Pain continues to be a very formidable foe in the care of the hospice patient. The incidence among hospice admissions may range from 50 to 80 percent. With such a high initial incidence of pain, the rapidity with which pain can be controlled becomes a very high priority for the hospice effort. The assessment and management of pain in a home-based hospice program presents some unique problems--and opportunities, in that much of this work is done by hospice nurses on site, rather than by the physician, who might remain quite removed from the process. In the study described below, 250 consecutive admissions to either a hospice, or pre-hospice (bridge) program were assessed for pain on admission. Those with pain scores of 5 or greater (on a 1 to 10 scale) were followed daily for 15 days by phone to reassess pain and treatment effects. Of the 250 consecutive patients surveyed, 41 (16 percent) gave pain scores of 5 or greater. Mean pain scores for the 41 patients dropped to < 5 within 24 hours of admission.

Antiplatelet therapy is a mainstay of secondary prevention of ischemic strokes. Recent studies, such as Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS), the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial, and the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT), have added much to our understanding about how best to utilize the various antiplatelet agents available. Aspirin has been shown to reduce the risk of recurrent strokes, and the combination of aspirin and dipyridamole has repeatedly been shown to outperform aspirin alone. Recently, clopidogrel was demonstrated to be "noninferior" to an aspirin/dipyridamole combination, and can be considered as a first-line agent. The American Stroke Association and American Heart Association have clear recommendations on how to utilize these agents.

Dementia is an illness that progressively affects cognition, emotion, and functional status. It can be complicated by delirium, an acute disturbance of consciousness and cognition that develops over a short course with fluctuating symptoms. Patients with dementia who experience delirium tend to have slower resolution of symptoms, more adverse events, and poorer outcomes. There are significant health care expenditures associated with delirium. Many health care providers fail to recognize and diagnose delirium. The confusion assessment method is a suggested tool for diagnosing delirium. Delirium is multifactorial, occurring in an individual who has a predisposing factor (dementia is the number 1 risk factor) and is exposed to further precipitating risk factors that are often preventable. The main focus of treatment and management of delirium should be on prevention, which can be achieved through assessing patients for predisposing and precipitating factors. If a patient does develop delirium, a reassessment of precipitating factors is the first step in treatment, and then nonpharmacologic or pharmacologic treatment can be considered. The use of antipsychotics or melatonin to treat delirium in dementia is considered off-label.

Formal HPM training should be a required component in residency education and considerations should be given to the 4-week format. This rotation provides a model that can be implemented in other residency programs nationally. Implementation of this rotation may help close the enormous gap of patients not receiving quality EOL care.

No abstract

Angioedema is a side effect that is often associated with the use of angiotensin-converting enzyme (ACE) inhibitor medications. These medications result in increased levels of circulating bradykinins. This case illustrates the result of a local traumatic event to the upper lip, presumably causing marked bradykinin release in a patient who was taking an ACE inhibitor. The local release of bradykinin from trauma, in addition to decreased bradykinin catabolism secondary to ACE inhibitor therapy, resulted in angioedema predominantly in the upper lip. The angioedema resolved with discontinuation of the ACE inhibitor. (J Am Board Fam Med 2008;21:577-9.)As the indications and usage of angiotensin-converting enzyme (ACE) inhibitor therapy increases, one of its potential side effects, angioedema, is becoming commonly encountered in primary care. Angioedema is a potentially life-threatening side effect of ACE inhibitor therapy, which has an estimated incidence of 0.1% up to 6%. 1 Angioedema resulting secondary to ACE inhibitor use may occur many years after therapy has been initiated. However, it most often occurs within the first week after starting therapy. 2 Up to 25% of reported cases of angioedema seem to be a result of ACE inhibitor therapy. 2 The other most common causes include allergic reactions, hereditary angioedema, C1 esterase inhibitor deficiency, and idiopathic angioedema. 2 The mechanism of action of ACE inhibitors includes the blockade of the ACE, which leads to vasodilation. Other actions of ACE inhibitors include blockade of the conversion of substance P to inactive peptides and the blockade of bradykinin degradation. The increase in circulating substance P and bradykinin, histamine release, and other mechanisms lead to vasodilatation and increased vascular permeability. 1-3 Angioedema does not resemble other forms of edema in that it does not appear in dependent areas and is often very transient and localized. 4 The most important risk factor for developing ACE inhibitor angioedema seems to be African-American race. The mechanism of this increased risk is not clear but may include bradykinin metabolism. Other risk factors include history of angioedema, allergies to seafood, and recent head or neck surgery. 2

In the next 30 years, the average age of the population will continue to increase, as will the prevalence of dementia. The management of advanced dementia requires the careful orchestration of communication, prognostication, patient care, and caregiver education. Understanding the specific tools available to establish prognosis and guide medical management in these complicated medical patients greatly improves patient and caregiver satisfaction at the end of the patient's life. In caring for patients with advanced-stage dementia, providers should be knowledgeable regarding the terminal nature of the condition and its common comorbid diseases, and should be prepared to educate the patients' caregivers, building a structure of support for the patient's benefit and navigating the complexities of end-of-life care.

We surveyed first-year medical students about preparedness for work at student-run clinics, and for addressing patients' access to care, and social issues. Most students did not know how to get uninsured patients ongoing care or medications outside of the student-run clinic. A large majority of students desired an orientation addressing these issues.