Continuous parenteral hydromorphone is used to treat pain in palliative care. Case reports have suggested that neuroexcitatory symptoms, such as agitation, myoclonic activity, and even seizures may occur during administration. However, little information exists on the incidence of these side effects or their relationship to the dose or duration of parenteral hydromorphone. A retrospective chart review was performed on 48 terminally ill hospice patients who received continuous parenteral hydromorphone for pain control. Chart reviews were conducted searching for three neuroexcitatory symptoms: agitation, myoclonus, and seizures; the incidence and relationship of these symptoms were statistically compared to the maximal dose and number of days on continuous parenteral hydromorphone. We found that agitation, myoclonus, and seizures were not associated with the patients gender, age, or diagnosis but found that agitation was associated (p < 0.01) in patients with known metastatic disease. Agitation, myoclonus, and seizures were independently associated with the maximal dose (p < 0.05, p < 0.001, and p < 0.05) and with the duration (p < 0.01, p < 0.05, and p < 0.01) of continuous parenteral hydromorphone A possible mechanism for these findings is hydromorphone-3-glucoronide, a metabolic product of hydromorphone, which has been implicated in neuroexcitatory symptoms in laboratory investigations.
Faced with a funding crisis that threatened a single-sponsor family medicine residency program critical to a county-wide health system, health care organizations located in the California community described in this article formed a nonprofit, corporate graduate medical education (GME) consortium to sponsor a new residency program. Institutional GME sponsors are typically single hospitals or academic medical centers associated with medical schools. However, as the authors describe, community-based residency sponsorship through a GME consortium can allow multiple stakeholders to assume a model of shared ownership that reflects alignment of pooled community resources with the distributive benefits associated with residencies. Although this community's stakeholders encountered expected governance complexities as they worked to reconcile competing interests, they successfully collaborated to develop the Valley Consortium for Medical Education by addressing a variety of fiscal, workforce benefit, and community coordination challenges. The authors describe the key phases of development and discuss the challenges that must be overcome to establish an institutional sponsor with multiple stakeholders. The financial pressure that traditional institutional sponsors are experiencing with the inexorable decline in GME funding may prompt them to explore partnerships in which they can share expenses for the mutual benefit of physician workforce development. The authors believe that the community-based GME consortium is a viable model to consider.
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