dyslipidemia and obesity were later found in 37 (22.7%) and 35 (21.5%) clients, respectively. Only 14 (8.6%) clients were prescribed medications for cardiometabolic abnormalities by psychiatrists in the clinic. Increasing focus on physical health is needed to better this population's long-term prognosis.

Social Determinants of Health in People Living with Psychiatric Disorders: The Role of Pharmacists.

Introduction: Social determinants of health (SDOH) affect outcomes of people living with psychiatric disorders, including substance use disorders. As experts in medication optimization, pharmacists play a vital role in identifying and addressing medication-related problems associated with SDOH. However, there is a paucity of literature on how pharmacists can be part of the solution. Objective: The purpose of this article is to provide a narrative review and commentary on the intersection between SDOH, medication-related outcomes in people living with psychiatric disorders, and the role of pharmacists in addressing them. Method: The American Association of Psychiatric Pharmacists appointed an expert panel to research the issue, identify barriers, and develop a framework for including pharmacists in addressing medication therapy problems associated with SDOH in people with psychiatric disorders. The panel used Healthy People 2030 as the framework and sought input from public health officials to propose solutions for their commentary. Results: We identified potential connections between SDOH and their impact on medication use in people with psychiatric disorders. We provide examples of how comprehensive medication management can afford opportunities for pharmacists to mitigate medication-related problems associated with SDOH. Conclusion: Public health officials should be aware of the vital role that pharmacists play in addressing medication therapy problems associated with SDOH to improve health outcomes and to incorporate them in health promotion programs.

Opioid Use Disorder Curricular Content in US-Based Doctor of Pharmacy Programs.

OBJECTIVES: To characterize the instructional settings, delivery methods, and assessment methods of opioid use disorder (OUD) content in Doctor of Pharmacy (PharmD) programs; assess faculty perceptions of OUD content; and assess faculty perceptions of a shared OUD curriculum. METHODS: This national, cross-sectional, descriptive survey study was designed to characterize OUD content, faculty perceptions, and faculty and institutional demographics. A contact list was developed for accredited, US-based PharmD programs with publicly-accessible online faculty directories (n = 137). Recruitment and telephone survey administration occurred between August and December 2021. Descriptive statistics were computed for all items. Open-ended items were reviewed to identify common themes. RESULTS: A faculty member from 67 (48.9%) of 137 institutions contacted completed the survey. All programs incorporated OUD content into required coursework. Didactic lectures were the most common delivery method (98.5%). Programs delivered a median of 7.0 h (range, 1.5-33.0) of OUD content in required coursework, with 85.1% achieving the 4-hour minimum for substance use disorder-related content recommended by the American Association of Colleges of Pharmacy. Just over half (56.8%) of faculty agreed or strongly agreed that their students were adequately prepared to provide opioid interventions; however, 50.0% or fewer perceived topics such as prescription interventions, screening and assessment interventions, resource referral interventions, and stigma to be covered adequately. Almost all (97.0%) indicated moderate, high, or extremely high interest in a shared OUD curriculum. CONCLUSION: Enhanced OUD education is needed in PharmD programs. A shared OUD curriculum was of interest to faculty and should be explored as a potentially viable solution for addressing this need.

Attitudes of individuals with schizophrenia toward pharmacists.

OBJECTIVES: To explore attitudes of people with schizophrenia toward pharmacists and identify ways in which pharmacists can enhance patient communication. METHODS: A questionnaire and semistructured interview were conducted in patients diagnosed with schizophrenia and/or schizoaffective disorder. Study measures assessed knowledge, expectations, communication, the pharmacy environment, and other providers. Interview transcripts were coded by theme and counted as participants replying to each question. RESULTS: Participants (n = 28) perceived pharmacists as knowledgeable about medications and mental illnesses and considered pharmacists' medication knowledge to be greater than their mental illness knowledge. They expected pharmacists to dispense medications, act professionally, and provide medication information. Participants reported being comfortable discussing medications with pharmacists but preferred talking with nonpharmacist providers. Participants indicated that pharmacists could improve communication by expressing interest in their well-being. CONCLUSION: People with schizophrenia view pharmacists as knowledgeable but perceive them primarily as dispensers of medication. For nondispensing pharmacists, describing their roles could be beneficial.

Promoting best practices for managing opioid overdoses in the field: A novel project Extension for Community Healthcare Outcomes program for first responders.

As the opioid overdose epidemic persists in the United States, it is important to provide specific first responder-oriented continuing education opportunities on interacting with, treating, and assessing individuals who overdose or who have Opioid Use Disorder (OUD). This research brief describes the first Extension for Community Healthcare Outcomes (ECHO) program focused on first responders and opioids, including the content covered and concomitant popularity and the registrants' objective knowledge and attitudes about opioids. Participation in the 'First Responders and Opioids ECHO' was free with no attendance requirements. Data include secondary assessment and description of the 9-session curriculum developed to address first responders' continuing education needs on OUD and overdose as well as objective knowledge and attitudes collected at program registration and granular attendance data by topic. Of 158 registrants, 102 attended at least one program session, with participants attending an average of 3.26 sessions (SD = 2.62). Registrants reported mixed knowledge levels, but even among this voluntary cohort of early adopters, objective knowledge about OUD and best-practice overdose response was only moderate. Registrants generally displayed non-stigmatizing and affirming attitudes and beliefs (e.g., substance use disorder is a treatable illness [M = 1.56, SD = 0.73]), with somewhat less agreement with items focused on harm reduction and medication-based treatment. A plausible case can be made that there is a need for evidence-based continuing education on opioids for first responders and related professionals. A motivated cohort of registrants displayed moderate but inconsistent knowledge and generally favorable attitudes. We encourage further systematic process and outcomes research on this topic.

The "new" marijuana.

Synthetic cannabinoid-induced toxicity is increasing in frequency across the US, with more than 1057 reported cases as of August 2010. There is a paucity of literature on synthetic cannabinoid toxicity; however, there are various reports of adverse effects including tachycardia, hypertension, tachypnea, chest pain, heart palpitations, hallucinations, racing thoughts, and seizures. While reports suggest that toxic symptoms last no longer than 3-4 hours, with no residual adverse effects in many cases, there is concern about serious acute and long-term toxicities. This article reviews the development, abuse, toxicity, treatment, and legal status of synthetic cannabinoids. It is important for health-care professionals to recognize and appropriately treat synthetic cannabinoid-induced toxicity.

Accuracy of a single-lead mobile smartphone electrocardiogram for QT interval measurement in patients undergoing maintenance methadone therapy.

STUDY OBJECTIVE: Methadone is associated with QT interval prolongation and torsades de pointes. Expert panel recommendations advocate a pre-methadone electrocardiogram (ECG) and another ECG at 30 days of therapy in patients with risk factors. Some guidelines recommend a pre-methadone ECG and routine ECG monitoring in all methadone patients, but this is controversial due to the resources required. Availability of a convenient, less resource-intensive method of ECG monitoring for patients taking methadone is desirable. The objective of this study was to assess the accuracy of a handheld smartphone ECG (iECG) for QT measurement in patients on maintenance methadone therapy in an urban opioid treatment program. DESIGN: Prospective study. SETTING: Urban opioid treatment program. PATIENTS: n = 115 patients in normal sinus rhythm who were on steady-state maintenance methadone therapy INTERVENTION: Patients (n = 115) underwent a simultaneous 12-lead ECG and a single-lead iECG. MEASUREMENTS AND MAIN RESULTS: The first three QT and RR intervals from lead II of the 12-lead ECG and simulated lead I from the iECG were compared using the Bland-Altman analysis of measurement agreement. Mean [± standard deviation) age was 34 ± 11 years; 71% were female, 75% were white. Compared to the 12-lead ECG, the iECG was associated with a QTc bias of - 0.14 ms (SD = 12 ms, 95% CI = -2.4 to 2.1 ms). The absolute mean difference in QTc between the two methods was 9.5 ± 7.1 ms. For identification of patients with methadone-associated QTc prolongation, the iECG performed moderately well [c-statistic 0.97 (95% CI 0.91-0.99); sensitivity and specificity 75% (95% CI 43-95%) and 99% (95% CI 94-99%), respectively]. The positive and negative likelihood ratios of the iECG for identifying patients with methadone-associated QTc prolongation were 77.25 (95% CI 10.69 to 558.18) and 0.25 (95% CI 0.09 to 0.67), respectively, while the positive and negative predictive values were 90% (95% CI 56-99%) and 97% (95% CI 92-99%), respectively. The accuracy of the iECG for identifying patients with QTc prolongation was 97% (95% CI 91-99%). CONCLUSION: A handheld smartphone ECG is accurate for QT interval measurement in patients taking maintenance methadone therapy, and its performance is moderately good for identifying patients with methadone-associated QTc prolongation.

Methadone-associated QT interval prolongation in patients undergoing maintenance therapy in an urban opioid treatment program.

STUDY OBJECTIVE: Methadone is associated with QT interval prolongation and torsades de pointes. The objective of this study was to (a) determine the incidence of QT interval prolongation among patients on maintenance methadone therapy in an urban opioid treatment program (OTP), (b) compare characteristics of patients who developed methadone-associated QT prolongation with those who did not develop QT prolongation, and (c) investigate the relationship between QT interval prolongation and stereospecific serum methadone and metabolite [2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP)] concentrations. DESIGN: Prospective study. SETTING: Urban opioid treatment program (OTP). PATIENTS: n = 93 patients on maintenance methadone therapy in an urban OTP. INTERVENTION: Patients underwent a 12-lead electrocardiogram (ECG) prior to initiating methadone and again during steady-state maintenance methadone therapy. In a subset (n = 43), blood was obtained to determine serum (S)- and (R)-methadone and (S)- and (R)-EDDP concentrations, which were compared in patients who developed Bazett's-corrected QT (QTc) prolongation [≥470 ms (men) or ≥480 ms (women) and/or ≥60 ms lengthening from pretreatment value] with those who did not have QTc prolongation. MEASUREMENTS AND MAIN RESULTS: Mean [± standard deviation (SD)] age was 36 ± 12 years; 73% were female, and 74% were white. QTc prolongation occurred in 14 (15.1%) patients. Patients who developed QTc prolongation were older (41 ± 13 vs. 35 ± 9 years, p = 0.03) and had a longer pre-methadone QTc compared with those who did not have QTc prolongation (429 ± 11 vs. 420 ± 20 ms, respectively, p = 0.02). Serum (S)-methadone concentrations were higher in patients with QTc prolongation compared to patients without prolongation (199 ± 81 vs. 128 ± 68 ng/ml, respectively, p = 0.01), whereas the difference in serum (R)-methadone concentrations between the groups did not reach significance (189 ± 68 vs. 125 ± 60 ng/ml, respectively, p = 0.08). Serum (R)-methadone concentrations correlated with QTc intervals [R2  = 0.15 (95% confidence interval (CI) 0.11-0.62, p = 0.0009)]. The correlation between serum (S)-methadone concentrations and QTc did not reach significance [R2  = 0.08 (95% CI -0.01 to 0.54, p = 0.06)]. Serum (S)-and (R)-EDDP concentrations were not significantly different between the groups and did not significantly correlate with QTc intervals. CONCLUSIONS: Approximately 15% of patients taking maintenance methadone therapy developed QT interval prolongation. Both serum (S)- and (R)-methadone concentrations, but not (S)- or (R)-EDDP, contribute to methadone-associated QT prolongation.

Pharmacological management of delirium in hospitalized adults--a systematic evidence review.

BACKGROUND AND OBJECTIVES: Despite the significant burden of delirium among hospitalized adults, there is no approved pharmacologic intervention for delirium. This systematic review evaluates the efficacy and safety of pharmacologic interventions targeting either prevention or management of delirium. DATA SOURCES: We searched Medline, PubMed, the Cochrane Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to October 2008. We included randomized, controlled trials comparing pharmacologic compounds either to each other or placebo. We excluded non-comparison trials, studies with patients aged < 18 years, a history of an Axis I psychiatric disorder, and patients with alcohol-related delirium. REVIEW METHODS: Three reviewers independently extracted the data for participants, interventions and outcome measures, and critically appraised each study using the JADAD scale. RESULTS: We identified 13 studies that met our inclusion criteria and evaluated 15 compounds: second-generation antipsychotics, first-generation antipsychotics, cholinergic enhancers, an antiepileptic agent, an inhaled anesthetic, injectable sedatives, and a benzodiazepine. Four trials evaluated delirium treatment and suggested no differences in efficacy or safety among the evaluated treatment methods (first and second generation antipsychotics). Neither cholinesterase inhibitors nor procholinergic drugs were effective in preventing delirium. Multiple studies, however, suggest either shorter severity and duration, or prevention of delirium with the use of haloperidol, risperidone, gabapentin, or a mixture of sedatives in patients undergoing elective or emergent surgical procedures. CONCLUSION: The existing limited data indicates no superiority for second-generation antipsychotics over haloperidol in managing delirium. Although preliminary results suggest delirium prevention may be accomplished through various mechanisms, further studies are necessary to prove effectiveness.

An exercise intervention for breast cancer survivors with bone loss.

PURPOSE: (a) to determine if 110 postmenopausal breast cancer survivors (BCS) with bone loss who participated in 24 months of strength and weight training (ST) exercises had improved muscle strength and balance and had fewer falls compared to BCS who did not exercise; and (b) to describe type and frequency of ST exercises; adverse effects of exercises; and participants' adherence to exercises at home, at fitness centers, and at 36-month follow up. DESIGN: Findings reported are from a federally funded multicomponent intervention study of 223 postmenopausal BCS with either osteopenia or osteoporosis who were randomly assigned to an exercise (n=110) or comparison (n=113) group. METHODS: Time points for testing outcomes were baseline, 6, 12, and 24 months into intervention. Muscle strength was tested using Biodex Velocity Spectrum Evaluation, and dynamic balance using Timed Backward Tandem Walk. Adherence to exercises was measured using self-report of number of prescribed sessions attended and participants' reports of falls. FINDINGS: Mean adherence over 24 months was 69.4%. Using generalized estimating equation (GEE) analyses, compared to participants not exercising, participants who exercised for 24 months had significantly improved hip flexion (p=0.011), hip extension (p=0.0006), knee flexion (p<0.0001, knee extension (p=0.0018), wrist flexion (p=0.031), and balance (p=0.010). Gains in muscle strength were 9.5% and 28.5% for hip flexion and extension, 50.0% and 19.4% for wrist flexion and extension, and 21.1% and 11.6% for knee flexion and extension. Balance improved by 39.4%. Women who exercised had fewer falls, but difference in number of falls between the two groups was not significant. CONCLUSIONS: Many postmenopausal BCS with bone loss can adhere to a 24 month ST exercise intervention, and exercises can result in meaningful gains in muscle strength and balance. CLINICAL RELEVANCE: More studies are needed for examining relationships between muscle strength and balance in postmenopausal BCS with bone loss and their incidence of falls and fractures.