Publications by authors named "Nathan Falk"

Primary care physicians are often the first to evaluate patients with extremity injuries. Identification of fractures and sprains and their proper management is paramount. After appropriate imaging is obtained, immobilization and determination of definitive management, either nonoperative or operative, is critical. Appropriate immobilization is imperative to injury healing. Nonsurgical management of upper extremity fractures often uses slings, short-term splinting, gutter splints, and/or short or long arm casts. Initial fracture stabilization of the lower extremity is usually accomplished with a posterior splint. Definitive management usually uses controlled ankle movement walker boots, hard-sole shoes, or casting.

Objective: To review the pharmacology, efficacy, and safety of ubrogepant as an abortive migraine treatment.

Data Sources: A literature search of MEDLINE and PubMed was performed (January 2006 through May 2021) using the following search terms: , and .

Study Selection And Data Extraction: Relevant studies evaluating ubrogepant's pharmacology, efficacy, and safety in humans for the treatment of migraine were considered.

Data Synthesis: Ubrogepant is a calcitonin gene-related peptide receptor antagonist approved by the Food and Drug Administration for the acute treatment of migraine via data from ACHIEVE I and II. From ACHIEVE I, ubrogepant demonstrated superiority to placebo in freedom from migraine pain at 2 hours postdose (50-mg dose: odds ratio [OR] = 1.83, 95% CI = 1.25-2.66; 100-mg dose: OR = 2.04, 95% CI = 1.41-2.95) and freedom from most bothersome symptom (MBS; 50-mg dose: OR = 1.70, 95% CI = 1.27-2.28; 100-mg dose: OR = 1.63, 95% CI = 1.22-2.17). ACHIEVE II trial demonstrated efficacy of ubrogepant 50 mg compared with placebo (2-hour pain freedom: OR = 1.62, 95% CI = 1.14-2.29; 2-hour MBS freedom: OR = 1.65, 95% CI = 1.25-2.20).

Relevance To Patient Care And Clinical Practice: Ubrogepant is a viable option for patients who are unable to tolerate nonsteroidal anti-inflammatory drug or triptan therapy because of ineffective relief or contraindications that limit use.

Conclusions: Ubrogepant is a well-tolerated effective abortive migraine treatment that bridges a gap in therapy for many patients who previously could not tolerate other first-line treatments.

Tuberculosis (TB) is the leading cause of infectious disease-related mortality worldwide, affecting 1.7 billion individuals with 9,000 new cases annually in the United States. Disease burden in the United States is greatest among immigrants from areas with high TB rates (eg, India, China, Philippines, Vietnam). Active TB infection can be recently acquired or latent TB infection (LTBI) that becomes active long after initial infection. LTBI testing is recommended for health care workers at hire, immigrants from high-burden areas, and those in high-risk environments (eg, homeless shelters, correctional facilities, long-term care). Health care workers can be tested with interferon gamma release assays (IGRA) or tuberculin skin tests (TSTs). For others older than 5 years, IGRA is recommended. For children younger than 5 years, TSTs are recommended. If test results are positive, several new therapeutic regimens have replaced the previously standard 9-month isoniazid regimen. For patients suspected of having active TB, testing involves chest x-ray, sputum for microscopy, cultures, and nucleic acid amplification tests. Active TB is managed with 2-months of intensive 4-drug therapy, followed by a 4-month continuation phase with isoniazid and rifampin. If multidrug-resistant TB is diagnosed, consultation with infectious disease subspecialists and the health department is recommended.

Coccidioidomycosis, histoplasmosis, and aspergillosis are all caused by inhaling a soil fungus. Most patients with coccidioidomycosis, which is endemic to California and Arizona, are asymptomatic, but 40% have influenzalike symptoms that frequently resolve without treatment. Rarely, coccidioidomycosis can disseminate. It typically is diagnosed with chest x-ray and antibody tests. Antifungal therapy is only needed for severe infections and individuals with extensive comorbidities. Histoplasmosis is endemic to central/eastern United States. Only 10% of cases are symptomatic, and they typically resolve without treatment. Severe illness can occur in immunocompromised individuals. Diagnosis typically is made with chest x-ray and urine/serum antigen tests. Antifungal therapy is indicated for mild infections that do not resolve and for those with more severe disease. Neither histoplasmosis nor coccidioidomycosis is spread from person to person. Aspergillosis also can be acquired in health care settings via person-to-person spread or contaminated medical devices. Aspergillus-related pulmonary disease includes an allergic syndrome, aspergillomas (fungus balls) in the lungs or sinuses, and chronic or invasive forms. The allergic syndrome is initially diagnosed with skin tests or immunoglobulin E levels and managed with steroids and antifungals. Aspergillomas and invasive disease are initially detected with x-rays and managed with antifungals.

Sarcoidosis is a systemic condition characterized by formation of granulomas that can involve many organ systems, with the lungs and intrathoracic lymph nodes involved in more than 90% of cases. Sarcoidosis also can involve the cardiac, ocular, hepatic, dermatologic, and central nervous systems. The presentation of pulmonary sarcoidosis is nonspecific. Less than half of patients initially have respiratory symptoms and the disease often is detected as an incidental finding of lymphadenopathy on chest x-ray. However, lymphadenopathy can occur in many other conditions, ranging from tuberculosis to cancer, so sarcoidosis should be diagnosed only after excluding these other conditions. Typical granulomatous findings on lymph node biopsy can increase confidence in sarcoidosis diagnosis after the other conditions are excluded. However, there are three syndromes which, if present, are diagnostic of sarcoidosis: Lofgren syndrome, Heerfordt syndrome, and lupus pernio. The majority of sarcoidosis cases resolve spontaneously, so treatment typically is reserved for patients with progressive pulmonary or extrapulmonary involvement, specifically ocular, cardiac, or central nervous system. Systemic corticosteroids are first-line treatment. Second-line treatment with methotrexate or hydroxychloroquine is used if steroids are ineffective or to enable steroid tapering. Refractory disease should be comanaged with a sarcoidosis subspecialist.

Occupational lung diseases are caused by workplace inhalation of chemicals, dusts, or fumes. They include asbestosis, silicosis, coal workers' pneumoconiosis (CWP), and occupational asthma. These diseases have nonspecific respiratory symptoms and are only identified if an occupational history is taken. Asbestosis typically is diagnosed 20 to 30 years after peak exposure, often when pleural plaques are noted on chest x-ray (CXR). Asbestosis is associated with an increased cancer risk, which is higher in smokers. Silicosis results from exposure to silica dust from sand, stone, and quartz. It is a fibrotic lung disease with acute, chronic, or accelerated presentations; CXR findings show interstitial fibrosis or nodular opacities. Silicosis increases risk of mycobacterial and fungal infections. In CWP, patients may present with mild symptoms and CXR findings showing small fibrous nodules; progressive massive fibrosis may develop, and there is a risk of mycobacterial and fungal infections. Occupational asthma (OA) can occur de novo from inhaling sensitizers that induce immunoglobulin E-mediated airway reactions, or from inhaling irritants such as smoke, dust, and fumes. OA also can be due to sensitizers/irritants aggravating preexisting asthma. There are no cures for these occupational lung diseases, so prevention, including elimination/control of workplace exposures, and early diagnosis are key.

Asthma is a heterogeneous condition involving various levels of chronic airway inflammation, bronchoconstriction, airway hyperresponsiveness, and mucus production. Although inhaled corticosteroids and long-acting bronchodilators have improved patient outcomes, asthma remains uncontrolled for at least 10% of patients, even when use of these therapies is maximized. Improved understanding of the biology, genetics, and role of immune cell signaling in asthma has led to the development of immunobiologic therapies. They are administered subcutaneously or intravenously and target immunoglobulin E or interleukins that are involved in the allergic response. In patients with allergic asthma, immunotherapy has been shown to reduce exacerbations, decrease the need for drug use, and reduce the overall cost of care. Allergy immunotherapy, traditionally administered via subcutaneous injections, can be effective in the management of allergic asthma. Sublingual allergy immunotherapy is an option for treating adults with asthma due to dust mite allergy. Bronchial thermoplasty is a procedure used to treat some patients with severe asthma that remains uncontrolled despite appropriate use of traditional asthma drugs. Asthma action plans have been shown to decrease exacerbations and emergency department admissions. These plans incorporate self-monitoring for symptoms, appropriate drug use, and self-management plans for acute symptoms.

Dementia is a significant and costly health condition that affects 5 million adults and is the fifth leading cause of death among Americans older than 65 years. The prevalence of dementia will likely increase in the future because the number of Americans older than 65 years is expected to double by 2060. Risk factors for dementia include age; family history of dementia; personal history of cardiovascular disease, cerebrovascular disease, diabetes mellitus, or midlife obesity; use of anticholinergic medications; apolipoprotein E4 genotype; and lower education level. The U.S. Preventive Services Task Force and the American Academy of Family Physicians have concluded that current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults. If dementia is suspected, physicians can use brief screening tests such as Mini-Cog or General Practitioner Assessment of Cognition. If the results are abnormal, further evaluation is warranted using more in-depth screening tools such as the Montreal Cognitive Assessment, Saint Louis University Mental Status Examination, or Mini-Mental State Examination. Diagnostic testing and secondary evaluation, including screening for depression, appropriate laboratory studies for other conditions that cause cognitive impairment, and magnetic resonance imaging of the brain, should be performed when cognitive impairment is confirmed. Routine cerebrospinal fluid testing and genetic testing for the apolipoprotein E4 allele are not recommended.

Chronic asthma is a major health concern for children and adults worldwide. The goal of treatment is to prevent symptoms by reducing airway inflammation and hyperreactivity. Step-up therapy for symptom control involves initiation with low-dose treatment and increasing intensity at subsequent visits if control is not achieved. Step-down therapy starts with a high-dose regimen, reducing intensity as control is achieved. Multiple randomized controlled trials have shown that inhaled corticosteroids are the most effective monotherapy. Other agents may be added to inhaled corticosteroids if optimal symptom control is not initially attained. Long-acting beta2 agonists are the most effective addition, but they are not recommended as monotherapy because of questions regarding their safety. Leukotriene receptor antagonists can be used in addition to inhaled corticosteroids, but they are not as effective as adding a long-acting beta2 agonist. Patients with mild persistent asthma who prefer not to use inhaled corticosteroids may use leukotriene receptor antagonists as monotherapy, but they are less effective. Because of their high cost and a risk of anaphylaxis, monoclonal antibodies should be reserved for patients with severe symptoms not controlled by other agents. Immunotherapy should be considered in persons with asthma triggered by confirmed allergies if they are experiencing adverse effects with medication or have other comorbid allergic conditions. Many patients with asthma use complementary and alternative agents, most of which lack data regarding their safety or effectiveness.