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Here&NowFebruary 2012 • Volume 3, Issue 2Attend FREE ADVANCE Job Fairs in person or online. Find upcoming events on page 47.35 The Surgical SuiteFor nurse practitioners andphysician assistants thinkingabout moving into a surgicalsetting or PA students preparingfor rotations, Robert M. Blumm,MA, PA-C, DFAAPA, outlines whatyou need to know about theoperating room team.38 Job SatisfactionFind out what a sample of NPsin primary care settings thinksabout workplace factors thatbring job satisfaction. RebeccaAnn Priebe, MSN, ACNP-BC,conducted her study in Michigan.Would the same things matterto PAs?Articles18 Salary Survey ResultsThe results of the 2011 National Salary Survey of NPs & PAs have beentabulated, and we’re kicking off our coverage with this month’s overviewof key findings. Like much of working America, NPs and PAs were paidless in 2011. The decline was much steeper for one of your professions,however. (Cover image by Tom Whalen, Kyle Kielinski and Doris Mohr)Columns & DepartmentsFirst & Foremost ..............................10Front & Center ...............................12Career & Workforce. ...........................16Role & Growth. ...............................17Calendar ...................................40Ad Index ....................................49Career Opportunities. ..........................5425 Prescribing AmidAntibiotic ResistanceThe man vs. microbe battle iscontinuing. The World HealthOrganization has deemedantimicrobial resistance oneof the three most importantproblems facing healthcareproviders today. In our CME/CEoffering for this month, Lynn A.Kelso, MSN, APRN, FCCM, FAANP,provides an overview of theissues.31 Primary Care AfterLiver TransplantThe survival rates for livertransplant recipients in theU.S. are improving, and thatmeans these patients requireprimary care services forchronic conditions that havenothing to do with transplantmanagement. Katherine Monday,MSN, NP, provides informationon the overall care of transplantrecipients over time.2531March 28-29: FREE events to further youreducation. Register for our education fairsat www.advanceweb.com.Copyright 2012 by Merion Matters. All rights reserved. Reproduction in any form is forbidden without writtenpermission of publisher. ADVANCE for NPs & PAs (ISSN 1096-6293) is published monthly by MerionPublications, Inc., 2900 Horizon Drive, Box 61556, King of Prussia, PA 19406-0956.ADVANCE for NPs & PAs is the official publication of the Association of FamilyPractice Physician Assistants.ADVANCE is free to certified nurse practitioners and physician assistantsand students with senior status. Our company also publishes magazines andwebsites for audiologists, laboratory administrators, health executives, healthinformation professionals, imaging and radiation oncology professionals, longtermcare managers and professionals, medical laboratory professionals, nurses, occupational therapypractitioners, physical therapy and rehabilitation professionals, respiratory care andsleep professionals, and speech-language pathologists.ADVANCE for NPs & PAs is an official journal of the National Academy ofDermatology Nurse Practitioners.Advance is a member of the National Association for Health Care Recruitment.Periodicals Postage Paid at Norristown, PA and additional mailing offices.Postmaster: send address changes to: ADVANCE for NPs & PAs, CirculationDepartment, Merion Publications, Inc., 2900 Horizon Drive, Box 61556, King ofPrussia, PA 19406-0956.Please Recycle This Magazine®4 ADVANCE for NPs & PAs

Whether you’re searching for CE or a healthcare degree,the ADVANCE online education fair has something for you!Online Education Fairfor Healthcare Professionals • March 28 • 12:00 PM – 6:00 PM ETRegister Now!This FREE online event makes it easierthan ever to learn more about schoolsand CE providers from all across the country.• Chat with admissions personnel elfrom the comfort ofyour computer• Have your questionsanswered in real time• Find helpful information onCE courses and healthcaredegree programs• Enjoy free educationalsessions on careerenhancement• View multimediapresentations• Enter to win cool prizes• Leave the event and sign backin as many times as you please eto accommodate your scheduleeA companion college fair will be held on March 29 for studentsts interested ested inobtaining a Bachelor’s degree, Associate’s degree or healthcare diploma. If you’recontemplating a career move, you can register for this online event too!Attend fromanywhereyoucan getonline!Getcareeradvice andthelatest updates onour events. twitter.com/ADVANCECareersNetwork with studentsand professionalsalready inthe field.facebook.com/ADVANCECareersRegister now to attend our FREE online education fairat www.advanceweb.com/eventsQuestions? Call 800-546-4987 or email ADVANCEevents@advanceweb.comADVANCE for NPs & PAs7

Now atadvanceweb.com/NPPAIntroducing Our RosaceaResource CenterWhat’s in YourBackyard?By now you’ve downloaded our guide to national2012 conferences for NPs & PAs and madetravel plans or penciled in some possibilities.Don’t forget to check out what’s available in yourstate or a neighboring state. Our 2012 guideto state NP and PA association conferences islive now. Find it under the Events tab at www.advanceweb.com/NPPA.➼ We recently launched a resource centerfocused on rosacea,and it’s housed withinour Dermatology &Aesthetics specialtycenter. Link to www.advanceweb.com/NPPARosacea to findarticles, blogs and more.Help for Patients WithSleep Problems➼ Our new Sleep ResourceCenter offers information toassist providers in all settingsas they work to help patientsachieve restful sleep. Visitwww.advanceweb.com/NPPASleep.What Can You Do to PreventPneumococcal Disease?In the United States, pneumonia ranks among the top 10 causes ofdeath — even though it is the most common vaccine-preventable illness.Our article explains why an efficient vaccine campaign for patients atrisk is appropriate for implementation in tertiary care settings. Find it byentering the author’s name, Amy R. Painter, in the Search Articles boxon our site.8 ADVANCE for NPs & PAs

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First&Foremostis published by Merion MattersPublishers of leading healthcare magazines since 1985.How Does Your SalaryStack Up?How does your salary stack up against that of peersin similar work settings? Do other NPs and PAs specializingin the same area get paid more or less than you do? Find out inthis month’s overview of results from the 2011 National SalarySurvey of NPs & PAs.This eagerly anticipated annual report is the No. 1 reasonpeople visit our website, and those visitors include everyonefrom clinicians to employers to national media outlets suchas Forbes, which cited our survey in a December 2011 blogpost about the future of medicine.The salary report contained in this issue outlines NPand PA salaries over time, average salaries by primary work setting, and salaries bygender. NP salaries have jumped by $27,000 since 2001 and PA salaries have risenby almost $24,000. That’s darn good growth for a decade!This month’s kickoff report also provides a data overview for each profession.What’s the age of the average NP and PA? How long has the average NP and PA beenin practice? Find out on page 24.As we did with the 2010 survey results, we’ve prepared focused reports that drillfurther down into the salary data. We’ll be publishing these on our website over thecoming months: salaries according to state in March, salaries by city in April, salariesaccording to academic degree in May, and a special geographic report in June.In July, we’ll post a question-by-question breakdown of all results. To ensure thatyou don’t miss any of these follow-up reports, sign up for our free enewsletter usingthe tool posted at the top of our homepage, www.advanceweb.com/NPPA. We’ll beannouncing the posting of each analysis in the enewsletter.In other content in this issue of ADVANCE for NPs & PAs, our CME/CE offeringprovides an update on progress against bacteria that are resistant to antimicrobialtreatment. We’re also proud to present articles on transitioning to the surgical specialtyand providing primary care to patients who have received liver transplants. And besure to check out the article reporting the results of a small study of job satisfactionamong nurse practitioners in primary care; would a survey of physician assistantsproduce similar findings? We’d love to hear your thoughts. Post your commentson our website or email our editorial team using the contact information at right(“How to Contact Us”).We’ll continue bringing you valuable clinical and professional information throughour print edition and web community. Be sure you don’t miss a single issue: Renewyour free subscription today by clicking the Subscribe button at the top of our homepageor by calling 800-355-1088. Our Subscriber Services team is available Mondaythrough Friday 8 a.m. to 6 p.m. Eastern. ■— Michelle Perron PronsatiThe Editor Recommends …➼ Find out how the implementation of electronic health records helped a pediatricpractice in Georgia hit important milestones. Enter “EHR in a Pediatric Practice”in the Search Articles box at www.advanceweb.com/NPPA.PublisherAnn Wiest KielinskiGeneral ManagerW. M. “Woody” KielinskiEditorial StaffEditor: Michelle Perron PronsatiSenior Associate Editor: Jennifer FordEditorial Assistant: Kelly WolfgangWeb Manager: Jennifer MontoneDesignVice President, Director of Creative Services:Susan BasileDesign Director: Walt SaylorArt Director: Doris MohrMultimedia Director: Todd GerberadvertisingDirector of Marketing Services: Christina AllmerArt Director: Chris WoffordEVENTSPublic Relations Director: Maria SeniorJob Fair Manager: Laura SmithEvents Product Manager: Mike ConnorADMINISTRATIONVice President, Director of Human Resources:Jaci NicelyVice President of Business Technology Operations:Joe RomelloInformation & Business Systems Director:Ken NicelyDigital Media Sales Director: Kim NobleCirculation Manager: Maryann KurkowskiBilling Manager: Christine MarvelSubscriber Services Manager: Vikram KhambattaMedia & Marketing OpportunitiesDisplay AdvertisingSales Director: Amy TurnquistManager of Custom Communications and MarketingServices: Shannon Coghlan ReissNational Account Executive: Shannon FergusonSales Associate: Ashley HackettHealthcare Facility AdvertisingSales Director: Kim NobleGroup Managers: Robert Murray, Dan StuartEducation AdvertisingSales Manager: Ed ZetoAccount Executive: Brock BamberSales Associates: Sarah Rucinski, Ashley WayneCUSTOM PROMOTIONsSales Manager: Mike KerrSenior Account Executives: Noel Lopez,Sue Borjeson-RomanoSales Associates: Kristen Erskine, Aarika Hoffner,Desirae Slaugh, Leah Stashko, Chris Wanner, GinaWillettHow to Contact Us• For a FREE subscription: Call (800) 355-1088 orsign up at www.advanceweb.com/NPPA• To reach the editor:Michelle Perron Pronsati, mpronsati@advanceweb.com or (800) 355-5627, Ext. 1221• To reach the senior associate editor andwebsite editor:Jennifer Ford, jford@advanceweb.com or(800) 355-5627, Ext. 1384• To reach the editorial assistant: Kelly Wolfgang,kwolfgang@advanceweb.com, Ext. 1158• To order article reprints: (800) 355-5627, Ext.1446• To place an advertisement (display, calendar orrecruitment): (800) 355-5627, Ext. 0ADVANCE for NPs & PAsMerion Matters • 2900 Horizon Dr.King of Prussia PA 1940610 ADVANCE for NPs & PAs

Help yourpatients feel goodinside and out.Sustenex® survives 10x betterthan other probiotics so it gets to whereit needs to be for healthy digestion. ‡Sustenex® contains BC 30 (Bacillus coagulans GBI-30, 6086),a unique probiotic with a natural protective layer of proteins whichallows the probiotic to better withstand the stomach’s acidic andhostile gastric environment. Sustenex® offers superior survivabilityversus other probiotics and yogurt so it can reach the digestive tract insignificant number and have the greatest health benefit. ‡Benefits of Sustenex®Proof #ApprovalDelivers 10x better survivability vs. other probiotics and yogurt ‡ColorsCreative DesignerSupports a healthy balance of beneficial bacteria Helps promote a healthy immune system Brand Manager RedAvailable in Capsules, Gummies & Soft Chews!Project Management BlueFor more information, visit www.Sustenex.comPackaging Engineer Pink THESE STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. THIS PRODUCT IS NOT INTENDED TO DIAGNOSE, TREAT, CURE Labeling OR PREVENT Specialist ANY DISEASE. Purple‡ Based on median % survivability of Sustenex® vs. probiotic supplements and 20 probiotic yogurts in simulated© 2012 Scientist Schiff Nutrition Group, Inc. Purplegastric pH for 2 hours. Survivability of probiotic cells is one of several factors influencing overall product effect.ResearchRegulatory Affairs683-A1BlackGreenBlackADVANCE for NPs & PAsNO CHA11

Front&CenterOTC MULTIPURPOSEMOISTURE BARRIERTEMPORARILY RELIEVESDISCOMFORT & ITCHINGProtects and Helps HealSkin Irritations from:• Incontinence of Urine orFeces• Diaper Rash• Wound Drainage• Minor Burns, ScrapesCALL1-800-800-3405For moreinformationand free sampleswww.calmoseptineointment.comFREE WEBINARSFROM ADVANCEFEBRUARY 2012■ Leading a Successful TeamTuesday, February 14 • 1:00 PM - 1:45 PM ETLearn the principles of winning formulas fromproven leaders: Elizabeth Dole, Rudy Giuliani,sales expert Tom Hopkins and Meg Whitman.This webinar will focus on how wisdom,strategic thought and courage intertwine tocreate successful teams. Included will be a brief introduction toleadership benchmarks and the SWOT Analysis.■ About the presenter: Shirley Premont is a consultant andtrainer with SpaceCycles, a cloud solutions and businessconsulting firm based in Redondo Beach, CA.Register now. http://nurse-practitioners-and-physician-assistants.advanceweb.com/Webinar/Editorial-Webinars/Leadinga-Successful-Team.aspxSIGN UP ONLINE FORTHESE FREE EVENTS!www.advanceweb.com/NPPANews for NPs & PAsMaine Working to Curb Opioid AbuseAfter a survey of controlled substance prescribers inMaine reported a high incidence of opioid abuse by stateresidents, a legislative committee voted to move ahead withefforts designed to curb this abuse.The survey was created by a work group formed by alegislative initiative titled “Resolve: To Reduce OpioidOverprescription, Overuse and Abuse.” (Find this documentat http://www.mainelegislature.org/legis/bills/bills_125th/billtexts/HP110202.asp.) Bonnie Lundquist, NP, an appointedmember of the work group, said that although the surveywas available to all prescribers, the majority of respondentsto the survey were physicians and NPs. Lundquist said themost striking results of the survey include the following:• 90% of prescribers characterize the opioid abuse andaddiction problem in their area as moderate or severe• 80% attempt to identify patients at risk for opioid diversionor addiction• 85% try to reduce risk of addiction or diversion by usingpatient education or treatment agreements.The survey also found that most prescribers use precautionarymeasures to avoid abuse, such as urine tests andpill counts. More than 350 respondents wrote comments,many of which indicated frustration with lack of treatmentoptions, the state’s prescription monitoring program,patients and legislation.“The comments were very telling about how huge this problemis and how providers agonize over it,” Lundquist said. Althoughthe response rate was 10% of the state’s controlled substanceprescribers, the survey was not statistically valid becauserespondents were not chosen at random, she explained.“Nevertheless, we do believe the survey is very informative,”she said. “As a long-term pain management provider, I feelvery strongly both about this topic and about the need forNPs to be at the table when such possible legislative actionis considered.”In January, the Maine Legislature’s Health and HumanServices Committee reviewed the report from the workgroup (http://www.maine.gov/dhhs/osa/pubs/osa/2011/LD1501SASCFinalReport.pdf) and approved the establishmentof a Drug Disposal Task Force to explore ways todispose of expired and unused medications. The committeevoted to continue to review the remaining recommendations.Lundquist is hopeful that the recommendations willbe implemented quickly.“I personally plan to continue following the progressof our report as it goes through state government,” shesaid, “and I am optimistic that I will be appointed to thestanding task force being established by the governor todeal with this issue.”12 ADVANCE for NPs & PAs

By Jennifer FordShe’s counting on you.You can count on us.Countersignature Changes Sought for PAsIn Pennsylvania, PAs are awaiting action on Housebills 1832 and 1833, which seek to remove the requirementfor countersignature by a physician on charts and formssigned by a PA. The bills would also allow PAs to performphysicals for police, foster care and day care clearance.Both bills were referred to the Committee on ProfessionalLicensure last fall. A public hearing on the bills is scheduledlater this month.The Pennsylvania Society of Physician Assistants (PSPA)worked with the state’s Board of Medicine and key interestgroups over several years, explaining the barriers to practiceand patient access that the existing language imposed, saidMark DeSantis, PA-C, PSPA chairman of governmental affairs.PSPA also sought guidance from a lobbyist group.“They were instrumental in garnering legislative sponsorship,”DeSantis said. Using email and direct mail, PSPAsent information to PAs, PA students and physicians whosupervise PAs about how to support the bill.Rep. Curt Sonney, who sponsored both bills, attendedthe PSPA annual conference in October and addressed thenearly 550 attendees.Eliminating the chart countersignature requirement wouldmake Pennsylvania’s practice laws more consistent withAAPA’s Six Key Elements of a Modern PA Practice Act, whichare discussed in an issue brief at http://www.aapa.org/uploadedFiles/content/Common/Files/SL_KeyElements_v3.pdf.Another Legislative SeasonBeckons in FloridaSeveral legislative initiatives are under way that couldimprove NP practice in Florida. HB 1195 has been introducedand would allow NPs to authorize involuntary psychiatricexaminations under the Baker Act. The Florida Councilof Advanced Practice Nurses Political Action Committee(CAP-PAC) worked with bill sponsor Rep. Daphne Campbellto submit the legislation in January.Susan Lynch, MSN, NP-C, vice chairwoman of publicrelations for CAP-PAC, is hopeful that the bill will pass.Many other providers, including PAs, physicians, psychiatricRNs, psychologists, social workers and marriage and familycounselors, already are able to involuntarily commit patientswho are suicidal or homicidal.According to the Sunshine State News, the Florida MedicalAssociation (FMA) deferred comment on this bill to FloridaPsychiatry Society executive director Margo Adams, whosaid her board has taken no position.HB 1195 is one of several attempts to expand statutoryauthority for NPs in Florida. NPs are also included in theAs health care professionals, you are committed to providingyour patients with the best care possible to help them managetheir heart failure. Introducing the Congestive Heart FailureCenter – offering medical expertise, educational and dietaryconsultations, plus on-site imaging services to ensure yourpatients have effective options available to not only managetheir heart failure, but improve their quality of life.Left Ventricular Assist Device (LVAD) consults and treatmentare also available through the Congestive Heart Failure Center.Call to schedule a consultation and determine if LVAD is aviable option for a patient.Frequent communication with the patient’s referring physicianand all members of the treatment team is of paramountimportance and is a critical aspect of the overall care plan.Call 1.855.4CV.CARE (1.855.428.2273) to schedule apatient for a consult or for imaging services. The CongestiveHeart Failure Center is one of several clinical services offeredin the Center for Advanced Cardiovascular Care .Visit TheHeartHospitalBaylor.com/cvcare to learn more.4716 Alliance Blvd, Pavilion II, Suite 300 • Plano, TX 75093Notice Regarding Physician Ownership: THE HEART HOSPITAL Baylor Plano is a hospital in which physicians havean ownership or investment interest. The list of the physician owners or investors is available to you upon request.Physicians are members of the medical staff at one of Baylor Health Care System’s subsidiary, community oraffiliated medical centers and are neither employees nor agents of those medical centers, THE HEART HOSPITALBaylor Plano or Baylor Health Care System. ©2012 Baylor Health Care System BID THHBP_347 1.12ADVANCE for NPs & PAs13

Front&Centerlanguage of SB 256, also introduced in January, which wouldallow NPs to clear young athletes for activity after head injury.The bill includes physician assistants in the list of providersthat would be approved for these evaluations.Another bill, HB 1267/SB 1014, introduced by Rep. Charles VanZant and Sen. Mike Bennett, makes another attempt at grantingauthority for Florida NPs to prescribe controlled substances.According to the bill text, it seeks to “expand scope of practiceto authorize advanced registered nurse practitioners toprescribe, order, administer, monitor and alter any drug or drugtherapies that are necessary for proper medical care & treatmentof patient.” Both versions of this bill had been referred to committeesat press time.According to Lynch, CAP-PAC garnered support from Sen.Alan Hays, a dentist, to help the group work with the FMA ona possible compromise on the topic of controlled substanceprescribing for nurse practitioners. This has been a longcontestedissue in Florida. Florida and Alabama are the tworemaining states in the country in which NPs cannot prescribeany controlled substance.“We’re hopeful that a compromise can be reached,” Lynchtold ADVANCE for NPs & PAs.ADVANCE has been closely covering nurse practitionerpractice struggles in Florida for many years. Read an opinionpiece and a review of past news about Florida nurse practitionerprescribing by CAP-PAC board member Jeffrey Hazzard,NP, at http://nurse-practitioners-and-physician-assistants.advanceweb.com/Web-Extras/Online-Extras/Opinion-The-Cost-of-Greed.aspx.Ohio Forms MultidisciplinaryHealthcare CouncilIn Ohio, representatives from the advanced practicenursing, physician assistant, physician and pharmacy professionsunited to form the Council for Ohio Healthcare Advocacy(COHCA; http://www.cohcaonline.org/).According to the group’s inaugural newsletter, “COHCAis a nonprofit organization committed to uniting healthcareprofessionals from multiple health disciplines for collectivedialogue and action. Our goal is to encourage continuousimprovement of patient care through education, professionaldevelopment, political advocacy, and sharing of healthcareinformation through collaboration and cooperation.” Thegroup will follow political and professional issues relevant toall professions involved.“As far as we know it’s the first one anyplace in the country,” saidCOHCA lobbyist Lori Herf. “It’s not intended to replace any othergroups, but we’ve all realized that it’s time to work together.”FNP Students Create BilingualDiabetes Education ProgramTo help increase diabetes awareness in the Hispaniccommunity, four students from the family nurse practitionerprogram at Samuel Merritt University (SMU) in Oakland, Calif.,recently organized and taught two free diabetes workshops atthe Davis Street Family Resource Center in San Leandro, Calif.The students taught classes in English and Spanish, address-Japanese Physicians VisitU.S. PA and NP ProgramsMichael De Rosa, PhD, PA-C, chairmanof the physician assistant programat Samuel Merritt University (SMU) inOakland, Calif., recently welcomed twocardiovascular surgeons from FujitaHealth University who are creating atraining program for providers in Japan.They traveled to California to visit theUniversity of California at San FranciscoNP program and SMU’s PA program toengage in a discussion about NP and PAtraining, role and practice issues.“This was an excellent opportunity forSMU to show off the high-quality medicaleducation we provide,” De Rosa said. “Thedoctors were truly impressed by the simulationexperiences we shared with them andthe level of training our PA students receive.Our visitors realize they have a long roadSMU professor Michael De Rosa, PhD, PA-C, Yasushi Takagi, Midori Nakashima, Takashi Watanabe,and SMU faculty Lina Gage-Kelly and Bill Stiers. courtesy SMUahead, but I think they were encouragedby what physician assistants can do withintheir healthcare system.”De Rosa says future collaborations,guest lecture opportunities and studentexchanges are being discussed.14 ADVANCE for NPs & PAs

An Integrated Risk Evaluation and Mitigation Strategy(REMS) for FENTORA® (Fentanyl Buccal Tablet) and ACTIQ®(Oral Transmucosal Fentanyl Citrate)IT IS WELL RECOGNIZED THAT THE JUDICIOUS USE OF OPIOIDScan facilitate effective and safe management of chronic pain. Nonetheless,the potential risks of misuse, abuse, addiction, and overdosemust be considered when prescribing opioid medications. Inan effort to manage the risks associated with all opioids, the U.S.Food and Drug Administration (FDA) now requires a Risk Evaluationand Mitigation Strategy (REMS) for certain medications. A REMS isa regulatory program designed to improve the quality of medicationuse, and it contains components that are intended to ensurethat the benets of a medication or therapeutic class outweighany risks.Rapid-onset opioids, including products such as FENTORA® (fentanylbuccal tablet, Cephalon, Inc., Frazer, Pennsylvania) and ACTIQ®(oral transmucosal fentanyl citrate, or OTFC, Cephalon, Inc., Frazer,Pennsylvania), are important treatment options for opioid-tolerantpatients with chronic cancer pain accompanied by breakthroughpain (BTP). Recently, the FDA adopted the more descriptive term,transmucosal immediate-release fentanyl (TIRF), for the class ofrapid-onset opioids. Cephalon, Inc., is committed to maintainingaccess to appropriate pain management for the often debilitatingeffects of BTP in opioid-tolerant patients without compromisingpatient or public safety. Thus, Cephalon has implemented the recentlyFDA-approved ACTIQ and FENTORA REMS program to helpmitigate potential safety concerns observed with opioids. Eventually,this approved REMS will be merged with REMS for other TIRFproducts.In this supplement, we present the background of the REMS program,a brief review of BTP along with the clinical data supportingthe use of FENTORA and ACTIQ for BTP in appropriate opioidtolerantpatients, and an overview of the recently approved REMSfor fentanyl buccal tablet and OTFC. Healthcare professionals whoprescribe opioids will be required to enroll in the REMS program inorder to prescribe these products. Although we understand thatthis may require additional effort for those involved in prescribing,distributing, and dispensing TIRF products, we hope that thesesteps will ensure that these important medications are appropriatelydistributed to and received by the patients who need them.THE STEERING COMMITTEE FOR ACTIQ® AND FENTORA® REMSRandy J. Bradway, MS, RPhBill CampbellClaire Jurkowski, MDRobert F. Kaper, MDJames Ottinger, RPhCephalon, Inc.*Frazer, Pennsylvania*Cephalon, Inc., is now a wholly owned subsidiary of Teva Pharmaceuticals.Cephalon | ADVANCE for NPs & PAs | 1ADVANCE for NPs & PAsA

The Risk Evaluation and Mitigation Strategy(REMS): BackgroundBY JAMES OTTINGER, RPH, AND SUSAN FRANKS, MSCEPHALON, INC. | FRAZER, PENNSYLVANIAIn 2007, the FDA Amendments Act provided the FDA with theauthority to require pharmaceutical manufacturers to developa REMS to ensure that the benets of a drug outweigh itsrisks. 1 A REMS can be mandated for any newly approved prescriptiondrug or biologic product or for any previously approved drugor biologic product if the FDA becomes aware of new safety information.In 2009, the FDA issued a draft “Guidance for Industry”outlining the format and content of a REMS program. 1 Each REMSis designed to minimize inappropriate use without hinderingpatient access to medications. 2 Currently, approximately 200REMS programs have been approved by the FDA covering a widevariety of therapeutic areas, including opioid medications. 3A REMS program can have 5 components: (1) “Medication Guide”or patient package insert; (2) “Elements to Assure Safe Use”; (3)communication plan; (4) implementation system; and (5) timetablefor submission of assessment. Each REMS, however, does not haveto encompass all of these components 1 (see sidebar).REMS: IMPLICATIONS FOR OPIOIDSThe use of opioid medications is an essential part of pain managementfor many chronic pain patients. In an effort to manage therisks associated with opioids, certain classes of opioids have beenincluded in the federal mandate to develop a REMS.In February 2009, the FDA contacted the manufacturers of alllong-acting and extended-release opioid formulations, includingoxymorphone, oxycodone, morphine, methadone, transdermalbuprenorphine, transdermal fentanyl, and hydromorphone, andmandated that the manufacturers design a REMS program to accommodateall of these products. 2 To date, the FDA has approvedseveral individual REMS programs for these opioid medicationswhile the class-wide REMS is being designed. 3 In April 2011, theFDA sent notication letters to all manufacturers of long-actingopioids and extended-release opioids formally notifying them ofthe need to submit a single-system REMS. Letters included specicguidance and templates for prescriber training and patienteducation. 4 Although specic medical education is not mandatoryfor prescribing extended-release and long-acting opioids in theREMS, separate legislation has been proposed in the U.S. Houseof Representatives that would link mandatory training or certicationto the Drug Enforcement Administration registration numberthat already is required to prescribe controlled substances. 5In October 2010, the FDA contacted the manufacturers of TIRFproducts to harmonize individual TIRF product REMS that wereThe “Medication Guide” or patient package insertcomponent of REMS serves as the primary educationaltool for healthcare professional–directed patienteducation and is distributed to patients by the pharmacyat the time of dispensing. 1 Important elements of the“Medication Guide” or patient package insert includea description of the safety, including the adverse eventprole of the medication, warnings and precautions,storage requirements, and dosing.The “Elements to Assure Safe Use” can includeprescriber and pharmacist training and certication,restrictions on where the medication is dispensed, evidenceof patient safe use conditions, patient education,safety protocols, patient monitoring and enrollment ordata collection forms, and medication monitoring procedures.1 The mechanism by which these elements aredisseminated is described in the communication plan.This component of the REMS may include letters tohealthcare professionals or other stakeholders regardingmedication risks and specic protocols to fosterappropriate medication utilization. 1In the implementation system, the drug manufacturermust take reasonable steps to monitor andevaluate the implementation of the REMS by the stakeholders(e.g., healthcare providers, pharmacists) whoare responsible for executing its various elements. 1 Inthe timetable for submission of assessment section, anassessment of the effectiveness of the REMS must besubmitted to the FDA no less frequently than 18 months,3 years, and 7 years after REMS approval. 1 This is theonly component mandated for all REMS programs. TheFDA may, at its discretion, require more frequent submissionof REMS assessments.approved or under active review. In parallel, the FDA requestedthat the manufacturers work together to create a single, sharedsystem for all TIRF products. In contrast to the REMS for extendedreleaseand long-acting opioids, REMS programs for TIRF productscontain a mandatory education element. A REMS meetingthe new FDA requirements has been approved for FENTORA®2 | ADVANCE for NPs & PAs | CephalonBADVANCE for NPs & PAs

(fentanyl buccal tablet, Cephalon, Inc., Frazer, Pennsylvania) andACTIQ® (OTFC lozenge, Cephalon, Inc., Frazer, Pennsylvania). 6REMS programs meeting the new FDA requirements have beenapproved for the fentanyl sublingual tablet (Abstral®, ProStrakan,Inc., Bedminster, New Jersey) and fentanyl nasal spray (Lazanda®,Archimedes Development Ltd, Nottingham, UK). Revisions to theexisting REMS for fentanyl buccal soluble lm (Onsolis®, MedaPharmaceuticals, Inc., Somerset, New Jersey) are under review asof this writing. 3 To date, FDA has not required REMS programs fornon-TIRF, short-acting opioid products.Breakthrough Pain in Cancer and NoncancerPatients: An OverviewBY ARVIND NARAYANA, MDCEPHALON, INC. | FRAZER, PENNSYLVANIAPatients with chronic pain often experience transitory exacerbationsof pain despite long-term treatment with anaround-the-clock opioid. These exacerbations, or ares, thatoccur on a background of otherwise well-controlled, persistent,chronic pain are dened as BTP. 7 The prevalence of BTP is high; in arecent survey of community-dwelling patients with chronic canceror noncancer pain, 33% and 48%, respectively, experienced BTP. 8In patients with chronic pain who have controlled persistent pain,the presence of BTP has been associated with increased healthcarecosts due to hospitalizations and emergency department visits, 9and patients with BTP have greater functional impairment, disability,depression, and anxiety, as well as poorer quality of life thanpatients without BTP. 10,11Many BTP episodes reach peak intensity within minutes, farsooner than the onset of analgesia produced with conventional,orally administered, short-acting opioid medications (30 to 60minutes). 11-13 TIRF products have been developed to address theneed for opioids with a rapid onset of analgesia that more closelymatches the time prole of a typical BTP episode.FENTANYL BUCCAL TABLET: CLINICAL DATA REVIEWThe fentanyl buccal tablet is a rapid-onset, schedule II opioid approvedby the U.S. Food and Drug Administration in 2006 for thetreatment of BTP in patients with cancer who are already receivingand are tolerant to opioid therapy for their underlying persistentcancer pain. 14 Fentanyl buccal tablet utilizes OraVescent® drugdelivery technology (CIMA Labs, Inc., Eden Prairie, Minnesota),which employs a chemical reaction to enhance the rate and extentof absorption of fentanyl through the buccal mucosa. 15The clinical efficacy and safety program for fentanyl buccal tabletencompasses 8 well-designed, peer-reviewed, published clinicalstudies. Three of these studies included patients with cancerrelatedBTP, 16-18 and 5 included patients with noncancer-related BTP(e.g., neuropathic or low back pain). 19-23 The analgesic response toFBT in these studies (as measured by the percentage of episodesof BTP with a ≥33% improvement in pain intensity) is presented inFigure 1. In general, the inclusion and exclusion criteria in thesestudies are representative of the patient selection standards thatcan be employed in clinical practice. Each study included opioidtolerantpatients who were receiving around-the-clock opioids fortheir controlled persistent pain. 16-23 In some studies, patients hadto have an average pain intensity score of ≤6 (or in some studies,

FIGURE 1. PERCENTAGE OF BREAKTHROUGH PAIN EPISODES WITH ≥33% IMPROVEMENT IN PAIN INTENSITY AT 30 MINUTES IN RANDOMIZED,DOUBLEBLIND, PLACEBOCONTROLLED, FENTANYL BUCCAL TABLET STUDIES. ADAPTED WITH PERMISSION FROM FINE ET AL, 2010. 35*ALL P

Application site reactions or abnormalities were reported in 12%of patients; these incidences tended to occur early in treatment,were transitory, and led to study discontinuation in approximately1% of patients. Serious adverse events that were considered possiblyrelated or directly related to study drug were reported in 2of the 3 double-blind, placebo-controlled studies described earlier.One patient experienced accidental overdose resulting in a loss ofconsciousness. 20 This patient was admitted to the hospital and fullyrecovered. Another patient experienced pneumonia and had anaccidental overdose of opioid medication, and in another patient,abuse of opioid medications resulting in withdrawal symptomswas reported. 21 During the long-term safety study, serious adverseevents occurred in 18% of patients, the most common of whichincluded chest pain, pneumonia, and vomiting (5 patients each). 23ORAL TRANSMUCOSAL FENTANYL CITRATE:CLINICAL DATA REVIEWOTFC is a TIRF formulation approved by the Food and DrugAdministration in 1998 for the treatment of BTP in patients withcancer who are already receiving and are tolerant to around-theclockopioid therapy for their underlying persistent cancer pain. 27Each OTFC lozenge consists of fentanyl, incorporated in a sweetenedmatrix and attached to a handle. The patient administersOTFC by rubbing the lozenge along the inside of the cheek, whichcauses the lozenge to dissolve in the mouth, allowing rapid absorptionof fentanyl through the buccal mucosa. 28The efficacy and safety of OTFC was assessed in a randomized,double-blind, placebo-controlled study of opioid-tolerant patientswith cancer. 29 After an open-label titration period to identify aneffective dose of OTFC, 92 patients entered a double-blind, crossoverphase, where they were given 10 randomly ordered treatments(7 doses of OTFC at the effective dose identied and 3doses of placebo) in the form of identical lozenges to treat 10 BTPepisodes. Signicant differences in pain intensity were observedat all time points after OTFC administration compared with placebo(P

FIGURE 2. SUMMARY OF RESPONSIBILITIES AND BENEFITS WITH THE APPROVED ACTIQ AND FENTORA REMS. PMS=PHARMACY MANAGEMENTSYSTEM; REMS=RISK EVALUATION AND MITIGATION STRATEGY.FIGURE 3. MEDICATION PRESCRIPTION FLOW WITH THE ACTIQ AND FENTORA REMS. PMS=PHARMACY MANAGEMENT SYSTEM.6 | ADVANCE for NPs & PAs | CephalonFADVANCE for NPs & PAs

priate patients (i.e., only opioid-tolerant patients).• Preventing inappropriate conversion between fentanyl products.• Preventing accidental exposure to children and others for whomthe medication was not prescribed.• Educating prescribers, pharmacists, and patients about thepotential for misuse, abuse, addiction, and overdose.The REMS integrates available technology to help ensure appropriatepatient selection and education, checks and balances withinthe distribution channel, and dispensing of the medication for theappropriate, intended use. The ACTIQ and FENTORA REMS:• Ensures that appropriate patients have access to their medicineswhile preserving availability at retail pharmacies.• Enrolls prescribers and pharmacies through education aboutappropriate patient selection and additional key safety informationin order for patients to receive medications they need.• Enhances the dialogue about patient safety at the point of prescribingthrough required patient education about safe andappropriate use.• Uses existing and familiar technology within the normal pharmacystakeholder workow to minimize disruption.Elements of the approved ACTIQ and FENTORA REMS that willbe most relevant to healthcare professionals are the “MedicationGuide” and “Elements to Assure Safe Use.” The “Medication Guide”is an education tool for patients that contains specic, productrelatedinformation such as administration guidelines, warningsand contraindications, adverse events, and proper dosing writtenin easy-to-understand language for non-healthcare professionals.Healthcare professionals who prescribe these products will beresponsible for reviewing the “Medication Guide” with, and providinga copy of it to, each patient at the time FENTORA or ACTIQ isprescribed, and pharmacists dispensing these products will be requiredto provide the guide to each patient with each prescription.The “Elements to Ensure Safe Use” will require that FENTORA andACTIQ are accessed through a single, closed system that requiresstakeholders to complete specic education, assessment, andenrollment requirements (Figure 2).Healthcare professionals who want to prescribe FENTORA orACTIQ for outpatient use must enroll in the ACTIQ and FENTORAREMS program. Although prescriber enrollment is not required forinpatient use, it is required when healthcare professionals wishto prescribe FENTORA or ACTIQ upon patients’ discharge. Healthcareprofessionals may enroll online by accepting the program’srequirements and completing an education program and knowledgeassessment and an enrollment form. In addition, healthcare professionalsmust complete and sign a patient-prescriber agreementform for each new patient before the rst prescription is written.This form conrms that the patient is opioid tolerant and has beenreceiving around-the-clock treatment with an opioid medication formore than 1 week. It also acknowledges that the healthcare professionalhas provided and reviewed the “Medication Guide” with thepatient and that the patient has been informed about the risks,benets, and appropriate use of FENTORA or ACTIQ. The patientprescriberagreement form also must be signed by the patient.Pharmacies must assign a designated pharmacist to completea pharmacy-specic education program to train other pharmacystaff, a knowledge assessment, and an enrollment form. To ensurea controlled distribution model, the pharmacy will be eligible topurchase FENTORA and ACTIQ from enrolled distributors and dispensethese medications to eligible patients only upon completionof these steps. Furthermore, the existing pharmacy managementsystem (PMS) of enrolled pharmacies will be used to communicatewith the REMS database. Through this communication channel,prescriber enrollment and completion of the patient-prescriberagreement form can be veried instantly. Prescription labels willbe printed only once these conditions have been met. Enrollmentin the ACTIQ and FENTORA REMS program may be completedonline at www.ACTIQandFENTORArems.com. Enrollment mustbe renewed every 2 years or sooner in the event of major safetyupdates to the product labeling or major program changes.The ACTIQ and FENTORA REMS program is a controlled, integratedsystem that is designed to ensure the safe and appropriatedistribution, prescribing, and dispensing of these medications.Furthermore, the ACTIQ and FENTORA REMS program requireskey stakeholders to work collaboratively (Figure 3). Doing so willhelp to enhance the dialogue between healthcare professionalsand patients, preserve the local prescriber-pharmacy relationship,and coordinate patient counseling to support the safe useof FENTORA and ACTIQ.According to provisions of the ACTIQ and FENTORA REMS,beginning March 2012, all stakeholders will need to be enrolledin order for a prescription to be lled. Cephalon, Inc., is also participatingin the development of a class-wide REMS for all transmucosalimmediate-release fentanyl products. 36 Although the specicdetails of this REMS are under negotiation with the FDA, the systemis likely to be similar to that of the recently approved ACTIQ andFENTORA REMS. Once it is approved, Cephalon, Inc., will work toensure a smooth transition to the shared system while maintainingaccess to appropriate treatments for breakthrough pain in opioidtolerantpatients with cancer.ACKNOWLEDGMENTSThe clinical studies of fentanyl buccal tablet or OTFC mentioned inthis supplement were sponsored by Cephalon, Inc. (Frazer, Pennsylvania).Writing support was provided by Peloton Advantage, Parsippany,New Jersey, funded by Cephalon, Inc.SPONSORED BY CEPHALON, INC.,FRAZER, PENNSYLVANIACephalon | ADVANCE for NPs & PAs | 7ADVANCE for NPs & PAsG

REFERENCES1. Guidance for Industry. Format and Content of Proposed Risk Evaluation andMitigation Strategies (REMS), REMS Assessments, and Proposed REMS Modications:Draft Guidance. Rockville, MD: US Dept of Health and Human Services,Food and Drug Administration; 2009.2. Craig DS. The Food and Drug Administration Risk Evaluation and MitigationStrategy. J Pain Palliat Care Pharmacother. 2010;24:145-148.3. U.S. Food and Drug Administration. Approved Risk Evaluation and MitigationStrategies (REMS). Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111350.htm.AccessedJuly 6, 2011.4. U.S. Food and Drug Administration. Post-approval REMS notication. Availableat: http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM251595.pdf. Accessed July 19, 2011.5. Sullivan T. FDA opioid REMS: White House proposes mandated certied CME.Policy and Medicine. 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A randomized, placebo-controlledstudy of fentanyl buccal tablet for breakthrough pain in opioid-treatedpatients with cancer. Clin J Pain. 2006;22:805-811.17. Slatkin NE, Xie F, Messina J, Segal TJ. Fentanyl buccal tablet for relief of breakthroughpain in opioid-tolerant patients with cancer-related chronic pain. J SupportOncol. 2007;5:327-334.18. Weinstein SM, Messina J, Xie F. Fentanyl buccal tablet for the treatment ofbreakthrough pain in opioid-tolerant patients with chronic cancer pain: a longterm,open-label safety study. Cancer. 2009;115:2571-2579.19. Simpson DM, Messina J, Xie F, Hale M. Fentanyl buccal tablet for the reliefof breakthrough pain in opioid-tolerant adult patients with chronic neuropathicpain: a multicenter, randomized, double-blind, placebo-controlled study. ClinTher. 2007;29:588-601.20. Portenoy RK, Messina J, Xie F, Peppin J. 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Farrar JT, Cleary J, Rauck R, Busch M, Nordbrock E. Oral transmucosalfentanyl citrate: randomized, double-blinded, placebo-controlled trialfor treatment of breakthrough pain in cancer patients. J Natl Cancer Inst.1998;90:611-616.30. Christie JM, Simmonds M, Patt R, et al. Dose-titration, multicenter studyof oral transmucosal fentanyl citrate for the treatment of breakthrough painin cancer patients using transdermal fentanyl for persistent pain. J Clin Oncol.1998;16:3238-3245.31. Portenoy RK, Payne R, Coluzzi P, et al. Oral transmucosal fentanyl citrate(OTFC) for the treatment of breakthrough pain in cancer patients: a controlleddose titration study. Pain. 1999;79:303-312.32. Passik SD, Messina J, Golsorkhi A, Xie F. Aberrant drug-related behavior observedduring clinical studies involving patients taking chronic opioid therapy forpersistent pain and fentanyl buccal tablet for breakthrough pain. J Pain SymptomManage. 2011;41:116-125.33. Ives TJ, Chelminski PR, Hammett-Stabler CA, et al. Predictors of opioid misusein patients with chronic pain: a prospective cohort study. BMC Health Serv Res.2006;6:46-55.34. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients:preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6:432-442.35. Fine PG, Narayana A, Passik SD. Treatment of breakthrough pain with fentanylbuccal tablet in opioid-tolerant patients with chronic pain: appropriate patientselection and management. Pain Med. 2010;11:1024-1036.36. U.S. Food and Drug Administration. FDA approves opioid analgesic to helpcancer patients manage pain. Enrollment in REMS program required for healthcare professionals. FDA press release. Available at: http://www.fda.gov/News-Events/Newsroom/PressAnnouncements/ucm239490.htm. Accessed July 12,2011.8 | ADVANCE for NPs & PAs | CephalonHADVANCE for NPs & PAs

Front&CenterFor more information and to download an applicationfor admission to the program, visit http://orthoparesidency.surgery.duke.edu.SMU students and the Alameda County Food Bank hosted a cookingdemonstration to illustrate healthy practices. courtesy SMUing topics such as blood sugar management and nutritiousmeal planning.FNP student Suzanne Portnoy said the bilingual workshopswere created to educate and improve glycemic control and selfmanagementskills in the Hispanic community and to promotebetter health through a series of face-to-face sessions.“Being told you have diabetes can leave you with a lot ofquestions,” Portnoy said. “The workshops encourage patientsto relate what they learn to their own experiences and makeplans to put that learning to work in their everyday lives.”For the past 3 years, SMU and the Davis Street FamilyResource, a private nonprofit organization, have been bringinglow-cost primary medical services to uninsured andunderinsured children and adults.Duke Launches Orthopedic SurgeryResidency for Physician AssistantsDuke University Medical Center in Durham,N.C., has created an orthopedic surgery residency for physicianassistants. The program is a 12-month residency thatprovides didactic education as well as clinical and surgicalexperience. PA residents will receive first assist OR training,first call responsibilities, emergency department responsibility,extensive clinical training, and other responsibilitiesthat a physician assistant will need to practice effectivelyin orthopedics.The residency program will provide exposure to all thesubspecialities within orthopedics. Applications are beingaccepted through March 30 and the first residents will beginthe program on Sept. 3.“The residency will give the PA the knowledge and skillsto make an immediate impact on their postgraduate practice,”said Ashley Grimsley, MHS, PA-C, codirector of theprogram.Occupy ANCC Movement Seeks toHalt NP Credential ChangeIn a nod to the recent Occupy movement that sweptthe country to seek financial reforms, a nurse practitionerwho disagrees with credentialing changes by the AmericanNurses Credentialing Center (ANCC) has started a campaignto reverse the changes.Rodney Fox, NP, PhD, started a Facebook groupcalled “Occupy ANCC: Say NO to retiring your NP credential.”Find the page at https://www.facebook.com/groups/320993387910854/.ANCC is retiring several credentials but will continue tomaintain certification of NPs with the retired credentials aslong as they continue to meet the requirements for renewal.The NP credentials that will be retired are acute care nursepractitioner, adult nurse practitioner, adult psychiatric–mentalhealth nurse practitioner and gerontological nurse practitioner.The ANCC has published FAQs about this change at http://www.nursecredentialing.org/APRN-FAQ.aspx.“It seems ridiculous to retire these highly esteemed credentials,”Fox said. “I am attempting to bring a unified voiceto others who may feel the same.”Although ANCC has acted in good faith to align its credentialswith the Licensure, Accreditation, Certification andEducation (LACE) consensus model, Fox said he believesANCC overlooked important issues in its decision.A divide could develop between newly certified NPs andNPs who maintain the retired credentials, he said, and thecredential inconsistency could also confuse patients. NPswith a retired credential will not be able to sit for boards ifthey allow it to lapse, he added.Fox is seeking support to find solutions to the issues heraises. At press time in late January, 53 NPs had joined theOccupy ANCC Facebook group.“A process that provides a mechanism to move all APRNstogether is best for APRNs and the community in need oftheir services,” Fox said.“I support the consensus model and believe the demandfor gerontology services will grow, but this is not a favorableway forward.” ■Share Your News➼ What’s going on in your state or organization?Let us know so that we can share it with our more than100,000 readers. Email your news to Kelly Wolfgang atkwolfgang@advanceweb.com.ADVANCE for NPs & PAs15

Career&WorkforceSocial media for NPs & PAs:Approach with cautionBy Maria Rubolino-Gallego, MSN, RN, FNP-C, Amy Zlomek Hedden, RN, MS, NP, andSylvia Gonzalez, BSN, RNsocial networking allows NPsand PAs to address patients’ healthcareconcerns in unique ways, to obtain upto-dateinformation on legislation, andto enhance the delivery of critical informationrelated to health. Through socialnetworking, researchers are better ableto recruit participants for clinical studiesand to disseminate findings to appropriateaudiences. 1 NPs and PAs who worklocum tenens may use social networkingsites to make connections and decisionsabout future contracts. 2Many human resource departments areadvertising employment opportunities onsocial networks. Employers are also usingsuch sites to screen the backgrounds andsocial presence of potential employees. 3 Arecent survey found that 45% of recruitersused Internet searches of social mediasites to screen applicants. 4 A survey ofemployers by Careerbuilder.com foundthat 18% had used online searches to discoverinformation that led to an applicantbeing hired. 5 However, 35% of employersdid not hire candidates based on searchfindings of inappropriate photos, negativediscussion of previous employers, andevidence of drug or alcohol use. 5Empowering PatientsSocial media offers a powerful, paperlessway for patients and providers to interactwith each other. 6 It also allows patientsto support each other. 6 For example,people diagnosed with cancer are able toaccess the Association of Cancer OnlineResources website (ACOR.org), wherethey can receive support and informationabout their condition and potentialtreatments. 7 Patients who join the sitecommunicate with each other on issuespertinent to life with cancer. 7,8Professional BoundariesProblems may arise when NPs or PAsaccept requests from patients (past orpresent) to socialize online. The No. 1misuse of social networking by healthcareprofessionals is the sharing of patientinformation. 9 Providers have been disciplinedor fired as a result of commentsthey have posted online.Nurse practitioners and physician assistantsshould be cautious about usingsocial networking sites and breachingprofessional codes of conduct. Alwaysobserve patient confidentiality. 8,9 Unless apatient has signed a release of information,it is a violation of law and professionalethics to disclose any information abouthim or her.Downsides to Social MediaSociety tends to judge people according totheir professional behavior and values aswell as actions in their personal lives. Withincreased use of social media, personallives are publicly displayed, blurring thelines between personal and professional.Although everyone is entitled to freedomof speech, be wary of writing posts thatmay damage your reputation.Social media aggregate sites warrantparticular concern. 10 For example, Spokeo.com pulls information from varioussources, including Facebook, Whitepages.com and Zillow.com. Basic informationMaria Rubolino-Gallego is a family nurse practitioner who is an associate professorat California State University in Bakersfield. She practices part time at Bakersfield Centerfor Women’s Health. Amy zlomek Hedden is an associate professor at California StateUniversity in Bakersfield and practices at Bakersfield Memorial Hospital. Sylvia Gonzalezis a registered nurse in the intensive care unit at Mercy Hospital of Bakersfield.Be Smart AboutSocial Media◗ Avoid sharing toomuch personalinformation.◗ Never shareany informationabout patients.◗ If you communicatewithpatients throughsocial media,tread carefully.is free to all users, and it may includehome addresses, telephone numbers,marital status (including spouse’s name)and personal interests. For an additionalmonthly fee, users can obtain more personalinformation, such as photos andvideos. 10 Spokeo does not guarantee theaccuracy of the information displayed.Opt-out is available, but Spokeo requiresan e-mail address, which may be sold tothird-party advertisers. 10 ■References1. Saver C. Tweeting, posting, and yammering:the role of social media in the OR. OR Manager.2010;26(2):1, 12-14.2. Sindel D. Online social networks help travelnurses make personal and professional connections.http://www.travelnursing.com/features/Online-Social-Networks-Help-Travel-Nurses-Stay-in-Touch_30402.aspx Accessed Jan. 25, 2012.3. Picnus JM. Facebook firings show privacy concernswith social networking sites. Healthcare RiskManagement. 2009;31(5):49-52.4. Forsyth L. What you need to know about socialnetworking. Qld Nurse. 2009;28(5):22-23.5. Haefner R. More employers screening candidatesvia social networking sites: Five tips for creating apositive online image. http://www.careerbuilder.com/Article/CB-1337-Getting-Hired-More-Employers-Screening-Candidates-via-Social-Networking-Sites/.Accessed Jan. 25, 2012.6. Hawn C. Take two aspirin and tweet me in themorning. How Twitter, Facebook, and other social mediaare reshaping health care. Health Aff. 2009;28(2):361-368.7. Rochman B. When patients share medical dataonline. Time. http://www.time.com/time/magazine/article/0,9171,1957460,00.html. Accessed Jan. 25,2012.8. American Association of Critical-Care Nurses.Patient 2.0: Patients share info on the web. AACN BoldVoices. 2010;2(5):11.9. Scott D, Troutman AK. Facebook firings show privacyconcerns with social networking sites. HealthcareRisk Management. 2009;31(5):46-60.10. Spokeo. http://www.Spokeo.com. Accessed Jan.25, 2012.Illustrtation by Tom Whalen16 ADVANCE for NPs & PAs

Role&GrowthIllustrtation by Tom WhalenThe power of culture andlanguage in patient careBy Candace C. Harrington, DNP, ANP-BC, GNP-BCCulture and language influencehow a patient perceives and interpretshealth and illness. Health disparitiesand subsequent poor health outcomesconstitute a national crisis. Evidenceshows that race, socioeconomic status andperceived biases adversely affect access tohealthcare, views of disease and wellness,and ability to understand and adhere totreatment recommendations. 1In 2003, the Institute of Medicine calledfor the examination of attitudes, behaviorsand corporate culture practices that contributeto health disparities. 2 To correctcultural and ethnic inequities, healthcareorganizations have incorporated elementsof cultural competence.What is Cultural Competence?Cultural competence results in an abilityto function effectively in cross-culturalsituations. 3 The first step toward culturalcompetence involves self-examination ofpersonal values, biases and philosophiesthat may skew perception, response andinterpretation of subjective data collectedduring healthcare encounters. Culturalcompetence is an ongoing process to buildthe skills necessary to remedy cultural,ethnic and racial inequalities. 4Appropriate ServicesIn 2001, the U.S. Department of Healthand Human Services Office of MinorityHealth introduced a framework for integrationof best practices for culturallyand linguistically appropriate services(CLAS). 3 The National Standards forCulturally and Linguistically AppropriateServices in Health Care have becomethe cornerstone for providing culturallyappropriate care in all healthcare settings. 1The CLAS standards apply to all organizationsthat receive federal funds. 3,5Culturally Competent CareCulturally competent care standardsaddress general provider and staff competenciesthat help ensure quality patientcenteredcare. 1-3 Patients should receiveunderstandable and respectful care in theirpreferred language, and that care shouldbe compatible with their cultural healthbeliefs and practices. 3 NPs and PAs canincorporate these standards by integratingpatients’ health beliefs and traditionalpractices (see table). In addition, NPs andPAs should recruit, retain and promotediverse staff and leadership who representthe demographic characteristics of theservice area. All staff members shouldreceive ongoing training in culturally andlinguistically appropriate care.Language Access ServicesLanguage access services (LAS) standardsrequire that federally funded service providersensure adequate language access topatients with limited English proficiency. 3NPs and PAs meet LAS standards byoffering and providing written and verbalnotices informing patients of their rightto receive bilingual services, interpreterservices and language assistive servicesin their preferred language.Candace C. Harrington is an adult and gerontologic nurse practitioner whoworks for Evercare in Greensboro, N.C. She is a member of the adjunct facultyfor Vanderbilt University School of Nursing in Nashville.Culturally CompetentQuestions for Patients◗ What do you callthis illness?◗ What do youthink causedthis problem?◗ What does your sicknessdo to you? How does it work?◗ How severe is your sickness?◗ What problems has your sicknesscaused you?◗ What kind of treatment do youthink you should get?◗ What are the most importantresults you hope to get?Organizational SupportsOrganizational supports for culturalcompetence standards foster the abilityto facilitate and enhance cultural competence.3 These standards emphasize theimportance of participatory collaborativepartnerships to facilitate community andpatient involvement in designing andimplementing CLAS-related activities.NPs and PAs should use these principles toguide strategic planning, program designand outcomes-based evaluations.NPs and PAs can affect positive changeby integrating cultural competence intotheir practice settings.A free interactive CME-accreditedcurriculum is available to help integrateculturally competent practices. Accessit at https://cccm.thinkculturalhealth.hhs.gov/. 4 ■References1. Putsch R, et al. (2003). Reflections on the CLASstandards: Best Practices, Innovations and Horizons.http://www.xculture.org/files/CLAS.Standards.Report.pdf.pdf. Accessed Jan. 4, 2012.2. Smedley BD, et al, eds. Unequal Treatment:Confronting Racial and Ethnic Disparities in HealthCare. Washington, D.C.: The National AcademiesPress; 2003.3. U.S. Department of Health and Human Services.Office of Minority Health. What is cultural competency?http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11. Accessed Jan. 4, 2012.4. U.S. Department of Health and Human Services.Office of Minority Health. A physician’s practicalguide to culturally competent care. Why culturallycompetent care? https://cccm.thinkculturalhealth.hhs.gov/. Accessed Jan. 4, 2012.5. U.S. Department of Health and Human Services.Office of Minority Health. National Standards onCulturally and Linguistically Appropriate Services.http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15. Accessed Jan. 4, 2012.ADVANCE for NPs & PAs17

Professional IssuesNationalSalaryReport201118 ADVANCE for NPs & PAs

Professional IssuesA dramatic drop in PA salary,but just a dip for NPsBy Michelle Perron Pronsatikyyle kielinski/tom Whalen/Doris mohr➼ In our still fragile economy, the fact that nursepractitioner and physician assistant salaries decreased in2011 is not surprising. What is surprising is how dramaticallydifferent those declines are.The 2011 National Salary Survey of NPs & PAs found thatthat the average full-time salary paid to PAs dropped by $2,006compared to 2010, while the average NP salary dipped byonly $187.Job market observers told ADVANCE for NPs & PAs that this decrease in PA wageslikely reflects an overall trend of declining salaries for PAs and NPs in specialty settings.“This impacts the PAs more because they have been overrepresented in thespecialties,” commented Renee Dahring, MSN, NP, a career consultant who writesfor our Career & Workforce column and our Career Coach blog. “Many specialtyemployers used to hire only PAs, but over this past year, more and more are openingthe positions to NPs, too. No doubt these employers have also noticed that NPsdon’t make as much money as PAs, so the influx of NPs into these areas has probablyhelped depress PA wages down closer to the NP level.”Survey MethodsWe conducted our annual survey using an online questionnaire created with softwarefrom Zarca Interactive, a Virginia-based company specializing in online datacollection. The survey was live from July 1 through Oct. 31, 2011.The 2011 survey drew a larger response than our first survey of the two professions,conducted in 2010. We collected 4,414 usable responses, and these represented3,116 NPs and 1,298 PAs.➤Michelle Perron Pronsati is the editor of ADVANCE for NPs & PAs. To contact her, sendan email to mpronsati@advanceweb.com.ADVANCE for NPs & PAs19

Professional IssuesTable 12011 Nurse Practitioner Salaries Over Time, 2001–20112011 results based on 3,116 NP responses2011 2010 2009* 2007* 2005* 2003* 2001*Average full-time salary $90,583 $90,770 $89,579 $81,397 $74,812 $69,203 $63,172Average part-time hourly rate $47.63 $43.77 $45.85 $40.32 $36.80 $33.89 $32.53*Source: The National Salary Survey of Nurse Practitioners, conducted biennially by ADVANCE for Nurse Practitioners from 2001 through 2009.2011 Physician Assistant Salaries Over Time, 2001–20112011 results based on 1,298 PA responses2011 2010 2009 2007 2005 2003 2001Average full-time salary $94,870 $96,876 $93,105* $86,214* $81,129* $76,039* $71,046*Average part-time hourly rate $50.52 $51.11 — — — — —*Source: American Academy of Physician Assistants National Physician Assistant Census Reports.Full-Time SalariesIn 2011, the average NP working fulltime earned a salary of $90,583, whilethe average PA working full time earned$94,870 (Table 1).Although PAs continued to outearnNPs in 2011, the gap is getting smaller.In 2010, the average PA took home $6,106more in full-time salary than the averageNP. But in 2011, the difference droppedto $4,287.Part-Time RatesThe National Salary Survey of NPs & PAsalso collects data on hourly rates paid forpart-time positions. In 2011, the averageNP working part time earned an hourlywage of $47.63 – an increase of $3.86 perhour over 2010. PAs experienced a slightdrop in hourly pay: The average PA workingpart time earned an hourly wage of$50.52, a 59-cent decline over 2010.Practice SettingAs usual, the most fascinating resultsare in the category of salary by primarywork setting (Table 2). We have organizedthese results in descending order. The topsalaries for NPs were paid in emergencydepartments, neonatal units and retailhealth clinics (the first time convenientcare has broken into the top 10). For PAs,mental health settings, surgery settingMen still make morethan women in bothprofessions, but thegender gap narrowedfor NPs in 2011.Among NPs, thedifference in salariespaid to men vs. womendropped from14.6% to 6.4%.and emergency departments deliveredthe highest pay rates.The data show some surprising salarydeclines. NPs in cardiology clinicsearned 10.42% less than in 2010, and NPsin oncology clinics earned 7.59% less.The biggest drop occurred in aestheticsand skin care practices, where NPsearned 10.42% less in 2011 than theydid in 2010.Among PAs, aesthetics and dermatologynotched the largest decline accordingto practice setting, a drop of 12.49%.Other salary cuts of note for PAs includea 9.92% drop in cardiology practices anda 7.77% drop in gerontology settingscompared to 2010.For the first time this year, we tabulateddata about part-time rates according topractice setting (Table 3).Gender Gap UpdateMen still make more than women in bothprofessions, but the gender gap narrowedfor NPs in 2011 (Table 4). Among nursepractitioners, the difference in salarydropped from $13,085 in 2010 to $7,396in 2011.Female PAs lost ground in 2011, withthe salary difference between men andwomen increasing from $11,007 in 2010to $13,327 in 2011.The gender breakdown of each pro-20 ADVANCE for NPs & PAs

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Professional IssuesTable 2Full-Time NP Salary by Primary Work SettingListed in descending order according to 2011 salarySetting (% of respondents) 2011 Salary 2010 Salary % ChangeEmergency Department (2.8%) $103,722 $104,549 −0.79%Neonatal Unit (0.57%) $99,810 $93,925 +6.27%Retail Clinic (3.06%) $96,800 $90,170 +7.35%Hospital (12.19%) $96,124 $93,943 +2.32%Gerontology (2.27%) $94,485 $93,668 +0.87%House Calls (0.82%) $93,785 $93,390 +0.42%Mental Health (2.83%) $92,396 $100,914 −8.44%Surgery (2.04%) $91,023 $91,511 −0.53%Oncology Clinic (2.11%) $90,862 $98,327 −7.59%Cardiology Clinic(2.11%) $90,370 $100,881 −10.42%HIV Clinic (0.48%) $89,506 $89,857 −0.39%Family Practice (15.68%) $89,317 $86,518 +3.24%Diabetes/Endocrinology (0.77%) $88,397 $89,710 −1.46%Aesthetics/Skin Care (0.39%) $88,106 $102,547 −14.08%Internal Medicine (7.09%) $87,950 $88,287 −0.38%Academia (1.61%) $87,643 $80,400 +9.01%Corrections (0.72%) $85,521 $91,630 −6.67%Women’s Health (5.75%) $82,183 $83,687 −1.80%Pediatrics (3.85%) $82,101 $85,618 −4.11%College Health (12 months; 1.13%) $80,521 $79,139 +1.75%Elementary or Secondary School (0.29%) $69,945 $77,513 −9.76%College Health (9 month; 0.52%) $60,684 $60,829 −0.23%Full-Time PA Salary by Primary Work SettingListed in descending order according to 2011 salarySetting (% of respondents) 2011 Salary 2010 Salary % ChangeMental health setting (1.39%) $112,445 $116,758 −3.69%Surgery setting (16.41%) $104,703 $102,760 +1.89%Emergency department (9.94%) $101,688 $103,489 −1.74%Diabetes/endocrinology practice (0.15%) $100,000 $69,000 +44.93%Cardiology practice (1.85%) $98,209 $109,030 −9.92%Academia (3.70%) $96,200 $95,215 +1.03%Aesthetics/dermatology practice (2.62%) $94,275 $107,727 −12.49%Hospital unit (other than surgery oremergency department) (16.49%)$93,506 $97,680 −4.27%House calls (0.23%) $93,333 $94,383 −1.11%HIV clinic (0.54%) $92,000 $91,333 +0.73%Women’s health practice (1.93%) $90,890 $87,974 +3.31%Worksite clinic(6.32%) $90,250 $95,296 −5.30%Oncology practice (1.39%) $90,217 $85,851 +5.09%Family practice (26.58%) $89,847 $90,528 −0.75%Retail clinic (2.54%) $89,583 $91,188 −1.76%Correctional facility (1.08%) $89,468 $81,404 +9.91%Gerontology setting (0.85%) $88,875 $96,364 −7.77%Pediatric practice (2.93%) $84,903 $86,894 −2.29%College or university clinic (1.85%) $79,999 $85,441 −6.37%Elementary or secondary school (0.08%) $66,000 $115,000 −42.61%fession is important to note. The 2011survey shows that 92% of NP respondentswere women and 8% were men, while58% of PA respondents were women and42% were men.New This YearThis year’s kickoff report features anothernew presentation (Table 5), an overviewof data highlighting number of years inpractice, number of patients seen eachweek, number of prescriptions written,number of over-the-counter productsrecommended, and average age.What’s Next?We will share additional data from the2011 National Salary Survey of NPs& PAs on our website in the comingmonths. Visit often to access focusedreports on NP and PA salary accordingto state, salary according to select cities,salary according to academic degree,and much more.To be notified of these focused reportsas they are posted, sign up for our freeenewsletter using the form posted atwww.advanceweb.com/NPPA.A Note About PrivacyADVANCE for NPs & PAs values readerand respondent privacy, and we will nevershare or inappropriately use personaldata obtained during the salary surveydata collection process.In the comment box posted at the end ofour salary questionnaire, several respondentsvoiced concerns about the personalinformation required to participate inthe survey.We collect age, city, state and genderinformation to present an accurate viewof the demographics of the respondents(Table 4 as well as the state and cityreports to be posted later). We collectemail addresses so that we can contactrespondents whose answers might needclarification.Our goal is to present the most accurateand representative data about salary andworkplace issues for NPs and PAs. Wethank the 4,414 respondents who tookthe time to complete the 2011 survey, andwe hope for even greater participationin 2012. Data collection for this year’ssurvey opens June 1. ■22 ADVANCE for NPs & PAs

Table 3New! NP Part-Time Hourly Rate by Practice SettingListed in descending order according to 2011 rateProfessional IssuesEditor’s note: 2011 is the first year for which we calculated this breakdown. Comparison to 2010 part-time hourly rates was not possiblefor three NP settings because data reporting was unreliable.Practice Setting (% of respondents) Hourly 2011 Hourly 2010 % DifferenceMental Health (2.83%) $64.75 $53.92 +1.67%Academia (1.61%) $62 $42.10 +3.2%House Calls (0.82%) $60.84 $53.50 +0.62%Aesthetics/Skin Care (0.39%) $59 $57.14 +0.31%Surgery (2.04%) $51.51 $40.60 +2.1%Internal Medicine (7.09%) $50.25 $42.25 +1.5%Oncology Clinic (2.11%) $50.09 $46.25 +0.76%Emergency Department (2.8%) $49.82 $52.68 −0.57%Gerontology (2.27%) $49.41 $56.14 −1.3%Corrections (0.72%) $48.65 $49.65 −0.20%Hospital (12.19%) $48.64 Data unreliable N/AHIV Clinic (0.48%) $47.47 $40.17 +1.5%Family Practice (15.68%) $46.25 Data unreliable N/ARetail Clinic (3.06%) $46.23 $47.69 −0.31%Neonatal Unit (0.57%) $45.31 $48.50 −0.70%Cardiology Clinic (2.11%) $44.75 $45.50 −0.16%Women’s Health (5.75%) $44.14 Data unreliable N/ACollege Health (12 months; 1.13%) $43.52 $42.67 +0.19%Pediatrics (3.85%) $43.24 $43.45 −0.04%College Health (9 months; 0.52%) $40.25 $40.81 −0.13%Diabetes/Endocrinology (0.77%) $40 $34.33 +1.4%Elementary or Secondary School (0.29%) $36 $45.33 −2.5%New! PA Part-Time Hourly Rate by Practice SettingListed in descending order according to 2011 ratePractice Setting (% of respondents) Hourly 2011 Hourly 2010 % DifferenceMental health setting (1.39%) $82.86 $52.25 +58.58%Aesthetics/dermatology practice (2.62%) $67.50 $78.10 −13.57%Surgery setting (16.41%) $61.67 $67.65 −8.84%Emergency department (9.94%) $58.04 $55.27 +5.01%Academia (3.70%) $57.92 $28.22 +105.24%Worksite (6.32%) $50.30 $49.08 +2.49%Correctional facility (1.08%) $50.00 0 0Oncology practice (1.39%) $50.00 $33.00 +51.52%Nursing home, assisted living or long-term care facility (0.85%) $48.67 $41.50 +17.28%Pediatric practice (2.93%) $46.69 $42.38 +10.17%Family practice (26.58%) $46.56 $45.64 +2.02%Retail clinic (2.54%) $44.72 $48.00 −6.83%College or university clinic (1.85%) $43.44 $52.60 −17.41%Women’s health practice (1.93%) $42.44 $42.37 +0.17%Hospital unit (other than surgery or emergency department) (16.49%) $41.88 $46.13 −9.21%Diabetes/endocrinology practice (0.15%) $37.00 $41.50 −10.84%Cardiology practice (1.85%) $34.33 $50.00 −31.34%Elementary or secondary school (0.08%) 0 0 0HIV clinic (0.54%) 0 0 0House calls (0.23%) 0 0 0➤ADVANCE for NPs & PAs23

Professional IssuesTable 4NP Salary by GenderGender 2011 Salary 2010 Salary % ChangeMale (8% of respondents) $97,329 $102,271 --4.8%Female (92%% of respondents) $89,933 $89,186 +0.8%Salary Difference $7,396 or 8.2% $13,085 or 14.6%PA Salary by GenderGender 2011 Salary 2010 Salary % ChangeMale (42% of respondents) $102,222 $102,669 --0.43%Female (58% of respondents) $88,895 $91,662 --3.02%Salary Difference $13,327 or 15% $11,007 or 12%Table 52011 Nurse Practitioner Data OverviewBased on 3,116 responses from nurse practitioners2011 2010 ChangeNumber of years in practice as an NP 9.3 9.29 +0.01%Annual full-time base salary $90,583 $90,770 −0.02%Part-time hourly rate $47.63 $43.77 +0.81%Number of patients each week 64.95 64.95 No changeOTC recommendations per week 28.61 29.57 −0.33%Prescriptions written per week 69.19 63.27 +0.85%Average age 47.7 47.7 No change2011 Physician Assistant Data OverviewBased on 1,298 responses from physician assistants2011 2010 ChangeNumber of years in practice as a PA 11.87 11.49 +3.31%Annual full-time base salary $94,870 $96,876 −2.07%Part-time hourly rate $50.52 $51.11 −1.15%Number of patients each week 80.47 79.77 +0.88%OTC recommendations per week 33.10 29.32 +12.89%Prescriptions written per week 78.71 71.41 +10.22%Average age 42.6 42.7 0.10 years youngerBrought to you by American Lifeline.Want More Information?➼ we have MORE TO SHARE. Sign up for our freeenewsletter to be notified when new reports are published. Findthe form at www.advanceweb.com/NPPA.24 ADVANCE for NPs & PAs

CME/CE: PharmacologyMan vs. MicrobeTreatment issues in an age of antibiotic resistanceBy Lynn A. Kelso, MSN, APRN, FCCM, FAANP➼ In the late 1960s, U.S. SurgeonGeneral William H. Stewart was attributedwith the following bold statement:“It is time to close the book on infectiousdiseases and declare the war againstpestilence won.” An increase in vaccineshad produced a dramatic decrease in theincidence of infectious diseases such assmallpox and polio, and multiple new antimicrobialagents were available to treatthe organisms that were causing infections.It appeared that we had an upperhand on infectious microbes. However,with increased and widespread use ofantimicrobial agents to prevent or treatinfections, resistance patterns continuedto emerge. It soon became clear that wewould never be able to defeat antimicrobialresistance. At best, we would needto keep pace with it.The mass production of penicillin, thefirst antibiotic, began in 1943, after theoutbreak of World War II. Just 4 yearslater, resistance to penicillin had developed.Many new antimicrobial agentshave been discovered and developed sincethen, but microbes have continued tokeep pace and develop further resistance.This poses great risk to patients and greatchallenges to healthcare providers.The World Health Organization hasdeemed antimicrobial resistance oneof the three most important problemsfacing healthcare providers today. 1 TheLynn A. Kelso is an acute care nurse practitionerwho is an assistant professor in theCollege of Nursing at the University of Kentuckyin Lexington. She has completed a disclosurestatement and reports no relationships relatedto this article.Learning Objectives1. Identify the causes of antibioticresistance.2. Discuss the educational needsof patients related to the use ofantibiotics.kyle kielinski3. Describe antibiotics newly approved andin development.4. List three ways to prevent the spread ofMDRO infections.ADVANCE for NPs & PAs25

CME/CE: PharmacologyThe Food and Drug Administration and the Infectious Diseases Society ofAmerica have challenged pharmaceutical companies to develop 10 newantimicrobial agents by 2020.acronym ESKAPE is being used to summarizethe most important and concerningresistant microbes: Enterococcusfaecium, Staphylococcus aureus,Klebsiella pneumoniae, Acinetobacterbaumannii, Pseudomonas aeruginosaand Enterobacter species. 1In 2001, the Infectious Diseases Societyof America (IDSA) took action on itsconcerns about the lack of new, novelantimicrobial agents for gram-negativemultidrug-resistant organisms (MDROs).The IDSA worked with the Food andDrug Administration to develop a chargefor pharmaceutical companies to develop10 new antimicrobial agents by 2020. 2We need new classes of antimicrobialsas well as new medications within existingclasses. Most recently introducedantimicrobial agents have focused onMDROs that are gram-positive organisms(see table). The development of antimicrobialsfor gram-negative organisms,particularly gram-negative bacilli, haslagged behind.Antimicrobial ResistanceBacteria can develop resistance to antimicrobialagents in various ways. Mutationof bacteria that have been exposed toantimicrobial agents can lead to thedevelopment of resistance to future useof the same medication. Bacteria can alsoshare genetic material that allows for thespread of antimicrobial resistance fromone species to another.Educating the public about the appropriateuse of antimicrobial agents isessential in the fight against increasingresistance. Patients who seek healthcareservices when they are sick often expecta prescription for an antibiotic, and it isup to healthcare providers to make thecorrect determination and to educatepatients about it. Proper drug and dosageselection are vital.Complicating the resistance problemis that it is easy to obtain antimicrobialmedications without a prescription.Advice about using pet antibioticsin humans is readily available on theInternet. The average pet supply storestocks numerous antimicrobial agents. Inthe fish aisle alone, ampicillin (Fish Cillin),tetracycline (Fish Cycline), cephalexin(Fish Flex), ketoconazole (Fish Fungus),amoxicillin (Fish Mox), erythromycin(Fish Mycin), and metronidazole (FishZole) can all be purchased in capsuleor tablet form. A bottle of 100 capsulescan be purchased for less than what aprescription for a human would cost –and it will provide enough medicationto save for future use. In addition, manybodegas and other ethnic variety storessell antibiotics by the pill.This can seem to be a great alternative,particularly when many patientsare without health and prescription drugcoverage. It is paramount, however, thatpatients understand the risks associatedwith taking a medication that has notbeen prescribed for them.Another way patients try to save moneyis to stop taking a prescribed medicationas soon as symptoms disappear.Depending on the infection being treated,the appropriate length of antimicrobialtreatment may be 7 to 10 days. When thepatient begins to feel better by the thirdday of the treatment course, he or she maynot complete the entire prescription. Butthe infection may not yet be adequatelytreated, and stopping the medication canput the patient at risk for developing aresistant, more virulent infection in thefuture. A “survival of the fittest” conceptmay play a role in the development ofresistance when bacteria are exposed tobut not eradicated by antimicrobials.Because of the speed with which bacteriamultiply, mutations are common.However, the sharing of genetic materialis more problematic because resistance toa specific antimicrobial agent or class ofagents can then be transferred betweenorganisms.MDROs in the United StatesMultidrug resistance is defined as theresistance of an organism to at least oneantimicrobial in at least three antimicrobialclasses. 3 Multidrug-resistant,gram-positive organisms, particularlymethicillin-resistant S aureus, (MRSA)and vancomycin-resistant enterococci(VRE) are longtime concerns, and mostefforts to generate new antimicrobialagents have focused on these organisms.While pharmaceutical companieshave made some efforts to developdrugs that are effective against MDROgram-negative organisms, infections bythese organisms have necessitated theuse of old antimicrobial agents such aspolymyxins. 1Although MDRO infections are a commonconcern in the hospital setting, ratesof MDRO infections in long-term carefacilities and in the community are rising.3 Patients who have been infected, orcolonized, with MDROs are dischargedto home or transferred to long-termcare facilities to continue treatment andrehabilitation. One study conducted at asingle long-term care facility found thatMDR gram-negative bacilli were isolatedfrom 11% of cultures, while MRSA andVRE were only isolated in 6% and 1% ofcultures, respectively. 3Extended-spectrum beta-lactamase(ESBL) infections in the community arerare, but the organism has been identifiedin urine cultures of patients in theoutpatient setting, including those whohave had no healthcare contact within6 months. 326 ADVANCE for NPs & PAs

CME/CE: PharmacologyNewer Antimicrobial AgentsApproved Agents 1,6 Class Activity Limitation Adverse ReactionDaptomycin (Cubicin;approved 2003)CyclicLipopeptide*MDR gm (+)Vancomycin-sensitiveEnterococcus faecalisInactivated by pulmonarysurfactantMyopathyTigecycline (Tigacil;2005)Doripenem (Dorbax;2007)Telavancin (Vibativ;2009)In clinical trials 1,5CeftobiproleCeftarolineBLI-489Ro 48-1220Glycylcycline*CarbapenemLipoglycopeptideCephalosporinsBeta-lactamaseinhibitorBeta-lactamaseinhibitorBroad spectrumMRSA, VRE, ESBLEnterobacter, anaerobesBroad spectrumBetter Pseudomonasaeruginosa andAcinetobacter speciescoverageGm (+) coverageMRSA coverageGm (+) coverageAnti-MRSA in animalmodelsRetains gm (−) coverageCombination withpiperacillinActive against all4-lactamasesSome activity againstorganisms resistant topiperacillin/tazobactamIncreases activity ofceftiaxone (Rocephin)Coverage forEnterobacteriaceaeLimited for PseudomonasNo MRSA orEnterococcus faeciumcoverageNo coverage for VREDecreased effectivenessof oral contraceptivesDecreases levels ofvalproic acidRed man syndrome withrapid infusionMay produce no improved coverage over currenttreatment options* New antimicrobial class27The greatest concern is with organismsthat develop resistance to all known treatmentoptions. Vancomycin-intermediateand vancomycin-resistant S aureus havebeen isolated and provided the impetusto develop new agents that could treatvancomycin-resistant organisms.Beta-Lactamase ResistanceBeta-lactamase is an enzyme producedby organisms to disable the beta-lactamring of specific antimicrobial agents.Microbes developed beta-lactamasesmore than 2 billion years ago to counternaturally occurring beta-lactam antibiotics.2 As newer antimicrobial agents weredeveloped and widely used, ESBLs beganto emerge. Organisms producing ESBLshave resistance to newer antimicrobialagents, including third-generation cephalosporins.1Four beta-lactamases render resistanceto penicillins, cephalosporins, carbapenemsand oxacillin. A recently discoveredbeta-lactamase renders Klebsiella speciesand Escherichia coli resistant to fluoroquinolones,aminoglycosides and otherbeta-lactam antimicrobials, such as carbapenems.4 This has generated concernbecause of the frequency with which Ecoli causes urinary tract infections. Thesemicrobes are only susceptible to polymyxinsand tigecycline (Tygacil), whichare infused intravenously and thereforeincrease hospitalization rates. 4Within the last 4 years, MDR gramnegativeorganisms that are resistantto polymixin have been isolated. 3 Twoof these isolates were also resistant totigecycline. 3 This leaves no options fortreatment of these organisms.New Treatment Options for MDROsAs stated previously, there is tremendousconcern about the lack of new,novel antimicrobial agents that will beeffective against MDR gram-negativeorganisms. The treatment of MRSA andVRE has been a particular concern overthe past decade, and new antimicrobialagents have been approved for use inthese infections. 5Daptomycin (Cubicin) is the firstcyclic lipopeptide, a new class of antimicrobialsused to treat MDRO grampositiveinfections. The major limitationof daptomycin is that it is inactivatedADVANCE for NPs & PAs

CME/CE: PharmacologyHealthcare providers must do all they can to prevent the spread of MDROsand to educate patients about the appropriate use of antibiotics.by surfactant and cannot be used totreat pulmonary infections. 6 Telavancin(Vibativ), a lipoglycopeptide derivative ofvancomycin, is effective against MRSAbut not VRE.Tigecycline is a broad-spectrum antimicrobialwith activity against MRSA andVRE as well as ESBL Enterobacteriaceae.It is representative of a new class of antimicrobialagents, glycylcyclines, whichare structurally related to tetracyclines. 6A restriction of tigecycline is its limitedactivity against Pseudomonas species.Doripenem (Doribax) is a carbapenem.It is not effective against MRSA. Whileit has a spectrum similar to the otherdrugs in this class, it has better activityagainst Pseudomonas aeruginosa andAcinetobacter species. 1Three beta-lactamase inhibitors are onthe market as of early 2012: sulbactam,clavulanic acid and tazobactam. Theseare not effective against all four classesof beta-lactamases, which has been alimitation. Several new beta-lactamaseinhibitors are being investigated. The onewith the best clinical data is classified asBLI-489 and has activity against all fourbeta-lactamase classes. 1In vitro and animal tests have demonstratedeffectiveness when combinedwith piperacillin and increased activityagainst organisms resistant to piperacillin/tazobactam(Zosyn). 1 Another newbeta-lactamase inhibitor, classified asRo 48-1220, has improved the action ofceftriaxone (Rocephin). 1Two recently introduced cephalosporins,ceftobiprole and ceftaroline,have shown activity against MRSA inanimal models. 1 They both retain activityagainst gram-negative organisms, butso far it is not clear that they are moreeffective against these organisms thancurrently used medications. 1Preventing the Spread of MDROsAs pharmaceutical companies try tokeep up with the need for new, novelantimicrobial agents, it is imperative thathealthcare providers focus on preventingthe spread of MDROs. Although it is wellknown that appropriate hand hygieneis an essential preventive strategy fordecreasing MDROs, many providersdo not follow hand hygiene recommendations.In a recent study of clinicianadherence to hand hygiene and barrierprecautions recommendations, appropriatehand hygiene only occurred 48.4%of the time upon the clinician exitinga patient room. 7 This finding is similarto that of other studies examining handhygiene adherence. In the same study,staff were observed exiting isolationrooms without removing their glovesand then using communal equipment. 7The appropriate use of gowns as barrierprecautions only occurred 67.9% of thetime when anyone was seen entering anisolation room. 7As more and more patients who havebeen infected with MDROs or whoremain colonized with MDROs enterlong-term care facilities and outpatientclinic settings, infection control practicesneed to be addressed. This is not onlytrue for personnel, but also for equipmentthat is used on multiple patients.Frequently, acute care hospitals providedisposable stethoscopes to be used in onepatient room. In the outpatient setting,personal stethoscopes are typically usedon multiple patients. While the use ofalcohol pads on stethoscopes after eachpatient contact is the standard way tocleanse the bell, this is not done regularlyby healthcare providers. A recentstudy examined whether using alcoholbasedhand gels on stethoscopes wouldbe as effective alcohol pads. It found thatEarn CME or CE Credits➼ Visit our test center to access this and other learning activities. Selectthe Education tab at the top of our homepage, www.advanceweb.com/NPPA.using alcohol-based hand gel significantlydecreased the colony counts culturedfrom stethoscope bells and eradicatedMRSA colonies. 8 Because this can bedone at the same time as hand hygiene,it is possible that using the alcohol-basedhand gel can increase the cleaning ofpersonal stethoscopes in between patientcontacts. 8 This theory has not been sufficientlystudied, however. 8It is also not clear what environmentalcleaning should occur after a patient whois infected or colonized with an MDROexits a clinic room. Terminal cleaningoccurs whenever a patient is transferredout of a hospital room, but this not anexpectation in the outpatient setting.Further research is needed to determinehow much environmental contaminationoccurs in clinic rooms.An Important ChallengeAntimicrobial resistance is one of themost important clinical challengestoday. Although new, novel antimicrobialagents are being developed, the amount isinsufficient to keep up with the demand.Healthcare providers must do all that theycan to prevent the spread of MDROs andto educate their patients about the appropriateuse of antimicrobial agents. ■References1. Bassetti M, et al. New treatment options againstgram-negative organisms. Crit Care. 2011;15(2):215.2. Spellberg B, et al. The epidemic of antibioticresistantinfections: a call to action for the medicalcommunity from the Infectious Diseases Society ofAmerica. Clin Infect Dis. 2008;46(2):155-164.3. Kallen AJ, Srinivasan A. Current epidemiologyof multidrug-resistant gram-negative bacilli inthe United States. Infect Control Hosp Epidemiol.2010;31(Suppl 1):S51-S54.4. Kumarasamy KK, et al. Emergence of a newantibiotic resistance mechanism in India, Pakistan andthe UK: a molecular, biological, and epidemiologicalstudy. Lancet Infect Dis. 2010;10(9):597-602.5. Talbot GH. The antibiotic development pipelinefor multidrug-resistant gram-negative bacilli: currentand future landscapes. Infect Control Hosp Epidemiol.2010;31(Suppl 1):S55-S58.6. Connor KA. New intravenous antibiotics: afocused pharmacotherapy update. AACN Adv CritCare. 2010;21(3):237-240.7. Clock SA, et al. Contact precautions for multidrugresistantorganisms: current recommendations andactual practice. Am J Infect Control. 2010;38(2):105-111.8. Schroeder A, et al. What’s growing on yourstethoscope? (And what to do about it). J Fam Pract.2009;58(8):404-409.28 ADVANCE for NPs & PAs

CME/CE: PharmacologyAntibiotic Resistance • NPPA18Questions1. A new beta-lactamaseinhibitor, Ro 48-1220, has beenshown, in clinical trials, toimprove the activity of whichcephalosporin?a. Cetazidime (Fortax)b. Ceftriaxone (Rocephin)c. Cefotaxime (Claforan)d. Cefotetan (Cefotan)2. Which recently FDA approvedantibiotic cannot be used totreat pneumonia?a. Daptomycin (Cubicin)b. Tigecycline (Tigacil)c. Doripenem (Doribax)d. Telavancin (Vabativ)3. All but which one of thefollowing resistant organismshave been identified by the WHOas most concerning?a. Staphylococcus aureusb. Klebsiella pneumoniac. Streptococcus pneumoniad. Enterococcus faecium4. The Infectious DiseasesSociety of America haschallenged pharmaceuticalcompanies with developingwhich number of newantimicrobial agents by 2020?a. 5b. 10c. 15d. 205. Of the recently FDA-approvedantibiotics, which one can cause‘red man syndrome’ if infused toorapidly?a. Daptomycin (Cubicin)b. Tigecycline (Tigacil)c. Doripenem (Doribax)d. Telavancin (Vabativ)6. Which antibiotic is the onlyone recently approved by theFDA that has coverage forPseudomonas aeruginosa?a. Daptomycin (Cubicin)b. Tigecycline (Tigacil)c. Doripenem (Doribax)d. Telavancin (Vabativ)7. After mass production ofpenicillin began in 1943, bywhich year had resistancedeveloped?a. 1946b. 1947c. 1948d. 19498. A newly discovered betalactamaserenders Klebsiellaand E coli resistant to all of thefollowing antibiotic classesexcept:a. Aminoglycosidesb. Cephalosporinsc. Carbapenemsd. Fluoroquinolones9. Appropriate hand hygieneadherence typically occurs whatpercentage of the time whenproviders exit patient rooms?a. 69%b. 51%c. 48.4%d. 32%10. When examining an increasein MDRO infections in longtermcare facilities, one recentstudy isolated MRSA in whatpercentage of cultures?a. 1%b. 6%c. 11%d. 18%Evaluation1. The content was appropriatefor my needs.a. strongly disagreeb. disagreec. neutrald. agreee. strongly agree2. The educational objectiveswere achieved.a. strongly disagreeb. disagreec. neutrald. agreee. strongly agree3. The information provided waspractical and can be applied tomy professional needs.a. strongly disagreeb. disagreec. neutrald. agreee. strongly agree4. The information in the articlewas fair, balanced, free ofcommercial bias and supportedby scientific evidence.a. strongly disagreeb. disagreec. neutrald. agreee. strongly agreeRegistration & Answer FormThis activity has been planned and implemented in accordance with the Essential Areasand policies of the Accreditation Council for Continuing Medical Education through thejoint sponsorship of Wayne State University School of Medicine and ADVANCE for NPs& PAs. The Wayne State University School of Medicine is accredited by the ACCME toprovide continuing medical education for physicians.The Wayne State University School of Medicine designates this educational activityfor a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should only claim creditcommensurate with the extent of their participation in the activity.This activity also is approved for 2 CE contact hours. The issuer of CE contact hoursis Merion Publications (a division of Merion Matters), which is approved as a provider ofcontinuing education in nursing by three agencies. For details on CE provider numbers,visit the CE Test Center on our website, www.advanceweb.com/NPPA.For PAs:To obtain CME credit, send the completed answer form and registrant informationto Wayne State University School of Medicine, Attn PA, University Health Center 9A,4201 Saint Antoine St., Detroit, MI 48201. Include a check for $10 payable to WayneState University. Or fax the completed form and credit card information to (313) 577-7554. Note: Discover and American Express NOT accepted. For online payment, visithttp://www.med.wayne.edu/cme/calendarReg.html. Test takers who earn a passingscore will receive a CME certificate by mail, or if paying online can receive an onlinetranscript once registered at http://www.med.wayne.edu/cme/calendarTran.html. Forquestions about CME, call Wayne State University at (313) 577-1453. CME form mustbe postmarked or received within 6 months of the last day of the month of this issue.For NPs:To obtain CE contact hours, take this test online at www.advanceweb.com/NPPA andreceive instant test results and a printable CE certificate upon passage. Or fax thecompleted form and credit card information to (610) 278-1426. Or send the completedanswer form and registrant information to Merion Matters CE Program for NPs, 2900Horizon Dr., King of Prussia, PA 19406. Include a check for $10 payable to MerionMatters. This activity is eligible for CE credit for 2 calendar years after publication.Antibiotic Resistance February 2012Test NPPA18EvaluationA B C D A B C D A B C D E1.2.3.4.5.6.7.8.9.10.1.2.3.4.Registrant Information (Please print)Subscriber No. (see mailing label) ____ ____ ____ ____ ____ ____ ____ ____ ____Required for Florida NPs: License No. ___________________________________________E-mail Address ______________________________________________________________Name ______________________________________________________________________Address ❏ Work ❏ Home ___________________________________________________City ____________________________________ State ______ Zip Code _______________Phone No. ❏ Work ❏ Home _________________________________________________Payment: $10❏ For PAs: Check Payable to Wayne State University❏ For NPs: Check Payable to Merion Matters❏ For PAs or NPs: Credit Card No. ________________________ Exp. Date___________Cardholder Name ________________________________________________________Signature _______________________________________________________________❏ American Express (NPs only) ❏ Visa ❏ MasterCard ❏ Discover (NPs only)Statement of CompletionI attest to having completed the CME/CE activity.Signature _____________________________________________ Date _________________Profession ❏ Nurse Practitioner ❏ Physician AssistantADVANCE for NPs & PAs29

It Burns You UpEffects of cigarette smoking on your body◗ Patient HandoutWhen you smoke, it’s not just your lungs that suffer. Chemicals from cigarettes do damage to almost every part of your body. Take a look: Brain: Increased risk of strokeEyes: Increased risk of cataracts Teeth: Yellow color, decay,gum diseaseFace: More wrinkles, acne Mouth: Bad breath, cancers of the mouth, tongue, lips Lungs: Cancer, COPD (chronic bronchitis, emphysema), asthma exacerbations Arms: Decreased blood flow Stomach: Acid secretions,cancer, ulcers Reproductive organs: Erectile dysfunction, cervical and uterine cancer, infertility, risks to unborn babies, miscarriageThroat: CancerEsophagus: Cancer Larynx: CancerHeart: Increased risk of heart attack, heartburnPancreas: CancerKidneys: CancerBladder: CancerBlood: Cancer of the myeloid line of blood cellsWant some good news?Your body starts to repair damage withinweeks of quitting. While there is no cure forCOPD, the best way to slow the lung damageis to stop smoking.Don’t get burned: Quit.For more information and for help to stopsmoking, visit www.smokefree.gov. Tofind out how much money you will save inyour lifetime if you quit smoking now, visitwww.costofsmoking.com.Legs: Decreased blood flowBones: Osteoporosis, arthritisInformation adapted from the Centers for Disease Control and Prevention.View and print this and other patient handouts on our website, www.advanceweb.com/NPPA.All handouts are posted in English and Spanish.Aaron roshong30 ADVANCE for NPs & PAs

Hepatologydiabetes and renal dysfunction. 4 Transplantcenters are becoming overwhelmed, andmore transplant recipients are seekingcare from primary care providers. 1,5 Whiletransplant centers are still managingimmunosuppressant medications andrejection episodes, primary care providersare being charged with managing themore long-term conditions. 4 Therefore, it isimportant for NPs and PAs to be familiarwith the overall care of a liver transplantrecipient over time, including immunosuppressanttherapies and the most commonpostsurgical complications. 1,5dave perilloAfter LiverTransplantImproved survival rates increase long-term primarycare needs By Katherine Monday, MSN, NP➼ The outcomes of liver transplantationhave been improving since the early1960s, when the procedure was first performed.1 In 2010, 6,892 liver transplantswere performed in the United States. 2 The1-year survival rate was 86.9%, and the5-year survival rate was 73.6%. 3As survival rates climb, transplantrecipients are developing chronic conditionssuch as hypertension, hyperlipidemia,Katherine Monday is an adult nurse practitioner at University of Cincinnati Physicians inCincinnati. She has completed a disclosure statement and reports no relationships relatedto this article.Immunosuppressant MedicationsAlthough the management of immunosuppressantmedications is the primaryresponsibility of the transplant center,primary care providers need to be awareof commonly used immunosuppressants,their side effects and the potential interactionswith other medications.Calcineurin inhibitors (CNIs) are oneof the most commonly used classes. Thepotential drug interactions with CNIsare numerous (Table 1). CNIs used afterliver transplant include tacrolimus andcyclosporine. The antimetabolites arealso commonly used and include azathioprineand mycophenolate mofetil.Sirolimus, a macrolide with suppressiveeffects similar to that of the CNIs (butless toxicity on the kidneys), is anothercommonly used medication after livertransplant. 1,5 Corticosteroids are alsofrequently used. 1Many of these medications have narrowtherapeutic windows, so exercise cautionwhen prescribing any drugs that mayaffect metabolism. Increased levels canlead to toxicity, and decreased levels canraise the risk of organ rejection. 5 Monitorfor side effects of immunosuppressanttherapy (e.g., weight gain, gingival hyperplasia,hirsutism, alopecia, acne, edema)to avoid confusion with posttransplantcomplications. 6HypertensionThe incidence of hypertension in livertransplant patients is between 45% and75%. 7 The primary contributors to hypertensionin the liver transplant popula-ADVANCE for NPs & PAs31

Hepatologytion are the use of CNIs and the use ofcorticosteroids. CNIs induce vasoconstrictionon the renal arterioles, leadingto decreased glomerular filtration andsodium retention. Corticosteroids contributeto hypertension by producingsodium and fluid retention, leading tovolume expansion. 8The target blood pressure for livertransplant recipients (and all patients)is < 130/80 mm Hg. 5 Diuretics, calciumchannel blockers, angiotensin-convertingenzyme (ACE) inhibitors, angiotensinII receptor blockers (ARBs) and betablockersare all effective antihypertensivesin transplant patients. 1,5 When selectinga medication to reduce blood pressure,consider factors such as comorbidities. 5Medications such as nicardipine, diltiazemand verapamil are metabolized bythe cytochrome P450 system. Avoid thesemedications because they can slow themetabolism of CNIs. 1,6,9 When prescribingACE inhibitors or ARBs, monitor potassiumlevels because they can intensifyCNI-related hyperkalemia. 6HyperlipidemiaIn patients who have received a livertransplant, the prevalence of hyperlipidemiais between 51% and 66%. 7 Totalcholesterol may increase by 20% to 43%,triglycerides may increase by 38% to 56%,and HDL may decrease by 50%. 5 Someof these increases are a result of usinghigh-dose corticosteroids, which increasethe liver’s secretion of LDL. 5,10Corticosteroids should be slowlytapered after the initial transplantperiod and only used when necessarythereafter. Patients taking cyclosporineare at risk for hyperlipidemia becausethe drug binds to the LDL cholesterolreceptor, increasing LDL levels in theblood. 11 Sirolimus can have a negativeeffect on serum lipid levels, and this isthought to be due to its effect on theinsulin-signaling pathway, which in turnaffects lipid metabolism. 11 Tacrolimus canhave a minimal effect on lipid levels, andmycophenolate mofetil and azathioprinehave little to no effect. 1The increased prevalence of obesityand diabetes in posttransplant patientsalso contributes to hyperlipidemia. 6 Riskfactors for hyperlipidemia after livertransplant include female gender, cholestaticliver disease, diabetes, obesity andpre-existing hyperlipidemia. 1 Patientsshould be screened for hyperlipidemiaannually. 5 Goals for cholesterol managementshould be the same as for the generalpopulation, including a total cholesterollevel of < 200 mg/dL, an LDL level of< 130 mg/dL, and a triglyceride level of< 150 mg/dL. 12Counsel all patients about dietary andlifestyle modifications including the needto reduce dietary saturated fat, cholesteroland sodium intake and to exercise atTable 1Medications That Affect Serum Levels ofCalcineurin InhibitorsMedications That Increase CNILevels (risk of toxicity)◗ Calcium channel blockersDiltiazemVerapamil◗ Many antifungals, including:FluconazoleKetoconazole◗ Many antibiotics, including:AzithromycinClarithromycinErythromycin◗ Methylprednisolone◗ Metoclopramide◗ Omeprazole◗ Nicardipine◗ AllopurinolMedications That Decrease CNILevels (risk of rejection)◗ AnticonvulsantsCarbamazepinePhenobarbitalPhenytoin◗ Nafcillin◗ Rifampin◗ Terbinafine◗ St. John’s wort◗ Orlistatleast 30 minutes per day on 3 to 4 dayseach week. 13 If modifications alone donot reduce lipid levels, try reducing thedose or eliminating the medications thatare contributing to hyperlipidemia. Butbefore making any changes in immunosuppressantregimen, consult the patient’stransplant center or hepatologist.If drug therapy is necessary, HMG-CoA reductase inhibitors (statins) arean effective choice for initial therapy. 5,11Of the statins, pravastatin or fluvastatinmay be the best choice because neither ismetabolized by the same cytochrome P450metabolic pathway as CNIs and sirolimus.Other statins, such as atorvastatin, lovastatinand simvastatin, may be used as longas liver function is monitored for possibledrug interactions. 1,11,14 To reduce the risk ofadverse side effects, start with low doses ofstatins and gradually increase as needed. 5,11Bile acid sequestrants can decrease theabsorption of CNIs and mycophenolatemofetil, so take that into considerationbefore initiating therapy. 1 Fish oil supplementscan be used to reduced triglyceridelevels with minimal to no effect on immunosuppressantlevels. 11HyperglycemiaThe prevalence of posttransplant diabetesmellitus (PTDM) after liver transplantationcan be as high as 31% to 38%. 7Risk factors for PTDM include advancedage, obesity, high-dose tacrolimus dosedconcomitantly with steroids, Hispanic orblack ethnicity, pretransplant diabetes,and hepatitis C seropositivity. 1Management of PTDM in liver transplantrecipients is similar to that requiredby the general population, with treatmentaimed at preventing microvascularand macrovascular disease. Counselall patients with diabetes about dietarymodifications such as portion control andreduction of simple carbohydrates, as wellas exercise and blood sugar monitoring. 5As with hypertension, consider trying tocontrol hyperglycemia by reducing oreliminating tacrolimus and steroids andprescribing a different immunosuppressiveagent. Immunosuppressants such asazathioprine, mycophenolate mofetil andsirolimus do not have the same effect onblood sugar and may be better optionsfor patients with PTDM. 7➤32 ADVANCE for NPs & PAs

Help givethem freedomfrom occasionalirregularity *ACTIVIA ® helps withoccasional irregularity *RECOMMEND©2012 The Dannon Company, Inc.ACTIVIA ® 33Get yourcouponreferralpad**TODAY!Offer availableto healthcareprofessionalsonly.**Scan this code to request yourcoupon referral pad or go towww.activia.us.com and clickon “for healthcare professionals.”*Clinical studies show that ACTIVIA, ® with Bifidus Regularis ® (Bifidobacterium animalis lactis DN-173 010), helps with slow intestinal transitwhen enjoyed 3 times per day for two weeks as part of a balanced diet and healthy lifestyle.ADVANCE for NPs & PAs

HepatologyFirstline therapy for overweight patientswith PTDM is metformin. 15 For patients ofideal weight, a sulfonylurea should be used.If oral agents do not adequately controlglucose levels, insulin may be needed. 5Tight glucose control is important inpatients with PTDM, especially those withhepatitis C. Patients with hepatitis C are atgreater risk for infection, cardiovascularcomplications, graft loss and death thanpatients without this virus. 6,16RejectionOrgan rejection occurs when the patient’simmune system attacks the transplantedorgan. Although rejection is most commonin the first 3 months after liver transplant,it can occur at any time. 1 Signs ofrejection include increased liver enzymes,fever, jaundice, fatigue and abdominalpain or distension. 1,6 An increase in liverfunction of 1.5 times normal is generallyconsidered significant. 1 Rejection is diagnosedvia liver biopsy. Rejection episodesare typically managed by a transplantcenter, and treatment usually involveshigh-dose corticosteroids. 1,6InfectionInfections are the primary cause ofmorbidity and mortality in patientsafter transplant. 17 Due to high levelsof immunosuppression, even relativelycommon infections such as pharyngitisand urinary tract infections can progressto sepsis. 17 Patients with a fever greaterthan 38.5° C should receive a completeworkup including urine, blood and sputumcultures, chest x-ray, complete bloodcount, and liver function testing. 17 Signsof sepsis include fever greater than 38.5°C, hypotension, increased heart andrespiratory rates, and altered mentalstatus. 17 The most common viral infectionsin the posttransplant patient arecytomegalovirus, Epstein-Barr virus andherpes viruses; these usually occur in thefirst 6 months after transplantation. 6Vaccinations are an important toolfor preventing infection. Inactivatedvaccines are safe for patients both beforeand after transplant, but live vaccines arenot routinely given to immunosuppressedpatients due to the risk of shedding livevirus (Table 2). 1,6 Transplant patientsroutinely receive prophylaxis regimens toTable 2Common Inactivated and Live Virus VaccinesInactivated Vaccines◗ Diphtheria◗ Hepatitis A & B◗ Haemophilus influenza type b◗ Human papillomavirus◗ Influenza inactivated◗ Meningococcal◗ Pertussis◗ Pneumococcal◗ Tetanusprevent Pneumocystis carinii and variousfungal, bacterial and viral illnesses. 4Renal DysfunctionSome level of renal dysfunction is commonin liver transplant recipients, but the riskof this progressing to chronic renal failureis only about 10%. 6 Approximately 14% ofpatients have a normal glomerular filtrationrate 6 months after transplant. 6 Themost notable cause of renal insufficiency isthe CNIs. Their use can lead to reversibleacute nephropathy and irreversible chronicrenal damage. 6 When chronic renal damageis suspected, a prescriber (usuallythe patient’s hepatologist) may attemptto decrease CNI doses and add a secondagent, or he or she may completely switchfrom CNIs to sirolimus or mycophenolatemofetil. 1,6 In addition to reducing or eliminatingCNIs, the management of renaldysfunction includes avoiding NSAIDs,aminoglycosides and other medicationsthat are nephrotoxic. 6Recommendations for PracticeAs liver transplantation becomes moreprevalent and successful, transplant centersare relying on primary care providersto assume more responsibilities forpatients’ ongoing care. Many factors mustbe considered when treating a transplantrecipient. To reduce morbidity and mortality,primary care providers must havea working knowledge of the factors thatmake transplant recipients unique. Theymust educate themselves about immunosuppressantmedications, signs of rejectionand common complications afterliver transplantation. Transplant centersmust be notified before any change inLive Vaccines*◗ Live attenuated influenza◗ Measles◗ Mumps◗ Polio (oral)◗ Rotavirus◗ Rubella◗ Vaccinia◗ Varicella◗ Yellow fever*Live vaccines should not be given to a patient who has received a liver transplant.immunosuppression is attempted and ifsigns of organ rejection surface. ■References1. McGuire BM, et al. Long-term managementof the liver transplant patient: recommendationsfor the primary care doctor. Am J Transplant.2009;9(9):1988-2003.2. U.S. Department of Health & Human Services,Health Resources and Services Administration. OPTN/SRTR annual report. http://optn.transplant.hrsa.gov/data/annualreport.asp. Accessed Jan. 10, 2012.3. Heller JC, et al. Long-term management afterliver transplantation: primary care physician versushepatologist. Liver Transpl. 2009;15(10):1330-1335.4. Aqel BA. Should transplant hepatologistsserve as primary care physicians? Liver Transpl.2009;15(10):1162-1163.5. Hasley PB, Arnold RM. Primary care of the transplantpatient. Am J Med. 2010;123(3):205-212.6. Kallwitz ER, Cotler SJ. Care of the liver transplantpatient. Dis Mon. 2008;54(7):486-507.7. Desai S, et al. Cardiovascular risk factors followingorthoptic liver transplantation: predisposingfactors, incidence and management. Liver Int.2010;30(7):948-957.8. Sethi A, Stravitz RT. Review article: medicalmanagement of the liver transplant recipient — aprimer for non-transplant doctors. Aliment PharmacolTher. 2007;25(3):229-245.9. Gonwa TA. Hypertension and renal dysfunctionin long-term liver transplant recipients. Liver Transpl.2001;7(11 Suppl 1):S22-S26.10. Rossetto A, et al. Cardiovascular risk factors andimmunosuppressive regimen after liver transplantation.Transplant Proc. 2010;42(7):2576-2578.11. Watt KD, Charlton MR. Metabolic syndrome andliver transplantation: a review and guide to management.J Hepatol.2010;53(1):199-206.12. U.S. Department of Health & Human Services.National Heart, Lung, and Blood Institute. Third Reportof the Expert Panel on Detection, Evaluation, andTreatment of High Blood Cholesterol in Adults. (AdultTreatment Panel III). http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.Accessed Jan. 20, 2012.13. Barclay L. Overview of lifestyle interventions inthe management of hyperlipidemia in the primary caresetting. http://www.medscape.com/viewarticle/721503.Accessed Jan. 10, 2012.14. Zachoval R, et al. Short-term effects of statintherapy in patients with hyperlipoproteinemia afterliver transplantation: results of a randomized crossovertrial. J Hepatol.2001;35(1):86-91.15. Charlton M. Obesity, hyperlipidemia, and metabolicsyndrome. Liver Transpl. 2009;15(11 Suppl 2):S83-S89.16. Bloom RD, Crutchlow MF. Transplant-associatedhyperglycemia. Transplant Rev. 2008;22(1):39-51.17. McCashland TM. Posttransplantation care: roleof the primary care physician versus transplant center.Liver Transpl. 2001;7(11 Suppl 1):S2-S12.34 ADVANCE for NPs & PAs

SurgeryThe circulator is the manager of the operating room record and is available tohelp any member of the team, particularly in an emergency situation such asthe onset of cardiac arrest or malignant hyperthermia.patient information and consents. Uponthe patient’s admission to the hospital,the preoperative holding nurse interactswith the patient, checks the chart againfor completeness, and assures that allconsents, notes and orders are signedby anesthesia staff and the surgeon. Heor she also starts the IV and administersordered medications. This nurseis critical to the timely flow of surgicalprocedures.The Circulating NurseThe circulator is responsible for the acquisitionof all supplies, sterile equipment,machines and sets needed for surgery.The circulator then works with the scrubnurse or scrub technologist to set upthe case and assure that all necessaryequipment and supplies are in order. Thecirculator then gathers all the necessaryequipment for the administration ofanesthesia.After placing the patient on the ORtable, checking the patient’s ID bracelet,verifying the patient’s surgeon and thescheduled procedure, the nurse in thisrole reassures the patient and may providewarming blankets. The circulatorthen assists the anesthesiologist in theadministration of anesthesia and helpsdress all “scrubbed personnel.”The patient must be in a specific positionfor surgery. The circulator workswith the anesthesiologist, the surgeonand the first assistant to achieve therequired position and documents allsafety measures. The circulator thenprepares the patient’s surgical site withthe appropriate preoperative washingagent and prep materials.Prior to the start of surgery, the circulatorcalls a time out in which thename of the patient, his or her condition,the site of surgery and the procedureis verified with the surgeon and all inthe room. As the case commences, thecirculator supplies the sterile membersof the team with additional sutures andsupplies, oversees the sterility of all themembers of the team, communicateswith all departments and facilitates theacquisition of emergency equipment andadditional supplies such as blood.The circulator is the manager of theOR record and is available to help anymember of the team, particularly in anemergency situation, such as the onset ofcardiac arrest or malignant hyperthermia.The circulator performs an importantfinal step: He or she orders a count ofall sutures, needles, sponges, lap pads,etc., and confirms the count is correct.He or she applies dressings and assistsin the extubation of the patient and thesafe transfer to the PACU. 2The Scrub NurseThe scrub nurse may be an RN or anLPN. He or she has specialty trainingin surgery and surgical technique andinstrumentation. 3 The scrub nurse gatherssupplies prior to the case (along withthe circulator) and plans for additionalsupplies that may be needed. The scrubnurse then scrubs for the case and thesetup of all sterile equipment. This personis the sterile staff member and suppliesthe surgeon and assistants with sterileinstruments, sutures and other supplies.The scrub nurse is an excellent source ofinformation for PA students or NPs whoare new to the surgical suite.The scrub nurse has the authority tonote a break in technique and to requestthat sterile scrubbed personnel changegloves or gowns. The scrub nurse anticipatesthe needs of the surgical team. Atthe conclusion of a procedure, the scrubnurse may assist in applying dressingsand the safe moving of the patient fromthe table to the OR stretcher.The PACU or Recovery Room NurseThe PACU or recovery room nurse acceptsthe patient from the OR and immediatelyprovides a secure environment for properairway, oxygenation, suction and care.This nurse is an expert in critical careand is responsible for the safety of thepatient while he or she is in this area aswell as the safe movement of the patientfrom the PACU to any other area of thehospital. The PACU Nurse can be a sourceof information for postoperative ordersand medications and your right hand ifan emergency occurs.The Surgical TechnologistThe surgical technologist has the sameresponsibilities as the scrub nurse, buthe or she has less responsibility in anemergency because he or she is workingunder nursing and has limitations on theability to administer drugs and bloodproducts. The surgical tech is a trained(often certified) member of the team whocan provide insight into the needs of thesurgeon, his or her approach, his or hermannerisms in surgery, his or her areasof intolerance, and the specific requirementsof the first assistant.The AnesthesiologistThe anesthesiologist is a physician whois an expert in pulmonary medicine andproviding sleep and analgesia for thepatient who is undergoing surgery. 4 Theanesthesiologist consults with the patientprior to surgery to discuss the plannedprocedure and anesthetic. 5 He or shedetermines whether the patient shouldhave local, regional, spinal or general anesthesia.This decision is based on medicaland surgical history, family history andpsychological status. The anesthesiologistmaintains constant awareness of thepatient’s cardiopulmonary status.After entering the OR, the anesthesi-➼ We’re seeking PAs to review manuscripts. Interested? Send an email to mpronsati@advanceweb.com.36 ADVANCE for NPs & PAs

Surgeryologist checks the IV line and makes sure that all preoperativemedications have been administered. He or she connects thepatient to cardiac leads and assures that the patient’s cardiacand pulmonary status are being monitored prior to and duringthe course of anesthesia. He or she attaches a pulse oximeterand blood pressure cuff and ensures that all necessary equipmentand drugs are available to perform intubation.During the surgery, the anesthesiologist maintains an openairway, proper breathing and circulation and keeps the patientin a highly oxygenated state to administer drugs as needed.The anesthesiologist is also responsible for positioning andevaluating both the intake and output of the patient. The secondanesthesia provider is the certified registered nurse anesthetistor physician assistant anesthetist. These professionals areexperts in managing a patient under anesthesia. 6 They haveobtained graduate-level education in this area. 7,8The First AssistantNumerous types of “first assistants” exist in the OR, and theyinclude surgeons, residents, interns, medical students, familyphysicians, PAs, NPs, certified registered nurse first assistants,registered nurse first assistants, perfusionists and certifiedsurgical technologists–certified first assistants.The responsibility of the first assistant is to be the assistantsurgeon during a procedure. This requires knowledge of anatomyand physiology, surgical handling of tissues, surgical instrumentationand surgical procedures. In addition, the first assistant mustbe skilled in suture techniques, positioning, sterilization, steriletechnique, prepping and draping, pre- and postoperative care,and the use of suctioning equipment, splints and casts. The firstassistant must have well-honed decision-making skills. 9Physician assistants who specialize in surgery have a specialtyorganization, the American Association of Surgical PhysicianAssistants (AASPA), which provides continuing educationand networking opportunities. 10 The surgical PA orders tests,interprets test results and writes admitting orders, progressnotes and postoperative orders. Surgical PAs determine whena patient may ambulate or be discharged, write prescriptions,perform discharge summaries and plan postoperative followup.11 Nurse practitioners may also function in this role.All hospitals establish criteria for who may “first assist” andon what cases. NPs apply for credentials in the same manner asPAs and must specify a supervising surgeon. For informationon APNs transitioning to a first assist role, see the followingarticle: http://www.medscape.com/viewarticle/499689.website for the Association of periOperative Registered Nurses,to find advice for preventing surgical site infections. Additionalguidance is available from the Centers for Disease Control andPrevention at www.cdc.gov/handhygiene/24. ■References1. Kurzweg FT. The patient, his surgeon and the record. In: The Surgeon’s Handbook.Garden City, N.Y.: Medical Examination Publishing Company , Inc.; 1982: 3.2. Position statement of the Association of periOperative Registered Nurses. OnePerioperative Registered Nurse Circulator Dedicated to every Patient Undergoinga Surgical or Other Invasive Procedure. http://www.aorn.org/Clinical_Practice/Position_Statements/Position_Statements.aspx. Accessed Jan. 23, 2012.3. Centers for Medicare and Medicaid Services. Conditions of participationfor hospitals: surgical services. http://www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf. Accessed Jan. 23, 2012.4. Sweeny F. Who’s the person giving my anesthesia? In: Sweeny F. The AnesthesiaFact Book. Perseus Publications; 2003: 3-12.5. University of Cincinnati Residents, Berry S. The Mont Reid Surgical Handbook.4th ed. Mosby;1997.6. Sumpter R. Anesthesia. In: Labus JB. The Physician Assistant SurgicalHandbook. W.B. Saunders; 1998: 19.7. All about anesthesia. American Association of Registered Nurse Anesthetists.http://www.aana.com/forpatients/Pages/All-About-Anesthesia.aspx. AccessedJan. 23, 2012.8. Facts about AAs. American Academy of Anesthesiologist Assistants website.http://www.anesthetist.org/factsaboutaas/. Accessed Jan. 23, 2012.9. Weis MK. The first assistant and collaborative practice. In: Rothrock JC, SeifertPC. Assisting in Surgery: Patient-Centered Care. Competency & CredentialingInstitute; 2009: 387-405.10. American Association of Surgical Physician Assistants website. www.aaspa.net. Accessed Jan. 23, 2012.11. Blumm RM, Condit D. Surgical physician assistants help solve contemporaryproblems. Bull Amer Coll Surg. 2003;88(6):14-18. http://www.facs.org/fellows_info/bulletin/2003/blummcondit0603.pdf. Accessed Jan. 23, 2012.12. Manz EA, et al. Clipping, prepping and draping for surgical procedures.Managing Infection Control. 2006;August: 84-97.Preventing Surgical Site InfectionsThere is no better manner in which to conclude this overview ofthe OR team than to focus on prevention of surgical site infections.Surgical site infections affect 750,000 U.S. patients everyyear. 12 These infections can increase length of stay in a hospitalfor up to 10 days. Increased length of stay adds $20,842 to theaverage patient’s hospital charges. 12 These excess charges arenow absorbed by the institution, not the insurance company.Appropriate implementation of the perioperative role canrender these infections preventable. Visit www.AORN.org, theADVANCE for NPs & PAs37

Professional IssuesJob SatisfactionWhat makes a difference to NPs?By Rebecca Ann Priebe, MSN, ACNP-BC➼ The recruitment and retentionof nurse practitioners is an importantissue in primary care. Employers’ successin attracting and retaining qualifiedNPs depends on NP job satisfaction. 1 Itis beneficial for employers to understandwhat factors keep NPs in their jobs. 2PurposeThis study sought to examine factorsthat contribute to NP job satisfactionand dissatisfaction. The study exploredan array of intrinsic and extrinsic factorsusing the Misener Nurse Practitioner JobSatisfaction Scale. The specific researchquestions addressed were:1. What factors do NPs perceive ascontributing to their job satisfaction?2. What factors do NPs perceive ascontributing to their job dissatisfaction?3. Do NPs perceive intrinsic factorsas satisfiers or dissatisfiers?4. Do NPs perceive extrinsic factorsas satisfiers or dissatisfiers?5. Is job satisfaction linked with age,length of NP certification and length ofemployment?Conceptual FrameworkThe Herzberg two-factor theory is theconceptual framework that guided thisresearch study. 2 Herzberg hypothesizedthat job satisfaction and job dissatisfactionare represented on two separatecontinuums. Employees may be satisfiedwith some aspects of their jobs and dissatisfiedwith others. 2 He suggested thatfactors of satisfaction are intrinsic factors,which he identified as achievement,recognition, work itself, responsibilityand advancement. He suggested thatfactors of dissatisfaction are extrinsic;they include working conditions, interpersonalrelationships, salary, security,administration and supervision. 3In this study, I used Herzberg’s theoryto operationalize the Misener NursePractitioner Job Satisfaction Scale. Thisscale incorporates the intrinsic andextrinsic factors proposed by Herzbergto assess job satisfaction among NPs.Related LiteratureBullough 4 initiated research about jobsatisfaction among pediatric NPs at theUniversity of California. The longitudinalstudy surveyed 17 NP students about satisfactionat the start of their program andthen 1 year after graduation. The researchdocumented no significant differencebetween the participants’ pre- and posttestopinions. All but one replied that theywere equally if not more satisfied withtheir NP role after graduation. The authorconcluded that intrinsic factors positivelycorrelated with job satisfaction. 4More recent research has identifiedspecific factors contributingto satisfaction and dissatisfactionwith NP jobs. A study byKoelbel et al. 1 used the Indexof Job Satisfaction and theMinnesota SatisfactionQuestionnaire to measureglobal, general, intrinsicand extrinsic factorsin NP job satisfaction.These researchers determinedsatisfaction to berelated to increased professionalism,performinginteresting and challengingwork, assuming more responsibility, experiencingachievement, receiving recognition,and having potential for growth.Koelbel et al. identified factors relatedto dissatisfaction as salary limitations,poor working conditions, questionable jobsecurity, poor coworker relationships andthe constraints of policies. In this sampleof 146 NPs, the researchers reportedthat intrinsic factors were sources of jobsatisfaction, and extrinsic factors weresources of job dissatisfaction. Ninetypercent of NPs were satisfied with theirjobs, regardless of extrinsic factors.More recently, a study by De Milt etal. 5 examined the relationship betweenNP satisfaction and turnover. This crosssectional,descriptive study included 254NPs and used the Misener scale and theAnticipated Turnover Scale to analyzecurrent job satisfaction and the NPs’jeffrey leeserRebecca Ann Priebe is an acute care nurse practitioner at Pulmonary MedicineAssociates in Warren, Mich. She has completed a disclosure statement and reportsno relationships related to this article.38 ADVANCE for NPs & PAs

Professional Issuesintent to leave their current positions. Theresults showed an overall NP satisfactionrate of 75% (197.2). Factors contributingto satisfaction included intrapracticepartnership and collegiality. The factorthat was least satisfying was benefits. DeMilt et al. concluded that NPs who weresatisfied in their current positions did notintend to seek employment elsewhere. 5MethodsI used a quantitative, cross-sectional, surveymethodology for this study. I deviseda probability sample by randomly selectingprimary care clinics from an onlinetelephone directory and a governmentwebsite. All practices were located insoutheast Michigan. I contacted eachclinic to identify one NP to receive themailed survey. The NP had to have earnedcertification and been practicing at thatclinic for more than 3 months.Once approval was obtained, I sent aletter to the NPs, explaining the researchstudy. The mailing included a demographicquestionnaire, the Misener scale,and a self-addressed envelope. By returningthe demographic questionnaire andsatisfaction scale, informed consent wasimplied. Of the 100 mailed surveys distributed,58 usable surveys were returned,for a response rate of 58%.InstrumentsThe demographic questionnaire collectedinformation on age, gender, race,NP certification and length of time atcurrent job. I used the Misener scale toassess overall job satisfaction. This contains44 items divided into six subscales.The three subscales that represent jobsatisfaction are challenge/autonomy,professional growth and collegiality. Thethree subscales for job dissatisfaction areprofessional/social/community interaction,time and benefits. Each item is ratedon a 6-point Likert scale that ranges from6 (very satisfied) to 1 (very dissatisfied),for a total possible score of 264.Validity was established by Misener andCox on the original instrument as well asthe revised 44-item Misener survey. Contentvalidity was evaluated by a literature reviewto collect examples of satisfiers and dissatisfiersfrom other NP job satisfaction studies.Internal consistency and reliability for the44-item Misener survey using Chronbach’salpha was estimated as 0.96. Coefficientalpha reliability estimates were calculatedfor each of the six subscales, and rangedfrom 0.79 for the benefits subscale to 0.94for intrapractice partnership. 2 Evaluationof the psychometric properties deemedthe Misener survey appropriate for usein this study.ResultsNP Demographics. The average respondentwas older than 41 (n = 49, 83.05%),female (n = 58, 100%), white (n = 58,100%), certified as an NP for more than5 years (n = 44, 75.86%), and employedat her current job more than 5 years(n = 30, 50.85%).Descriptive statistics. I compared theperceived satisfaction of each item usingmean ratings. The three items NPs rated4.00 (minimally satisfied) or lower weresupport for continuing education (4.00),monetary bonuses in addition to salary(3.84), and opportunity to receive compensationfor services outside normalduties (3.71). Herzberg identifies these asextrinsic factors. In contrast, the threeitems NPs rated 5.45 or higher (satisfiedto very satisfied) were percentage of timespent in direct patient care (5.45), senseof accomplishment (5.55), and ability todeliver quality care (5.48). These factorsare considered intrinsic by Herzberg.After examining the total results, theaverage total score was 211.79 or an overallsatisfaction rating of 80.22%. This totalalso represents a mean item rating of 4.81on the Misener scale and numeric Likertscale, which suggests that the NPs wereminimally satisfied to satisfied in theircurrent positions.Relationships among NP characteristicsand satisfaction. I analyzed the differencesin the Misener scale and its subscales inrelation to age, time certified as an NP,and time in current position. The differencesbetween gender and race to jobsatisfaction were not calculated becauseof absence of variability. By applyingLevene’s tests for equality of variance,the appropriate t-test was used.No significant differences were notedaccording to age group (younger than 40and 41 and older), nor were any foundaccording to years in NP practice. NPsat their jobs more than 5 years perceivedtheir benefits as more satisfying thanNPs at their job less than 5 years (t =−2.34, p = 0.02).Although this finding was not statisticallysignificant, NPs employed less than5 years tended to be more satisfied withgrowth opportunities than NPs employedmore than 5 years (t = 1.64, p = 0.11).ImplicationsThe study results suggest that intrinsicfactors help keep NPs satisfied in theirjobs and extrinsic factors increase jobdissatisfaction. Future research shouldexamine a larger, more diverse populationof NPs that would make results moregeneralizable. It is essential to assessfactors of job satisfaction and dissatisfactionin order to keep NPs (and PAs)employed and functioning at highestcapacity. Research to improve aspectsof practice is necessary to ensure theirretention and satisfaction. ■References1. Koelbel PW, et al. Job satisfaction of nurse practitioners:an analysis using Herzberg’s theory. NursePract. 1991;16(4):43-56.2. Misener TR, Cox DL. Development of the Misenernurse practitioner job satisfaction scale. J Nurs Meas.2001;9(1):91-108.3. Herzberg F. Work and the Nature of Man. Cleveland:World Publishing; 1966.4. Bullough B. Is the nurse practitioner role a source ofincreased work satisfaction? Nurs Res. 1974;23(1):14-19.5. De Milt DG, et al. Nurse practitioners’ job satisfactionand intent to leave current positions, the nursingprofession, and the NP role as a direct care provider. JAm Acad Nurse Pract. 2011;23(1):42-50.Are PAs Happy on the Job?➼ Physician assistants, have you conducted asimilar study of PA job satisfaction? We’d like to hearabout the results. To submit your article, please follow theGuidelines for Contributors posted under the Resourcestab at www.advanceweb.com/NPPA.ADVANCE for NPs & PAs39

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CalendarPA/NJ/DE Pediatric and FamilyNurse Practitionersand Student NPsTop 3 reasons to join the Pennsylvania/Delaware Valley Chapter of theNational Association ofPediatric Nurse Practitioners1.) Collegiality & Camaraderie - Meetother PNPs at our events, learn aboutlocal employment opportunities,volunteer with us, check out our grantopportunities!2.) Continuing education: Sunday,March 4, pharmacology luncheon andWednesday, May 9, Spring dinner.Events are usually open to nonmembers,check our web site.3.) Connections & Resources on ourweb site:www.padelvalnapnap.orgPractitioner Education AssociatesSkills + Education = CondencePractitioner Education Associates (PEA) places an emphasis on presenting complex topics in an easilyunderstandable manner. "Hands on" interactive workshops are our specialty. Participants will improve theircon dence in procedural skills after completion. There are also opportunities to tailor courses to your needswith a minimum of 20 participants.We are taking registrations for the 2012 NP Skills Boot Camps(18 hr CE) plus Optional Workshops (3 hr CE each)"Boot Camps" include Suturing, Minor Ofce Procedures, EENT,X-ray interpretation of Chest/Abdomen/Extremities and Splinting Workshops."Optional Workshops" include Slit lamp, Dental & EKG.Please visit our website for the agendas & outlines for the workshops included in each "Boot Camp"March 2-4, 2012, May 17-19, 2012, August 2-4, 2012and October 19-21, 2012 in Pittsburgh, PAContact us:Phone: 412.366.0265 • Email: ramponi@npskillsnow.comwww.NPskillsNow.comACTFAST!Get exclusive contentDelivereD riGht to Yourinbox each WeekADVANCE has a helpful solutionto fit your hectic schedule.sign up for our free weekly e-newsletterand we’ll bring the news to you.once a week, we’ll send you an email highlighting the latestnp&pa developments, including:• Timely industry news updates• Featured articles you won’t find in print• Stimulating blog entries• Exclusive multimedia• Contests and surveysSIGN UP TODAYVisit www.advanceweb.com/nppa. Just enter your name, email address andzip code halfway down the right side of the page. it’s that simple!advance FOR46 ADVANCE for NPs & PAs

FREE HEALTHCAREJOB FAIRS& SESSIONSIN PERSONMake a day of it at a FREE in-personjob fair. Meet recruiters, play games,win prizes & shop for new gear!March 15 • New York, NYJacob K. Javits Convention CenterApril 10 • Oaks, PAGreater Philadelphia Expo Center at OaksMay 1 • Melville, NYMelville Marriott Long IslandONLINESign up to attend a FREE online jobfair right at home! Chat with recruiters,gather info and instantly submit your resume.June 6 Mid-Atlantic& Lower Great Lakes RegionalJune 20 Northeastern RegionalRegister today!Visit: www.advanceweb.com/event • Call: 800-546-4987 • Email: ADVANCEevents@advanceweb.comComplete details, session agendas, exhibitor lists, prizes and directions can be found at www.advanceweb.com/events.ADVANCE for NPs & PAs47

UP TO 5* HOURS OF FREE CLASSESIN-PERSON SESSIONS**ONLINE SESSIONSMood Disorders & ChildrenGeneticsIN-PERSON ATTENDEE REGISTRATION FORMMail this form to ADVANCE Job Fairs & Career Events,3100 Horizon Drive, King of Prussia, PA 19406 or fax to 610-270-3184.All information is required to process your registration, so please print clearly.Migraines & Other HeadachesHelping Consumers Navigate HealthcareSHOW: DATEEARLY REGISTRATION DEADLINEEvidence vs. EmotionsHow U Rite MattersFOR SESSION DETAILS, VISIT WWW.ADVANCEWEB.COM/EVENTSOR CALL 800-546-4987.*In-person shows only. Up to 2 hours of free classes at online job fairs.**Sessions vary by city.MEET RECRUITERS FROM TOP FACILITIESNEW YORK, NY • MARCH 15Jacob K. Javits Convention CenterADVANCE Healthcare Shop:For Gear, Gadgets & GiftsArchCareBetter Healthcare OT/PT/SLP, PLLCCareOneCerebral Palsy Associations ofNew York StateThe College of New RochelleCommunity Regional Medical CentersComprehensive NetworkElizabeth Seton Pediatric CenterFavorite Healthcare Staffi ngFelician CollegeFlorida HospitalThe Gideons InternationalGotham Per Diem IncGreenKey Resourceshealthfi rstHorizon Healthcare StaffingLutheran Medical CenterMemorial Sloan-Kettering Cancer CenterMercy CollegeMJHSThe Mount Sinai Medical CenterNortheast Georgia Health System, IncNYU Langone Medical CenterOmni Childhood CenterOutreach Physical & Occupational Therapy& Speech Rehabilitation, PLLCPACE University Lienhard School of NursingPacifi c College of Oriental MedicineRCM Health Care ServicesSelfhelp Community Services, IncSignature Learning ResourcesSt. Luke’s Episcopal Health SystemTheraCare of New York, Inc.SPONSORS ARE IN BOLDU.S. Army Healthcare RecruitingVisiting Nurse RegionalWalden UniversityWinston ResourcesYeled V’Yalda E.C.C.SAVE10%WITH OUR COUPON IN THE PROGRAMGUIDE DISTRIBUTED AT THE JOB FAIROAKS, PA • APRIL 10Greater Philadelphia ExpoCenter at OaksADVANCE Healthcare Shop:For Gear, Gadgets & GiftsCareOneThe Gideons InternationalWalden UniversityMELVILLE, NY • MAY 1Melville Marriott Long IslandADVANCE Healthcare Shop:For Gear, Gadgets & GiftsThe Gideons InternationalHorizon Healthcare StaffingMercy CollegeMJHSTheraCare of New York, IncWalden UniversityONLINE JOB FAIR MID-ATLANTIC &LOWER GREAT LAKES REGIONAL •JUNE 6www.advanceweb.com/eventsFavorite Healthcare StaffingONLINE JOB FAIR NORTHEASTERNREGIONAL • JUNE 20www.advanceweb.com/eventsFavorite Healthcare StaffingVisit the ADVANCE Healthcare Shop booth at in-person job fairs for huge savingson hundreds of items including scrubs, professional products and more.www.advancehealthcareshop.comGET RECRUITING WITH US TODAY!Interview potential staffers on the spot at an ADVANCE Job Fair.Call 800-546-4987 today to be an exhibitor at an upcoming event.They’ll remember you better with an awesome customized giveaway.Easily customize items from thousands of choicesfrom ADVANCE Custom Promotions:www.advancecustompromotions.comNEW YORK, NY: 3/15 2/27OAKS, PA: 4/10 3/26MELVILLE, NY: 5/1 4/16Registration includes FREE admission to the exhibit hall and classes.Parking and lunch are not included.Register for all ONLINE EVENTS right up to the dayof the event at www.advanceweb.com/events____________________________________________________________________FULL NAME____________________________________________________________________FACILITY/SCHOOL (if your confi rmation is being mailed to this location)____________________________________________________________________TITLE____________________________________________________________________SPECIALTY____________________________________________________________________HOME ADDRESS____________________________________________________________________CITY STATE ZIP____________________________________________________________________PHONE (WORK)PHONE (HOME)____________________________________________________________________FAXEMAIL____________________________________________________________________SIGNATUREWe may occasionally send you mail/email with special offers from selectedcompanies. Check the box below if you do not wish to receive such offers.MAILINGS:❍ I don't wish to receive special offers from selected companies via mailEMAIL OFFERS:When you provide your email address, you will receive an email from ADVANCE to welcomeyou and help you manage your email preferences.GET MORE DETAILS ATWWW.ADVANCEWEB.COM/EVENTSOR EMAIL ADVANCEEVENTS@ADVANCEWEB.COM• Prize details• Driving directions• Complete session agendas• Exhibitor lists and locations• Restaurant recommendations• Hotel recommendations and moreFOLLOW US ON TWITTERtwitter.com/ADVANCECareersRACE TO FIND NANCYNancy the Job Fair Navigator is taking lapsaround the exhibit hall. Go for the gold andfind her in record time. Winner receives cash!FIND US ON FACEBOOKfacebook.com/ADVANCECareersNPPA2012013048 ADVANCE for NPs & PAs

Advertiser IndexAt www.advanceweb.com/NPPA, our searchable online ResourceDirectory allows you to access information about companies and products,as well as submit requests for additional details. Find the Resource Directoryunder the Products tab on the homepage.Support the Companies Who Support Your ProfessionThe companies listed in this advertiser index support the NP and PA professionsby advertising in ADVANCE for NPs & PAs. Their support keeps our peer-reviewedjournal coming to you free of charge. Please contact these advertisers or visittheir websites to learn more about their products or services.WHAT DOESYOUR MAILINGLABEL SAY?It’s time to check the mailing label on the frontof this magazine to see if you need to subscribeor renew NOW! Even if you already receive themagazine, you might not be an official subscriber.That’s why you need to contact us to update yoursubscription status. Otherwise, the post office requiresthat we stop sending you this magazine. So, pleasetake a moment to subscribe or renew today.SUBSCRIBE ONLINE ATWWW.ADVANCEWEB.COM/NPPA(just click on the subscribe button at the top right corner of our home page)OR CALL 800-355-1088M-F 8:00am-6:00pm ESTOR SNAP THIS TAGADVERTISER PHONE # OR WEB ADDRESS PG #Advanced Practice Education Associates www.apea.com 45Aesthetic Medical Educators Training www.aestheticmedicaltraining.com 40American Lifeline www.florajen.com 2American Medical Software www.americanmedical.com 37AFPPA www.afppa.org 44Barkley & Associates www.NPcourses.com 40Baylor Health www.thehearthospitalbaylor.com/cvcare 13Calmoseptine www.calmoseptineointment.com 12Cephalon www.nuvigil.com 15Chamberlain Medical Resources, Inc. www.CMR4CME.com 42Contemporary Forums www.contemporaryforums.com 42Dannon www.activia.us.com 33Fitzgerald Health Education Associates www.fhea.com 41Marsh www.proliability.com/55804 3Merion Matters www.advancweb.com/events 7Merion Matters www.advanceweb.com/events 47–48Merion Matters www.advancehealthcareshop.com 50–53Merion Matters www.advanceweb.com/NPPA 49Midland College www.midland.edu 40NAPNAP www.napnap.org 46NPACE www.npace.org 44NPSkillsNow.com www.npskillsnow.com 46Purdue Pharma L.P. IntermezzoRX.com/register 5-6Quinnipiac University www.quinnipiac.edu 45Schiff Nutrition Group ProSamples.SchiffMegaRed.com 21Schiff Nutrition Group www.sustenex.com 11Teva Respiratory ProAirHFA.com/healthcare-professionals 70–72Troy University www.troy.edu 43University of Science, Arts & Technology www.usat-montserrat.org 44Wolters Kluwer Health ncnpconference.com 46Xlear, Inc. www.xlear.com 9NPPA 02/12IT’S FREE AND ALWAYS WILL BE!Advertising Policy: All advertisements sent to Merion Publications Inc. for publication must comply with allapplicable laws and regulations. Recruitment ads that discriminate against applicants based on sex, age,race, religion, marital status or any other protected class will not be accepted for publication. The appearanceof advertisements in ADVANCE Newsmagazines is not an endorsement of the advertiser or its products orservices. Merion Publications does not investigate the claims made by advertisers and is not responsiblefor their claims.ADVANCE for NPs & PAs49

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Career OpportunitiesEAST SOUTH CENTRALEAST SOUTH CENTRALEAST SOUTH CENTRALFACULTYLooking for a new careeropportunity?FACULTYFACULTYINTERNATIONALINTERNATIONALINTERNATIONALLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICwebsite or by calling (800) 355-1088.ToMIDDLEplace anATLANTICad in this section,call ADVANCE atMIDDLE(800) 355-JOBSATLANTIC(5627).Regional Directory:New MIDDLE England. ...................54ATLANTICMiddle Atlantic ..................58Upper MOUNTAINSouth Atlantic ..............61Each month, the ADVANCE for NPs & PAsOpportunities Section presents the latestjob openings from across the country. Forconvenience, listings are arranged by region,with state headings to further guide your search.These positions are also posted and updateddaily at the “Jobs” tab at our website, www.advanceweb.com/NPPA.Sign up or renew your FREE subscription at theLower South Atlantic ..............63East MOUNTAINNorth Central. ...............64West North Central ...............65West MOUNTAINSouth Central ...............65Southwest .....................66Mountain NATIONAL ......................66Pacific ........................67National .......................68NATIONALNATIONALNEW ENGLANDNEW ENGLANDConnecticut, New HampshireTeam up with theHealthCare Businessof the Decade.Nurse Practitioner/Physician Assistant - Cardiologywww.cheshire-med.comNEW ENGLANDPACIFICPACIFICat your bestPACIFICSOUTHWESTSOUTHWESTBe your best … at Yale-New Haven Hospital. Ours is an environment where your career can thrive: a 966-bed, Magnet recognized, tertiary medicalSOUTHWESTresearch. This is a truly extraordinary environment, oering some of the most challenging and rewarding careers in healthcare today.UPPER SOUTH ATLANTICUPPER enables you SOUTH to build a ATLANTICfull life beyond our hospital walls. Yale-New Haven Hospital — It’s the place for YOU!UPPER SOUTH ATLANTICWEST NORTH CENTRAL WEST NORTH CENTRALYale-New Haven Hospital offers generous compensation, comprehensive benefitsWEST and exceptional NORTH opportunities CENTRAL for learning and professional growth. EOEWEST SOUTH CENTRALWEST SOUTH CENTRALWEST SOUTH CENTRALcenter with more than 3,600 physicians and advanced practitioners, providing comprehensive, multidisciplinary care in more than 100 specialty areas.Yale-New Haven Hospital ranks among the best hospitals in the U.S. and is nationally recognized for its commitment to teaching and leading-edge clinicalBuilding on an unsurpassed commitment to learning, professional growth and the highest quality patient care, Yale-New Haven Hospital transforms everyadvanced practice career into a unique opportunity to rise to the top of your chosen specialty eld. e oer a dynamic ork/ife Balance Program thatOur service expansion has created many new opportunities for mid-level Physician Assistants and Nurse Practitioners:To learn more, call us toll free at 866-811-7797,or visit our career site at: 54 ADVANCE for NPs & PAs

Rhode Island, New Hampshire, Vermont“Connecting Communities to Quality Care”FAMILY NURSEPRACTITIONEROpportunitiesThe Providence Community Health CentersInc., (PCHC) is the largest state-wide networkof community health centers in Providence,Rhode Island.Our services include Family Practice, Pediatric,Internal Medicine, OB/GYN, allergy/asthma,dermatology, nutrition, reproductive healthand WIC.PCHC seeks experienced Certified Family NursePractitioners. Spanish is a plus. As a NationalHealth Service Core Approved Site, school loanrepayment may be possible.Qualifications include: Licensed RN with aBachelors of Science, Certified Family NursePractitioner with 3-5 years experience.To learn more about these exciting positions,please forward your resume to:Career OpportunitiesDiana ChristianSenior Human Resources Generaliste-mail: dchristian@providencechc.orgor fax: 401-444-0469advancecustompromotions.com1-877-776-6680Rutland/Killington, VermontWe have good opportunities for mid-level providers in multiple areas. Competitivesalaries with good benefits. Affiliated with Rutland Regional Medical Center.Family Practice Nurse PractitionerGastroenterologyOccupational HealthPhysiatryPsychiatryEmergency DepartmentSend Your Resume to: bbanco@rrmc.orgRebecca Banco, In-house Physician Recruiter • From the publishers of ADVANCE Newsmagazines• Custom gifts, giveaways & promotional products• Exclusive healthcare designs you won't find anywhere else• Free design, copy & creative services• Staff gifts & event giveaways for every budgetATTEND FREE CE SESSIONS AT ADVANCE JOB FAIR &CAREER EVENTS AT WWW.ADVANCEWEB.COM/JOBFAIRSADVANCE for NPs & PAs55

ConnecticutCareer OpportunitiesBorn to HealEach of us was born to do something great. Bridgeport Hospital can provideyou with a work environment that is at once passionate, professional and trulyrewarding. place for you to thrive. e are a private, not-for-prot, acute carehospital located in Connecticut’s most populous city. Bridgeport Hospital, amember of the world-class Yale New Haven Health System, combines thestate-of-the-art services and technologies of a large, high acuity urban hospitalwith the personalized care of a community hospital.Consider one of the following opportunities … become part of something great.Physician Assistant – PsychiatrySuccessful candidate will work as part of a multidisciplinary team in ahospital-based inpatient psychiatric department. Candidates must havea Bachelor’s degree; be a graduate of an accredited physician assistantprogram; NCCP certication; Connecticut license or eligibility.Psychiatric experience/background preferred, but new graduatesare encouraged to apply.Advanced Nurse Practitioner – ED CrisisThe ED Psych Crisis is a 6-bed locked unit providing psychiatric evaluationsto a wide variety of populations. Candidates must be an RN with a Master’sdegree in Psychiatric/Mental Health Nursing; 3-5 years of related clinicalexperience; certication in Psychiatric/Mental Health as a clinical specialist,PRN licensure and certication as a icensed Independent Practitioner in CT.Job MarketCompetition‘In most areas of the country, the supplyof NPs and PAs is greater than thedemand. For every job posted, recordnumbers of applicants apply.’—Renee Dahring, MSN, NP,in the September 2010issue of ADVANCE.professional growth. EOE.We are committed to providing ourclinical staff with the resources andsupport to build a truly satisfyingcareer. We offer generous compensation,comprehensive benefits, a stableenvironment and exceptionalHow Many NPs?opportunities for learning andThere are 158,348 U.S. nurse practitioners,according to the Health Resourcesand Services Administration’s recentlypublished quadrennial study of the U.S.To learn more and apply: BridgeportHospitalCareers.orgnursing population.... Caring for Your LifeBP‘ThhowheyfePPOnBa6–Webde• From the publishers of ADVANCE Newsmagazines• Custom gifts, giveaways & promotional products• Exclusive healthcare designs you won't fi nd anywhere else• Free design, copy & creative services• Staff gifts & event giveaways for every budgetNPs, PAs and theHealthcare Home‘NP and PA organizations are monitoringimplementation of healthcare homescarefully, seeking to ensure that languagepermits NPs and PAs to be leaders.’—Editor Michelle Pronsati in theDecember 2010 issue of ADVANCE.NPCoscStprarphroacCall: 1-877-776-6680Visit: advancecustompromotions.comTHE BEST JOB FAIR & CAREER EVENTWWW.ADVANCEWEB.COM/JOBFAIRS56 ADVANCE for NPs & PAs

ConnecticutThe Mid-level Practitioner is accountable for delivering comprehensivequality patient care, including diagnostic and therapeutic interventionsaccording to standards of practice for children from birth throughadolescence. The Practitioner functions as a member of an inpatientphysician team within an integrated academic model, with the potential fora clinical academic position. This position treats and evaluates patients withchildhood illness, coordinates care with team members, staff, communityagencies and a wide variety of providers, and consults with attendingphysicians to discuss care and monitor outcomes. Participates in peerreview, development and consultation and maintains professionalexpertise through involvement in professional organizations andcontinuing education programs. Demonstrates knowledge of the agerelateddifferences and needs of patients in appropriate, specific populationsfrom neonate through adolescence and applies them to practice.Connecticut Childrenʼs Medical CenterConnecticut Children’s Medical Center is a nationally recognized leader in pediatric care and the region’sonly academic medical center devoted exclusively to the care of children. Connecticut Children’s MedicalCenter offers a full range of services for children from birth through age 18 and provides quality care through10 affiliated community hospitals and 15 practice locations.Mid-level Practitioner/Inpatient Management TeamCandidate will have a current CT license as a Physician Assistant orPediatric Advanced Practice Registered Nurse (APRN), current Basic LifeSupport (BLS)/CPR in adult, child, and infant, and formal training inpediatrics. Pediatric Advanced Life Support (PALS) certification requiredwithin six months of hire. Two years’ work experience in pediatrics ispreferred. Willingness to work flexible hours/days to meet the needs ofpatients and programs and services, and a commitment to providingpediatric health care in an urban community-based setting required. Musthave ability to manage complex family issues, and provide patient/familyteaching and discharge planning. Bilingual and bicultural in English andSpanish preferred.Career OpportunitiesConnecticut Children’s Medical Center offers excellent benefits including on-site child care, educational assistance,free parking, paid time-off, and more.For these and other nursing opportunities, please apply online at: www.connecticutchildrens.orgConnecticut Children’s Medical Center282 Washington Street, Hartford, CT 06106Giving children the care they deserveGiving health care professionals opportunities to succeedWe encourage diversity in theworkplace. AA/EOE M/F/D/VDON’T MISSA SINGLEFREEISSUE OFADVANCESUBSCRIBE TODAY800.355.1088Charting a new course to success!PA/APRNTHE BREAST CENTERFull-time, Mon. - Fri., DaysSupport physicians with patient care and manage all patient follow-up.Responsible for performing small office-based procedures (e.g. biopsies),taking ultrasound images, triaging patients in the office or bytelephone, and assessing and communicating lab/biopsy results tophysicians and patients.Must be licensed and in good standing as an APRN or PA in CT.Experience in breast surgery and oncology preferred. Excellentinterpersonal, bedside manner, and communication skills and theability to effectively work with patients and families of all ages andbackgrounds and with staff at all levels of the organization required.Interested candidates, please contactClinical Recruiter, Nancy Miko at: nmiko@stmh.orgWATERBURY, CTJOB OPENINGS – SENT DIRECTLY TO YOUR E-MAILSIGN UP TODAY AT WWW.ADVANCEWEB.COMwww.stmh.orgWe are an Equal Employment Opportunity Employer M/F/D/VADVANCE for NPs & PAs57

p-ed, NP,010CE.tiorcesly.S.ngageCareer OpportunitiestheCE.Bridging the NP andPA Knowledge GapJoin a new circle of friends and colleagues at‘The Mount two Auburn professions Hospital and suffer find all from the challenges, hugeopportunities and recognition you’re lookingholes for. Located in understanding Cambridge, just what, a short where, walkfrom Harvard Square, we are a Harvard-affiliatedwhy and how they each exist. It’s in theregional teaching hospital offering the challengeseye of of tertiary the care beholder in a supportive, how friendly much environment. the differencesPHYSICIAN matter.’ ASSISTANT OPENINGSDepartment —Roderick of S. Medicine Hooker, PhD, (Full-time) MBA, PA,Our Department of in Medicine the September is a busy 2010inpatient medical service. Ideal candidatesissue of ADVANCE.will have current MA Physician AssistantLicense, a MA/Federal Narcotic License,and preferably 2 or more years of clinicalexperience in an inpatient setting. Priorcompletion of an accredited PhysicianAssistant program is required.Department of CardiothoracicSurgery (Full-time)This is an outstanding opportunity for anexperienced Physician Assistant to join aPresident hospital-based service Obamaproviding care inthe O.R., SICU and inpatient floors. You’llProclaims manage cardiothoracic PA patients Weekthroughthe continuum of care from pre-test toOn discharge, PA Day inclusive on Oct. of 6, the 2010, operating PresidentBarackroom. ScheduleObamaisproclaimedMon-Fri withOctoberO.R.call responsibility. Current MA Physician6–12 Assistant as National license required; Physician Cardiothoracic AssistantPA experience is preferred.Week. It marked the first time this celebrationhad been recognized by presidentialproclamation.See Your Future Take Shapewww.mountauburnhospital.orgResumes may also be faxed to (617) 499-5168or mailed to Human Resources,330 Mount Auburn St., Cambridge, MA 02138. EOE.NPs & PAs HavePrescribing PowerConsidering that about 3.9 billion prescriptionswere written in the UnitedStates in 2009, NPs and PAs pull theirprescribing weight. Given that thereare an estimated 773,800 activephysicians, NPs and PAs together writeroughly 23% of all prescriptions whileaccounting for 21% of prescribers.1-877-776-6680LOWER SOUTH ATLANTICMIDDLE ATLANTICMassachusetts, New Jersey, Pennsylvania, New YorkMIDDLE ATLANTICMIDDLE ATLANTICNURSE PRACTITIONERMOUNTAINSamaritan CelebratingMOUNTAINHealthcare & Hospice iscurrentlyMOUNTAINseeking a highly motivatedNurse NPs Practitioner & PAs for our PalliativeMedicine‘Despite NATIONAL thatProgram.you and yourNursecolleaguesPractitionerstill are relatively small in number, youPositionNATIONALis Full-Time.are loud in voice, and you have madeand NATIONAL will continue to make an enormousimpact on health care in America.NEW ENGLAND RequirementsCountless millions • Master’s of patients Degree who’d in Nursing • RN licensehave NEW otherwise ENGLAND gone untreated • will APN continueto be • able Experience to access in healthcare Palliative Care, Hospice or GeriatricscertificationNEW•ENGLANDExcellent clinical, interpersonal and communication skills.because of the dedicated work of youandPACIFICyour colleagues. Send resume In the to: case Allison of the Rad, Recruitment SpecialistNP–PA team, the whole Samaritan is much greater Healthcare and Hospicethan PACIFIC the sum of 5 its Eves parts.’ Drive, Suite 300 • Marlton, NJ 08053—Editor Michael E-mail: Gerchufsky careers@samaritanhealthcarenj.orgin thePACIFIC December 2010 P: issue (856) of 552-3212 ADVANCE. F: (856) 552-1004SOUTHWESTSOUTHWESTMideast SOUTHWESTGets ItsUPPER SOUTH ATLANTIC1st PA ProgramThe UPPER Kingdom SOUTH of Saudi Visit ATLANTIC Arabia us at www.samaritanhealthcarenj.orginitiatedto see a list of all our current openings.its UPPER inaugural SOUTH physician ATLANTIC assistant classof 27 students at the Prince SultanWEST NORTH CENTRALMilitary College of Health Sciences inthe WEST Eastern NORTH Province CENTRAL capital of DhahranEOEthisSt. Christopher’s WEST past autumn. NORTH Hospital for CENTRALNURSE PRACTITIONERSChildren, a Magnet facility,All NP positions require Master’s Degree, NYS NP licenseWEST SOUTH CENTRALand St. Christopher’s Pediatricwith ANCC/AANP certification as an Adult or Family NP,and AHA BLS & ACLS.Associates WEST are committed SOUTH to CENTRALdelivering quality care to each• Bariatric Coordinator, - FT, DaysClinical experience in Bariatrics with knowledge ofWEST SOUTH CENTRALBariatric Surgery Center of Excellence Standards.• Cardiology - FT, EvesPrevious Cardiology experience or interest in CardiologyServices desired.• Palliative & Geriatric - FT, DaysHospice or Palliative Care experience preferred.and every one of our patients,each and every time. Positionsare available for full-timeand per diem Nurse Practitioners with PAlicensures and MSN degrees. If you are ready to advancein your career while impacting the lives of our pediatricpopulation, consider the following opportunities:• CARDIOLOGY - FULL-TIME• CARDIOTHORACIC SURGERY - FULL-TIME• EMERGENCY MEDICINE - FULL-TIME• NEONATAL - FULL-TIME & PER DIEMFor more information, including job requirements,benefits and job information, visit our website atwww.stchristophershospital.com orE-mail Susan McFalls, Nurse Recruiter atsusan.mcfalls@tenethealth.comEOE, M/F/D/VPHYSICIAN ASSISTANTS• Critical CareFT, Nights & Weekends, 12 hour shiftsRequires NYS PA license with NCCPA certification, andAHA BLS & ACLS. Critical Care experience and skillsare preferred.APPLY ONLINE: www.SouthNassau.orgNurse Practitioner/Physician AssistantFT/PT for busy Family Practice inBergen County, NJ. New Grads Welcome.E-mail resumé to jcforti@optonline.netor Fax: 201-368-961858 ADVANCE for NPs & PAs

New York, PennsylvaniaexceenceFIND YOURSELF AT THE CENTER OFNurse PractitionersCareer OpportunitiesWe currently have the following NP opportunitiesavailable to join our team. Positions require an MSN,NYS NP certification with prescriptive privilegesplus a minimum of two years of relevant NP experience.NeurosurgeryInpatient, 11.5-hour flex rotatingRequires acute care NP with at least one year ofneurosurgery or critical care experience.CardiothoracicInpatient and office practice, 11.5-hour daysRequires adult or acute care NP with cardiothoracicexperience.OB/GYN (Uro-Gynecology)Outpatient, School of Medicine Faculty Group PracticeMonday to Friday, 7.5-hour day shiftRequires FNP or Women’s Health NP with urogynecologyexperience.Inpatient Hematology/Oncology11.5-hour nightsHiring Bonus: $5,000 with one year minimum ofrecent experience as NP in Hematology/Oncology(Paid in increments over 1 year)General SurgeryDays (6 a.m. – 6 p.m.) & Nights (6 p.m. – 6 a.m.)Requires adult or acute NP and general surgeryexperience.Urgent Care - Bellevue Hospital10-hour flex Per DiemNYU School of Medicine opportunity located at BellevueHospital. Recent primary care experience, nursingexperience in an emergency dept. setting is preferred.Per Diem NPsMinimum 2 years experience in medicine,neurosurgery or critical care.For further information and to apply online, please visit www.nyulmc.org/careers.We are an equal opportunity employer.Orthopedic Hospital • Bensalem, PANurse Practitioner• Orthopedic experience preferredbut not required• Competitive salary and benefitsFor more information, visitwww.rothmanspecialtyhospital.comE-mail resume to: magostinelli@nueterra.orgSubject line: Nurse Practitioner• EOEMountain Medical ServicesURGENT CAREis looking to hire Four Practitioners to work in a fastpaced medical facility in upstate NY.• Positions in primary care or urgent care settings• Four great locations - Lake Placid, Saranac Lake,Massena & Malone Offices• Full-time, Part-time & Per Diem Positions• Salary dependent on experience• Prefer 1 - 2 years experiencePlease contact Lindsay LaPointe for more information.To apply please E-mail: Ladams@mountainmedical.netWWW.ADVANCEWEB.COM/JOBFAIRSCome work with us!Nurse PractitionerMIT Medical seeks a nurse practitioner tocollaborate with physicians on the provisionof primary and urgent care to patients.Will assess patients’ health status throughinterview and physical exam and synthesizethis clinical information to formulate healthproblem(s) and appropriate treatmentstrategies, and provide health maintenanceand health promotion for patients and theirfamilies. Will provide these services accordingto age-specific plans of care.Requirements: current certification/licensureas a nurse practitioner, current CPRcertification, and two years of experience as anurse practitioner in a relevant age-specificambulatory setting. Hospital-based RNexperience preferred.For more information about MIT Medical,please visit http://medweb.mit.edu.Interested candidates may apply online athttp://web.mit.edu/jobs. Please referencejob number mit-00008337 and indicatewhere you saw this posting.MIT is an equal opportunity/affirmative actionemployer. Applications from women, minorities,veterans, older workers, and individuals withdisabilities are stronglyencouraged.http://medweb.mit.eduSUBSCRIBE TODAY — CALL 800.355.1088Nurse PractitionerPhysician AssistantHeart Failure ProgramFull-Time, Flexible Hours8- or 10-Hour ShiftsAt Abington Memorial Hospital, the work ischallenging and the rewards are great! Joina team committed to improving the quality oflife for both patients and employees!We are seeking a NP/PA with at leastthree years experience as a mid-levelprovider in the medical management ofheart failure patients. Ideal candidate willhave a background in general cardiology.Requirements include graduation from anaccredited institution with certificate fromNP/PA program at the graduate level orgreater; current NP/PA licensure in the stateof PA; ACLS certification; and prescriptiveauthority Medical DEA number. Cardiologyspecialty degree and certification preferred.Apply online: www.amh.orgReq #2011-1084A TJC-Certified Joint Replacement Program for Hips and KneesA TJC-Certified Primary Stroke CenterEqual opportunity employerADVANCE for NPs & PAs59

New York, New JerseyCareer Opportunities#1 IN NEW YORK, #6 IN THE NATION — U.S.News & World Report, America’s Best Hospitals — Honor Roll RankingsRespected, Empowered & Growing: The PA Team at NYPPhysician Assistants at New York’s #1 Hospital (U.S. News and World Report) are aself-governed discipline – far beyond a “nine to five” support role. For our expertise andexpanding responsibility, you’ll often hear PAs refer to NewYork-Presbyterian asa “PA-run institution.”Day and night shifts as well as per diem opportunities are currentlyavailable in the following specialties: “What keeps me here is the teamwork. As aPhysician Assistant in the wound healing service,I consult with dermatologists, podiatrists,nutritionists and others throughout the healingprocess. We share our knowledge, and do what’sbest for the patient. My biggest surprise was howeverybody shows such compassion and caring.”Marisol, Physician AssistantSurgeryWe harness the latest technology and excel in the most advanced units. Five state-ofthe-artSiemens Artis zeego ® medical imaging systems—more than any other hospitalin the world. Extraordinary technical expertise in aneurysm, pediatric epilepsy, spinaltumors and stroke. And we’re just getting started.Benefits include a Night Shift Differential (added compensation), hospital housing,hospital paid retirement, and much more. Join a hospital where employee andpatient satisfaction scores are at their highest levels ever. New grads and experiencedPA’s are encouraged to apply.Positions are available at NewYork-Presbyterian/Columbia University Medical Center,NewYork-Presbyterian Hospital/Weill Cornell Medical Center and NewYork-Presbyterian/The Allen Hospital.Experience life at our pace-setting hospital.Meet the amazing people, Making It Possible.Explore our stories, and start your journey atNYPCAREERS.ORG/PAEqual Opportunity EmployerLearn About Nursing’sBest Kept Secrets...Let’s Speak. –NancyAtlantiCare is a great place to work with excellent benefits and real opportunities forcareer growth. In fact, 94% of AtlantiCare employees say they would recommend workingat AtlantiCare to friends or family. We are also the recipient of the 2009 Malcolm BaldrigeNational Award for Quality. Join us and help make a difference, one person at a time.Advanced Practice NursesCritical Care – Full-Time, NightsCardiology/Stress Lab – Part-Time, DaysCardiology – Full-Time, DaysPhysician AssistantCritical Care – Full-Time, NightsAs Atlantic City’s first hospital, our tradition of healthcare excellence began over 100 yearsago. Now a prestigious teaching hospital with campuses in Atlantic City and Pomona, ARMChas expanded to meet the growing healthcare needsof one of New Jersey’s fastest-growing communities.For more information or to apply online, visitwww.atlanticare.org EOE, m/f/d/vIf you’d like to hear about great opportunities that youmay not have thought of, speak to Nancy. She can tellyou about the rewards of careers in correctional andoutpatient nursing, answer your questions while youtour a facility, and tell you about the opportunities forprofessional growth and advancement.PSYCHIATRIC APNWellness / Recovery Centert Clres elt ystesCrss nterventon rorFlexible Hours. Experienced Prescribing APN.Current NJ RN / NP and DEA andCDS licenses required.MEDICAL NPsFull-time, M-F, Essex County Jail.Per diem at Hudson, Middlesex,Camden and Atlantic.We offer excellent compensation.Full-Time employees enjoy agenerous benefits package.Call or send resume:Nancy DeLapo,Director of Staff DevelopmentPhone 856-797-4761NDeLapo@cfgpc.comFax 856-797-4798www.cfghealthsystems.comEOE60 ADVANCE for NPs & PAs

MIDDLE ATLANTICSMFAIRMOUNTBEHAVIORAL HEALTH SYSTEMPennsylvania, Middle Atlantic, New York, DelawareMIDDLE ATLANTICMOUNTAINMOUNTAINMOUNTAINNATIONALNURSE PRACTITIONERFamily Practice (Per Diem - Weekends) NATIONALNATIONALNEW ENGLANDFairmount Behavioral Health System, a leading provider of Psychiatric Servicesfor Adults, Adolescents, and Children in Philadelphia, has immediate openings forper diem Family NP.Responsibilities include functioning in the expanded role as a professional nurse,medical diagnosis or prescription of medical therapeutic or corrective measures incollaboration with and under the direction of a physician licensed in PA. Primaryresponsibilities will include: H&P’s as per hospital guidelines, assistance with psychiatricevaluations, nursing assessments, assisting physician in the care and treatmentof patients within licensure guidelines, and working primarily with the AdmissionsMedical Director to provide assessment/evaluation/intake/and referral services.Must be licensed Family NP. Position is per diem; hours available on weekendsand/or evenings.PACIFICLicensed Family NP in the Commonwealth of Pennsylvania with demonstratedmedical experience and proven leadership, strong clinical skills, and high motivation.Interested candidates should submit resume to HR Department. NURSE PRACTITIONERS(FNP)PA and DE areasBilingual a PlusWe will Educate andTrain for DermatologyExcellent Salary & Benefits,Vacation, Incentives, &Time off for CMEs.Call 732.814.0769 • Fax 732.244.2804E-mail: schlitz2003@yahoo.comNeurosurgical practice lookingfor a FT CRNPDuties include first surgical assist, pre & postop care,history, physicals & patient edu. Prev. surgical exp.desired but not necessary. Compensation pkg toinclude salary & bonus opportunity, pension/profitsharing program. No on call.Send resume to Stephanie Kurtz,Lancaster NeuroScience & Spine Associates1671 Crooked Oak Dr., Lancaster, PA 17601Fax: 717.569.2380 | skurtz@lancspine.comNEW ENGLANDNEW ENGLANDPACIFICPACIFICSOUTHWESTSOUTHWESTSOUTHWESTUPPER SOUTH ATLANTICfrom hope to happinessHOPEIS HEREUPPER SOUTH ATLANTICUPPER SOUTH ATLANTICWEST NORTH CENTRALWEST NORTH CENTRALWEST NORTH CENTRALWEST SOUTH CENTRALWEST SOUTH CENTRALWEST SOUTH CENTRALExcellent People,Excellent Hospital.Nurse PractitionerOpportunitiesLancaster General Health has a variety of NursePractitioner opportunities available.Positions include:* Heart Failure - full-time; acute care NP with previousexperience preferred* Cardiology/EP - full-time; acute care NP with previousexperience preferred* Psychiatry - full-time; psychiatric NP preferred; willconsider FNP with experience* Family Medicine - full and part-time; FNP requiredWe offer an excellent benefits package, including theability to purchase Medical/Dental insurance, paidmalpractice insurance and more.For further information and confidential consideration,send resume/CV to Beth A. Calabria atbcalabria2@lghealth.orgFax 717.544.1902Visit our website at www.lancastergeneral.orgBeebe Medical Center is a progressivecommunity hospital located in scenic southern Delaware. Though our beautiful seashore community is a major draw, ouraccomplishments as a healthcare provider are what really impress people.Find out for yourself why it’s better at Beebe Medical Center.- BS degree required from anaccredited physician asst program. One year surgical experience, DE licensure as Registered Physician Assistant.- Delaware APN licensure, NRP and CPR certification and 2-4 yearsexperience in a Neonatal Inpatient care practice required.- Current Delaware Advanced PracticeNurse licensure required. Current CPR & ACLS certification. Minimum three years experience.- Current Delaware PA or NP licensure andcurrent CPR Certification. Two - four years experience in Pulmonary and Critical Care Inpatient hospital setting required.Career OpportunitiesPsychiatric NursePractitionerSubstance Abuse Treatment Centerin midtown Manhattan seeks aFull-time Psych NP. Substanceabuse experience preferred.Fax CV to 212-843-5040.E-mail: kcjones@acirehab.org- Three full-time positions. One part-time position.MS with FNP certification. Must have valid Advanced Practice licensure in Delaware.EOEPlease see our website, for full position descriptions and to apply online.ADVANCE for NPs & PAs61

MarylandCareer OpportunitiesThe advanced practice nurse you’re prepared to be is waiting.At a place where advanced nursing is so established in the care model,you can work at the vanguard, without blazing the trail.And where, for more than 240 NPs, CRNAs, CNSs and CNMs,a job has become a mission.Sound interesting? Meet some of your new peers at umm.edu/nursing.Watch their videos. Then, connect with them on Facebookto get even more scoop. You’re going to fit right in.University of MarylandMedical CenterMEDICINE ON A MISSION SMfacebook.com/marylandnursing@UMMCnursing© University of Maryland Medical Center62 ADVANCE for NPs & PAs

WVU Healthcare is the clinical partnership of WVUHospitals and University Health Associates. We’reproud to provide world-class service to the peopleof West Virginia and the surrounding region. Dueto the current expansion and growth, WVUHealthcare is seeking Nurse Practitionersto fill a number of challenging positions.Visit our website WVUhealthcare.com to apply onlinefor the following available opportuities:WVUH: Palliative Care | Behavioral Medicine | CTR/CCUWound, Ostomy and Continence | PreAdmissionUniversity Health Associates: Neonatal - ICUMedicine/Digestive Diseases | Surgery | Family MedicineWill accept a Physician Assistant or Nurse PractitionerNURSE PRACTITIONER (ADULT/FNP)Baltimore $125k+Exceptional opportunity for sharp & experienced NP (Adult/FNP). Must have excellent clinical/people skills, strong workethic, stable work history & excellent references. Prestigiousspecialty practice offers very competitive salary + bonus structure!If you are at the top of your game, send your resume to:harrisonsandra1976@gmail.com. Please include a day/evening telephone number you may be reached.GIVE YOURCAREERa fresh perspective!There are many reasons why you should explore the opportunitiesavailable at GW Medical Faculty Associates (MFA), the largest multispecialtyphysician practice in the Washington,DC area. In addition toour major investment in the best medical technology, we have 600doctors and 47 medical specialties. We are currently seeking candidatesto work as a member of a comprehensive, multidisciplinaryteam in the following positions:NP/PA Division of GeriatricsPrimary services will be provided to nursing home patients and thehome-bound elderly. The ideal candidate will have several years ofclinical experience with a geriatric population. Nursing home experiencea plus.NP/PA - Division of EndocrinologyResponsibilities include outpatient care with emphasis on diabetesand thyroid disorders and diabetes education. The ideal candidate willhave several years of clinical experience with an adult endocrinologypatient population. CDE preferred.All positions require a current NP or PA license in theDistrict of Columbia or immediate eligibility.MFA offers a competitive salary and acomprehensive benefits package includingtuition assistance for you and your family.For more information and to apply,please visit our website. EOEwww • GWDOCS • comINTERNATIONALINTERNATIONALLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICMIDDLE ATLANTICWest Virginia, Maryland, South Carolina, Florida, North CarolinaMIDDLE ATLANTICMIDDLE ATLANTICMOUNTAINMOUNTAINMOUNTAINNATIONALNATIONALNATIONALNEW ENGLANDNEW ENGLANDNEW ENGLANDPACIFICPACIFICPACIFICSOUTHWESTSOUTHWESTPractitioner sought forJob SOUTHWEST Marketbusy family practice in Sebring/Lake Placid, Florida.UPPER SOUTH ATLANTICCompetitionExperienced, motivated.‘In most UPPER areas Full-time. SOUTH of the Competitive country, ATLANTIC salary the supplyUPPER of NPswith bonus arrangement. Excellentbenefits.and SOUTH PAsFaxisCVgreater ATLANTICto HumanthanResourcesthedemand. ARNPNurse863-465-7266 For every job or posted, e-mail: recordWEST elina@strato.net. NORTH CENTRALnumbers of applicants apply.’WEST NORTH —Renee CENTRAL Dahring, MSN, NP,WEST NORTH in the CENTRAL September 2010issue of ADVANCE.WEST ARNP SOUTH & ARNP-PSYCH CENTRALFOR PINELLAS COUNTY JAIL FACILITYCurrently accepting applications for correctionalWEST ARNP SOUTH - Medical & CENTRALARNP-PSYCHGreat Benefits PackageWEST SOUTH CENTRALInterested applicants should send resume tohrresume@pcsonet.com • Visit www.pcsoweb.comor call (727) 582-6208 for any questions. EOE/ADA • The Pinellas CountySheriff’s Office has a no tobacco use policy six months prior to applicationHow Many NPs?There are 158,348 U.S. nurse practitioners,according to the Health Resourcesand Services Administration’s recentlypublished quadrennial study of the U.S.nursing population.PARNP/PAhysicianAssistantJoinBridginga dynamic teamtheof professionalsNP andPA in Knowledge the Orlando, FL area. GapImmediate opportunity for adedicated‘The two professionsARNP orsufferPA tofromjoinhugeour holes fast-paced in understanding hospital/offi what, ce practice where,specializing why and how in they Pulmonary each exist. diseases, It’s in theeyeCCMof theandbeholderSleep Disorders.how much the differencesmatter.’Above average benefi ts.E-mail or fax CV tomsimmons@PCCFL.com—Roderick S. Hooker, PhD, MBA, PA,407-539-2786 in the September 2010issue of ADVANCE.Full-time Positions - Raleigh Location. Raleigh Orthopaedicseeks North Carolina licensed Physician Assistants to join ourestablished team of mid-level practitioners and Orthopaedic surgeonsin providing quality patient care. We have opportunities working withfellowship trained Orthopaedic surgeons in the specialties of SportsMedicine and Hand & Upper Extremity.Must be able to work independently and be comfortable interpretingX-rays.PresidentRequires appropriate certifi cationObamaand NC licensure. Prefer 1to 3 years experience but will consider new grads. Athletic Trainingbackground preferred for Sports Medicine opportunity.Proclaims Resumes should be forwarded PA Weekwith cover letter to hr@raleighortho.comOn PA Day on Oct. 6, 2010, PresidentBarack Obama proclaimed OctoberDON’T 6–12 LET as YOUR National FREE Physician SUBSCRIPTION AssistantWeek. EXPIRE! It marked CALL the 800.355.1088 first time this celebrationhad been recognized by presidentialproclamation.ADVANCE for NPs & PAsCareer OpportunitiesCN‘DestiareanimCohatinbeanNPthaM1Thits63of

Florida, South Carolina, Wisconsin, IllinoisCareer Opportunitiesdge,thedif-, PA,010NCE.kBringing Home theContinuum of CareAMEDISYSPALLIATIVECARE OFCHARLESTON, SCYou can have it all!Life balance.Competitive salary.Bar-setting benefits.Recruiting now for the followingpositions in our CHARLESTON agency:• Nurse Practitioner• Hospice/Palliative Care - FTTo apply, please visitwww.amedisys.comAll applications are accepted online.For more info callLisa Carver, RN/Recruiter225-292-3031 orE-mail lisa.carver@amedisys.comEOE M/F/V/DCelebratingNPs & PAs‘Despite that you and your colleaguesstill are relatively small in number, youare loud in voice, and you have madeand will continue to make an enormousimpact on health care in America.Countless millions of patients who’dhave otherwise gone untreated will continueto be able to access healthcarebecause of the dedicated work of youand your colleagues. In the case of theNP–PA team, the whole is much greaterthan the sum of its parts.’—Editor Michael Gerchufsky in theDecember 2010 issue of ADVANCE.64 ADVANCE for NPs & PAsSCAN TOSEARCH JOBSEAST NORTH CENTRALEAST NORTH CENTRALJoinEASTUsNORTHand SeeCENTRALHow Your Career Can ShineEAST SOUTH CENTRALEAST SOUTH CENTRALEAST SOUTH CENTRALJoin Marshfield Clinic and practice state-of-the-art medicine at one of the largest patient care,research & educational systems in the United States. Live in a family-oriented community withshort commutes and plenty of recreational opportunities. With an integrated health caredelivery system, supported by more than 775 physicians and 7000+ employees, you will have theability to treat patients with the care and compassion they deserve. Join us!INTERNATIONALNurse Practitioners:• Cardiology: Minocqua, LL110112• Emergency Medicine: Park Falls, LL110037• Gastroenterology: Marshfield, MC110248• Hospital, General Surgery:INTERNATIONALMarshfield,INTERNATIONALMC120081LOWER SOUTH ATLANTICStevens Point/Marshfield, MC110536LOWER SOUTH ATLANTICLOWER SOUTH ATLANTICMIDDLE ATLANTIC• Nephrology:• Oncology: Rhinelander, MC120065• Pain Management: Eau Claire, MC120079• Pulmonary:Marshfield, MC110558 & Weston, WA110126• Surgical, General Surgery:Marshfield, MC110758• Surgical, Neurosurgery: Eau Claire, EC110207MIDDLE ATLANTIC• Surgical, Urology: Wausau, WA110056• Urgent Care: Ladysmith, EC110250• Wound MIDDLE Healing: ATLANTIC Marshfield, MC110757MOUNTAINwww.marshfieldclinic.jobsMOUNTAINMOUNTAINNATIONALFor more information on our clinic locations and to apply, please visit:Marshfield Clinic, 1000 N. Oak Ave., Marshfield, WI 54449Marshfield Clinic is an Affirmative Action/Equal Opportunity Employer that values diversity.Minorities, females, individuals with disabilities and veterans are encouraged to apply.NATIONALNATIONALNEW ENGLANDNEW ENGLANDPACIFICPACIFICSOUTHWESTSOUTHWESTSOUTHWESTUPPER SOUTH ATLANTICUPPER SOUTH ATLANTICUPPER SOUTH ATLANTICHPPPhysician Assistants:• CVT Surgery: Marshfield, MC110546• Cardiology: Minocqua, LL110115• Emergency Medicine: Park Falls, LL110041• Gastroenterology: Marshfield, MC110249• Surgical, General Surgery: Marshfield, MC110759• Surgical, Float Pool: Marshfield, MC110054• Surgical, Neurosurgery: Eau Claire, EC110285• Surgical, OB/GYN: Marshfield, MC110430• Surgical, Urology: Wausau, WA110057• Urgent Care: Ladysmith, EC110251Enjoy:• Low cost of living in clean, safe environments• Easy access to Chicago, Madison, Milwaukeeor Minneapolis/St. Paul• Competitive total compensation packageRelocation Assistance, Loan Assistance and SignOn Bonus may be available for some positions.Outstanding opportunity for 2 to 3 Exceptional NPs/PAs to build an innovative After Hours Clinic in a FamilyPractice NEW setting ENGLAND in Barrington, IL. This is a unique opportunity to see a variety of patients in an NP managed,autonomous setting providing collaborative support and advocacy for your role. PT evenings and weekends availablewith PACIFIC scheduling flexibility and growth potential. We also have FT Family Practice and Internal Medicine opportunitiesavailable. We have PT along with other FT opportunities. Additional opening for a FT Surgical PA to join busyPremier Ortho Practice. Responsibilities include; surgical assist in OR, hospital rounds, and some call.Qualifi ed candidates will become a part of our highly reputable team of providers and join us as we continue towardour goal of becoming one of the best community hospitals in the nation. Sherman Hospital, our brand new 255-allprivate bed facility features a 15 acre geothermal lake that heats and cools the hospital and saves us over $1 Millionper year in resources! The award winning lake is one of the largest in the world and just one of the reasons Shermanis leading the way to a cleaner, brighter future.Call Kathy Walters at 224-783-6270to schedule a phone interview with the Recruiter,Cheryl Vanderlaan or E-mail CV directly to:Cheryl.Vanderlaan@shermanhospital.orgEOE

MOUNTAINMOUNTAINNATIONALNATIONALNATIONALNEW ENGLANDNurse PractitionerEndocrinologyNEW ENGLAND& MetabolismNEW ENGLANDPACIFICMunson Medical Center is seeking an experienced NursePractitioner for our Endocrinology department. Munsonis a Magnet facility, named a Top 100 Hospital13 timesPACIFICand is located in beautiful Traverse City, Michigan.Requirements include: MI RN license, Mastersof Science in Nursing, Nurse Practitioner Specialty Certificationin the State of MI. Candidates should also becertified as Diabetes Educator, with minimum 3yrs experienceand have experience with insulin pump therapy.Excellent benefits and relocation assistance is available.PACIFICSOUTHWESTSOUTHWESTSOUTHWESTFor more information apply online atUPPERmunsonhealthcare.orgSOUTH ATLANTICUPPER or call SOUTH 1-800-713-3206 ATLANTICUPPER SOUTH ATLANTICWEST NORTH CENTRALWEST NORTH CENTRALWEST NORTH CENTRALWEST SOUTH CENTRALWEST SOUTH CENTRALWEST SOUTH CENTRALRUN YOUR OWN CLINIC.TREAT YOUR OWN PATIENTS.SHARE IN OUR SUCCESS.MinuteClinic Family Nurse Practitioners are today’shealth care heroes treating and educating patients tohelp them live healthier lives. With the strength andsupport of a Fortune 20 company, you will have thetools, training and resources needed to be a healer, aneducator, a hero.Join MinuteClinic and experience professional autonomy,alternative schedule options, rewarding benefi ts andthe opportunity to create the career of a lifetime.HEAL PATIENTS. REDEFINE HEALTH CARE.Become ourfan on Facebookminuteclinicjobs@cvs.com | www.minuteclinic.jobs877.MIN.CLIN (646.2546)FIND A NEW JOB ATAN ADVANCE JOB FAIR& CAREER EVENTCALL 800.546.4987 FOR DETAILS!WEST NORTH CENTRALWEST NORTH CENTRALWEST SOUTH CENTRALMichigan, Minnesota, TexasWEST SOUTH CENTRALWEST SOUTH CENTRALU.S. News & World Report and named theJob MarketCompetition‘In mostApplyareasonlineofatthe country, the supplyof utsouthwestern.edu/careersNPs and PAs is greater than thedemand. Or contact For every Denise job Allen, posted, 214-645-5682 recordnumbers Denise.Allen@utsouthwestern.eduof applicants apply.’—Renee Dahring, MSN, NP,in the September 2010issue of ADVANCE.MBS Integrated Care, a division of Harden Healthcare,provides Mid-Level providers in the long-term care andhome health setting. We are a growing company withopportunities available across Texas. We are currentlyseeking Mid-Level providers for the followinglocations:How Many NPs?Nursing Home Providers:• CORSICANAThere are 158,348 U.S. nurse practitioners,according to • SAN the ANGELO Health Resources• DENISONand Services Administration’s • TEMPLE recentlypublished If you are quadrennial interested in a study great opportunity of the U.S. withan expanding organization please contact:nursing population.Tracy Shultz, Recruiter attshultz@hardenhealthcare.comor by phone at 1-866-607-2722.Feel free to visit our website to learn more:www.mbsintegratedcare.comadvancecustompromotions.com1-877-776-6680We set an exampleto follow by the way we lead.UT Southwestern.Acute Care Nurse Practitioneror Physician AssistantRequires Critical Care experience;Neuro experience preferred.Acute Care Nurse PractitionerVAD CoordinatorRequires Cardiovascular and MechanicalCirculatory Support Device experience.Bridging the NP andWe are the future of medicine, today.PA Knowledge Gap‘The two professions suffer from hugeholes in understanding what, where,why and how they each exist. It’s in theDallas, Texaseye of the beholder how much the differencesmatter.’—Roderick S. Hooker, PhD, MBA, PA,NP/PAin the September 2010• Full-time & Part-timeClinic & ER • Central & South issue Texas of ADVANCE.Send CV to:Jerrylewis1976@aol.comFor more informationCall 800-460-8159Fax 866-853-2039The Lewis GroupPresident ObamaProclaims PA WeekOn PA Day on Oct. 6, 2010, PresidentBarack Obama proclaimed October6–12 as National Physician AssistantWeek. It marked the first time this celebrationhad been recognized by presidentialproclamation.Custom gifts giveawaysand promotional products.Career OpportunitiesCeNP‘Despstill aare loand wimpaCounhavetinuebecaand yNP–PthanDMi1stThe Kits inof 27Militathe Ethis pADVANCE for NPs & PAs65

Career OpportunitiesEOESOUTHWESTSOUTHWESTSOUTHWESTUPPER SOUTH ATLANTICUPPER SOUTH ATLANTICUPPER SOUTH ATLANTICWEST NORTH CENTRALWEST NORTH CENTRALWEST NORTH CENTRALWEST SOUTH CENTRALWEST SOUTH CENTRALWEST SOUTH CENTRALNew Mexico, Arizona, IdahoOne of only three Pathways designatedhospitals in the western U.S.Join our World-Class TeamScottsdale Healthcare (SHC), the first and only Magnet® Hospital System inArizona, is renowned for world-class care that puts the individual first. We carefor our patients as well as the people who work here by providing a cultureof respect and compassion—plus fantastic quality-of-life features like on-sitechild care. SHC is a leader in the fields of trauma, orthopedics, neurosurgery,cardiovascular and critical care.Nurse Practitioners (FT & PT)We currently have opportunities for Nurse Practitioners to work collaborativelywith members of our healthcare team in the areas of:• Ortho/Neuro• Bariatric• Trauma• Occupational HealthPhysician Assistants (FT)Opportunities for Physician Assistants include our Endocrine TumorCenter of Excellence and our Level 1Trauma Center.If you want a career with a respected, Magnet healthcare system, joinour dedicated and compassionate team of professionals at ScottsdaleHealthcare!To learn more about ouropportunities and to apply:www.shc.org/careersEOE/AA/M/F/D/V66 ADVANCE for NPs & PAsThink excellence.Think UNM Hospitals.At University of New Mexico Hospitals,excellence is the basis of our every action. It’sevident in the accreditations, recognition, andhonors that reflect our continued commitment toquality, and in our leadership as the only LevelI Trauma Center in the state. More importantly,it’s visible in the care each member of ourorganization provides to our patients.UNMH has an exceptional EAST NORTH opportunity CENTRAL in ourSouthwest Mesa Clinic for:Nurse Practitioner/Physician EAST NORTH CENTRAL AssistantPrimary Care EAST NORTH CENTRALAdditional opportunities EAST SOUTH are available CENTRAL for:Nurse Practitioner/Physician EAST SOUTH CENTRAL AssistantInpatient, Primary Care, Neurology Clinic,Neurosurgery Outpatient EAST SOUTH Discharge CENTRAL ClinicAdvanced Practice FACULTY Nurse - InpatientBring your nursing FACULTY expertise to UNMH andredefine your career FACULTY with an organizationcommitted to supporting your career qualityand growth. INTERNATIONALINTERNATIONALINTERNATIONALLOWER SOUTH ATLANTICVisit us on Facebook atfacebook.com/UNMHospitalsLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICMIDDLE ATLANTICLearn more about UNMH and apply to our latestnursing openings at http://hospitals.unm.edu/jobsMIDDLE ATLANTICSUBSCRIBE TODAY!MIDDLE ATLANTICMOUNTAINMOUNTAINMOUNTAINNATIONALNP/PA for Urgent Care in SW IdahoWe are seeking a Full Time NP/PA withUrgent Care experience to join us.NATIONALNATIONALNEW ENGLANDThe providers at Saint AlphonsusMedical Group are part of a medical teamof over 200 board-certified physicians andmid-levels at 38 clinics throughout SWIdaho and Eastern Oregon.NEW ENGLANDExcellent salary and benefits.NEW ENGLANDPACIFICGrant Scholes 800-309-5388,e-mail scholesg@sarmc.orgor fax CV to 208-367-7964PACIFICPACIFICSOUTHWESTSOUTHWESThttp://www.saintalphonsus.org/career-video.html

FACULTYFACULTYINTERNATIONALINTERNATIONALINTERNATIONALLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICMIDDLE ATLANTICNP/PA for Urgent Care in SW IdahoWe are seeking a Full Time NP/PA withUrgent Care experience to join us.The providers at Saint AlphonsusMedical Group are part of a medical teamof over 200 board-certified physicians andmid-levels at 38 clinics throughout SWIdaho.MIDDLE ATLANTICExcellent salary and benefits.MIDDLE ATLANTICMOUNTAINSylvia Chariton 800-309-5388,e-mail sylvchar@sarmc.orgor fax CV to 208-367-7964MOUNTAINMOUNTAINNATIONALhttp://www.saintalphonsus.org/career-video.htmlNATIONALNATIONALNEW ENGLANDNEW ENGLAND1-877-776-6680NEW ENGLANDadvancecustompromotions.comPACIFICPACIFICIdaho, CaliforniaYou’ll love our passion.You’ll love our passion.Voted one of the "Best Places to Work in LA - 2011-2012"live | work | relaxHealthCare Partners Medical Group is a multi-specialty medical group that is recognizedfor its quality of care and high rates of patient satisfaction. HealthCare Partners has over3,500 employees, including 500+ primary care and specialty physicians, caring for morethan 500,000 patients throughout Los Angeles County and Northern Orange County. HCPoperates 40 medical clinics, five urgent care centers, two medical spas, and an ambulatorysurgery center. If you’re looking to make a difference with a large, financially stable, wellrecognized, privately-owned Medical Group, HealthCare Partners is the employer for you!As part of our continued growth, we are currently seeking outgoing Nurse Practitioners andPhysician Assistants to join our team. In this role, you will have the opportunity to provide care and support tovariety of patients and work in a multi-disciplinary office practice while achieving the work/life balance you’ve been looking for!!HealthCare Partners offers competitive salaries and a wide range of benefits to our fulland part-time employees including medical, dental and vision insurance, 401(k), continuingeducation, tuition reimbursement, free Basic Life and AD&D, free long term disabilitycoverage, a generous holiday schedule, paid time off and more.PACIFICSOUTHWESTAt NorthBaySOUTHWESTHealthcare we believe in the idea that healthcare should still care. That’s why we’ve created anenvironment that cultivates your commitment to compassionate care and allows it - and you - to ourish. Join us.SOUTHWESTUPPER SOUTH ATLANTIC Director, Musculo-Skeletal Service LineUPPER SOUTH ATLANTICFAIRFIELD, CAUPPER SOUTH ATLANTICOrthopedic Physician Assistant or Nurse PractitionerWEST NORTH CENTRALpreferred. Minimum 5 years of management experience at aWEST NORTH CENTRAL director level or higher required. Master’s Degree in a relatedWEST NORTH CENTRAL Health Care eld required.WEST SOUTH CENTRALFor more information or to apply,WEST SOUTH CENTRALplease contact Donna Dabeck, Nurse RecruiterWEST SOUTH CENTRALat: (707) 646-3322, e-mail: ddabeck@northbay.orgor visit: www.NorthBayJobs.orgEOECareer OpportunitiesYou’ll love it here.www.NorthBayJobs.orgADVANCE for NPs & PAs67

Career OpportunitiesOrthopaedic PASeeking an experienced Ortho PA.Includes clinic, surgical & some trauma.Call required.888-890-8301, ext. 1907-228-8324 (fax)kghrecruiters@peacehealth.orgwww.peacehealth.orgUrgent need for PAs/NPsto provide critical services for ourservice men and women.• PA/FNP - Millington, TN• NPs - Women’s Health - Lackland AFB, TXFull-time, long-term contracts offeringattractive remuneration packages with full benefi ts.Interested applicants please e-mail resume to:OMV Medical, Inc.at: recruiting@omvmedical.com orcall Linda or Brian at 800-773-3105www.omvmedical.comBeautiful Southern Oregon - Grants PassSeeking two experienced certified FNPs for in-house positionsin acute care and primary care. Guaranteed salary andgenerous benefits. No call requirements. Financially healthymulti-specialty group serving southern Oregon for over 58 years. Visitour website at www.grantspassclinic.com. Contact Susan Sartainby e-mail at ssartain@grantspassclinic.com or by telephoneat 541-472-5505.Family/Adult Nurse PractitionerHemophilia Treatment CenterUnder the general supervision of the HTC medical director,provides direct adult patient care, leads and coordinatesstaff and resources to provide appropriate care and serviceto patients and families within HTC environment.Bilingual-Spanish speaking preferred.Looking to join a dedicated,caring, experienced team?To apply please send your resume and a cover letter torhondel@laoh.ucla.edu • http://orthohospital.org/FACULTYFACULTYINTERNATIONALINTERNATIONALINTERNATIONALLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICLOWER SOUTH ATLANTICMIDDLE ATLANTICAlaska, California, Oregon, NationalNURSE PRACTITIONER/PHYSICIAN ASSISTANT OPPORTUNITIESMIDDLE ATLANTICMIDDLE ATLANTICMOUNTAINMOUNTAINMOUNTAINNATIONALNATIONALNATIONALNEW ENGLANDNEW ENGLANDThe Sign of Excellence in Emergency Medicine ®NEW ENGLANDPACIFICPACIFICPeaceHealthSacred Heart Medical CenterPeaceHealth Medical GroupPACIFICSOUTHWESTSOUTHWESTSOUTHWESTUPPER SOUTH ATLANTICUPPER SOUTH ATLANTICFREEUPPER SOUTH ATLANTICWEST NORTH CENTRALOcean WEST NORTH City, MD CENTRAL CondoWEST NORTH PA / CENTRAL NPSummer Positions (4 week min.)WEST SOUTH CENTRALWEST SOUTH CENTRALWEST included. SOUTH Please CENTRAL send resume.Luxury beach condo w/pool. Sun & funw/us at our friendly urgent care center.Salary, malpractice, & all condo costsER/EDFamily PracticeUrgent Care75th St. Medical Center7408 Coastal HwyOcean City, MD 21842Email: vgongmd@gmail.comPhone: (410) 524-0075Fax: (410) 524-0066www.75thstmedical.comLocated in the lush Willamette Valley between the rugged PacicCoast and the magnicent Cascade Mountains, Eugene, Oregonis a welcoming blend of cutting-edge culture and breathtakingwilderness. Guided by our mission and values, PeaceHealthprovides evidence-based and compassionate healthcare in thePacic Northwest.PeaceHealth Medical Group is seeking experienced, board certi-ed Nurse Practitioners/Physician Assistants to join our group.We have opportunities in:ANP • FNPNeurohospitalist NP • Hospitalist NPUrgent Care NP • PMHNPCardiovascular NP/PAWound and Ostomy NPGNP • Cardiology Outpatient NPIf you are looking for a career that engages your heartas well as your mind, we encourage you to consider PeaceHealth.Please visit our website at www.peacehealth.org.Contact Brooke Hausmann at 541-222-2508 or e-mail atbrhausmann@peacehealth.org for more information or to apply.Career Positions Available forNurse Practitioners and Physician Assistantsin New Jersey, New York, Rhode Islandand North Carolina.Emergency Medical Associates (EMA)Join a democratic group which is nationally recognized fordelivering high quality care, innovation, unparalleledsupport (i.e. scribes) and exceptional patient satisfaction formore than 30 years! Work in a culture that is committed tolife-work balance.EMA NP’s and PA’s enjoy excellent compensation, comprehensivebenefi ts (Full Health, 401k match, Profi t Sharing,PTO & Professional Expenses) and career growth.Contact: Dan Rizzo877-692-4665 x1048RizzoD@alpha-apr.comwww.ema.net/careersUrgent need for PAs/NPsto provide critical services for ourservice men and women.• PA/FNP - Millington, TN• NPs - Women’s Health - Lackland AFB, TXFull-time, long-term contracts offeringattractive remuneration packages with full benefi ts.Interested applicants please e-mail resume to:OMV Medical, Inc.at: recruiting@omvmedical.com orcall Linda or Brian at 800-773-3105www.omvmedical.comCareer Positions & Locum Tenens ContractsWe represent opportunities nationwide in every specialty for new graduates,experienced professionals, faculty members, and management professionals.For over 2 decades, our founder has been paving the way for your profession,education, careers, practice acts, compensation and privileges. Registeronline or by phone for a career opportunity or contract assignment.Internet: www.AtwaterConsulting.com Phone: 770-806-0864Bobby Atwater, CPC, CMSR • E-mail: Contact@AtwaterConsulting.com68 ADVANCE for NPs & PAs

NationalCareer OpportunitiesADVANCE for NPs & PAs69

BRIEF SUMMARY OF PRESCRIBING INFORMATION FORPROAIR ® HFA (ALBUTEROL SULFATE) INHALATION AEROSOLFor Oral Inhalation OnlySEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION1 INDICATIONS AND USAGE1.1 BronchospasmPROAIR HFA Inhalation Aerosol is indicated for the treatment or preventionof bronchospasm in patients 4 years of age and older with reversibleobstructive airway disease.1.2 Exercise-Induced BronchospasmPROAIR HFA Inhalation Aerosol is indicated for the prevention ofexercise-induced bronchospasm in patients 4 years of age and older.4 CONTRAINDICATIONSPROAIR HFA Inhalation Aerosol is contraindicated in patients with ahistory of hypersensitivity to albuterol and any other PROAIR HFA InhalationAerosol components. Rare cases of hypersensitivity reactions, includingurticaria, angioedema, and rash have been reported after the use of albuterolsulfate [see Warnings and Precautions (5.6)].5 WARNINGS & PRECAUTIONS5.1 Paradoxical BronchospasmPROAIR HFA Inhalation Aerosol can produce paradoxical bronchospasmthat may be life threatening. If paradoxical bronchospasm occurs,PROAIR HFA Inhalation Aerosol should be discontinued immediately andalternative therapy instituted. It should be recognized that paradoxical bronchospasm,when associated with inhaled formulations, frequently occurs withthe first use of a new canister.5.2 Deterioration of AsthmaAsthma may deteriorate acutely over a period of hours or chronicallyover several days or longer. If the patient needs more doses of PROAIR HFAInhalation Aerosol than usual, this may be a marker of destabilization of asthmaand requires re-evaluation of the patient and treatment regimen, givingspecial consideration to the possible need for anti-inflammatory treatment,e.g., corticosteroids.5.3 Use of Anti-inflammatory AgentsThe use of beta-adrenergic-agonist bronchodilators alone may not beadequate to control asthma in many patients. Early consideration should begiven to adding anti-inflammatory agents, e.g., corticosteroids, to the therapeuticregimen.5.4 Cardiovascular EffectsPROAIR HFA Inhalation Aerosol, like other beta-adrenergic agonists,can produce clinically significant cardiovascular effects in some patients asmeasured by pulse rate, blood pressure, and/or symptoms. Although such effectsare uncommon after administration of PROAIR HFA Inhalation Aerosolat recommended doses, if they occur, the drug may need to be discontinued.In addition, beta-agonists have been reported to produce ECG changes, suchas flattening of the T wave, prolongation of the QTc interval, and ST segmentdepression. The clinical significance of these findings is unknown. Therefore,PROAIR HFA Inhalation Aerosol, like all sympathomimetic amines, shouldbe used with caution in patients with cardiovascular disorders, especially coronaryinsufficiency, cardiac arrhythmias, and hypertension.5.5 Do Not Exceed Recommended DoseFatalities have been reported in association with excessive use of inhaledsympathomimetic drugs in patients with asthma. The exact cause ofdeath is unknown, but cardiac arrest following an unexpected development ofa severe acute asthmatic crisis and subsequent hypoxia is suspected.5.6 Immediate Hypersensitivity ReactionsImmediate hypersensitivity reactions may occur after administrationof albuterol sulfate, as demonstrated by rare cases of urticaria, angioedema,rash, bronchospasm, anaphylaxis, and oropharyngeal edema. The potentialfor hypersensitivity must be considered in the clinical evaluation of patientswho experience immediate hypersensitivity reactions while receiving PROAIRHFA Inhalation Aerosol.5.7 Coexisting ConditionsPROAIR HFA Inhalation Aerosol, like all sympathomimetic amines,should be used with caution in patients with cardiovascular disorders, especiallycoronary insufficiency, cardiac arrhythmias, and hypertension; in patientswith convulsive disorders, hyperthyroidism, or diabetes mellitus; and inpatients who are unusually responsive to sympathomimetic amines. Clinicallysignificant changes in systolic and diastolic blood pressure have been seen inindividual patients and could be expected to occur in some patients after use ofany beta-adrenergic bronchodilator. Large doses of intravenous albuterol havebeen reported to aggravate preexisting diabetes mellitus and ketoacidosis.5.8 HypokalemiaAs with other beta-agonists, PROAIR HFA Inhalation Aerosol may producesignificant hypokalemia in some patients, possibly through intracellularshunting, which has the potential to produce adverse cardiovascular effects.The decrease is usually transient, not requiring supplementation.6 ADVERSE REACTIONSUse of PROAIR HFA may be associated with the following:• Paradoxical bronchospasm [see Warnings and Precautions (5.1)]• Cardiovascular Effects [see Warnings and Precautions (5.4)]• Immediate hypersensitivity reactions [see Warnings and Precautions (5.6)]• Hypokalemia [see Warnings and Precautions (5.8)]6.1 Clinical Trials ExperienceA total of 1090 subjects were treated with PROAIR HFA InhalationAerosol, or with the same formulation of albuterol as in PROAIR HFA InhalationAerosol, during the worldwide clinical development program.Because clinical trials are conducted under widely varying conditions,adverse reaction rates observed in the clinical trials of a drug cannot be directlycompared to rates in the clinical trials of another drug and may notreflect the rates observed in practice.Adult and Adolescents 12 Years of Age and Older: The adverse reactioninformation presented in the table below concerning PROAIR HFAInhalation Aerosol is derived from a 6-week, blinded study which comparedPROAIR HFA Inhalation Aerosol (180 mcg four times daily) with a doubleblindedmatched placebo HFA-Inhalation Aerosol and an evaluator-blindedmarketed active comparator HFA-134a albuterol inhaler in 172 asthmatic patients12 to 76 years of age. The table lists the incidence of all adverse events(whether considered by the investigator drug related or unrelated to drug)from this study which occurred at a rate of 3% or greater in the PROAIR HFAInhalation Aerosol treatment group and more frequently in the PROAIR HFAInhalation Aerosol treatment group than in the matched placebo group. Overall,the incidence and nature of the adverse events reported for PROAIR HFAInhalation Aerosol and the marketed active comparator HFA-134a albuterolinhaler were comparable.Adverse Experience Incidences (% of Patients)in a Six-Week Clinical Trial*Body System/Adverse Event(as Preferred Term)PROAIRHFAInhalationAerosol(N = 58)MarketedactivecomparatorHFA-134aalbuterolinhaler(N = 56)MatchedPlaceboHFA-134aInhalationAerosol(N = 58)Body as a Whole Headache 7 5 2Cardiovascular Tachycardia 3 2 0Musculoskeletal Pain 3 0 0Nervous System Dizziness 3 0 0Respiratory System Pharyngitis 14 79Rhinitis 5 42* This table includes all adverse events (whether considered by the investigatordrug related or unrelated to drug) which occurred at an incidencerate of at least 3.0% in the PROAIR HFA Inhalation Aerosol group andmore frequently in the PROAIR HFA Inhalation Aerosol group than inthe placebo HFA Inhalation Aerosol group.Adverse events reported by less than 3% of the patients receivingPROAIR HFA Inhalation Aerosol but by a greater proportion of PROAIRHFA Inhalation Aerosol patients than the matched placebo patients, whichhave the potential to be related to PROAIR HFA Inhalation Aerosol, includedchest pain, infection, diarrhea, glossitis, accidental injury (nervous system),anxiety, dyspnea, ear disorder, ear pain, and urinary tract infection.In small cumulative dose studies, tremor, nervousness, and headachewere the most frequently occurring adverse events.Pediatric Patients 4 to 11 Years of Age: Adverse events reported in a3-week pediatric clinical trial comparing the same formulation of albuterol asin PROAIR HFA Inhalation Aerosol (180 mcg albuterol four times daily) to amatching placebo HFA inhalation aerosol occurred at a low incidence rate (nogreater than 2% in the active treatment group) and were similar to those seenin adult and adolescent trials.6.2 Postmarketing ExperienceThe following adverse reactions have been identified during postapprovaluse of PROAIR HFA. Because these reactions are reported voluntarilyfrom a population of uncertain size, it is not always possible to reliably estimatetheir frequency or establish a causal relationship to drug exposure. Reportshave included rare cases of aggravated bronchospasm, lack of efficacy,asthma exacerbation (reported fatal in one case), muscle cramps, and variousoropharyngeal side-effects such as throat irritation, altered taste, glossitis,tongue ulceration, and gagging.The following adverse events have been observed in postapproval useof inhaled albuterol: urticaria, angioedema, rash, bronchospasm, hoarseness,oropharyngeal edema, and arrhythmias (including atrial fibrillation,supraventricular tachycardia, extrasystoles). In addition, albuterol, like othersympathomimetic agents, can cause adverse reactions such as: angina, hypertensionor hypotension, palpitations, central nervous system stimulation,insomnia, headache, nervousness, tremor, muscle cramps, drying or irritationof the oropharynx, hypokalemia, hyperglycemia, and metabolic acidosis.7 DRUG INTERACTIONSOther short-acting sympathomimetic aerosol bronchodilators shouldnot be used concomitantly with PROAIR HFA Inhalation Aerosol. If additionaladrenergic drugs are to be administered by any route, they should beused with caution to avoid deleterious cardiovascular effects.70 ADVANCE for NPs & PAs

7.1 Beta-BlockersBeta-adrenergic-receptor blocking agents not only block the pulmonaryeffect of beta-agonists, such as PROAIR HFA Inhalation Aerosol, but mayproduce severe bronchospasm in asthmatic patients. Therefore, patients withasthma should not normally be treated with beta-blockers. However, undercertain circumstances, e.g., as prophylaxis after myocardial infarction, theremay be no acceptable alternatives to the use of beta-adrenergic-blockingagents in patients with asthma. In this setting, consider cardioselective betablockers,although they should be administered with caution.7.2 DiureticsThe ECG changes and/or hypokalemia which may result from the administrationof non-potassium sparing diuretics (such as loop or thiazide diuretics)can be acutely worsened by beta-agonists, especially when the recommendeddose of the beta-agonist is exceeded. Although the clinical significance of theseeffects is not known, caution is advised in the coadministration of beta-agonistswith non-potassium sparing diuretics. Consider monitoring potassium levels.7.3 DigoxinMean decreases of 16% and 22% in serum digoxin levels were demonstratedafter single dose intravenous and oral administration of albuterol, respectively,to normal volunteers who had received digoxin for 10 days. The clinicalsignificance of these findings for patients with obstructive airway disease whoare receiving albuterol and digoxin on a chronic basis is unclear. Nevertheless,it would be prudent to carefully evaluate the serum digoxin levels in patientswho are currently receiving digoxin and PROAIR HFA Inhalation Aerosol.7.4 Monoamine Oxidase Inhibitors or Tricyclic AntidepressantsPROAIR HFA Inhalation Aerosol should be administered with extremecaution to patients being treated with monoamine oxidase inhibitorsor tricyclic antidepressants, or within 2 weeks of discontinuation of suchagents, because the action of albuterol on the cardiovascular system may bepotentiated. Consider alternative therapy in patients taking MAO inhibitorsor tricyclic antidepressants.8 USE IN SPECIFIC POPULATIONS8.1 PregnancyTeratogenic Effects: Pregnancy Category C:There are no adequate and well-controlled studies of PROAIR HFA InhalationAerosol or albuterol sulfate in pregnant women. During worldwidemarketing experience, various congenital anomalies, including cleft palateand limb defects, have been reported in the offspring of patients treated withalbuterol. Some of the mothers were taking multiple medications during theirpregnancies. No consistent pattern of defects can be discerned, and a relationshipbetween albuterol use and congenital anomalies has not been established.Animal reproduction studies in mice and rabbits revealed evidence of teratogenicity.PROAIR HFA Inhalation Aerosol should be used during pregnancyonly if the potential benefit justifies the potential risk to the fetus.In a mouse reproduction study, subcutaneously administered albuterolsulfate produced cleft palate formation in 5 of 111 (4.5%) fetuses at an exposureapproximately eight-tenths of the maximum recommended human dose(MRHD) for adults on a mg/m 2 basis and in 10 of 108 (9.3%) fetuses at approximately8 times the MRHD. Similar effects were not observed at approximatelyone-thirteenth of the MRHD. Cleft palate also occurred in 22 of 72 (30.5%) fetusesfrom females treated subcutaneously with isoproterenol (positive control).In a rabbit reproduction study, orally administered albuterol sulfate inducedcranioschisis in 7 of 19 fetuses (37%) at approximately 630 times the MRHD.In a rat reproduction study, an albuterol sulfate/HFA-134a formulationadministered by inhalation did not produce any teratogenic effects at exposuresapproximately 65 times the MRHD [see Nonclinical Toxicology (13.2)].8.2 Labor and DeliveryBecause of the potential for beta-agonist interference with uterine contractility,use of PROAIR HFA Inhalation Aerosol for relief of bronchospasmduring labor should be restricted to those patients in whom the benefits clearlyoutweigh the risk. PROAIR HFA Inhalation Aerosol has not been approvedfor the management of pre-term labor. The benefit:risk ratio when albuterol isadministered for tocolysis has not been established. Serious adverse reactions,including pulmonary edema, have been reported during or following treatmentof premature labor with beta 2-agonists, including albuterol.8.3 Nursing MothersPlasma levels of albuterol sulfate and HFA-134a after inhaled therapeuticdoses are very low in humans, but it is not known whether the componentsof PROAIR HFA Inhalation Aerosol are excreted in human milk.Caution should be exercised when PROAIR HFA Inhalation Aerosol isadministered to a nursing woman. Because of the potential for tumorigenicityshown for albuterol in animal studies and lack of experience with the use ofPROAIR HFA Inhalation Aerosol by nursing mothers, a decision should bemade whether to discontinue nursing or to discontinue the drug, taking intoaccount the importance of the drug to the mother.8.4 Pediatric UseThe safety and effectiveness of PROAIR HFA Inhalation Aerosol forthe treatment or prevention of bronchospasm in children 12 years of age andolder with reversible obstructive airway disease is based on one 6-week clinicaltrial in 116 patients 12 years of age and older with asthma comparingdoses of 180 mcg four times daily with placebo, and one single-dose crossoverstudy comparing doses of 90, 180, and 270 mcg with placebo in 58 patients[see Clinical Studies (14.1)]. The safety and effectiveness of PROAIRHFA Inhalation Aerosol for treatment of exercise-induced bronchospasm inchildren 12 years of age and older is based on one single-dose crossover studyin 24 adults and adolescents with exercise-induced bronchospasm comparingdoses of 180 mcg with placebo [see Clinical Studies (14.2)].The safety of PROAIR HFA Inhalation Aerosol in children 4 to 11 yearsof age is based on one 3-week clinical trial in 50 patients 4 to 11 years of agewith asthma using the same formulation of albuterol as in PROAIR HFA InhalationAerosol comparing doses of 180 mcg four times daily with placebo. Theeffectiveness of PROAIR HFA Inhalation Aerosol in children 4 to 11 years ofage is extrapolated from clinical trials in patients 12 years of age and olderwith asthma and exercise-induced bronchospasm, based on data from a singledosestudy comparing the bronchodilatory effect of PROAIR HFA 90 mcg and180 mcg with placebo in 55 patients with asthma and a 3-week clinical trialusing the same formulation of albuterol as in PROAIR HFA Inhalation Aerosolin 95 asthmatic children 4 to 11 years of age comparing a dose of 180 mcgalbuterol four times daily with placebo [see Clinical Studies (14.1)].The safety and effectiveness of PROAIR HFA Inhalation Aerosol inpediatric patients below the age of 4 years have not been established.8.5 Geriatric UseClinical studies of PROAIR HFA Inhalation Aerosol did not includesufficient numbers of patients aged 65 and over to determine whether theyrespond differently from younger patients. Other reported clinical experiencehas not identified differences in responses between elderly and younger patients.In general, dose selection for an elderly patient should be cautious,usually starting at the low end of the dosing range, reflecting the greater frequencyof decreased hepatic, renal, or cardiac function, and of concomitantdisease or other drug therapy [see Warnings and Precautions (5.4, 5.7)].All beta 2-adrenergic agonists, including albuterol, are known to be substantiallyexcreted by the kidney, and the risk of toxic reactions may be greaterin patients with impaired renal function. Because elderly patients are morelikely to have decreased renal function, care should be taken in dose selection,and it may be useful to monitor renal function.10 OVERDOSAGEThe expected symptoms with overdosage are those of excessive betaadrenergicstimulation and/or occurrence or exaggeration of any of the symptomslisted under ADVERSE REACTIONS, e.g., seizures, angina, hypertensionor hypotension, tachycardia with rates up to 200 beats per minute,arrhythmias, nervousness, headache, tremor, dry mouth, palpitation, nausea,dizziness, fatigue, malaise, and insomnia.Hypokalemia may also occur. As with all sympathomimetic medications,cardiac arrest and even death may be associated with abuse of PROAIRHFA Inhalation Aerosol.Treatment consists of discontinuation of PROAIR HFA InhalationAerosol together with appropriate symptomatic therapy. The judicious use ofa cardioselective beta-receptor blocker may be considered, bearing in mindthat such medication can produce bronchospasm. There is insufficient evidenceto determine if dialysis is beneficial for overdosage of PROAIR HFAInhalation Aerosol.The oral median lethal dose of albuterol sulfate in mice is greater than2,000 mg/kg (approximately 6,800 times the maximum recommended dailyinhalation dose for adults on a mg/m 2 basis and approximately 3,200 times themaximum recommended daily inhalation dose for children on a mg/m 2 basis).In mature rats, the subcutaneous median lethal dose of albuterol sulfate isapproximately 450 mg/kg (approximately 3,000 times the maximum recommendeddaily inhalation dose for adults on a mg/m 2 basis and approximately1,400 times the maximum recommended daily inhalation dose for children ona mg/m 2 basis). In young rats, the subcutaneous median lethal dose is approximately2,000 mg/kg (approximately 14,000 times the maximum recommendeddaily inhalation dose for adults on a mg/m 2 basis and approximately 6,400 timesthe maximum recommended daily inhalation dose for children on a mg/m 2 basis).The inhalation median lethal dose has not been determined in animals.U.S. Patent Nos. 5605674, 5695743, 7105152, 7566445Mktd by: Teva Respiratory, LLCHorsham, PA 19044Mfd by: IVAX Pharmaceuticals IrelandWaterford, IrelandCopyright ©2010, Teva Respiratory, LLCAll rights reserved.PROAIR ® HFA is a registered trademark of Teva Respiratory, LLCManufactured In Ireland Rev. 07/10PA0710BS-DADVANCE for NPs & PAs71

ProAir ® HFA OFFERS YOUR PATIENTSTHE BENEFITS OF BEING THE#1 MANAGED CARE PREFERREDALBUTEROL INHALERWidest formulary coverage meansProAir HFA is available to morepatients when you prescribe itCovered for 94% of patients1Our preferred formulary coverage meansmore insured patients may pay lessProAir HFA has the most preferredaccess of any albuterol inhaler 1Preferred Formulary Coverage 131%83%67% Ventolin ® HFA45% Proventil ® HFAXopenex HFA ®ProAir HFA0 10 20 30 40 50 60 70 80 90 100To learn more about the many other benefits that ProAir HFA offers, visit ProAirHFA.com/healthcare-professionalsProAir HFA (albuterol sulfate) Inhalation Aerosol is indicated in patients 4 years of age and older for thetreatment or prevention of bronchospasm with reversible obstructive airway disease and for the preventionof exercise-induced bronchospasm.Important Safety Information• Inhaled albuterol sulfate can produce paradoxical bronchospasm that may be life-threatening. It should berecognized that paradoxical bronchospasm, when associated with inhaled formulations, frequently occurs withthe first use of a new canister.• Fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs in patientswith asthma.• ProAir HFA, as with all sympathomimetic amines, should be used with caution in patients with cardiovasculardisorders (especially coronary insufficiency, cardiac arrhythmias, and hypertension), convulsive disorders,hyperthyroidism, and diabetes.• Potential drug interactions can occur with beta-blockers, diuretics, digoxin,or monoamine oxidase inhibitors, and tricyclic antidepressants.• Do not exceed the recommended dose.• Adverse events, which occurred at an incidence rate of at least 3% withProAir HFA, include headache, tachycardia, pain, dizziness, pharyngitis,and rhinitis.Please see Brief Summary of full Prescribing Information on the preceding pages.REFERENCES: 1. Fingertip Formulary ® . Glen Rock, NJ: Fingertip Formulary, LLC; January 2012.2. IMS Health National Prescription Audit, TRx Data; December 2009, July 2010, and February 2011.ProAir is a registered trademark ofTeva Respiratory, LLC.The brands listed are the registeredtrademarks of their respective owners.©2012 Teva Respiratory, LLC120048The # 1dispensedalbuterolinhaler 272 ADVANCE for NPs & PAs