Medicine Advice Research Articles

Success in the Face of Reform

We hear repeatedly that health reform will dramatically affect the way postacute and long-term care (PA/LTC) will participate in the U.S. health care system. New models of care delivery include accountable care organization, medical homes, and demonstration projects that combine Medicare and Medicaid dollars. All have core principles of accountability, integration of care, emphasis on long-term health outcomes, and better transitions. So, where do physicians look for guidance in the postreform world? Many of us immediately think of innovative centers such as the Cleveland Clinic and the Mayo Clinics. There is certainly much to learn from them, but how transferable are their practices? How dependent are their models on concentrated populations and resources? What do they offer to rural or suburban practices? At the same time, some independent physician practices are trying to chart their own paths through the changing environment without sacrificing physician leadership. One such model is Chappel Health and Wellness in central Florida. It's led by Chris Chappel, MD, CMD, and includes three other physicians and six physician assistants. They operate three clinics and provide medical direction to 25 PA/LTC facilities in the three counties around Orlando. What makes Dr. Chappel's practice model unusual is that it incorporates “discharge clinics” in cooperation with local hospitals. These clinics streamline transitions from the acute setting by giving patients on-site access to a pharmacy, a home health agency, and a durable medical equipment provider. The discharge clinics also set the immediate follow-up appointments with primary care physicians and specialists. The pharmacy's presence alone mitigates what is a major contributor to hospital readmissions, medication errors. Each Chappell clinic also has a wellness program incorporating diet and exercise coaching in a 5,500 square-foot gym. In a final twist, Chappel Health and Wellness has a clinical research arm staffed by a pharmacist and two physicians. Dr. Chappel has been working with Florida's Quality Improvement Organization on a project to reduce hospital readmissions. The collaboration includes four nursing homes, two home health agencies, and a patient-advocacy and coaching organization. The project targets seven of the leading readmission diagnoses, including heart failure, chronic obstructive pulmonary disease, and sepsis. The linchpins of the project are two: immediately offering a health coach to a patient at hospital discharge and use of the Interventions to Reduce Acute Care Transfers (INTERACT) program for improving long-term care transitions. The results have been dramatic. Nursing homes have become more comfortable treating patients with complex diagnoses and talking with family members about care-setting choice. Hospital admission rates of residents in the four nursing homes have decreased from 26% to 17% and are still falling. Thus, Chappel Health and Wellness is firmly planted in both community-based and facility-based long-term care. Dr. Chappel describes the model as a medical village concept within a clinic. He and his colleagues strive to follow the Institute of Medicine's advice on how to give appropriate and affordable care: “Deliver the right care at the right time by the right provider in the right setting.” Is Dr. Chappel naïve in trying to go it alone in the post–health reform world? He says that he is striving to let primary care do what it does best and eliminate or reduce the need for the administrative middle man of an accountable care organization (ACO), for instance. “I think we are years away from bundled payments for physician services in the outpatient world. If it happens sooner, our concept will be ready for it and will have a track record, especially when it comes to decreasing 30-day readmits,” Dr. Chappel said. Maybe he's not naïve. He says that physician groups partnering with hospitals, nursing homes, insurance companies, and other entities is inevitable. “We are starting small to work out the bugs, then expanding in whatever direction it takes us.” The handwriting is on the wall. Governmental payers, employers, and health insurance companies are all pushing for more integrated health care systems, where physicians and hospitals are held accountable for the overall cost and quality of care. It is likely that all physicians will need to participate in systems requiring more communication, care coordination, and quality-data reporting. The Chappel Health and Wellness model strives for coordinated services that are rooted deeply in a profound respect for patients. In Dr. Chappel's view, hospitals, LTC facilities, and physicians' practices can and must work together effectively.

The Duke and the Stars: Astrology and Politics in Renaissance Milan by Monica Azzolini (review)

Reviewed by: The Duke and the Stars: Astrology and Politics in Renaissance Milan by Monica Azzolini Michael A. Ryan Monica Azzolini. The Duke and the Stars: Astrology and Politics in Renaissance Milan. Cambridge, Mass.: Harvard University Press, 2013. xiii + 370 pp. Ill. $49.95 (978-0-674-06663-2). The intersection of astrology with the construction of political power is the focus of Monica Azzolini’s The Duke and the Stars: Astrology and Politics in Renaissance Milan. In her excellent book, Azzolini demonstrates that astrology in late medieval Italian courts, far from being some mere pastime or plaything, was central toward the fashioning of authority among members of the Italian political elite. This was especially so during a time of significant crisis, as the Italian peninsula found itself on the brink of external invasion at the waning of the fifteenth century. In particular, Azzolini studies how astrology was crucial within the world of the Sforza dukes of Milan. These Renaissance princes held astrologers in high esteem and patronized them to such an extent that every political and medical decision they enacted was done solely after extensive consultation with their resident court astrologer. A historian of science, Azzolini breaks new ground in fifteenth-century political history with her meticulous archival research. Over the course of five chapters, Azzolini traces this deep connection between astrology and Renaissance political praxis. She primarily analyzes the private letters exchanged between the dukes and their astrologers, plus the graduation papers of those students from the University of Pavia, which provided the Sforza dukes with their astrologers, although she also investigates imagery from late medieval and early modern manuscripts and incunabula. Her first chapter goes into extensive detail about both the scientific curriculum of study for astrologers trained at the University of Pavia and the techniques and principles that astrologers learned to cast horoscopes and genitures, as well as to diagnose and treat maladies. Her second chapter delves deeply into the sensitive role that astrological prognostications played in the political world of the Renaissance. This information was a double-edged sword, used to counsel a Renaissance prince and to provide valuable secret information for his enemies. Chapter 3, an in-depth study of the sickly, intemperate, and cruel Galeazzo Maria Sforza, demonstrates the role of astrological medicine in attempts to restore his health, along with the duke’s attempt to control the production and circulation of astrological prognostications about him on the eve of his 1476 assassination. Readers of this journal will find the fourth chapter of Azzolini’s book particularly germane, as Azzolini demonstrates the centrality of physician–astrologers within the Sforza court, those individuals who operated within the two disciplines, dispensing in equal amounts astrological medicine or astrological political advice when the heavens were most auspicious. Physician–astrologers such as Ambrogio Varesi da Rosate, specifically, were invaluable advisers for the Sforza dukes and occupied positions of prestige and power within their court. These physician– astrologers’ fortunes, however, waxed and waned with those of their noble patrons. For instance, the rise and fall of the astrologer Varesi was tied directly to the shifting fortunes of Ludovico Sforza, the focus of the fifth chapter of Azzolini’s study and, for all intents and purposes, the last of the Sforza dukes. Ludovico’s increasing [End Page 380] reliance upon Varesi to chart his every move, which sometimes bordered on the irrational, reflected his growing insecurity about the future. This culminated in the 1494 descent of the French in Italian affairs and the foreign occupation of Milan in 1499. Disgraced, Ludovico eventually fled Milan to later be incarcerated, ushering in a dour period when the arts and sciences suffered in Milan and studies at the University of Pavia languished. As his patron’s fortunes collapsed, so did Varesi’s, as he fell into ignominy, losing his possessions and his property. Scholars of premodern astrology, broadly, and those who work on the juncture of astrology, medicine, and political authority, specifically, will find a treasure trove of materials in Azzolini’s splendid book. In addition to being very familiar with the extant scholarly, especially Italian, secondary literature, Azzolini distills a great quantity of detailed information via her lucid and accessible prose...

Knowledge, Attitudes, and Practices of US Practitioners Who Provide Pre‐Travel Advice

As international travel increases, many health care professionals are being asked to provide pre-travel advice. We designed an anonymous web-based survey to assess the extent to which primary care providers (PCPs) provide travel medicine advice and how their understanding and delivery of itinerary-specific advice and management compare with that of travel medicine specialists. We surveyed randomly selected US PCPs registered in the Pri-Med Institute (now pmiCME) database and US travel medicine specialists from the International Society of Travel Medicine (ISTM), American Society of Tropical Medicine and Hygiene (ASTMH), and Centers for Disease Control and Prevention (CDC) yellow fever (YF) vaccine provider mailing lists. SAS software (SAS Institute, Cary, NC, USA) was used for all analyses. Of 14,932 e-mails sent to valid e-mail addresses, 902 yielded complete or partially completed surveys (6.0% response rate). Eighty percent of respondents personally provided pre-travel advice (95% of travel medicine specialists versus 73% of PCPs). About two thirds of PCPs (68%) providing pre-travel consultations saw <50 travelers per year whereas 30% of travel medicine specialists saw <50 travelers per year. More travel medicine specialists (59%) than PCPs (18%) saw >500 travelers per year. Familiarity with travel-specific vaccines (YF, Japanese encephalitis) and provision of written educational materials increased as volume of travelers increased. Familiarity with antimalarial side effects and malaria resistance patterns, and knowledge scores based on brief pre-travel scenarios were higher in travel medicine specialists, ASTMH or ISTM certificate holders, and respondents who saw more pre-travel patients. Many PCP survey participants provided pre-travel advice, but most saw few travelers. Volume of travelers and holding an ASTMH or ISTM certificate had the greatest influence on knowledge of travel medicine and provision of appropriate advice and recommendations. Creating easily accessible travel medicine education programs for US providers from a wide range of disciplines is needed to improve the management of travelers.

What do community pharmacists do?: results from a work sampling study in London

Government and professional groups within the pharmacy have sought to extend the role of pharmacists from dispensing-focused towards the provision of further pharmaceutical services. The aim of this research was to describe how pharmacists in current English community pharmacy practice spend their time using a work sampling method. Ten community pharmacies across London were purposively selected. Trained observers visited one pharmacy each to record the activities of the responsible pharmacist, using a fixed-interval work sampling technique. Activities were recorded every minute, into one of 18 predefined, piloted and tested activity codes. Data were recorded for 4 h each day for 1 week at each pharmacy during 2011. A total of 12 306 observations were recorded across the pharmacies. The pharmacists spent the majority of their time assembling and labelling products (median 25.2%; quartiles 19.0, 31.0) and monitoring prescriptions for clinical appropriateness (10.6%; 8.3, 13.0). The next most prevalent activity code was rest, waiting and breaks (8.6%; 6.9, 15.3). They spent more time offering non-prescription medicines advice (6.6%; 3.5, 7.6) than prescription medicines counselling (3.8%; 2.8, 5.6). The provision of pharmaceutical services accounted for 3.2% (0.8, 7.5) of pharmacists' time. Overall, 46.2 % (35.2, 56.2) of their time was spent on activities deemed to be 'Professional'. Despite repeated attempts during the last decade to shift pharmacists' roles towards patient-care activities, on the basis of this research, community pharmacists continue to spend the majority of their time on technical dispensing (as opposed to cognitive patient-centred) tasks.

Medicines advice often goes ignored by patients

Medicines advice often goes ignored by patients

Patients rate medicines advice from pharmacists more highly than that from doctors and nurses

Patients rate medicines advice from pharmacists more highly than that from doctors and nurses

The place of new oral anticoagulants in travel medicine

New oral anticoagulants are increasingly used instead of vitamin K antagonists or low molecular weight heparins. Hence, more individuals treated with new oral anticoagulants will seek travel medicine advice. Travel medicine experts should therefore become familiar with new oral anticoagulants and with their impact and role in travel medicine. This review summarizes pharmacological characteristics and approved indications of dabigatran, rivaroxaban and apixaban, and highlights their relevance for travellers on permanent oral anticoagulation and for the prophylaxis of travellers' thrombosis. Compared to vitamin K antagonists, the new oral anticoagulants have many advantages: they do not have interactions with food, they have lower potential for drug-drug interactions and do not require regularly performed laboratory tests. The oral administration, obviating the need to carry needles and syringes during travel may give the new oral anticoagulants a further advantage over low molecular weight heparins. Clinical experience with the new oral anticoagulants, however, is still rather limited and there is concern regarding the clinical management of patients treated with new oral anticoagulants who suffer from severe bleeding or who need urgent invasive procedures. Overall, it remains an individual decision based on a risk/benefit analysis as to whether or not patients on long-term treatment with vitamin K antagonists should be switched to new oral anticoagulants for intended travel. Further caution is also indicated so that the availability of orally administered new anticoagulants should not lead to undifferentiated and unjustified prescription of anticoagulants for the prophylaxis of traveller's thrombosis.

Sector must work together to improve medicines advice

Sector must work together to improve medicines advice

Basic medicines advice not being offered, conference hears

Basic medicines advice not being offered, conference hears

Haut und berufliche UV-Strahlung künstlicher Quellen

In various areas of professional activity, exposure of skin to ultraviolet radiation coming from artificial sources may occur. These UV rays differ from the solar UV radiation due to their intensity and spectrum. We review current developments with the introduction of statutory exposure limit values for jobs with UV radiation from artificial sources, a selection of relevant activities with artificial UV exposure and an overview of the occurrence of skin disorders and dermatologically relevant skin diseases caused by these specific occupational exposures. The latter is relevant for medical advice in occupational dermatology and occupational medicine. On the basis of existing studies on welders and studies regarding occupations with "open flames" (using the example of the glassblower) it is evident that so far no reliable data exist regarding the chronic photodamage or the occurrence of UV-typical skin cancers, but instead clear evidence exists regarding the regular occurrence of acute light damage in these occupations.

P05.08. A study of complementary therapies and counselling: an integrative model for refugee health care

Purpose Two qualitative research studies were conducted to examine the experiences of refugee women involved in a complementary therapies (CT) program and to investigate counsellors’ reasons for referral to CT. Combined, the two studies aim to provide a comprehensive overview of this innovative model of integrative health care. The Victorian Foundation for Survivors of Torture, known as ‘Foundation House’, is a mental health service for refugees and asylum seekers in Melbourne, Australia. The organisation was established in 1987 and within two years incorporated a CT program with the aim to provide a holistic and culturally relevant health care approach. The inclusion of CT (naturopathy, Western herbal medicine, massage, yoga, nutritional and dietary advice) as a core component of the service delivery positioned the organisation as one of the first Westernbased torture trauma services to fully integrate psychological care and non-biomedical health care practices.

Prescriber Feedback to Improve Quality Use of Medicines among Older People: the Veterans' MATES Program

ABSTRACTSince 2004, the Department of Veterans' Affairs (DVA) has funded the Veterans' Medicines Advice and Therapeutics Education Services (MATES) program. The main intervention of the program is quarterly targeted patient‐specific prescriber feedback. The feedback comprises a list of relevant medications dispensed to each patient and notes about potential medication‐related problems specific to the intervention. Supportive educational material is provided to assist general practitioners (GPs) resolve these medication‐related problems. Veterans identified in the GP mailing are sent an educational brochure highlighting medication issues and encouraging them to speak with their doctor. To enable pharmacists to support this practice change, educational material is also provided to all pharmacies and accredited pharmacists. The most recent of the 28 interventions implemented to date have addressed osteoporosis, opioid‐induced constipation and urinary incontinence. Overall, program materials have been mailed to 249 454 veterans, 34 527 GPs and around 8000 pharmacies and accredited pharmacists. Evaluation has demonstrated a doubling of home medicines review (HMR) rates in the veteran population. Analyses of the DVA data have reported a 45% reduction in hospitalisation for heart failure following HMR among veterans with heart failure (adjusted hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4–0.8), and a 79% reduction in hospitalisation for haemorrhage (HR 0.2; 95%CI 0.05–0.9) 2 to 6 months after an HMR in veterans dispensed warfarin. Veterans' MATES has resulted in clinically significant improvements in medication and health service use.

Group interviews with people taking long-term medication: comparing the perspectives of people with arthritis, respiratory disease and mental health problems

Abstract Objective To examine experiences of medicine use, advice and support from the perspectives of people taking medicines long term for arthritis, respiratory disease and mental health problems. Method Twelve group interviews were conducted, four with each of the three chronic illness groups. Setting Interviews were arranged through national and local voluntary organisations and conducted as part of their regular meetings. Key findings The most prominent issue for all the Arthritis Care groups was information about side effects. People discussed the benefits of having this information and the reasons they believed that it was not generally provided. People with respiratory disease described difficulties of obtaining information as a problem in the operation of the health service in Britain, where participants may or may not find out about different products by chance. In all these discussions there were examples of how people used their regular group meetings to inform each other. For people with mental health problems, participation in decisions concerning medicines and the attitudes of health professionals were the most prominent issues. Members of all groups, across all chronic illnesses, claimed that adequate information was not shared with them during consultations with professionals. However, different perspectives of involvement in decision-making regarding therapy were distinguishable. Pharmacy services did not feature prominently in any of the group discussions. Conclusion The study revealed differences between the illness groups in the emphasis participants placed on different issues. However, there were also common concerns, in particular relating to obtaining information and the attitudes of professionals. While pharmacy services were not prominent in discussions, a range of unmet needs concerning medicines were identified. This indicates that opportunities exist for pharmacists to provide more responsive services that would be valued by people taking long-term medication.

An investigation into the effect of advice from the Scottish Medicines Consortium on the use of medicines in Scotland's Health Service

The aims of the study were to determine the effect of advice from the Scottish Medicines Consortium (SMC) on the use of medicines within Scotland's National Health Service (NHS) and generate hypotheses that may explain differences in the impact of advice on the use of individual medicines. A retrospective analysis of medicine advice issued between January 2002 and December 2005 was performed. The inclusion criterion was medicines with a 'not recommended for use' decision (NRD) from the SMC (57 out of 207 medicines submitted). The exclusion criteria were medicines used predominately in secondary care and medicines with multiple indications. In total, 20 medicines fulfilled these criteria. The volume of prescribing was measured by each medicine's gross ingredient cost to the prescribing budget. Before the SMC published advice there was use, though limited, of all 20 medicines. After an NRD, the pattern of use was variable, with the use of some medicines stabilizing or declining but others increasing. We identified factors to help explain unexpected use in some cases. These included delays between medicine launch and initial SMC advice, the publication of conflicting advice from different national bodies and failure to engage with relevant clinical experts early in the medicine review process. This study demonstrates the complex relationship between advice following health technology assessment and change in clinical practice. When this study was done there were significant limitations in the collection of prescribing data within the NHS, which recent changes promise to improve.

Integration of complementary and alternative medicine information and advice in chronic disease management guidelines

The growing evidence on the benefits and risks of complementary and alternative medicine (CAM) and its high rate of use (69% of Australians) - particularly for chronic or recurrent conditions - means increasing attention on CAM. However, few people disclose CAM use to their GP, and health professionals tend to inadequately discuss CAM-related issues with their patients, partly due to insufficient knowledge. As clinical and non-clinical chronic condition management guidelines are a means to educate primary health care practitioners, we undertook a content analysis of guidelines relevant to two common chronic conditions - cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) - to assess their provision of CAM-related information. Ten current Australian guidelines were reviewed, revealing scant CAM content. When available, the CAM-relevant information was brief, in some cases unclear, inconclusive and lacking in direction to the GP or health care provider. Although we focus on CVD and T2DM, we argue the value of all chronic condition management guidelines integrating relevant evidence-informed information and advice on CAM risks, benefits and referrals, to increase GP awareness and knowledge of appropriate CAM therapies, and potentially to facilitate doctor-client discussion about CAM.

Travelers' Thrombosis—A State of Practice in Germany

Evidence-based guidelines to prevent travelers' thrombosis (TT) are still missing. We wanted to know whether travelers perceive the risk of TT, how they and their physicians cope with this in daily life, and whether recommended thrombosis prophylaxis (TP) was actually performed. A standardized questionnaire (Q1) asking for age, gender, travel habits, and the assessment of the risk of TT was given to randomly incoming travelers seeking for travel medicine advice prior to long haul travel. A second questionnaire (Q3) focusing on the actually performed TP was answered by these travelers after return. The physician assessed travelers' thrombosis risk (TR) and gave specific recommendations for TP in questionnaire Q2. Besides analysis of age, gender, the awareness of the risk of TT, travelers' TR, duration, and kind of travel, we compared performed and recommended TP and analyzed the influence of relevant factors on TP. A total of 315 travelers (43.3% male, aged 43.2 ± 15.9 y) took part in this survey. We received responses from 275, 309, and 248 travelers who answered Q1, Q2, and Q3, respectively. Travelers (91.6%) were aware of the risk of TT which was significantly higher among travelers aged 60 years and older. Travelers' TR had a significant influence on recommended and performed TP (p < 0.001). We found a moderate agreement between recommended and performed TP (kappa coefficient = 0.54). More travelers than recommended performed a specific TP (49.6% vs 39.8%) which was mainly done by the intake of acetylsalicylic acid (ASA). Travelers are well aware of the risk of TT and are compliant to perform at least the recommended TP for which physicians predominantly consider travelers' TR. The high rate of non-recommended intake of ASA and the different dosage regimes recommended for TP with ASA or heparin, however, indicate the need of better information for travelers and physicians.

Use of simulated patients to assess the clinical and communication skills of community pharmacists

To investigate the quality and appropriateness of Emergency Hormonal Contraception (EHC) supply from community pharmacies. Community pharmacies in the southwest of England during 2007. Two simulated patient ('mystery shopper') scenarios to each participating pharmacy, one where the supply of EHC would be appropriate (scenario 1) and one where there was a drug interaction between EHC and St John's Wort, and the supply inappropriate (scenario 2). Pharmacy consultations were rated using criteria developed from two focus groups: one with pharmacist academics and one with female university students. Feedback to pharmacists to inform their continuing professional development was provided. Scores on rating scales encompassing the clinical and communication skills of the participating community pharmacists completed immediately after each mystery shopper visit. 40 pharmacist visits were completed: 21 for scenario 1 and 19 for scenario 2. Eighteen pharmacists were visited twice. Five pharmacists visited for scenario 2 supplied EHC against professional guidance, although other reference sources conflicted with this advice. Pharmacies which were part of the local PGD scheme scored higher overall in scenario 1 (P = 0.005) than those not part of the scheme. Overall the communication skills of pharmacists were rated highly although some pharmacists used jargon when explaining the interaction for scenario 2. Formatively assessing communication skills in an integrative manner alongside clinical skills has been identified as an important part of the medical consultation skills training and can be incorporated into the routine assessment and feedback of pharmacy over-the-counter medicines advice.

‘At the moment it is just a couple of eccentrics doing it’: concordance in day-to-day practice

Abstract Objectives To assess the feasibility and acceptability of concordance in pharmacy practice through examination of communication between customers and pharmacists in two community pharmacies in consultations for over-the-counter medicines. Method A qualitative pilot study involving data drawn from six sources: audiotaped training session with all the pharmacists involved, observational field work in the pharmacies, audiotaped consultations with pharmacists and customers, debriefing interviews with pharmacists after the consultation, and semi-structured interviews with customers a few days after their consultation. Setting Two community pharmacies that concentrate their services on medicine advice and dispensing, one in a deprived inner-city area, the other in a more affluent suburban area of London. Key findings The pharmacists developed a personal understanding of concordance which informed their practice. Customers reported a high level of satisfaction with services they received from the respective pharmacists. Their accounts of the consultations verified the pharmacists' patient-centredness in their day-to-day practice. Conclusion The implementation of a concordance model was possible through the development of a personalised, patient-centred model which drew on the model of concordance but was adapted in accordance with both structural constraints as well as the personal style of the pharmacists involved.

Does Advice from Pharmacy Staff Vary According to the Nonprescription Medicine Requested?

Community pharmacy has long been advocated as an appropriate gateway of supply for nonprescription medicines and health-related advice. Consumers sometimes self-treat the symptoms of minor illness, yet there is conflicting evidence over their ability to do so properly. Emerging trends also suggest a variable approach to nonprescription medicine supply by pharmacy staff. Understanding of this is limited and more structured exploration is needed. To explore variation in pharmacy staff response to requests for nonprescription medicines from different legislative schedules through analysis of data collected using pseudo-patient methods. Consumers posed as pharmacy patrons (ie, pseudo-patients, simulated patients) and requested 1 of 3 specific nonprescription medicines by name. Two of these, ibuprofen and a branded cold and flu medication, could be sold by any pharmacy staff member (these were considered Pharmacy Medicine). The third, a combination analgesic containing paracetamol (acetaminophen), codeine, and doxylamine, required pharmacist involvement in the sale (considered Pharmacist Only Medicine). Pseudo-patient visits measured the service provided in each pharmacy by observing whether staff performed particular behaviors such as providing advice regarding the drugs. Staff response was generally superior when pseudo-patients requested the combination analgesic that required pharmacist intervention. Medicine advice was provided verbally to 84.9% of pseudo-patients requesting this analgesic compared with 51.1% of those requesting the cold and flu medication. Similar trends were observed for other behaviors. Emerging patterns imply that pharmacy staff response may vary according to the medicine requested. It may be that pharmacists and their staff prioritize drugs or behaviors that they consider critically relevant as part of a risk management approach. This has possible implications for future scheduling policy. Further research using a range of scenarios would more fully explore the breadth of such behavior. This would aid identification of medicines that trigger professional intervention and inform development of targeted training programs.

The Travel and Tropical Medicine Manual, 4th Edition

Like the previous editions of The Travel and Tropical Medicine Manual, the 4th edition continues to successfully teach the fundamentals of travel and tropical medicine and serve as a useful reference. The manual is well-organized and literally (measuring 12 × 20 cm) and figuratively handy. It has many appealing tables and figures, a colorful cover, and a reasonable price. It remains appropriately titled, with some chapters written from a travel perspective and others from a tropical medicine perspective. The manual contains 45 chapters divided into 7 sections (Pre-Travel Advice, Advice for Special Travelers, Fever, Diarrhea, Skin Lesions, Sexually Transmitted Diseases, and Worms). The current edition has a new coeditor (Christopher A. Sanford) and new chapters on urban medicine and health advice for long-term expatriates. Its audience should continue to be primary care providers who routinely counsel patients on travel-related issues, infectious disease physicians with an interest in travel medicine, other travel medicine practitioners, and trainees doing rotations in travel medicine. However, its technical terminology and concepts prevent the manual from achieving its stated goal of being a “perfect source” for travelers. The greatest strengths of the manual continue to be its practical suggestions for counseling travelers prior to their departure and evaluating patients with post-travel illnesses. Notable chapters discuss general approaches to travel medicine, immunizations, managing jet lag and motion sickness, counseling HIV-infected travelers, malaria prevention, avoiding and self-treating travelers’ diarrhea, evaluating diarrhea in returned travelers, tropical dermatology and sexually transmitted infections. The manual also has outstanding tables in its approach to travel medicine chapter. Other informative tables describe the safe selection of food and water, drugs for preventing and treating traveler’s diarrhea, the use of melatonin to prevent jet lag, potential interactions between antiretroviral and travel-related medications, and the differential diagnoses of travel-related skin lesions. The manual wisely refers readers to internet sites such as www.cdc.gov/travel for up-to-date travel advice. Although the manual has shortcomings, it has no serious deficiencies. Incorporating contributions from 49 authors results in chapters of variable quality, some redundancies, and occasional omissions. A 20-page chapter on water disinfection appears disproportionately lengthy when compared with the immediately preceding 12-page chapter on the prevention and self-treatment of traveler’s diarrhea. Although the chapter on women travelers discusses male condoms superficially, this important topic is well addressed in the chapter on sexually transmitted infections. In future editions of the manual, the editors should consider including more than 2 photographs in the 74-page section on skin lesions, using a larger font, and enlarging the figures. Clinicians who routinely evaluate patients before or after traveling should definitely consider purchasing this manual, reading select chapters in the pretravel and special travelers sections, and keeping it in their travel clinic as a useful reference.