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Topical formulations of diclofenac, a nonsteroidal anti-inflammatory drug commonly prescribed to treat musculoskeletal complaints such as osteoarthritis, low back pain, and myofascial pain, are available in the form of a solution, gel, and patch. The topical application of diclofenac results in substantially lower systemic exposure to diclofenac compared with oral diclofenac, resulting in a more favorable side effect profile. To the authors' knowledge, this is the first case report of a lower gastrointestinal bleed associated with diclofenac topical patch use in a 77 yr-old-woman with a history of colonic mass and atrial fibrillation on antiplatelet therapy.

Objective The purpose of this study was to evaluate the effects of methylphenidate on heart rate and blood pressure in patients with acquired brain injury. Design The records of 60 consecutive hospitalized patients with acquired brain injury were reviewed for treatment with methylphenidate. Seventeen patients met the inclusion criteria. Systolic blood pressure, diastolic blood pressure, and heart rate recordings were compared before and after the introduction of methylphenidate. Results There was no significant difference in mean systolic blood pressure, diastolic blood pressure, and heart rate when patients received (118 mm Hg, 74 mm Hg, and 88 bpm) and did not receive (118 mm Hg, 73 mm Hg, and 86 bpm) methylphenidate. It was unclear whether there was a true trend toward medication effect on heart rate and blood pressure during the peak dose period. Conclusions This retrospective study points to safe sympathetic effects of methylphenidate, yet future prospective studies are warranted to clarify the effects of methylphenidate on heart rate and blood pressure in the acquired brain injury population.

Objective To determine the percentage of international normalized ratios (INRs) maintained within the therapeutic range for patients receiving chronic anticoagulation treatment with warfarin during inpatient rehabilitation. Design A consecutive, 4-month, retrospective chart review of all patients receiving oral anticoagulation treatment was conducted in a large academic rehabilitation center. The percentage of INRs within and out of the therapeutic range, frequency of blood samples, length of therapy, and warfarin dose prescribed by physicians were calculated. A total of 181 patients receiving chronic anticoagulation treatment were identified. A total of 3,709 blood samples were analyzed. In 74 patients, the primary physician recommended a therapeutic range (Group 1). In the remaining 107 patients, no therapeutic range was specified, and a target INR range of 2.0-3.0 was assumed (Group 2). Results In Group 1, the INRs were in the recommended range in 38.2% of all blood samples. In Group 2, 37.6% of all blood drawn was within an INR range of 2.0-3.0. Statistical analysis showed that no better accuracy was obtained when the INR range was predefined by a physician (Group 1) or assumed to be in the 2.0-3.0 range (Group 2; P = 0.839). Conclusions Despite frequent physician monitoring, this study demonstrates the difficulty in maintaining INRs within therapeutic ranges for patients receiving oral anticoagulation. An overall tendency for underdosing is observed. Improvement is necessary, given the high morbidity and mortality associated with insufficient anticoagulation in rehabilitation inpatients.

Pressure ulcers are a prevalent and potentially serious medical problem encountered in both the medical and rehabilitation settings. Because the progress of rehabilitation is often interrupted by the presence of pressure ulcers, the efficient care of these wounds is of great interest to the rehabilitation team. Patients in two acute care facilities with Stage III or IV pressure ulcers were identified and consented to participate in the study contained herein. All wounds were mechanically debrided of necrotic tissue, and then the patients were randomly assigned to the conservative treatment group (A; n = 18) or the conservative treatment plus whirlpool group (B; n = 24). Conservative treatment included measures to maximize pressure relief and wound care with wet-to-wet dressings using normal saline. The dressings were changed twice daily and when they became soiled. Whirlpool was administered for 20 min per day in Group B patients. Only those patients whose ulcers were followed-up for 2 or more wk were included in the study. Ulcers were then measured by a physician who was blinded as to the treatment groups. Ulcer dimension changes over time were compared between groups. The results indicate that the conservative treatment plus whirlpool group improved at a significantly faster rate than did the conservative treatment only group (P < 0.05).