Referral and Management of Pretibial Lacerations in Two District General Hospitals.

Background Pretibial lacerations are common injuries that have a significant yet underestimated association with morbidity and mortality. Although they may occur in any age group, they are commonly followed by an often relatively minor trauma in elderly and frail patients. The six-month mortality among such patients may be more than double the age group average. Currently, 5.2 in 1000 patients per year present to the emergency departments in UK hospitals due to pretibial lacerations. The associated acute admissions have a high financial cost. Despite the significant disease burden, there is a paucity of evidence on the optimal management of such injuries. This study aimed to describe the typical demographic and injury factors of individuals presenting to two district general hospitals, as well as their subsequent management and referral. Methodology Relevant patients were identified through NHS coding searches. Subsequently, it was found that 99 patients presented to an NHS trust with pretibial lacerations throughout 2020. A retrospective manual evaluation of clinical documentation was performed to identify the details of the patients' injury, management, referral, and demographics. Results The patients had a mean age of 55.4 (SD 28.3), and 56.6% were female. The most commonly presenting mechanism of injury was direct blunt trauma. The majority of cases were solely managed and discharged directly by the emergency department (74.8%). Of the 99 patients, 25 (25.3%) were referred to specialist services, 12 (12.1%) were managed conservatively, and 13 (13.1%) underwent operative intervention. The mean length of stay for those referred was 5.9 days, and the mean for the same was greater for those managed conservatively compared to those managed operatively (9.0 vs. 2.6 days). Among patients discharged by the emergency department, the most common method of wound closure was steristrips (n = 40; 54.1%), followed by conservative management with dressings (n = 22; 29.7%), sutures (n = 10, 13.5%) and glue (n = 5; 6.8%). Conclusions Overall, this study showed that the majority of patients presenting with pretibial lacerations have minor wounds that can be effectively managed in the emergency department. However, those with considerably more injuries should be provided an early referral to specialist services, where they would ideally receive early surgery and comprehensive follow-up.

Pressure Injury Outcomes of a Prone-Positioning Protocol in Patients With COVID and ARDS.

BACKGROUND: During the COVID-19 outbreak, standard methods for treating acute respiratory distress syndrome (ARDS) were used for patients presenting with ARDS. One such treatment method involves placing patients prone to improve oxygenation and reduce mortality risk. Challenges in preventing pressure injuries in patients placed prone have been reported, and no studies have explored the effects of including a certified wound and skin care nurse as part of the care team on the incidence of pressure injuries in SARS-CoV-2-infected patients with ARDS. OBJECTIVES: To evaluate the association between including a certified wound and skin care nurse on a multiprofessional pronation team and prevention of pressure injuries in SARS-CoV-2-infected patients with ARDS. METHODS: This multicenter observational cohort study used retrospective data from the electronic health record. The intervention group consisted of SARS-CoV-2-infected patients diagnosed with ARDS who were treated by a multidisciplinary prone-positioning team that included a certified wound and skin care nurse specialist. The comparison group of SARS-CoV-2-infected patients with ARDS was treated by a multidisciplinary prone-positioning team that did not include a certified wound and skin care nurse specialist. RESULTS: As shown by multivariable logistic regression mixed-effect modeling, patients in the intervention group had a 97% lower adjusted odds ratio of a pressure injury developing than did patients in the comparison group (0.03 [95% CI, 0.01-0.14]; P < .001). CONCLUSION: The inclusion of a certified wound and skin care nurse on a multiprofessional prone-positioning team significantly reduced the odds of pressure injuries developing in patients infected with SARS-CoV-2.

The Complexity of Managing a Burned Irreducible Umbilical Hernia in an Adult.

We present a case of a 65-year-old male with a longstanding non-symptomatic irreducible umbilical hernia who presented with a three-day-old full-thickness thermal burn to the hernia. The burn was sustained while operating a metal drop forger, where the patient was repeatedly exposed to 30-second bursts of heat from the furnace, with temperature exceeding 1350°C. He estimated he had this exposure approximately 48 times during an 8-hour shift, giving him a total of 24 minutes cumulative exposure to the heat. The patient reported that he normally wore an abdominal binder under his heat-resistant apron to temporarily flatten and protect his hernia. On the day of the injury, he had not been wearing this binder. The patient was initially unaware that he had sustained a burn; upon delayed presentation to the hospital, he had cellulitis surrounding a 0.25% total body surface area (TBSA) full-thickness burn. Contrast-enhanced CT abdomen demonstrated an umbilical hernia with a neck diameter of 2.3cm, with breach of the hernia fascia but no communication between the bowel and burnt tissue. After discussion between Plastic Surgery and General Surgery teams the decision was made to manage the burn non-operatively with daily flamazine dressings and empirical antibiotics for the cellulitis. Once this area had healed, elective mesh repair of the umbilical hernia was carried out. This is the first adult case of a full-thickness burn overlying an umbilical hernia to be reported in the literature. The case highlights both an unusual aetiology and a rare injury, as well as the multi-disciplinary teamwork required to manage it successfully.

Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma.

BACKGROUND: Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used. OBJECTIVES: Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site. SEARCH METHODS: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles. SELECTION CRITERIA: We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity. MAIN RESULTS: We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT. AUTHORS' CONCLUSIONS: Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.

Reflectance confocal microscopy for diagnosing cutaneous melanoma in adults.

BACKGROUND: Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Early detection and treatment is key to improving survival; however, anxiety around missing early cases needs to be balanced against appropriate levels of referral and excision of benign lesions. Used in conjunction with clinical or dermoscopic suspicion of malignancy, or both, reflectance confocal microscopy (RCM) may reduce unnecessary excisions without missing melanoma cases. OBJECTIVES: To determine the diagnostic accuracy of reflectance confocal microscopy for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with any lesion suspicious for melanoma and lesions that are difficult to diagnose, and to compare its accuracy with that of dermoscopy. SEARCH METHODS: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; and seven other databases. We studied reference lists and published systematic review articles. SELECTION CRITERIA: Studies of any design that evaluated RCM alone, or RCM in comparison to dermoscopy, in adults with lesions suspicious for melanoma or atypical intraepidermal melanocytic variants, compared with a reference standard of either histological confirmation or clinical follow-up. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. To compare RCM with dermoscopy, we grouped studies by population (defined by difficulty of lesion diagnosis) and combined data using hierarchical summary receiver operating characteristic (SROC) methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of specificity at the point on the SROC curve with 90% sensitivity as this value lies within the estimates for the majority of analyses. We investigated the impact of using a purposely developed RCM algorithm and in-person test interpretation. MAIN RESULTS: The search identified 18 publications reporting on 19 study cohorts with 2838 lesions (including 658 with melanoma), which provided 67 datasets for RCM and seven for dermoscopy. Studies were generally at high or unclear risk of bias across almost all domains and of high or unclear concern regarding applicability of the evidence. Selective participant recruitment, lack of blinding of the reference test to the RCM result, and differential verification were particularly problematic. Studies may not be representative of populations eligible for RCM, and test interpretation was often undertaken remotely from the patient and blinded to clinical information.Meta-analysis found RCM to be more accurate than dermoscopy in studies of participants with any lesion suspicious for melanoma and in participants with lesions that were more difficult to diagnose (equivocal lesion populations). Assuming a fixed sensitivity of 90% for both tests, specificities were 82% for RCM and 42% for dermoscopy for any lesion suspicious for melanoma (9 RCM datasets; 1452 lesions and 370 melanomas). For a hypothetical population of 1000 lesions at the median observed melanoma prevalence of 30%, this equated to a reduction in unnecessary excisions with RCM of 280 compared to dermoscopy, with 30 melanomas missed by both tests. For studies in equivocal lesions, specificities of 86% would be observed for RCM and 49% for dermoscopy (7 RCM datasets; 1177 lesions and 180 melanomas). At the median observed melanoma prevalence of 20%, this reduced unnecessary excisions by 296 with RCM compared with dermoscopy, with 20 melanomas missed by both tests. Across all populations, algorithms and thresholds assessed, the sensitivity and specificity of the Pellacani RCM score at a threshold of three or greater were estimated at 92% (95% confidence interval (CI) 87 to 95) for RCM and 72% (95% CI 62 to 81) for dermoscopy. AUTHORS' CONCLUSIONS: RCM may have a potential role in clinical practice, particularly for the assessment of lesions that are difficult to diagnose using visual inspection and dermoscopy alone, where the evidence suggests that RCM may be both more sensitive and specific in comparison to dermoscopy. Given the paucity of data to allow comparison with dermoscopy, the results presented require further confirmation in prospective studies comparing RCM with dermoscopy in a real-world setting in a representative population.

Reflectance confocal microscopy for diagnosing keratinocyte skin cancers in adults.

BACKGROUND: Early accurate detection of all skin cancer types is important to guide appropriate management and improve morbidity and survival. Basal cell carcinoma (BCC) is usually a localised skin cancer but with potential to infiltrate and damage surrounding tissue, whereas cutaneous squamous cell carcinoma (cSCC) and melanoma are higher risk skin cancers with the potential to metastasise and ultimately lead to death. When used in conjunction with clinical or dermoscopic suspicion of malignancy, or both, reflectance confocal microscopy (RCM) may help to identify cancers eligible for non-surgical treatment without the need for a diagnostic biopsy, particularly in people with suspected BCC. Any potential benefit must be balanced against the risk of any misdiagnoses. OBJECTIVES: To determine the diagnostic accuracy of RCM for the detection of BCC, cSCC, or any skin cancer in adults with any suspicious lesion and lesions that are difficult to diagnose (equivocal); and to compare its accuracy with that of usual practice (visual inspection or dermoscopy, or both). SEARCH METHODS: We undertook a comprehensive search of the following databases from inception to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA: Studies of any design that evaluated the accuracy of RCM alone, or RCM in comparison to visual inspection or dermoscopy, or both, in adults with lesions suspicious for skin cancer compared with a reference standard of either histological confirmation or clinical follow-up, or both. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities using the bivariate hierarchical model. For computation of likely numbers of true-positive, false-positive, false-negative, and true-negative findings in the 'Summary of findings' tables, we applied summary sensitivity and specificity estimates to lower quartile, median and upper quartiles of the prevalence observed in the study groups. We also investigated the impact of observer experience. MAIN RESULTS: The review included 10 studies reporting on 11 study cohorts. All 11 cohorts reported data for the detection of BCC, including 2037 lesions (464 with BCC); and four cohorts reported data for the detection of cSCC, including 834 lesions (71 with cSCC). Only one study also reported data for the detection of BCC or cSCC using dermoscopy, limiting comparisons between RCM and dermoscopy. Studies were at high or unclear risk of bias across almost all methodological quality domains, and were of high or unclear concern regarding applicability of the evidence. Selective participant recruitment, unclear blinding of the reference test, and exclusions due to image quality or technical difficulties were observed. It was unclear whether studies were representative of populations eligible for testing with RCM, and test interpretation was often undertaken using images, remotely from the participant and the interpreter blinded to clinical information that would normally be available in practice.Meta-analysis found RCM to be more sensitive but less specific for the detection of BCC in studies of participants with equivocal lesions (sensitivity 94%, 95% confidence interval (CI) 79% to 98%; specificity 85%, 95% CI 72% to 92%; 3 studies) compared to studies that included any suspicious lesion (sensitivity 76%, 95% CI 45% to 92%; specificity 95%, 95% CI 66% to 99%; 4 studies), although CIs were wide. At the median prevalence of disease of 12.5% observed in studies including any suspicious lesion, applying these results to a hypothetical population of 1000 lesions results in 30 BCCs missed with 44 false-positive results (lesions misdiagnosed as BCCs). At the median prevalence of disease of 15% observed in studies of equivocal lesions, nine BCCs would be missed with 128 false-positive results in a population of 1000 lesions. Across both sets of studies, up to 15% of these false-positive lesions were observed to be melanomas mistaken for BCCs. There was some suggestion of higher sensitivities in studies with more experienced observers. Summary sensitivity and specificity could not be estimated for the detection of cSCC due to paucity of data. AUTHORS' CONCLUSIONS: There is insufficient evidence for the use of RCM for the diagnosis of BCC or cSCC in either population group. A possible role for RCM in clinical practice is as a tool to avoid diagnostic biopsies in lesions with a relatively high clinical suspicion of BCC. The potential for, and consequences of, misclassification of other skin cancers such as melanoma as BCCs requires further research. Importantly, data are lacking that compare RCM to standard clinical practice (with or without dermoscopy).

Perforated caecal carcinoma masquerading as lower limb necrotising fasciitis: lessons learnt.

A 69-year-old man was admitted with non-resolving right leg cellulitis. Subsequent skin changes over the calf and discharging pus suggested necrotising fasciitis. After several wound debridements of the leg and imaging, the patient was found to have an iliopsoas abscess due to a metastatic perforated caecal tumour extending along the medial thigh to the calf. No micro-organisms indicative of typical necrotising fasciitis were isolated from the wound. The patient had an ileocaecal resection, and his leg was reconstructed with a split thickness skin graft. He continues to do well postoperatively. This case highlights key lessons when dealing with an unusual presentation leading to challenges in diagnosis such as: (1) the need for good interspecialty liaison, (2) prompt senior review and plan, and (3) 'thinking outside the box' when faced with a diagnostic challenge.

Evaluating evidence for atrophic scarring treatment modalities.

INTRODUCTION: Atrophic scars cause significant patient morbidity. Whilst there is evidence to guide treatment, there does not appear to be a systematic review to analyse the efficacy of treatment options. OBJECTIVES: To retrieve all evidence relating to atrophic scar treatment and evaluate using the Clinical Evidence GRADE score in order to allow clinicians to make evidence-based treatment choices. METHOD: Searches were performed in Medline, EMBASE, CINHL and Cochrane to identify all English studies published evaluating treatment of atrophic scars on adults excluding journal letters. Each study was allocated a GRADE score based on type of study, quality, dose response, consistency of results and significance of results. The end score allowed categorisation of evidence into high, moderate, low or very low quality. RESULTS: A total of 41 studies were retrieved from searches including randomised controlled trials, observational studies, retrospective analyses and case reports of which 7% were allocated a high-quality score, 10% a moderate score, 7% a low score and 75% a very low score. Treatment modalities included ablative laser therapy, non-ablative laser therapy, autologous fat transfer, dermabrasion, chemical peels, injectables, subcision, tretinoin iontophoresis and combination therapy. CONCLUSION: There is a paucity of good-quality clinical evidence evaluating treatment modalities for atrophic scarring. Evidence supports efficacy of laser, surgery and peel therapy. Further biomolecular research is required to identify targeted treatment options and more randomised controlled trials would make the evidence base for atrophic scar treatment more robust.

Therapeutic mammaplasty - impact on the delivery of chemotherapy.

UNLABELLED: Therapeutic mammaplasty allows breast conservation and maintains breast cosmesis in women with larger and ptotic breasts. They are associated with more post-operative complications, potentially delaying adjuvant treatment. Our aim is to investigate the impact of therapeutic mammaplasty on the timing of adjuvant chemotherapy, compared with conventional breast conservation surgery. METHODS: Retrospective data collection of breast cancer patients undergoing breast-conserving surgery at a single institution from 2009 to 2013. RESULTS: 1000 patients underwent breast-conserving surgery, 40 underwent therapeutic mammaplasty. Patients with a complication of mammaplasty had no delay to starting chemotherapy compared to those without complication (median 36 vs. 40 days). There was no delay to chemotherapy for patients requiring further breast cancer excision surgery following therapeutic mammaplasty compared with standard breast conservation surgery (36 vs. 39 days). CONCLUSIONS: There is no delay in commencing adjuvant chemotherapy following therapeutic mammaplasty surgery, even if there is a complication of surgery. However, patients with involved margins had a significant delay to chemotherapy whilst awaiting re-excision surgery.

A comparison study of the utilization of National Cholesterol Education Program guidelines by cardiology and internal medicine practices: implications for the advanced practice nurse.

PURPOSE: To determine whether patients with hypercholesterolemia were being treated according to the updated 2001 National Cholesterol Education Program (NCEP) clinical guidelines and whether a difference existed between internists and cardiologists in the implementation of these guidelines. DATA SOURCES: This retrospective study used data obtained from a review of 200 patient charts that were compared with the NCEP guidelines. CONCLUSIONS: Results indicated that 67% of internal medicine patients and 71% of cardiology patients who qualified for pharmaceutical treatment received prescriptions for cholesterol-lowering medications. The difference between internal medicine and cardiology physicians was not statistically significant. IMPLICATIONS FOR PRACTICE: Like physicians, nurse practitioners should become familiar with and utilize the updated guidelines as standards of practice to promote and improve patient outcomes over the life span.