Reducing Hypoglycemia

Treatment of Type 2 Diabetes with Special Consideration to Reduce Hypoglycemia

 


Learning Objectives

After participating in this educational activity, participants should be better able to:

  1. Apply strategies to individualize glycemic targets in patients with type 2 diabetes
  2. Discuss the limitations of frequently used conventional therapies for the treatment of patients with type 2 diabetes
  3. Outline the risk factors and clinical consequences of hypoglycemia
  4. Implement strategies to minimize hypoglycemia risk in the treatment of patients with type 2 diabetes


Overview

This educational activity will focus on the optimal management of patients with type 2 diabetes while minimizing hypoglycemia risk. Specifically, this program will help clinicians identify patients who are at an increased risk for hypoglycemia and will highlight the limitations of frequently used conventional therapies. There will also be discussion on how to optimize therapy while minimizing the risk of hypoglycemia in patients with type 2 diabetes.

 

continue-to-activity

This activity has expired and is no longer available for CME; however, we hope you still enjoy the education.

Published on March 10, 2015

Read More

Understanding of Obesity

Neurobiological Understanding of Obesity: New Treatment Guidelines and Patient-Centered Approach


Learning Objectives

After participating in this educational activity, participants should be better able to:

  1. Screen for risk factors of obesity and diagnose obesity as a disease early in its evolution
  2. Prescribe pharmacological intervention for obesity based on the neurobiology and pathophysiology of the disease following the National Heart, Lung and Blood Institute (NHLBI) guidelines
  3. Describe the safety and efficacy studies of various agents and create awareness of post marketing and long term pharmacovigilance studies to assess long term risks
  4. Focus on obesity as disease and provide communication strategies to build ongoing collaborative relationships with obese patients


Overview

Obesity has reached epidemic proportions for both children and adults and has become a major public health problem. Two-thirds of adults are overweight; one-third of them are obese. Obesity is associated with significant health risks and comorbidities including diabetes, metabolic syndrome, cancer, heart disease, depression, sleep apnea, osteoarthritis, and others.

Lifestyle interventions focused on diet, physical activity, and behavioral therapy are essential components to treating obesity and should be incorporated throughout the continuum of care. Some patients will successfully achieve weight loss with these efforts alone; however it is well documented that long-term weight loss and maintenance is difficult to achieve. When “first-line” interventions alone have not succeeded, the National Heart Lung and Blood Institute (NHLBI) guidelines recommend pharmacological intervention as an option.

This CME article will present the clinical realities of obesity encouraging an open provider/patient relationship that enhances care, allowing for discussions on goals, adherence, barriers, and expectations.

continue-to-activity

 

This activity has expired and is no longer available for CME; however, we hope you still enjoy the education.

Published on December 30, 2014

Read More

Advance Directives

Preparing for Death with Dignity via Advance Directives

 

Print This Post Print This Post

Have you ever thought about how you are going to die? Will you die comfortably or tragically? Will death overtake you suddenly or perhaps be a slow, painful process? The uncertainties surrounding death abound, but one thing is for sure, it is inevitable. The subject of death can be an uncomfortable one for many people, for various reasons. Yet in medicine, death and dying are commonly encountered occurrences, particularly when dealing with patients within the geriatric population.

However, many elderly adults and their loved ones may not have given serious consideration to how their lives may end and how they will manage and react when that time comes. They are not prepared for the inevitable. But, preparation is just the thing they need, in order to make peace with death and dying. Advance directives are the key to being prepared. They encourage people to think about their own death and how to take some control over the process. For patients who want to prepare and learn more about developing an advance directive, they seek guidance from their healthcare provider. For this reason, healthcare providers need to be knowledgeable about advance directives and be able to advise their patients. The Agency for Healthcare Research and Quality (AHRQ) reported that only 12% of patients who had an advance directive involved their physician in its creation and 65% to 76% of providers were unaware that their patients had advance directives.[1]

For the patient that does not yet hold an advance directive, particularly if that patient is elderly, addressing this topic at the healthcare visit becomes particularly vital. As people age, their risk for developing any number of chronic diseases greatly increases. In fact, the AHRQ has determined that approximately 80% to 85% of people aged 65 and beyond, will eventually become ill and meet their demise related to a chronic illness. In particular, cerebrovascular and cardiovascular diseases, Alzheimer’s disease, diabetes, renal disease and obstructive pulmonary disease are the main culprits, as each lends itself to progressive declines in physiological and mental health and function over less predictable lengths of time. There can also be occasional exacerbations that may require hospital admission. [1] Furthermore, according to Dr. Peter Saul, in his presentation of “Dying in the 21st Century,” there are four main categories through which people face death. Because of these, advance directives are not only necessary, but should become a health initiative priority. They include: death related to frailty, organ failure in the case of chronic disease, terminal illness, and sudden (unexpected) death. [2]

What exactly is an advance directive? An advance directive consists of several components that document or help people to express their wishes regarding treatment actions to be taken if they were to become critically ill, involved in a serious accident, in a coma, or become severely cognitively impaired and therefore unable to express these wishes for themselves. The concept of the advance directive was created as a provision of the Omnibus Budget Reconciliation Act proposed in November 1990, in order to give patients a choice in the medical treatments they receive. Also, through the Patient Self-Determination Act passed by Congress in 1991, patients were empowered to become active participants in medical decisions “affecting the condition and length of their life,” including being able to accept or reject treatments and create an advance directive. [3, 4] The advance directive is formulated by patients, often in discussion with their loved ones, and/or healthcare provider, and/or pastor. Advance directive components include the living will, medical durable power of attorney, do-not-resuscitate (DNR) orders, Protective Medical Decisions Document (PMDD), and the Physician Orders for Life Sustaining Treatment (POLST).

The living will also known as a healthcare directive or declaration, is a document that contains the patients’ predetermined wishes regarding the treatment modalities and measures to sustain life they would want and expect for themselves, in any serious health situation where they were unable to express these needs themselves. [5] For example, a patient with a neurological disease may pre-express in the living will that if he/she were to one day end up in coma, he/she would not want to be given artificial nutrition or hydration via feeding tubes. Further, in this document, patients could state their wishes regarding the use of mechanical respiration ventilators, hemodialysis, and in the event of death, even donation of their organs. [5] The living will is initiated by the patient’s attending physician in the event of three concurrent occurrences: the patient has lost the ability to make medical decisions, the patient must have an end-stage illness or injury from which the person will most likely not recover, and that artificially sustaining the patient’s life will hinder the ability to die naturally. [6]

The medical or healthcare power of attorney (POA) is a document that identifies one particular person (such as a spouse or family member or close friend), named by the patient, to be the “agent” or “proxy” (also known as a “surrogate” or “representative”) to make decisions regarding treatment modalities, in the event that the person is seriously incapacitated and cannot speak for himself. The decision to choose an agent should be made with deliberation and thought, as the chosen one must be able to convey and abide by the patient’s predetermined wishes and make choices for the patient in any unforeseen situation. If this were to happen, the agent would then be able to make unbiased decisions, on the patient’s behalf, based on knowledge of the patient’s values and wishes. [5] Additionally, a person may consider a second or even a third agent in the event the first one named is not available or is unable to make the necessary decisions. [6]deathbed

The PMDD is a written form of the durable power of attorney for healthcare (DPOA). Available through the Patients’ Rights Council, its purpose is similar to that of the medical POA. However, the PMDD goes one step beyond, by providing patients with increased protection (in the event of their decision making incapacity) against an agent who decides to terminate their (patients’) lives directly and intentionally, via assisted suicide or euthanasia. Besides the primary agent, alternative representing agents may be named in the PMDD, as well. [7]

The DNR order is written by a physician. It states the patients’ wishes as to whether or not they would want cardiopulmonary resuscitation (CPR) in the event they sustained cardiac or pulmonary arrest. The DNR may exist in two forms; one that addresses the CPR situation within the hospital setting and another for pre-hospital CPR situations, such as at home or in a nursing facility. [8]

Finally, the POLST is a standardized form initiated by physicians with their patients, in order to document the patients’ wishes regarding certain types of life sustaining treatments they desire or do not wish to have when their health condition is serious and they are unable to express what they want (at that time). Signed by both the physician and patient, it becomes part of the medical record, thereby making it portable and valid in any locality that patients may be in, even if they were to experience a serious health crisis when away from home. [9]

When a patient without an advance directive is hospitalized with a serious medical condition and unable to communicate, physicians must delegate that responsibility to whomever they deem appropriate to make choices on behalf of the patient. Usually this is the patient’s next of kin. Given that physicians are often unaware of patients’ wishes or who their choice of agent would have been, the doctors will make that decision for the patients. But later, if the doctors do not agree with the choices made by the agent whom they have chosen, they may then feel free to choose another. [10] This whole situation can be turned around by having an advance directive ready and available. Then, if doctors are in disagreement with the patients’ or their agent’s decisions, under federal law, doctors are required to inform the patients or their agent of that in advance at time of potential admission. In states such as Texas with an even more stringent law, doctors/facilities must render care even if they consider it to be “futile care” until provisions can be made to transfer the patient to another facility or physician who will honor the patient or agent’s choices. [10]

The responsibility for the development of a patient’s advance directive lies not only with the patient, but ultimately with the patients’ healthcare provider, as this is a very important component of the patient’s comprehensive health care. In preparation for addressing this issue with the provider patients should contemplate and discuss various items with their trusted loved ones including: [6]

  • Their attitudes towards life, including activities that bring them joy and situations they fear
  • Their attitudes about potentially losing control and independence
  • How their attitudes may be influenced by religious beliefs
  • Their attitudes towards being seriously ill or injured
  • Their attitudes regarding overall health, being ill, dying, and death
  • Their understanding of the choices for medical treatment, in the event of serious illness or injury
  • Their feelings about being unable to communicate their wishes should they become brain dead, go into a perpetual coma, or become terminally ill
  • Their feelings about having healthcare providers make treatment decisions independent of the wishes of patients
  • Informing their loved ones of their expectations for treatment at the end of life
  • Informing loved ones of their fears and concerns regarding treatments under certain circumstances
  • Knowing how their loved ones would feel about the patient’s advance directive choices and if they could respect them
  • Selecting their primary medical POA and alternates based upon the knowledge that their chosen agents clearly understand the reasons behind the patient’s beliefs and decisions and could be trusted to abide by their wishes
  • Determining if their chosen agents would be willing to accept this responsibility
  • Ensuring that their agents understand the patient’s current health conditions, how these conditions could negatively progress, treatment options available,  adverse effects of these treatments, and prognosis with and without treatment including measures that may be used to prolong and sustain life
  • Their idea of what “quality of life” means to them
  • Their idea of what “dying with dignity” and “no heroic measures” means to them
  • Their thoughts about pain and their expectations regarding how their pain should be managed
  • Ensuring that they are informed about pain management options and effects
  • Their thoughts about life after death and how that thought may influence their advance directive choices
  • Discovering if they have any obstacles discussing issues regarding advance directives
  • Being aware of both their own and their loved ones’ understanding of the purpose of an advance directive

Healthcare providers, on the other hand, need to prepare to discuss advance directives with their patients by first being aware of their own feelings regarding the issues involved. Next, they must increase their own comfort level when discussing this topic with their patients. According to the results of patient surveys regarding advance directives, “most adults would prefer to discuss advance directives while they are well, preferably with a doctor who has known them over time…they look to their doctors to initiate the discussion”. [11] Yet, only approximately 15% to 25% of adults have actually completed advanced directives usually after hospitalization with a serious illness. [11] Further, a study of outpatients aged 65 years and older has determined that “a doctor’s inquiry increased two- to three-fold the chances that individuals would have an advance directive on file with their health plan”. [11]

Drs. Zwieg and Mehr from the University of Missouri-Columbia School of Medicine recommend that end-of-life care discussions between healthcare providers, their patients, and their families should consist of four main components. First, patient preferences should be determined. This could include their thoughts on treatments they want and those that they don’t. Second, prognosis for disease states that patients are experiencing should be discussed. This could include thoughts on how much time certain treatments or procedures would buy patients, as well as how these may affect their quality of life. Third, the goals of providing such treatments and procedures should be addressed. This could include knowing not only the outcomes hoping to be achieved, but also informing patients of the benefits, risks and even the financial cost involved. Lastly, a management plan should be developed keeping patients’ goals in the forefront. This could include advance directives that permit both broad and specific decisions to be made in various circumstances of serious illness and/or injury and death. [12]

Overall, it is most important for healthcare providers to be respectful and emotionally supportive of their patients’ choices. In discussing advance directives, providers must be aware of patients’ values and goals. [13] They should address any concerns, questions, and fears that patients and their families and/or agent’s may have and supply information necessary to make informed decisions.  Also, providers should keep a copy of advance directives in the patient’s medical record. Patients should be reminded to give copies to their primary agent and alternates, children, and any other people who need to know the patient’s wishes. Copies can be filed, without cost, at patients’ local hospitals. [6]

Of course, patients should be aware that they can change their advance care decisions if ever the need arises. Usually this will require destroying the original and copies of the old advance directives and replacing them with the updated ones. Living wills and medical power of attorney usually require two witnesses (one may need to be a notary) to observe the patient’s signing and dating the advance directive. [6] Patients should check their state regulations for guidance regarding the creation of advance directives (or consult the National Hospice and Palliative Care Organization’s website). [14] A lawyer is not required for this process. [5] Advance directives should be reviewed each year, dated and initialed. The original should be readily available when needed. Additionally a card stating that patients have advance directives should be kept in their wallet, in case of an emergency. [6]

Having an advance directive is a vitally important part of the healthcare plan. Healthcare providers need to make the time to address this topic with their patients. Advance directives will not only lessen their patients’ suffering and increase their peace of mind, but they will also provide a sense of autonomy and control over their death. [8] Additionally, they can take away some of the frustration, stress, confusion, guilt, and uncertainty for loved ones who are faced with the patient’s terminal situation. [15] Death and dying can be uncomfortable subjects to confront, but as healthcare providers, we must be able to do so every day. Providers may even teach by example by having an advance directive of their own. As was said by the late Dame Cicely Saunders, founder of the modern hospice movement, “You matter because you are you and you matter until the last moment of your life”. [16]


Karen Digby, BA, BSN, MS, GNP-BC, CWS

GNP Independent Contractor/Writer
Ann Arbor, Michigan

Published on November 26, 2013

 

Biosketch

Karen Digby is a nurse practitioner specializing in geriatrics. She received her training from New York University and the University of Michigan in Ann Arbor. In over ten years of practice, Karen has obtained a wealth of experience in various aspects of health care including home care, outpatient/ambulatory care, dementia care, subacute care, hospice, and assisted living and long-term care. Due to her expertise in geriatrics, Karen was selected as an item writer, by the American Nurses Credentialing Center, for the Gerontological Nurse Practitioner Board Certification Examination. She also co-authored an article on “Falls in the Elderly” in the Plastic Surgical Nursing Journal. Additionally, Karen is certified as a Wound Care Specialist through the American Academy of Wound Management.

References

  1. Kass-Bartelmes BL, Hughes R, Rutherford MK. Advance care planning: preferences for care at the end of life. Rockville (MD): Agency for Healthcare Research and Quality; 2003. Research in Action Issue #12. AHRQ Pub No. 03-0018. http://www.ahrq.gov/research/findings/factsheets/aging/endliferia/index.html
  2. Dr. Peter Saul. Dying in the 21st Century. TED Talk (TED x Newy). 2011. http://www.youtube.com/watch?feature=player_embedded&v=03h0dNZoxr8
  3. Department of Health and Human Services. Office of the Inspector General. Patient advance directives: early implementation experience. August 1993. http://oig.hhs.gov/oei/reports/oei-06-91-01130.pdf
  4. Rosen A, O’Neill J. Social work roles and opportunities in advance directives and health care decision making. National Association of Social Workers. March 1998. http://www.socialworkers.org/practice/aging/advdirct.asp
  5. Mayo Clinic. Consumer health. Living wills and advance directives for medical decisions. http://www.mayoclinic.com/health/living-wills/HA00014
  6. Advance medical directives. http://www.cpt.org/files/PP%20-%20Advance%20Directives.pdf
  7. Patients Right Council. Advance directive: protective medical decisions document. http://www.patientsrightscouncil.org/site/advance-directive-protective-medical-decisions-document/
  8. What is an advance health care directive? http://fcasocal.org/advance-directives.html
  9. Pope TM, Hexum M. Legal briefing: POLST: physician orders for life-sustaining treatment. J Clin Ethics. 2012 Winter;23(4):353-376.
  10. Marker RL. Patients Rights Council. Advance directive: protecting yourself and your family (part 2).  http://www.patientsrightscouncil.org/site/advance-directive-protecting-yourself-and-your-family-part-two/
  11. Wissow LS, Belote A, Kramer W, Compton-Phillips A, Kritzler R, Weiner JP. Promoting advance directives among elderly primary care patients. J Gen Intern Med. 2004 Sep;19(9):944-951.
  12. Zweig S, Mehr DR. Helping older patients and their families decide about end-of-life care. Missouri Medicine. 2003 Jan-Feb: 100(1): 62-28.
  13. Fischer GS, Arnold RM, Tulsky JA. Talking to the older adult about advance directives. Clin Geriatr Med. 2000 May;16(2):239-254.
  14. National Hospice and Palliative Care Organization. http://www.caringinfo.org/i4a/pages/index.cfm?pageid=1
  15. Span P. Why do we avoid advance directives? The New York Times. April 20, 2009. http://newoldage.blogs.nytimes.com/2009/04/20/why-do-we-avoid-advance-directives
  16. Clark D. Cicely Saunders: Selected writings 1958-2004. New York, NY: Oxford University Press, 2006.
Read More

CLL Latest Advances

ASCO 2013: Making Relevant the Latest Advances for CLL

 

Print This Post Print This Post

 

Dr_Koffman_2     Dr_Wierda_2

Overview:

The world of Chronic Lymphocytic Leukemia (CLL) is constantly changing. These videos are intended to provide information and clarify a few of the important, yet very relevant, factors that affect patients with CLL, their choices, and your role as their healthcare provider.


This activity is targeted for healthcare providers with patients with CLL.

continue

 

 



Published on November 7, 2013

 

Read More

An Influenza-like Illness that is Not Influenza

This case study reviews best practices for diagnosing and treating Lyme disease.

Case study: You are wrapping up clinic in the afternoon, when you see one of your long-time patients in the waiting room.  Bob is a relatively healthy 57-year-old man with a history of well-controlled hypertension. You saw him within the last month and made some adjustments to his medications, but you did not expect to see him back this soon.

When you walk into the examining room, Bob greets you and tells you that he is doing well with his blood pressure. But he has now developed a new-onset fever, headaches, and muscle pain. He is concerned because he feels much worse than he has in the past with these symptoms, and he skipped his flu vaccine this year. What do you do next?

Obviously, the differential diagnosis for these symptoms is vast. Bob could have an infectious disease brought on by a virus, bacteria, or parasite. He could have an underlying malignancy or a drug reaction from his new medication. Your next step is to gather more data by doing a physical exam. On exam, Bob is febrile and slightly tachycardic. His breath sounds are clear; he has no evidence of bruising or bleeding, and no abdominal pain. However, you notice a circular red rash with a central clearing at Bob’s ankle. What do you ask Bob?

You ask Bob if he has had a recent tick bite. A circular red rash with a central clearing is erythema migrans – the pathognomonic sign of Lyme disease. In early stages, the rash may appear like a solid red papule. Given time, the untreated rash will often increase in size and develop a central clearing. Solid red rashes may also be caused by other tick-borne illnesses, so remain vigilant.  You obtain serologies to test for Lyme disease, but given your high index of suspicion for Lyme disease and the fact that you are practicing in a Lyme endemic part of the country, you preemptively treat the patient.

States where Lyme disease is common include Connecticut, Delaware, DC, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, and Wisconsin.[i] People can become infected with Lyme disease in other states if they have traveled to Lyme endemic areas. So remember to ask about travel history and recent tick exposure.

Professional guidelines recommend that providers start high-risk patients on antibiotic treatment even before receiving the final results from laboratory tests. Lyme disease can be prevented by administering a single 200 mg dose of doxycycline within 72 hours of an Ixodes tick bite.[ii] For patients like Bob, a complete course of oral doxycycline is necessary.[iii] Counsel him to take his antibiotics as prescribed and to finish the entire course of treatment in a timely manner.  Recommend that your patients wear long sleeve shirts and pants when they are in forested areas and to check themselves for ticks. Anti-tick sprays can also be effective preventative measures. What if Bob fails to improve or relapses? See what the author would do in the comments section below. Weigh in with your thoughts and join the conversation. 

[i] Centers for Disease Control. Lyme Disease Statistics. Centers for Disease Control Website. https://www.cdc.gov/lyme/stats/tables.html. Updated November 21, 2016. Accessed February 9, 2017.

[ii] Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001;345(2):79-84.

[iii] Wormser GP, Ramanathan R, Nowakowski J, et al. Duration of antibiotic therapy for early Lyme disease. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2003;138(9):697-704.

 

Dr. V. Silverstein
Durham, NC

Read More

Targeting CGRP: Emerging Solutions in Migraine

Targeting CGRP: Emerging Solutions in Migraine

Program Overview1
In light of the evidence regarding the tremendous burden of migraine, leaders in the headache field have called for increased awareness of the availability of preventive efforts.

Dr. Diamond and Dr. Green will engage you in a lively discussion and presentation outlining the current landscape of chronic migraine including future thoughts on acute and preventative treatment. Our experts will share exciting data on new targets under development which have the potential to change the landscape of treatment in the future.

Participate in this interactive and forward-thinking activity to make sure you are prepared and “in the know” on the current and ongoing clinical trials targeting calcitonin gene-related peptide (CGRP) and their impact on the current unmet need in the treatment options for preventive treatment in migraine.

Learning Objectives
After completing this activity, the participant should be better able to:

  • Summarize the current landscape in the management and treatment of chronic migraine
  • Identify emerging therapies targeting CGRP in the treatment of migraine
  • Demonstrate knowledge of the role of the neuropeptide CGRP as a therapeutic target in the treatment of migraine
  • Summarize the current efficacy and safety data of CGRP monoclonal antibodies from clinical trials and their relation to other treatment options for the prevention of migraine headaches

Faculty/Planning Committee

Merle L. Diamond, MD
President, Managing Director
Diamond Headache Clinic
Chicago, Illinois

Mark W. Green, MD, FAAN
Director, Headache and Pain Medicine
Professor of Neurology, Anesthesiology, and Rehabilitation Medicine
Mount Sinai School of Medicine
New York, New York

Release/Expiration Dates
Release Date: December 28, 2016
Expiration Date: December 28, 2017


Accreditation Statement: MediCom Worldwide, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Designation Statement: MediCom Worldwide, Inc. designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


MediCom Worldwide, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity is acceptable for 1.0 contact hour of Continuing Education Credit. Universal Activity Number: 827-0000-16-133-H01-P. Knowledge-based CPE activity.

In order for CPE Monitor to authenticate credit, pharmacists/technicians must provide their e-Profile ID number from NABP and date of birth (in MMDD format) when registering for a CPE program. Please make sure to provide this information in your Member Profile accessed through the login/registration on the home page of this site.


Accreditation Statement: MediCom Worldwide, Inc., 101 Washington Street, Morrisville, PA 19067 is approved by the California Board of Registered Nursing, Provider Number CEP11380. MediCom designates this CNE activity for 1.0 contact hour. Program Number: 16-133-048

Activity provided by MediCom Worldwide, Inc.

Published on Primary Issues, 1/24/2017

Participant will be leaving Primary Issues and completing this activity on the hosts website (Emerging Solutions in Pain).

Read More

‘Tis the Season: Recognizing and Managing Post-Holiday Health Problems

Ah, the winter holidays: warm memories created when loving families get together to celebrate over home-cooked meals and pass down traditions from generation to generation. Or not.

For health care practitioners, January is the time of year when patients come to primary care clinic with season-specific health problems. New-onset chest pain, in particular, seems to be a common concern. At one end of the spectrum are patients who complain of the burning substernal chest pain associated with heartburn from drinking too much alcohol and eating excessively rich foods. On the other end of the spectrum are patients who present, often acutely or too late, with serious cardiovascular events, including myocardial infarctions, acute heart failure, and strokes. In fact, the days between Christmas and the New Year are some of the deadliest all year.

As we learned in medical school, death rates due to cardiac events go up between December 25 and January 7 in what is known as the “Christmas Holiday Effect.”  The commonly held assumption was that temporally, these cardiovascular deaths are associated with cold weather – not excess holiday cheer. However, a new study published last month in the Journal of the American Heart Association suggests that other factors associated with the holidays are more likely to be the cause of cardiovascular deaths than cold temperatures. [1] In this study, the temporal effect of the holidays on cardiovascular health was examined in a part of the world where cold in December is not an issue: the Southern hemisphere. Researchers found that people living in New Zealand were still more likely to die of cardiac events between December 25 and January 7, even though it is summer there. The cause for the temporal uptick in mortality rates does not appear to be related to cold temperature, infectious diseases, or the arbitrariness of the monthly reporting cycle. However, it is unclear what causes the increase in cardiac deaths.  Is it associated with increased alcohol and food consumption, worse emotional stress, delayed care, or displacement of death until after the holidays (where people modify their time of death until after a significant milestone has occurred)? Additional studies are needed.

The holiday season is also associated with other chest-pain inducing health problems, including what is colloquially known as “holiday heart” and panic attacks. Holiday heart syndrome is described as atrial arrhythmias, usually atrial fibrillation, associated with binging on alcohol.[2] However, a new study suggests that alcohol may increase atrial fibrillation at much smaller doses than previously assumed, through a combination of direct toxicity and by contributing to co-morbidities such as hypertension, obesity, and sleep disorders.[3] Any time patients present with arrhythmias or chest pain, it is important for practitioners to ask about alcohol use while obtaining a clinical history. If the EKG shows arrhythmias, practitioners should also remember to check a blood chemistry and normalize any electrolyte disturbances they discover.

Panic attacks also have a temporal pattern, peaking on weekends and holidays.[4] In contrast, the frequency of people evaluated for panic attacks decreases in the middle of the workweek. Potential reasons for increased panic attacks over the holidays may be that patients are more likely to have down-time to perseverate, may be more likely to consume alcohol and illicit drugs, or perhaps the anticipation of work stress is enough to trigger panic attacks in vulnerable patients.

In any case, these new studies serve to confirm what we have long suspected: the post-holiday clinic is different from the clinic at other times of the year. So, as we prepare to answer our patient’s questions about the best way to manage holiday weight gain, quit smoking, and start an exercise program, let’s take the time to consider what other health problems crop up this time of year and prepare to manage them.

Have you experienced the “Christmas Holiday Effect” in your practice?

[1] Knight J, Schilling C, Barnett A, Jackson R, Clarke P. Revisiting the “Christmas Holiday Effect” in the Southern Hemisphere. J Am Heart Assoc. 2016;5(12)

[2] Carey MG, Al-zaiti SS, Kozik TM, Pelter M. Holiday heart syndrome. Am J Crit Care. 2014;23(2):171-2.

[3] Voskoboinik A, Prabhu S, Ling LH, Kalman JM, Kistler PM. Alcohol and Atrial Fibrillation: A Sobering Review. J Am Coll Cardiol. 2016;68(23):2567-2576.

[4] Kao LT, Xirasagar S, Chung KH, Lin HC, Liu SP, Chung SD. Weekly and holiday-related patterns of panic attacks in panic disorder: a population-based study. PLoS ONE. 2014;9(7):e100913.

 

Dr. V. Silverstein
Durham, NC

Read More

Basal Insulin: Innovative Approaches

Basal Insulin as a Foundation of Diabetes Treatments: Innovative Approaches

CME Information

1

Program Overview

This two-session activity, as part of the Joslin Diabetes Center Virtual Symposia Series, is designed to address current, topical challenges in the care of people who have diabetes and related conditions and comorbidities, updating providers on new treatment advances and guiding optimal strategies for personalized management of these conditions.

Accreditation/Designation Statements

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network and PlatformQ Health Education, LLC. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Live Online Activity

Primary Care Network designates each live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Session I: Optimizing Basal Insulin Therapy: Evolving Tools and Treatment Designs
Wednesday, February 1, 2017 from 11:00AM – 12:00PM EST.

Session II: Optimizing Basal Insulin Therapy: Implementation, Management, and Overcoming Barriers
Wednesday, April 5, 2017 from 11:00AM – 12:00PM EST.

Online On-Demand Enduring Material

Primary Care Network designates each enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Enduring Materials Date of Release/Expiration

Session I: The enduring material will be available from February 1, 2017 – October 5, 2017.
Session II: The enduring material will be available from April 5, 2017 – October 5, 2017.

Learning Objectives

At the conclusion of this activity, participants will be able to:

  • Describe the pharmacokinetics and pharmacodynamics of the newer ultra-long basal and follow-on biologic (“biosimilar”) insulin formulations and how these differ from older formulations
  • Determine indications and methods to transition from analog basal insulin to ultra-long basal insulins and follow-on biologic (“biosimilar”) basal insulins to help achieve individualized patient treatment goals
  • Examine the evidence-based, guideline-driven protocols for therapeutic advancement to basal insulin therapy alone or in combination with other treatment modalities to achieve individualized patient goals
  • Identify potential patient, provider, and health care system barriers to initiation and titration of established and newer basal insulins, and methods to overcome these barriers

Jointly provided by Primary Care Network, PlatformQ Health Education, LLC and its collaborating partner Joslin Diabetes Center.

PCN_web joslin_diabetes_center_logo

 

click-here
Participant will need to initially complete a short registration form with Diabetes Series Live to participate in this activity. Future participation in Diabetes Series Live activities will allow you to skip the registration process and only require you to log-in.

Published February 12, 2017

 

Read More

Recent Advances in Intensifying Once-Daily Basal Insulin

A Whole New Ballgame: Recent Advances in Intensifying Once-Daily Basal Insulin

Print This Post Print This Post1

 

Program Overview
New medications and those just over the horizon are rapidly changing our options in treating our patients with diabetes who are falling short of glycemic goals. Dr. Eden Miller reflects on the recent advances in intensifying once-daily basal insulin.

Learning Objectives
After completing this activity, the participant should be better able to:

  1. Utilize improvements in basal insulin analogs and devices to address patient barriers to insulin
  2. Identify unmet needs in the management of patients with type 2 diabetes mellitus with basal insulin
  3. Identify patients with type 2 diabetes mellitus for whom basal insulin alone or with oral agents is inadequate to achieve glycemic control
  4. Describe the rationale for combining glucagon-like peptide-1 receptor agonists with basal insulin
  5. Implement strategies to support patient-centered care

Target Audience
Family Medicine Physicians, Nurse Practitioners, Physician Assistants, and other clinicians with an interest in diabetes care

Faculty & Disclosures
Eden Miller, DO
Director and Co-Founder, Diabetes Nation
High Lakes Healthcare
Bend, OR

Dr. Miller discloses that she and her husband are on the advisory boards for Abbott, Novo Nordisk, Boehringer Ingelheim, Eli Lilly and Janssen. She and her spouse are on the speakers’ bureau for Abbott, Novo Nordisk, Boehringer Ingelheim, Eli Lilly and Janssen.

Acknowledgement of Commercial Support
This CME webinar is supported by an educational grant from Novo Nordisk.

CME Information – AAFP Accreditation
This enduring activity, “A Whole New Ball Game: Recent Advances in Intensifying Once-Daily Basal Insulin”, has been reviewed and is acceptable for up to 1.00 Prescribed credit by the American Academy of Family Physicians. Term of approval begins 11/01/2016. Term of approval is for one year from this date. AMA PRA Category 1 Credit is also available. Physicians, Nurse Practitioners, and Physician Assistants should claim only the credit commensurate with the extent of their participation in the activity.

Instructions
To receive credit for this activity, the participant must first complete the activity pre-test questions. After listening to the entire webinar, the participant must complete the session post-test, evaluation, and all required personal information. To receive CME certificate, the participant will need to pass the post-test with 70% accuracy or better. If the participant receives less than 70%, the participant should review the activity/questions and take the test again. A printable certificate will be provided as an Adobe “PDF” file. Most users typically have Adobe Reader installed. If you do not have it installed, you can download it at https://get.adobe.com/reader/.

Contact Information
Nora Williams
Primary Care Education Consortium
Charlotte, NC 28277

Phone: 704-752-0257
Email: nwilliams@pceconsortium.org

Content for this activity provided by: Illinois Academy of Family Physicians, Primary Care Metabolic Group, and Primary Care Education Consortium

 

Published on Primary Issues, 1/9/2017

OnDemand-Slides_Audio

Participant will be leaving Primary Issues and completing this activity on the hosts website

Read More

Long-Acting, Reversible Contraception: A Case Study

This case study reviews the current options for long-acting, reversible contraception approved by the FDA in the United States.

Case Study: The patient is a 19-year-old woman who presents to your outpatient primary care clinic for a new-patient visit. Before entering the exam room, you review her chart and note that she is a healthy young woman with a minimal past medical history. Upon entering the room, you see a well-nourished patient in no apparent distress. The patient introduces herself as Emily Jones. She tells you that she recently relocated to the area and has come to your office to establish care. She would like to have refills on her EpiPen and discuss options for birth control.

You remember reading in her chart that she has a past medical history positive for peanut allergy, and the patient confirms that she has had several episodes of anaphylaxis since she was diagnosed in early childhood. You write a prescription for EpiPen for her. Then you ask her what she has used in the past for birth control. Emily tells you that she has been taking generic birth control pills for the past two years, but she often forgets to take her daily pill.

On further questioning, you obtain the patient’s complete social history, which includes a distant history of smoking and one current sexual partner. You ask Emily if she has been using birth control pills for contraception or for management of other medical problems, such as endometriosis. She tells you that she has had two previous sexual relationships with men and was using birth control for contraception.  She was also using condoms to prevent sexually transmitted diseases. Two years ago, Emily was diagnosed with Chlamydia and was treated with antibiotics. Her STD was diagnosed at the Public Health Department after her boyfriend at the time developed symptoms.  She has never had pelvic inflammatory disease and retested negative for STDs a year ago after breaking up with her boyfriend. Emily denies any previous pregnancies, miscarriages or live births. She did not experience any side-effects from her birth control pills. However, she was not taking her birth control pills consistently. At this point, the patient has a question for you:

“What about long-term birth control? Is there something I can just get once and not think about it until I’m ready to have kids?”

Question: What are the long-term birth control options currently available in the United States?

Answer:  Until recently, adolescents were not encouraged to use long-acting, reversible contraception (LARC) such as intrauterine devices (IUDs) and subdermal implants.[1] However, studies have shown that adolescents have much higher contraceptive failure rates when they use oral contraceptive pills, the vaginal ring, or patches. As a result, organizations like the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the World Health Organization have been investigating the long-term effects of intrauterine devices and subdermal implants. Multiple studies have shown that outcomes in pregnancy prevention are much better with long-term contraception in adolescent populations, equaling the contraceptive rates of sterilization. At the same time, LARC do not negatively impact future fertility and are safe for patients.

Health care providers insert and remove all forms of long-acting, reversible contraception. As a result, decreased access to health care providers is a meaningful barrier to care for women like Emily who are interested in long-term contraception. At the same time, primary care providers who prescribe birth control have the opportunity to improve care for their patients by familiarizing themselves with the different forms of long-acting reversible contraception available and counseling their patients responsibly.

At this time, two types of intrauterine devices and one type of subdermal implant are approved for long-acting contraception. The intrauterine devices currently approved in the United States are the levonorgestrel-releasing IUDs and the copper T 380A.[2] The subdermal implant is the etonogestrel-releasing (ENG) subdermal implant going by the name Nexplanon. Nexplanon is identical to Implanon except for the addition of barium, which serves as a radiographic tracer.

Levonorgestrel-releasing IUDs come in several doses, including the Mirena (releases 20 mcg of levonorgestrel per 24 hours) and the Skyla (releases 14 mcg of levonorgestrel per 24 hours). Levonorgestrel-releasing IUDs last for five years and prevent fertilization by thickening cervical mucus, thinning the endometrial lining, and suppressing ovulation in some women. They also improve dysmenorrhea and significantly decrease monthly blood loss during menstruation.

The copper T 380A (ParaGard) is a non-hormonal device consisting of a polyethylene frame encased in copper. Copper appears to be spermicidal and the copper T 380A works by inhibiting fertilization. This device lasts up to ten years, longer than any other approved long-acting reversible contraceptives. However, it does not improve menorrhagia or dysmenorrhea, and may worsen these symptoms in some patients.

Health care providers insert and remove IUDs through the cervix. Some patients experience severe pain on insertion, while many either experience no pain or minimal pain. A Cochrane review in 2009 concluded that there were no interventions that conclusively decrease pain during or after insertion, although previous trials used NSAIDs for pain control with variable results.[3] Some health providers are concerned that inserting IUDs in adolescents will increase risk of PID and STDs. Studies do not support this concern; however, adolescents do have high rates of STDs at baseline. Therefore, health care providers should test patients either before IUD insertion or at the time of insertion for asymptomatic Chlamydia and Gonorrhea. If there is frank purulent discharge or other signs of an STD, IUD insertion should be postponed until after the patient has been effectively treated.

The ENG implant is approved for three years of use and provides excellent contraceptive effectiveness. It works by inhibiting ovulation, thickening cervical mucus and thinning the endometrial lining to prevent conception. In addition to preventing pregnancy, the ENG decreases dysmenorrhea and improves acne. Its primary side-effect is unpredictable menstrual bleeding.  Health care providers insert the device into the patient’s upper arm under local anesthetic. The ENG is 4 cm long, with a 2mm diameter. Unlike the IUD, patients do not need to undergo a pelvic exam or STD testing prior to insertion.

Given these long-acting reversible contraceptive options, which ones would you recommend for this patient and why? Let us know in the comments section below.

[1] Mcnicholas C, Peipert JF. Long-acting reversible contraception for adolescents. Curr Opin Obstet Gynecol. 2012;24(5):293-8.

[2] Hardeman, J. and Weiss, B. Intrauterine Devices: An Update. American Family Physician. 2014 Mar 15;89(6):445-450.

[3] Allen RH, Bartz D, Grimes DA, Hubacher D, O’brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev. 2009;(3):CD007373.

Dr. V. Silverstein
Durham, NC

Read More

Chronic Respiratory Diseases

Early Identification and Diagnosis of Chronic Respiratory Diseases: The ‘Primary’ Role in Improving Patient Outcomes in Asthma, COPD, and IPF

CME Information

Accreditation/Designation Statements

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Boston University School of Medicine and Rockpointe. Boston University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Boston University School of Medicine designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

All other healthcare professionals will be issued a certificate of participation.

Release/Expiration Date

This internet, enduring activity (audio/slides) will be available for one year, beginning December 26, 2016 through December 26, 2017.

Program Overview

Effective treatments for common chronic respiratory conditions are available to alleviate symptoms, prevent disease progression, and improve quality of life; however, many patients attribute their shortness of breath and decreased ability to perform usual activities to the normal aging process and only seek treatment in urgent-care settings for acute exacerbations. Because many respiratory conditions present with similar symptoms, patients with asthma, chronic obstructive pulmonary disease (COPD), and idiopathic pulmonary fibrosis (IPF) may be misdiagnosed and are not engaged in appropriate routine care for their conditions, causing a costly cycle of exacerbation and progressive lung damage. Thus, an awareness of “red flags” in patient histories and physical exams can lead primary care physicians to perform appropriate diagnostic tests to differentiate these conditions and ensure appropriate treatments based on established guidelines.

Primary care providers (PCPs) are in a key position to detect the early warning signs of chronic respiratory diseases and initiate treatments earlier in the disease course to delay progression and improve outcomes for patients with asthma, COPD, and IPF. In COPD, for example, 85% of patients with COPD visited their primary care doctor or a clinic at least once with respiratory symptoms in the 5 years before diagnosis. According to the National Committee for Quality Assurance (NCQA), early diagnosis of COPD may protect against worsening symptoms, as several studies have found that lung function declines faster in the earlier stages of disease. However, as many as 50% of individuals with COPD symptoms have not received a diagnosis. This program is designed to provide PCPs and family physicians with the awareness to screen at-risk patients for common respiratory conditions and perform and interpret appropriate diagnostic tests to confirm diagnoses of asthma, COPD, and IPF.

Learning Objectives

After completing this activity, the participant should be better able to:

  1. Detect the early warning signs of common respiratory diseases and apply appropriate diagnostic tests to make timely and accurate diagnoses of COPD, asthma, and IPF in the primary care setting
  2. Provide guideline-driven care for patients with COPD, asthma, and IPF, including specialist referrals when necessary
  3. Describe strategies to facilitate patient self-management and a multidisciplinary care approach for chronic respiratory conditions by engaging patients and monitoring for response and progression

Jointly provided by Boston University School of Medicine and Rockpointe.

Published December, 2016

 

Read More

Migraine Management

Tools for Successful Migraine Management

CME Information

Accreditation/Designation Statements

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network (PCN) and Rockpointe. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Primary Care Network designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

All other healthcare professionals will be issued a certificate of participation.

Release/Expiration Date

This internet, enduring activity (audio/slides) will be available for one year, beginning December 26, 2016 through December 26, 2017.

Program Overview

Migraine is a devastating chronic neurological pain condition that affects nearly 38 million Americans, resulting in significantly reduced quality of life and a staggering loss of human productivity. Primary care providers (PCPs) are usually the first clinicians to examine patients when they report headache pain, and therefore are in a key place to manage these patients for optimal quality of life.

The educational initiative will provide PCPs with the knowledge and skills to provide care following the three tenets of effective management of migraine headache: 1) establish a proper diagnosis; 2) provide patient education; and 3) ensure adequate treatment. During this activity, expert faculty will present patient case studies, including applying criteria for diagnosis and differentiating migraine from other types of headache. Faculty will also provide strategies for effective patient communication and education, as well as preventive strategies and practical information on the treatments for acute migraine.


Learning Objectives

After completing this activity, the participant should be better able to:

  1. Describe current diagnostic criteria for diagnosing headache and migraine
  2. Apply patient education protocols to teach migraine patients about the prevention and management of migraine disorders, especially regarding the need for compliance with pharmacologic and non-pharmacologic approaches
  3. Explain the currently approved therapeutic options for migraine, and formulate individual management plans for treating migraine by combining pharmacologic and non-pharmacologic approaches

 

Jointly provided by Primary Care Network and Rockpointe.

pcn_rockpointe_logo

Published December, 2016

 

Read More

Achieving Gout Goals

Achieving Gout Goals in Your Practice

CME Information

Accreditation/Designation Statements

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network (PCN) and Fortis Spectrum. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Primary Care Network designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

All other healthcare professionals will be issued a certificate of participation.

Release/Expiration Date

This internet enduring activity will be available for one year, beginning November 30, 2016 through November 30, 2017.

Program Overview

Gout is the most common form of inflammatory arthritis affecting 4% of US adults. In a recent study of more than 13,000 patients with gout, less than one-third (1/3) “ever” achieved target serum urate goals over an extended follow-up period.  In short, gout is a problem for patients and straining healthcare systems. Although gout is a problem in primary care, there are paths leading to improved care, better outcomes, and reduced costs.

Dr. Paul Doghramji is a clinician and educator with many years of gout practice experience.  Significant research over the past 8-10 years has led to expansion of therapeutic options for treating gout and providing focus to the need for gout-ready practices.  To that end, Dr. Doghramji summarizes the new information into useful practice guidance.

Learning Objectives

After completing this activity, the participant should be better able to:

  1. Treat patients to goal, achieving uric acid (UA) levels of 6 mg/dL or 5 mg/dL by utilizing appropriate ULT
  2. Design individualized treatment plans that optimize patient knowledge and response

 

Jointly provided by Primary Care Network and Fortis Spectrum.

pcn_fortis_logo

continue-to-activity

Published November 30, 2016

 

Read More

T2DM: A Case-based Approach

Effective and Timely Management of Patients with T2DM: A Case-based Approach

CME Information

Program Overview

Primary care clinicians in all settings are frequently not meeting guideline-recommended performance measures for diabetes. Many clinicians cite an improved understanding of the mechanisms of action of anti-hyperglycemic agents in the context of T2DM pathophysiology as an urgent educational need. The recent approvals of novel anti-hyperglycemic agents, in addition to the publication of cardiovascular outcomes results for some of the non-insulin therapies, warrant education for clinicians who are unclear on which therapies to initiate and how and when to appropriately intensify anti-hyperglycemic therapies. Evidence suggests that primary care clinicians are also unsure when to initiate insulin therapy, which insulin and how much to use, and how to intensify insulin in patients who need it. Another contributor to poor patient outcomes is non-adherence to therapies, whether due to fear of injections, fear of side effects, or increased dosing frequency and/or pill burden.

Leading faculty in the field of T2DM management help address these gaps in this clinically relevant, case-based, patient-centered educational activity. Faculty review current guideline recommendations and clinical-trial data pertaining to non-insulin, insulin, and insulin plus non-insulin therapies. Faculty provide strategies for effective patient management and communication.

This activity was developed from the live session held during the MEDX Regional CME conference in Atlanta, GA on September 23, 2016.

Learning Objectives

After completing this activity, the participant should be better able to:

Module 1: New Thinking and Approaches in the Management of Type 2 Diabetes
1. Assess the current understanding of the pathophysiology of T2DM and the targets of various anti-hyperglycemic therapies

Module 2: Type 2 Diabetes Management – Case 1: Reducing Hypoglycemic Risk and Case 2: Reducing Cardiovascular Risk
1. Target the pathophysiological disturbances in patients with T2DM using mono- or combination therapies based on efficacy and safety
2. Manage patients with T2DM optimally in accordance with guideline recommendations

Module 3: Type 2 Diabetes Management – Case 3: Initiation and Intensification of Insulin
1. Achieve optimal glycemic control in a timely manner in T2DM patients who are not at goal by appropriately initiating and intensifying insulin or insulin plus non-insulin therapies

Module 4: Patient Engagement to Overcome Barriers, Minimize Risk, and Improve Adherence
1. Communicate effectively with T2DM patients to overcome barriers, minimize risk, and improve adherence

Release/Expiration Date

This internet, enduring activity (audio/slides) will be available for one year, beginning December 15, 2016 through December 15, 2017.

Accreditation/Designation Statements

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Primary Care Network (PCN) and Rockpointe. Primary Care Network is accredited by the ACCME to provide continuing medical education for physicians.

Primary Care Network designates each enduring material for the number of AMA PRA Category 1 Credits™ listed below. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Module 1: New Thinking and Approaches in the Management of Type 2 Diabetes
0.5 AMA PRA Category 1 Credit

Module 2: Type 2 Diabetes Management – Case 1: Reducing Hypoglycemic Risk and Case 2: Reducing Cardiovascular Risk
0.5 AMA PRA Category 1 Credit

Module 3: Type 2 Diabetes Management – Case 3: Initiation and Intensification of Insulin
0.25 AMA PRA Category 1 Credit

Module 4: Patient Engagement to Overcome Barriers, Minimize Risk, and Improve Adherence
0.25 AMA PRA Category 1 Credit

All other healthcare professionals will be issued a certificate of participation.

Jointly provided by Primary Care Network and Rockpointe.

 

pcn_rockpointe_logo

Click below to begin a CME activity:
module2_button

module3_buttonmodule4_button

Published December 15, 2016

 

Read More