The American journal of medicine
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In this article, we review the principal objectives and ideal elements of opioid contracts, as articulated by proponents of the practice. We examine the limited empirical evidence for the effectiveness of opioid contracts in achieving their intended objectives and identify areas of uncertainty and of ethical concern regarding their implementation. We argue that the challenge in deciding about implementing opioid contracts in clinical practice relates to the multiplicity of potential objectives they might serve, to a lack of empirical evidence regarding their effectiveness, and to ethical concerns over their implementation. Specialty and primary care clinicians contemplating the use of opioid contracts in treating patients with chronic nonmalignant pain need to be sensitive to these considerations, and further debate and research is necessary to establish the proper objectives, elements, effectiveness, and ethical justifications of opioid contracts in clinical practice.
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For the primary care physician, the occurrence of a red eye is a frequent and prominent finding of a disease process in patients. A careful history and simple examination with the observation of typical clinical signs are important for the management of this common disorder. ⋯ Simple diagnostic methods and an emergency management with some useful topical ophthalmic preparations are included. Although several conditions can be treated by the primary care physician the clinical signs that require an urgent ophthalmic consultation are chemical burns, intraocular infections, globe ruptures or perforations, and acute glaucoma.
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The successful treatment of patients at increased risk for fracture requires proper diagnosis and the development of a treatment plan that permits the patient to take medications in accordance with dosing guidelines and on the correct schedule. Data indicate that patients with osteoporosis who have good long-term medication compliance experience substantially lower risk of fracture. Persistence with therapy also correlates with better bone mineral density and improved suppression of bone turnover markers. ⋯ Monthly dosing of ibandronate, a bisphosphonate, was recently approved by the US Food and Drug Administration (FDA). Although extending the dosing interval may improve compliance and persistence with bisphosphonate therapy, it is important to recognize that missed doses or improper dosing may have greater consequences with extended dosing intervals. This article highlights the importance of educating patients about their diagnosis and long-term treatment plan, including the importance of persistence with therapy and compliance with dosing recommendations.
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Review
Current concepts in validity and reliability for psychometric instruments: theory and application.
Validity and reliability relate to the interpretation of scores from psychometric instruments (eg, symptom scales, questionnaires, education tests, and observer ratings) used in clinical practice, research, education, and administration. Emerging paradigms replace prior distinctions of face, content, and criterion validity with the unitary concept "construct validity," the degree to which a score can be interpreted as representing the intended underlying construct. Evidence to support the validity argument is collected from 5 sources:
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Review
Selective serotonin reuptake inhibitors and increased bleeding risk: are we missing something?
Selective serotonin reuptake inhibitors (SSRIs) are first line agents to treat clinical depression. Although these medications exhibit a favorable safety profile, there are multiple case reports, registries, and uncontrolled studies suggesting that use of SSRIs might be associated in the increased risk of bleeding events. There is also emerging evidence that these side effects of SSRIs are due to blockade of serotonin reuptake in platelets and subsequent platelet dysfunction. ⋯ Independently of the brand, use of SSRIs is indeed associated with increased bleeding risk. Although such complications are rare, their frequency is growing, and physicians should be aware of SSRI-induced hemorrhages, especially in patients with hereditary platelet defects, and those treated with antiplatelet agents. Prospective studies are urgently needed to determine whether SSRIs will yield additional bleeding risks when used long term concomitantly with aspirin or clopidogrel.