Diabetes is associated with numerous complications. One of the most debilitating microvascular sequelae is painful diabetic peripheral neuropathy (PDPN). PDPN results from a multi-faceted pathogenesis involving direct axonal degeneration; free radical mediated cellular apoptosis, and microvascular perfusion abnormalities. While tight glycemic control has been shown to modulate the history of this diabetic complication, practicing clinicians have access to numerous published practice recommendations for treatment. Of the frequently utilized medication classes, anticonvulsants, antidepressants, anesthetics, and the neuromodulators are perhaps the most widely understood. The gabapentinoids are considered by many as first line therapy. Others recommend tricyclic antidepressants firstline. The provider treating PDPN must consider the medication side effects and monitoring parameters, the co-morbid disease states, and the ultimate effects on diabetic control. Finally, the clinician must address patient expectations of treatment. Goals may include increased functionality, decreased pain and improved sleep. Here multiple treatment modalities and evidence-based guidelines are reviewed.
Medication nonadherence is a strong predictor of adverse events and unplanned 30-day readmissions in post-myocardial infarction (MI) patients. Nonadherence with dual antiplatelet therapy (DAPT) is of particular concern in post-MI patients, given the high rate of percutaneous coronary intervention in this population. Review of post-MI quality measures revealed that compared to national benchmarks, our safety net hospital had lower DAPT adherence rates and higher unplanned 30-day readmission rates. The aim was to improve these important quality measures by creating a transition of care pathway primarily focused on medication accessibility and affordability of DAPT and early follow-up. A multidisciplinary task force created a transition of care pathway that included bedside medication delivery, patient assistance program enrollment for medications, and follow-up within 10 days of discharge in a dedicated post-MI clinic. Resources for the pathway (personnel and hospital) were already available and repurposed. We compared quality measures of DAPT adherence, proportion of patients evaluated early after hospital discharge, and unplanned 30-day readmissions before and after the initiative. Following initiation of the transition of care pathway, DAPT adherence increased from 56% pre-intervention to 92% post-intervention (P < 0.0001). The proportion of patients scheduled for early clinic followup after discharge increased and unplanned 30-day readmissions decreased following initiation of the pathway. A transition of care pathway for post-MI patients using readily available resources was associated with increased DAPT adherence and decreased 30-day unplanned readmissions.
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