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| Title: “Challenges in the Diagnosis and Management of Neuropathic Pain in the Primary Care Setting”
| | | AAPA Release Date: October 2, 2009 | | | AAPA Expiration Date: October 31, 2010 | | | Presented by: The American Academy of Physician Assistants | | | Funding: Supported through an educational grant from Pfizer, Inc. | |
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Faculty
| Lawrence Herman, MPA, RPA-C, DFAAPA
Moderator
Physician Assistant
Senior Clinical Coordinator
Assistant Professor
Department of Physician Assistant Studies
New York Institute of Technology
Old Westbury, NY
Director, Medical Education
Island Medical Physicians, PC
Hauppauge, NY
Mr. Herman is an Assistant Professor (with tenure) and Senior Clinical Coordinator in the Department of Physician Assistant Studies at New York Institute of Technology, New York College of Osteopathic Medicine affiliation in Old Westbury. He is also Vice President of Medical Education and Senior PA at Island Medical Physicians PC, in Hauppauge, New York, where he sees patients and is responsible for setting all of the practice guidelines for a large, multi-office family practice group.
He received a master of public administration in health administration and health system finance from Long Island University in Brookville, New York. He was certified by the National Commission on Certification of Physician Assistants, with special distinction in both surgery and primary care and remains certified in primary care.As a Distinguished Fellow of the American Academy of Physician Assistants, Mr. Herman has served and chaired numerous AAPA committees as well as being a Past-President of the New York State Society of Physician Assistants. He has contributed numerous book chapters to the literature and has published over 30 peer-reviewed articles. He has participated in several clinical pharmaceutical trials and continues to be an invited speaker at international and national meetings. He is the 2009 recipient of the New York Institute of Technology Annual Scholars Award for significant publication scholarship activities, the 2008 Standard of Excellence Award for providing the highest level of research and scholarship, and the 2007 and 2008 Educator of the Year award. | Bruce D. Nicholson, MD
Clinical Associate Professor
Anesthesia
Penn State University School of Medicine
Hershey, PA
Director
Division of Pain Medicine
Lehigh Valley Hospital and Health Network
Allentown, PA
Dr. Nicholson received his medical degree from Eastern Virginia Medical School, Norfolk. He continued his postgraduate medical training in anesthesia and pain medicine in the Department of Anesthesiology at the University of Virginia, Charlottesville.Dr. Nicholson is a member of several professional societies, including the American Society of Anesthesiology, the American Society of Regional Anesthesia and Pain Medicine, the International Association for the Study of Pain, and the American Pain Society. He has authored and co-authored journal articles, abstracts, and book chapters, and is a frequent invited lecturer at conferences and symposia. Dr. Nicholson’s research interests include mechanisms, co-morbidities, and treatment of neuropathic pain. Clinical interests include palliative medicine as well as therapeutic studies for the treatment of acute and chronic pain management. | Christopher M. Eten, MPAS, RPA-C
Physician Assistant
Westhampton Primary Care Center
Westhampton Beach, NY
Mr. Eten completed his Physician Assistant studies at Alderson-Broaddus College in Philippi, West Virginia in 2001. Upon graduation, he was board certified by the National Commission on Certification of Physician Assistants in both Primary Care and Surgery and remains so in Primary Care. He received his Masters Degree in 2006 from Alderson-Broaddus as well.Since 2001, Mr. Eten has worked clinically in Primary Care, Emergency Medicine, and Neurosurgery. He is currently practicing clinically at the Westhampton Primary Care center, a satellite facility of Southampton Hospital. He is a member of the American Academy of Physician Assistants as well as the New York State Society of Physician Assistants. Additionally, Mr. Eten has served on a panel to assist with the development of curriculum for the Johnson and Johnson Diabetes Institute in Milpitas, California. | |
© 2009 American Academy of Physician Assistants. All rights reserved.
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| | Title: “Challenges in the Diagnosis and Management of Neuropathic Pain in the Primary Care Setting” | | AAPA Release Date: October 2, 2009 | | | | AAPA Expiration Date: October 31, 2010 | | | | Presented by: The American Academy of Physician Assistants | | | Funding: Supported through an educational grant from Pfizer, Inc. | | | Program Overview | Neuropathic pain is a complex, chronic pain state that is commonly accompanied by tissue injury. Patients experiencing neuropathic pain frequently have injured, damaged, or dysfunctional nerve fibers and these same nerve fibers send incorrect signals to pain centers. The impact of a nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury.Neuropathic pain is a rather frequent condition with an annual incidence of almost 1% of the general population and affecting women and middle-aged persons more often.(1) Unlike nociceptive pain – pain triggered for protection and caused by an obvious stimulus – neuropathic pain is not beneficial or protective and can have an obvious cause (such as diabetic peripheral neuropathy or postherpetic neuralgia) or in other cases it has no obvious cause whatsoever. Neuropathic pain responds poorly to traditional pain treatment and may get worse instead of better over time, especially when left un- or under-treated. Until recently, the treatment has mostly consisted of traditional analgesics suggesting that pharmacological treatment of neuropathic pain is suboptimal. For some people, it can lead to serious disability and many of those left inadequately treated develop a co-morbid depression.There are multiple causes of neuropathies including systemic diseases such as diabetes, kidney, and liver disease. Diabetes mellitus is a leading cause of peripheral neuropathy in the United States. About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage and may develop Diabetic Peripheral Neuropathy (DPN).(2) Kidney disorders can result in severely damaged nerve tissue and the majority of patients on dialysis develop polyneuropathy. Some liver diseases also lead to neuropathies.Infections and autoimmune disorders can cause peripheral neuropathy. Most notably, herpes varicella-zoster, herpes simplex-members and cytomegalovirus can damage sensory nerves, causing attacks of sharp, lightning-like pain. Postherpetic neuralgia (PHN) often occurs after an attack of shingles and can be particularly painful. The human immunodeficiency virus (HIV), which causes AIDS, also causes extensive damage to the central and peripheral nervous systems. The HIV virus can cause several different forms of neuropathy, each strongly associated with a specific stage of active immunodeficiency disease.There are litanies of other causative factors associated with painful peripheral neuropathies including but not limited to: hormonal imbalances, vitamin deficiencies, excessive alcohol consumption, and connective tissue disorders. Trauma or surgery can be one element of a more widespread neuropathic pain condition called complex regional pain syndrome. Cumulative nerve damage resulting in peripheral neuropathies can result from repetitive, forceful, awkward or stressful activities. Many primary or adjuvant cancer drugs, anticonvulsants, antiviral agents, and antibiotics have side effects that can include peripheral nerve damage, thus limiting their use or forcing patients into making difficult choices to either stop life-saving or life-extending treatments or live with chronic pain.Diagnosing peripheral neuropathy is often difficult because the symptoms are highly variable.(3) A thorough neurological examination is usually required and involves taking an extensive patient history (including the patient’s symptoms, work environment, social habits, exposure to any toxins, history of alcoholism, HIV or other infectious disease, and family history of neurological disease), performing tests that may identify the cause of the neuropathic disorder, and conducting tests to determine the extent and type of nerve damage. Rarely, referral to a specialist is necessary.In most cases, neuropathic pain is not fully reversible, but is treatable, and is best treated with medications distinct from traditional pain medications. A partial to a marked improvement is often possible with proper treatment. Neuropathic pains tend to be treated disparately by primary care providers, with dozens of pharmacological choices utilized, although only some are FDA-approved and fewer still completely successful in completely relieving pain. Neuropathic pain has been treated with acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDS), as well as narcotics running the gamut from codeine to fentanyl and methadone. Data supports the advantages of certain anti-epileptic drugs (AEDs) and antidepressants (including TCAs, SSRIs and SSNRIs) as efficacious treatments, although these are not necessarily the treatment of choice for many clinicians.In many cases of neuropathic pain – but especially those that do not respond to initial treatments – a team approach is necessary and might include primary care providers, pain specialists, anesthesiologists, physical/occupational therapists, and surgeons. Although these patients may sometimes be frustrating for primary care providers to treat and may require significant investment of time and effort, a comprehensive approach to patient management can provide improved patient outcomes. | | References | - Dielman JP, Kerklaan J, Huygen FJ, et al. Incidence Rates and Treatment of Neuropathic Pain Conditions in the General Population.Pain.2008 Jul 31;137(3):681-8. Epub 2008 Apr 24.
- Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic Neuropathies: A Statement by the American Diabetes Association.Diabetes Care.2005;28:956-962
- Peripheral Neuropathy Fact Sheet, National Institute of Neurological Disorders and Stroke. Retrieved November 23, 2008 from http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.html
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Faculty
| | Lawrence Herman, MPA, RPA-C, DFAAPA Moderator Physician Assistant Senior Clinical Coordinator Assistant Professor Department of Physician Assistant Studies New York Institute of Technology Old Westbury, NY Director, Medical Education Island Medical Physicians, PC Hauppauge, NY | | | Bruce D. Nicholson, MD Clinical Associate Professor Anesthesia Penn State University School of Medicine Hershey, PA Director Division of Pain Medicine Lehigh Valley Hospital and Health Network Allentown, PA | | | Christopher M. Eten, MPAS, RPA-C
Physician Assistant
Westhampton Primary Care Center Westhampton Beach, NY | | | Intended Audience | | Physician Assistants | | |
Clinical Dialogue Program Description
| | Clinical Dialogues are 15-20 minute video-moderated discussions featuring leading experts and are designed to engage the users and deliver the most up-to-date educationally relevant programs possible. The interactive "give-and-take" format of these programs provides for lively discussions that distill topics into clinically-pertinent "need to know" information which users may immediately apply to clinical practice. This Internet-based CME activity includes an optional pre-and post-survey, a CME post-test and program evaluation (feedback). CME credit will be awarded to those achieving a grade of 70% or higher on the post-test.
| | |
eCase Challenge Program Description
| | eCase Challenges are 20 minute text-based case study programs where PAs are presented with challenging case scenarios and are asked to make patient management decisions. At the conclusion of each case, there is a Clinical Pearl video that the participant can view which highlights the key take away messages from each program. This Internet-based CME activity includes an optional pre-and post-survey, a CME post-test and program evaluation (feedback). CME credit will be awarded to those achieving a grade of 70% or higher on the post-test. | | | Educational Objectives | |
At the conclusion of this activity, the physician assistant should be better able to:
| - Identify risk factors and the clinical manifestations of neuropathic pain
- Identify and utilize appropriate screening tools to assist in identifying and quantifying degrees of neuropathic pain and functionality in primary care patient populations
- Recognize the pathophysiology that differentiates nociceptive from neuropathic pain
- Identify and integrate non-pharmacologic and pharmacologic options to treat mild, moderate, and severe neuropathic pain within patient population sub-groups using evidence-based data
- Describe the specific differences associated with common classes of medications utilized to treat neuropathic pain and medication choices for neuropathic pain based upon evidence-based guidelines
- Prescribe both short- and long-term medications including the use of multiple classes of medications concurrently to treat depression and improve patient outcomes
| | | Accreditation Statements |  | | Each program in this initiative has been reviewed and is approved for a maximum of 0.5 hour of AAPA Category 1 CME credit by the Physician Assistant Review Panel. Physician assistants should claim only those hours actually spent participating in the CME activity. This program was planned in accordance with the AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs. Approval is valid for one year from the issue date of October 2, 2009. Participants may submit the self-assessment at any time during that period. | | |
Responsibility Statement
| | The American Academy of Physician Assistants takes responsibility for the content, quality, and scientific integrity of this CME activity. | | | Faculty Disclosures | | It is the policy of the American Academy of Physician Assistants to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member has with the commercial interest of any commercial product discussed in an educational presentation. The participating faculty reported the following: | | Lawrence Herman, MPA, RPA-C, DFAAPA, reports that he has no relationship with any commercial interests whose products or services may be mentioned during this presentation.
| | Bruce D. Nicholson, MD, reports receiving honoraria from Pfizer and PriCare; has been a consultant for Pfizer, Endo, King, and PriCare; has received grants/research support from J&J and Medtronic; and has been a speaker for Pfizer and PriCare.
| | Christopher M. Eten, MPAS, RPA-C, reports that he has no relationship with any commercial interests whose products or services may be mentioned during this presentation.
| | | Off-Label Discussion | | Larry Herman, RPA-C, Christopher Eten, RPA-C, and Bruce Nicholson, MD discuss tricyclic antidepressants which are not indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy. Serotonin-norepinephrine reuptake inhibitors are also discussed as a class of drug for the management of neuropathic pain associated with diabetic peripheral neuropathy, but not all drugs in this class are approved for this indication. | | Disclaimer | | The opinions and comments expressed by faculty and other experts, whose input is included in this program, are their own. This enduring material is produced for educational purposes only. Please review complete prescribing information of specific drugs mentioned in this program including indications, contraindications, warnings, and adverse effects and dosage before administering to patients. | | |
Archived Presentation
| | The Clinical Dialogue and eCase Challenge will be archived for clinicians. CME credits will be provided by the AAPA from October 2, 2009 through October 31, 2010 for physician assistants at www.AAPA.org. | | | Obtaining CME Credits | | Upon completion of your participation in the program, physician assistants will be directed to www.AAPA.org to complete a post-test and receive your certificates. | | | Successful completion of the self-assessment by physician assistants is required to earn Category 1 CME credit. Successful completion is defined as a cumulative score of at least 70% correct. Upon successful completion of the post-test, the AAPA will issue a certificate of completion for your records. | | |
Technical Requirements
| | Processor Speed: 1.4 GHz P3 | | Memory: 256 MB RAM (20MB available) | | Operating Systems Supported: Windows 2000/XP, MAC | | Browsers Supported: Internet Explorer 5.5 or greater, Mozilla Firefox and Safari 3.525 or greater | |
Additional Requirements: Flash player 8.0 or greater, 800x600 Resolution or higher with 32-bit color
| | Connection Speed: 128 Kbps or better | | Adobe Acrobat 6.0 or greater | | | Sponsored by the American Academy of Physician Assistants | 
| Supported through an educational grant from Pfizer, Inc.
| | Produced by: |  | | |
© 2009 American Academy of Physician Assistants. All rights reserved.
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| “Challenges in the Diagnosis and Management of Neuropathic Pain in the Primary Care Setting” | | |
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| | Title: “Challenges in the Diagnosis and Management of Neuropathic Pain in the Primary Care Setting” | | AAPA Release Date: October 2, 2009 | | | | AAPA Expiration Date: October 31, 2010 | | | | Presented by: The American Academy of Physician Assistants | | | Funding: Supported through an educational grant from Pfizer, Inc. | | | Program Overview | Neuropathic pain is a complex, chronic pain state that is commonly accompanied by tissue injury. Patients experiencing neuropathic pain frequently have injured, damaged, or dysfunctional nerve fibers and these same nerve fibers send incorrect signals to pain centers. The impact of a nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury.Neuropathic pain is a rather frequent condition with an annual incidence of almost 1% of the general population and affecting women and middle-aged persons more often.(1) Unlike nociceptive pain – pain triggered for protection and caused by an obvious stimulus – neuropathic pain is not beneficial or protective and can have an obvious cause (such as diabetic peripheral neuropathy or postherpetic neuralgia) or in other cases it has no obvious cause whatsoever. Neuropathic pain responds poorly to traditional pain treatment and may get worse instead of better over time, especially when left un- or under-treated. Until recently, the treatment has mostly consisted of traditional analgesics suggesting that pharmacological treatment of neuropathic pain is suboptimal. For some people, it can lead to serious disability and many of those left inadequately treated develop a co-morbid depression.There are multiple causes of neuropathies including systemic diseases such as diabetes, kidney, and liver disease. Diabetes mellitus is a leading cause of peripheral neuropathy in the United States. About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage and may develop Diabetic Peripheral Neuropathy (DPN).(2) Kidney disorders can result in severely damaged nerve tissue and the majority of patients on dialysis develop polyneuropathy. Some liver diseases also lead to neuropathies.Infections and autoimmune disorders can cause peripheral neuropathy. Most notably, herpes varicella-zoster, herpes simplex-members and cytomegalovirus can damage sensory nerves, causing attacks of sharp, lightning-like pain. Postherpetic neuralgia (PHN) often occurs after an attack of shingles and can be particularly painful. The human immunodeficiency virus (HIV), which causes AIDS, also causes extensive damage to the central and peripheral nervous systems. The HIV virus can cause several different forms of neuropathy, each strongly associated with a specific stage of active immunodeficiency disease.There are litanies of other causative factors associated with painful peripheral neuropathies including but not limited to: hormonal imbalances, vitamin deficiencies, excessive alcohol consumption, and connective tissue disorders. Trauma or surgery can be one element of a more widespread neuropathic pain condition called complex regional pain syndrome. Cumulative nerve damage resulting in peripheral neuropathies can result from repetitive, forceful, awkward or stressful activities. Many primary or adjuvant cancer drugs, anticonvulsants, antiviral agents, and antibiotics have side effects that can include peripheral nerve damage, thus limiting their use or forcing patients into making difficult choices to either stop life-saving or life-extending treatments or live with chronic pain.Diagnosing peripheral neuropathy is often difficult because the symptoms are highly variable.(3) A thorough neurological examination is usually required and involves taking an extensive patient history (including the patient’s symptoms, work environment, social habits, exposure to any toxins, history of alcoholism, HIV or other infectious disease, and family history of neurological disease), performing tests that may identify the cause of the neuropathic disorder, and conducting tests to determine the extent and type of nerve damage. Rarely, referral to a specialist is necessary.In most cases, neuropathic pain is not fully reversible, but is treatable, and is best treated with medications distinct from traditional pain medications. A partial to a marked improvement is often possible with proper treatment. Neuropathic pains tend to be treated disparately by primary care providers, with dozens of pharmacological choices utilized, although only some are FDA-approved and fewer still completely successful in completely relieving pain. Neuropathic pain has been treated with acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDS), as well as narcotics running the gamut from codeine to fentanyl and methadone. Data supports the advantages of certain anti-epileptic drugs (AEDs) and antidepressants (including TCAs, SSRIs and SSNRIs) as efficacious treatments, although these are not necessarily the treatment of choice for many clinicians.In many cases of neuropathic pain – but especially those that do not respond to initial treatments – a team approach is necessary and might include primary care providers, pain specialists, anesthesiologists, physical/occupational therapists, and surgeons. Although these patients may sometimes be frustrating for primary care providers to treat and may require significant investment of time and effort, a comprehensive approach to patient management can provide improved patient outcomes. | | References | - Dielman JP, Kerklaan J, Huygen FJ, et al. Incidence Rates and Treatment of Neuropathic Pain Conditions in the General Population.Pain.2008 Jul 31;137(3):681-8. Epub 2008 Apr 24.
- Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic Neuropathies: A Statement by the American Diabetes Association.Diabetes Care.2005;28:956-962
- Peripheral Neuropathy Fact Sheet, National Institute of Neurological Disorders and Stroke. Retrieved November 23, 2008 from http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.html
| | |
Faculty
| | Lawrence Herman, MPA, RPA-C, DFAAPA Moderator Physician Assistant Senior Clinical Coordinator Assistant Professor Department of Physician Assistant Studies New York Institute of Technology Old Westbury, NY Director, Medical Education Island Medical Physicians, PC Hauppauge, NY | | | Bruce D. Nicholson, MD Clinical Associate Professor Anesthesia Penn State University School of Medicine Hershey, PA Director Division of Pain Medicine Lehigh Valley Hospital and Health Network Allentown, PA | | | Christopher M. Eten, MPAS, RPA-C
Physician Assistant
Westhampton Primary Care Center Westhampton Beach, NY | | | Intended Audience | | Physician Assistants | | |
Clinical Dialogue Program Description
| | Clinical Dialogues are 15-20 minute video-moderated discussions featuring leading experts and are designed to engage the users and deliver the most up-to-date educationally relevant programs possible. The interactive "give-and-take" format of these programs provides for lively discussions that distill topics into clinically-pertinent "need to know" information which users may immediately apply to clinical practice. This Internet-based CME activity includes an optional pre-and post-survey, a CME post-test and program evaluation (feedback). CME credit will be awarded to those achieving a grade of 70% or higher on the post-test.
| | |
eCase Challenge Program Description
| | eCase Challenges are 20 minute text-based case study programs where PAs are presented with challenging case scenarios and are asked to make patient management decisions. At the conclusion of each case, there is a Clinical Pearl video that the participant can view which highlights the key take away messages from each program. This Internet-based CME activity includes an optional pre-and post-survey, a CME post-test and program evaluation (feedback). CME credit will be awarded to those achieving a grade of 70% or higher on the post-test. | | | Educational Objectives | |
At the conclusion of this activity, the physician assistant should be better able to:
| - Identify risk factors and the clinical manifestations of neuropathic pain
- Identify and utilize appropriate screening tools to assist in identifying and quantifying degrees of neuropathic pain and functionality in primary care patient populations
- Recognize the pathophysiology that differentiates nociceptive from neuropathic pain
- Identify and integrate non-pharmacologic and pharmacologic options to treat mild, moderate, and severe neuropathic pain within patient population sub-groups using evidence-based data
- Describe the specific differences associated with common classes of medications utilized to treat neuropathic pain and medication choices for neuropathic pain based upon evidence-based guidelines
- Prescribe both short- and long-term medications including the use of multiple classes of medications concurrently to treat depression and improve patient outcomes
| | | Accreditation Statements |  | | Each program in this initiative has been reviewed and is approved for a maximum of 0.5 hour of AAPA Category 1 CME credit by the Physician Assistant Review Panel. Physician assistants should claim only those hours actually spent participating in the CME activity. This program was planned in accordance with the AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs. Approval is valid for one year from the issue date of October 2, 2009. Participants may submit the self-assessment at any time during that period. | | |
Responsibility Statement
| | The American Academy of Physician Assistants takes responsibility for the content, quality, and scientific integrity of this CME activity. | | | Faculty Disclosures | | It is the policy of the American Academy of Physician Assistants to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member has with the commercial interest of any commercial product discussed in an educational presentation. The participating faculty reported the following: | | Lawrence Herman, MPA, RPA-C, DFAAPA, reports that he has no relationship with any commercial interests whose products or services may be mentioned during this presentation.
| | Bruce D. Nicholson, MD, reports receiving honoraria from Pfizer and PriCare; has been a consultant for Pfizer, Endo, King, and PriCare; has received grants/research support from J&J and Medtronic; and has been a speaker for Pfizer and PriCare.
| | Christopher M. Eten, MPAS, RPA-C, reports that he has no relationship with any commercial interests whose products or services may be mentioned during this presentation.
| | | Off-Label Discussion | | Larry Herman, RPA-C, Christopher Eten, RPA-C, and Bruce Nicholson, MD discuss tricyclic antidepressants which are not indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy. Serotonin-norepinephrine reuptake inhibitors are also discussed as a class of drug for the management of neuropathic pain associated with diabetic peripheral neuropathy, but not all drugs in this class are approved for this indication. | | Disclaimer | | The opinions and comments expressed by faculty and other experts, whose input is included in this program, are their own. This enduring material is produced for educational purposes only. Please review complete prescribing information of specific drugs mentioned in this program including indications, contraindications, warnings, and adverse effects and dosage before administering to patients. | | |
Archived Presentation
| | The Clinical Dialogue and eCase Challenge will be archived for clinicians. CME credits will be provided by the AAPA from October 2, 2009 through October 31, 2010 for physician assistants at www.AAPA.org. | | | Obtaining CME Credits | | Upon completion of your participation in the program, physician assistants will be directed to www.AAPA.org to complete a post-test and receive your certificates. | | | Successful completion of the self-assessment by physician assistants is required to earn Category 1 CME credit. Successful completion is defined as a cumulative score of at least 70% correct. Upon successful completion of the post-test, the AAPA will issue a certificate of completion for your records. | | |
Technical Requirements
| | Processor Speed: 1.4 GHz P3 | | Memory: 256 MB RAM (20MB available) | | Operating Systems Supported: Windows 2000/XP, MAC | | Browsers Supported: Internet Explorer 5.5 or greater, Mozilla Firefox and Safari 3.525 or greater | |
Additional Requirements: Flash player 8.0 or greater, 800x600 Resolution or higher with 32-bit color
| | Connection Speed: 128 Kbps or better | | Adobe Acrobat 6.0 or greater | | | Sponsored by the American Academy of Physician Assistants |  | | | Supported through an educational grant from Pfizer, Inc. | | | Produced by: |  | | |
© 2009 American Academy of Physician Assistants. All rights reserved.
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