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While it’s important throughout life to maintain good dental
health, it isn’t uncommon for senior citizens to unintentional-
ly let their oral health habits fall by the wayside. Whether it
be other, seemingly more important, health issues or the
physical inability to practice proper oral care, like arthritis,
disability, and demen-
tia - a staggering num-
ber of elderly citizens
are experiencing a state
of oral decay and along
with that, adverse
health issues.
The decay of the teeth
and gums is preventa-
ble. By practicing good
oral hygiene and keep-
ing scheduled dental
hygiene visits with
your dentist, you’ll
keep and maintain
strong and healthy
teeth and gums. In
turn, you can worry
less about developing uncomforta-
ble gum disease-related illnesses.
An online study published by the Cen-
ter for Disease Control and Preven-
tions (CDC) shows that one in five
senior citizens have untreated tooth
decay and 68% of seniors aged 65 or
older have some form of periodontitis,
commonly referred to as gum disease.
Periodontal disease is an infection of
the muscle and bone surrounding the
tooth. The muscle and bone include the
gums, the cementum that covers the
tooth and its root, the periodontal liga-
ment, and the alveolar bone. In its ear-
liest stages, only the gums are affected and may show signs
of inflammation, including sensitivity, bleeding, or soreness.
As gum disease progresses, all of the supporting tissue and
bones are affected.
The bacteria found in plaque buildup is the primary cause of
periodontitis. How-
ever, other factors
including hormonal
changes, illnesses
such as cancer and
diabetes, medica-
tions, poor oral
hygiene, poor nu-
trition, and a fami-
ly history of dental
disease can con-
tribute to the devel-
opment of perio-
dontitis.
If plaque is not re-
moved through
proper brushing
and flossing, it
hardens and turns
into tartar. Tartar is
calcified plaque
that sits on the enamel below the gum line and is difficult to
remove. Without proper care and routine dental visits, plaque
and tartar will continue to spread. The spread of plaque and
tartar under the gum line increases the risk of inflammation
and increases the likelihood that you’ll experience new
health problems as the bacteria enters the bloodstream.
Untreated periodontitis can lead to cavities, root decay, and
darkened teeth. Symptoms include persistent bad breath, red
or swollen gums, bleeding gums, pain when eating, loose
teeth, receding gums, and increased sensitivity – all of which
can be especially uncomfortable for a senior citizen.
If allowed to spread without treatment, it can lead to a num-
ber of additional, and potentially dangerous, health condi-
tions including heart disease, respiratory infections, kidney
The Benefits & Importance of Oral Health
A Publication of Neil Medical Group, The Leading Pharmacy Provider in the Southeast
May/June 2019
PHARM NOTES
Volume 22, Issue 3
Continued on page 4
Inside this issue:
The Benefits &
Importance of
Oral Health
1
Kratom: A New
Opiod?
2-3
Conclusion: The
Benefits of Oral
Health
4
Consequences of
Long Term Laxa-
tive & Probiotic
Use
5
F-757: Unneces-
sary Medication
Tag
6-7
Neil Medical
Group Contact
Information
8
Kratom: A New Opiod?
Page 2
PHARM NOTES
Have you ever heard of the plant known as Kratom? Some
people think that it is the world’s next miracle drug, while oth-
ers say it is dangerous and should be illegal to use. With our
nation experiencing an opioid epidemic, the increased availa-
bility of kratom in the United States has led to the concern
about where the natural opioid should fit into medical prac-
tice.
Kratom, also known as Mitragyna speciosa, is a tree that is
found in parts of Africa and Southeast Asia, specifically in
Thailand, Malaysia, Indonesia and Papua New Guinea. The
tree has large dark green leaves that are broad, glossy and oval
shaped. The leaves and small stems of the tree are what is pri-
marily used for consumption. Kratom can be extracted from
leaves being dried and brewed as a tea, chewed, smoked, or
crushed into a powder to be packaged into capsules. The
leaves contain approximately 0.8% in weight of mitragynine
but this can vary based on the season and geographic location
of the tree. Mitragynine is the most prevalent of the kratom
alkaloids (60% of the total alkaloid content)
and exhibits its psychoactive effects by acti-
vating the µ- (mu) opioid receptor, similar to
morphine. Other prevalent alkaloids include
isopaynantheine, mitraciliatine, paynanthe-
ine, speciociliatine, speciogynine, and 7-
hydroxymitragynine which aid in activation
of δ-(delta) and κ-(kappa) opioid receptors.
At low doses, consumption of kratom pro-
duces stimulant effects and at high doses it
produces sedative effects. Noticeable effects
are often observed within 10-20 minutes of
consumption, full effects are seen after 30-60
minutes and can last for 5-7 hours after in-
gestion. Activation of these opioid receptors
leads to the analgesic properties which is
why kratom is most often used to treat
chronic pain and opioid withdrawal. Other
uses include: anxiety, cough, depression,
diabetes, diarrhea, hypertension, sexual per-
formance, mood improvement, and to enhance physical endur-
ance. Due to the similarity with opioids, kratom has many
similar side effects, which can be found in Table 1.
Notable drug interactions include the
use of kratom along with other CNS
depressants, which further increases
the risk of respiratory depression by
activation of the µ-receptor. It is also
recommended to be cautious with the
use of kratom when used together
with medications that are CYP 450
1A2, 2C19, 2D6 and 3A4 substrates.
In vitro studies suggest that kratom is
an inhibitor of these enzymes, which
results in an increase in the blood
concentrations of drugs that are me-
tabolized by these pathways. Specific
examples of medications often used
in Long Term Care facilities that af-
fected by CYP 450 pathways can be
found in Table 2. In patients with
psychiatric disorders, evidence has
shown patients that consume kratom
Table 1. Common Side Effects With The Use of Kratom
Hallucinations Aggression
Nausea Hypothyroidism
Vomiting Intrahepatic cholestasis (impaired re-lease of bile from liver cells caus-ing impaired liver function).
Constipation
Delusions
Serious Side Effects
Respiratory depression Seizures
Severe withdrawal upon cessation of habitual use
Signs of Withdrawal
Decreased appetite Anxiety
Diarrhea Insomnia
Muscle pain, spasms, tremors Nervousness
Hot flashes Negative mood changes
Page 3
Volume 22, Issue 3
have an increased risk of suicide com-
pared to people who do not have a psy-
chiatric disorder. Also, with side effects
of hallucinations and delusions, existing
psychiatric disorders may be exacerbat-
ed. Kratom has been illegal in Thailand
since 1946, under the Kratom Act, and in
Australia since 2005. It is currently legal
to possess and consume kratom within
the United States, however Alabama,
Arkansas, Indiana, Tennessee and Wis-
consin have banned the use of kratom
and several other states are in the process
of banning kratom through legislation. In
November 2017, the Food and Drug Ad-
ministration (FDA) released a public
health advisory about deadly risks asso-
ciated with kratom. The FDA stated that
kratom is being used to treat serious
health conditions such as opioid use disorder, pain, anxiety
and depression, which should be treated
under the oversight of a licensed medical
provider. There has been a 10-fold increase
in calls to poison control centers regarding
kratom use from 2010-2015; and, a reported
36 deaths associated with kratom-
containing products. The FDA has not eval-
uated any products containing kratom to
assess its safety and effectiveness, and has
exercised jurisdiction over the unapproved
drug by conducting seizures and detaining
shipments of kratom products from entering
the United States. The Drug Enforcement
Administration (DEA) currently has kratom listed
as a Drug and Chemical of Concern. Due to the
opioid crisis, the FDA states action must be taken
against new products that have the potential to
cause addiction and that scientific evidence should
be utilized to determine the appropriate medicinal
use of kratom based on its risks and benefits.
Based on pharmacologic properties, kratom has
the potential to benefit those who are experiencing
pain and opioid withdrawal. However, kratom has
not been studied appropriately to determine its true
effectiveness, along with its risks. Using kratom to
treat pain and opioid withdrawal may pose serious
risks, which is why these conditions should be
managed under the supervision of a licensed
healthcare provider.
Article by Kayla Barker, PharmD Candidate
Wingate University School of Pharmacy
Table 2. Drug-Drug Interactions With the Use of Kratom
CYP 450 1A2 Clozapine Olanzapine
Haloperidol Cyclobenzaprine
CYP 450 2C19
Amitriptyline Citalopram
Diazepam Phenytoin
Warfarin Proton Pump Inhibitors
CYP 450 2D6
Metoprolol Fentanyl
Paroxetine Risperidone
Tramadol Trazodone
CYP 450 3A4 Alprazolam Budesonide
Simvastatin Carbamazepine
Page 4
The Benefits & Importance of Oral Health………………….continued from page 1
PHARM NOTES
disease, diabetes, rheumatoid arthritis, and risk of cancer.
You can prevent the build-up of plaque and bacteria by taking
care to brush your teeth twice a day, flossing daily, and using
an antiseptic mouthwash that contains fluoride. Brushing re-
moves the transparent layer of plaque from the surface of the
tooth and loosens food particles between the teeth and gums.
Brushing also stimulates blood flow in the gums which keeps
them healthy and helps to prevent periodontitis. It is recom-
mended that you brush your teeth twice a day for two minutes.
Flossing works to dislodge food particles and bacteria. If done
regularly, flossing can create and maintain a healthy gum
structure for your teeth. If you have inflammation or bleeding
of the gums, you can continue to floss your teeth. It’s even
likely that you’ll see a decrease in these symptoms. If your
gums continue to bleed or if you continue to experience pain-
ful inflammation after flossing, you should consult a dentist.
Take care to rinse with an antiseptic fluoride mouthwash.
You’ll kill remaining bacteria in your mouth while the fluoride
provides extra protection against cavities and works to prevent
tooth decay and strengthen weak spots and exposed roots.
Cavity prevention is an important aspect of proper oral and
dental hygiene. It is recommended that you rinse with mouth-
wash each time you brush.
Proper oral and dental hygiene keeps your mouth healthy and
in turn, decreases the risk of developing additional health
problems. For senior citizens, it is especially important to
practice proper oral care. Our immune system weakens as we
age, and we are no longer able to fight off infections or disease
as quickly and effectively as we once were. That’s why it’s
important to practice good oral hygiene to rid ourselves of the
bacteria before it can cause other health issues.
There are many benefits of practicing proper oral hygiene and
your smile is just one of many. From keeping a bright smile to
preventing dementia, you’re taking care of your body in a way
that has a profound effect on your overall health and wellness.
Benefits of good oral hygiene:
Removes surface stains. Removing surface stains helps
achieve a whiter and brighter smile. It also prevents per-
manent discoloration of the teeth and gums.
Freshens breath. Proper oral care helps to remove and
keep bacteria away from your mouth. If bacteria is left in
place, it will continue to spread and cause a foul odor.
Taking care to brush, floss, and rinse daily prevents bad
breath from occurring.
Saves money. An ounce of prevention is worth a pound
of cure. Taking care of your teeth now will help prevent
future tooth and gum related health problems, saving you
money on future dental bills.
Prevents gum disease. We’ve discussed how lack of
good oral care can lead to gum disease and other serious
health issues. Practicing proper oral hygiene helps prevent
gum disease and its associated symptoms and reduces the
risk of developing related diseases.
Reduces your chances of a heart attack or stroke. Good
oral care means preventing the bacteria and plaque build-
up from entering your bloodstream, effectively reducing
your chances of a heart attack or stroke.
Prevents or minimize diabetes. Gum disease makes it
harder to control your glucose and has the potential to af-
fect blood glucose levels. The inability to control your
blood glucose can contribute to the onset and progression
of diabetes.
Prevents dementia and Alzheimer’s disease. Research
shows that poor oral health increases your risk of develop-
ing dementia and Alzheimer’s disease. Studies have found
that when bacteria that enters the bloodstream reaches the
brain, brain cells are killed, leading to confusion and
memory loss.
Promotes wellness. When your teeth are proper ly
cared for, you feel a sense of wellness. This sense of well-
ness helps improve confidence and overall self-esteem. A
healthy mouth is a healthy body and mindset.
The best way to prevent future health problems related to gum
disease and create a healthy mouth is to practice good oral
care. Your routine should consist of brushing, flossing, and
rinsing using fluoridated products. This routine should be
completed twice a day, every day.
Maintaining your healthy smile shouldn’t be considered a
chore. Consider your routine to be a crucial part of your day. If
necessary, set aside ten minutes twice a day to brush, floss,
and rinse. With time, your routine will become a habit. Don’t
forget, good oral care requires routine check-ups with a den-
tist.
You should see a dentist twice a year to be sure your teeth and
gums are in good health. By practicing good oral health habits
and keeping your dentist appointments, you’ll learn to care for
your teeth to create a healthier mouth and a healthier you.
Article by Jennifer Brougher, PharmD, BCGP
Consultant Pharmacist, Neil Medical Group
Page 5
Volume 22, Issue 3
Consequences of Long Term Laxative & Probiotic Use in the Elderly
Constipation is one of the most frequently diagnosed gastroin-
testinal disorders with prevalence rising with age due to natu-
ral physiological changes often paired with increased use of
medications. The increased prevalence of constipation in elder-
ly patients not only leads to diminished quality of life, but also
a high economic burden related to complications. Complica-
tions from constipation such as fecal impaction and stercoral
ulcers can result in hospital visits for correction. Because of
the serious side effects associated with chronic constipation,
many patients are prescribed long-term daily laxative and/or
probiotic treatment. Approximately 50% to 74% of long-term
care (LTC) residents use laxatives and probiotics on a regular
basis for relief and prevention of constipation. Since many of
these laxative and probiotic medications are sold over-the-
counter at local drug stores, their use is widely accepted as
safe. However, research shows that prolonged use of laxative
agents and/or probiotics may not be as safe as commonly
thought. Below is an overview of the most commonly used
laxative agents and concerns related to each class with pro-
longed use.
Stimulant laxatives:
Stimulant laxatives work by directly stimulating the muscles
that line the gut and colon leading to increased intestinal motil-
ity and fluid secretion into the bowel. Medications commonly
used in this category are: Senna, aloe and Bisacodyl. There is
limited evidence to support the routine use of these agents due
to the side-effects associated with them. Although they typical-
ly result in relief of constipation, they can lead to dependence
if used long-term and are associated with side effects such as
abdominal cramping and discomfort, electrolyte abnormalities
and melanosis coli (a histologic finding of brown pigmentation
in the colonic mucosa). There are also concerns that long-term
use of Senna can lead to malabsorption and cathartic colon.
Cathartic colon results in loss of bowel function due to neuro-
muscular damage which may be irreversible and can be fatal
for older adults.
Osmotic laxatives:
Osmotic laxatives such as Miralax (polyethylene glycol), lac-
tulose, milk of magnesia and magnesium citrate work by creat-
ing an osmotic gradient in the intestines resulting in increased
water content in the stool making it easier to flow through the
colon. Prolonged use of these agents may lead to abdominal
cramping, bloating, flatulence and electrolyte imbalances.
More concerning is that prolonged use can lead to dehydration
resulting in central nervous system changes. Moreover, there is
a growing concern that polyethylene glycol-containing laxa-
tives may cause worsening neuropsychiatric events such as
dementia, depression, Alzheimer’s and Parkinson’s diseases
due to toxic byproducts that form when ethylene glycol is bro-
ken down in the body. This is concerning as many LTC resi-
dents already suffer from these diseases. Also, since these lax-
atives block the absorption of nutrients in the small intestine,
there is growing alarm for malnutrition specifically in older
adults.
Enemas and suppositories:
Enemas and suppositories are useful in patients that cannot
tolerate oral laxatives or are suffering from stool impaction.
Enemas should not be used long-term due to the risk of elec-
trolyte disturbances. Specifically, phosphate enemas should be
avoided in older adults due to the high risk of electrolyte ab-
normalities which has been reported fatal in some instances.
Mineral oil enemas are a safer alternative with only local ad-
verse effects reported of perianal irritation or soreness. Like-
wise, glycerin suppositories are safe alternatives to enemas and
have been shown effective in relieving constipation.
Chloride-channel activators:
The chloride-channel activator laxative Amitiza (lubiprostone)
is a prescription only medication that activates chloride chan-
nels to secrete chloride into the intestines increasing stool wa-
ter content without directly affecting the smooth muscle of the
colon. Electrolyte changes have not been significantly reported
with this agent, but prolonged use has been associated with
nausea, extreme diarrhea and headache. This agent is typically
reserved for constipation that does not respond to less expen-
sive treatment options and its long-term side effects are widely
unknown.
Probiotics:
Probiotics are commonly recommended for prevention and
treatment of constipation, but surprisingly, the strongest evi-
dence for the use of probiotics is in the management of diar-
rheal diseases such as diarrhea associated with antibiotic use
and infectious diseases. Probiotics work by aiding in the re-
plenishment of intestinal microbiota. Although probiotics are
widely accepted as being safe agents, they are not regulated by
the Food and Drug Administration (FDA), but instead are reg-
ulated as dietary supplements. This means there are often no
requirements for safety, purity, or potency before marketing
probiotics. Besides the obvious concerns of lack of control by
the FDA, another safety concern is the increased risk of infec-
tion posed by the long-term use of probiotics. Many strains of
probiotics have been chosen for use due to their ability to ad-
here to the intestinal mucosa which may also increase bacterial
translocation. Microbes can attach to the probiotics that adhere
to the intestines leading to infection. Studies have shown that
the increased risk of infection associated with prolonged probi-
otic use is low in healthy patients, but increases in those with
chronic diseases and those who are immune compromised or
debilitated which often describes residents of LTC facilities.
Long-term laxative and/or probiotic use in elderly patients
may not be as safe as once thought. It is vital that the risks as-
sociated with these seemingly harmless medications are con-
sidered before used long-term LTC residents.
Article by Anna Bruckelmeyer, PharmD Candidate
F-757: Unnecessary Medication Tag
Page 6
PHARM NOTES
How often have you heard, “Every drug must have an indica-
tion”? Nurses are being expected on a daily basis to deter-
mine why a medication is being used.
Unnecessary Medications
CMS regulation F-757 Unnecessary Medications requires an
indication for every medication ordered—chronic and short
term.
F-757 Unnecessary Medications is a broad classification: Per
CMS guidance, an unnecessary medication is any medication
that is:
In excessive dose (including duplicate therapy); or
For excessive duration; or
Without adequate monitoring; or
Without adequate indication for its use; or
In the presence of adverse consequences which indicate
the dose should be reduced or discontinued; or
Any combination of the reasons above.
Unnecessary medication is a frequent citation on state sur-
veys. According to CASPER, 21.6% of facilities were cited
for a F-329 (now F-757) deficiency based on a March 1, 2016,
report of data on the last standard health survey of active
SNF/NF. That is the sixth highest in the number of citations
for that reporting period.
What’s the Basis for the CMS Regulation?
Indication encompasses both a diagnosis such as seizure dis-
order, or short term symptom such as nausea, or wellness such
as influenza prevention. Technically, indication and diagnosis
are not identical, however, often these terms are used inter-
changeably.
Diagnosis is the traditional basis for decision-making in clini-
cal practice, providing a structure for organizing and interpret-
ing signs, symptoms and laboratory tests. An accurate diagno-
sis impacts positive outcomes as clinical decisions will be
made with a correct understanding.
It provides the foundation for a large part of what goes on
with the patient, determining prognosis, nursing care plan and
various therapies such as physical therapy and medication
regimens.
The diagnosis can affect whether a medication or durable
medical equipment is reimbursed, a prior authorization is ap-
proved or how clinical practice guidelines are implemented.
MDS data is dependent on diagnoses, too.
“Oh, Just Write Anything Down. What Difference
Does it Make?”
Sometimes the nurse thinks drug X is given for Diagnosis A
because that’s what the medication is usually used for. The
focus should be patient centered and the real question is not
what the drug can be used for, but what the drug is being used
for in this particular resident.
Deprescribing
Polypharmacy is a common occurrence in the elderly. As pa-
tients progress though life and acquire new diagnoses, medi-
cations are added. More medications can lead to adverse con-
sequences of their own as well as drug interactions and in-
creasing costs. Periodically, a patient’s medication regimen
should be reviewed to determine if any drugs could be re-
duced or stopped. Deprescribing is the planned and supervised
process of dose reduction or stopping of medications that
might be causing harm, or may no longer be of benefit ac-
cording to Deprescribing.org. The diagnosis being treated is
the first step in the process of evaluation for discontinuation.
Good resources can be found at the website:
https://deprescribing.org/ as well as https://medstopper.com
Sometimes a resident has a diagnosis but the medication is no
longer beneficial. Cholelithiasis can cause nausea and vomit-
ing. An antiemetic and Proton Pump Inhibitor may be added.
However, after the cholecystectomy recovery period, most
likely neither medication will still be needed.
Medications that are initially prescribed for cognitive impair-
ment should be re-evaluated over time. These medications do
not reverse dementia, rather they may slow the loss of certain
cognitive functions on a modest basis. As cognitive decline
continues, at some point there is little to no benefit. Money
that the family is using to purchase these medications could
be transferred to providing other needed services for their
family member.
When a patient elects to enter hospice care, most of their di-
Page 7
Volume 22, Issue 3
agnoses do not disappear, however, the need to treat con-
cerns such as hyperlipidemia need to be re-evaluated and
most medications like statins can be stopped.
As there is a concerted effort to reduce opioid use, there are
opportunities for reduction. Changing the dressing of a new
wound may be very painful at first, and a narcotic before the
change may provide comfort for the resident. As the wound
heals, the pain may diminish and the opioid can be stopped.
The opioid order will need to specify what type of pain it is
being used for so that the opportunity to stop it can be cor-
rectly assessed.
Two Wrongs Don’t Make it Right
Diagnostic errors are a common occurence. Adding wrong
indications to a patient’s medical record can also lead to
wrong information that moves through the medical record and
treatment plan into perpetuity. For example, if the nursing
home medication order states the PPI is for GERD and sends
the resident to the hospital, then the hospital picks up that di-
agnosis, continues the PPI and includes that diagnosis as well.
When the resident is readmitted back to the nursing home, the
PPI and the diagnosis of GERD get carried forward. This
toolkit is a great resource https://www.slideshare.net/
EngagingPatients/diagnostic-error-toolkit
Need to Know NOW!!!
In the era of paper charting, when a resident was admitted and
the nurse had trouble determining why a medication was giv-
en, the prescriber could be asked to clarify during a daily
“batch call”. The diagnosis could then be added to the direc-
tions, permanent problem list and care plan usually within the
first 24 hours. A common admission scenario now with EHR
is that the indication is a required data field for order entry of a
medication. Thus without an indication right now, the medica-
tion cannot be entered into the computer. And if the medica-
tion is not entered at that moment, the entire process is held
up. Thus, the nurse tries to find a feasible diagnosis, enters it
and moves on. By trying to improve the process of “every
drug must have an indication”, in some circumstances, a cas-
cade of events is set off with possibly an incorrect indication.
Searching High and Low
The best solution is for the prescriber to include the indication
in the directions. Additionally, when the provider verbally
gives an order, the nurse should ask for the indication or if the
nurse calls the prescriber for a problem and an order is given
the nurse should add that problem to the directions (for exam-
ple, “for nausea”, “ for diarrhea”)
Where to look:
EHR diagnosis list
Hospital or other facility H&P
Hospital or other facility Discharge Summary
PCP notes
ED reports
SLP reports
Consults—cardiology, eye care, psychiatry, wound
And one day you just might even ask Alexa!
Remember that the drug may be used for two diagnoses at the
same time, such as Metoprolol for HTN and Afib. Include
both in the indication. And finally, when a prescriber gives the
diagnosis for the medication, double check to make sure it’s
placed on the permanent problem list and on the nursing care
plan if it impacts that.
Pharmacists can be your best asset in dealing with this prob-
lem. Pharmacists, too on a daily basis, review the resident’s
medications and clinical information pouring over the above
listed areas to determine the indication for use and request an
indication from the prescriber if unable to find one.
.
Article by Wendy Nash, PharmD, BCGP, BCPS
PHARM NOTES
Kinston Pharmacy
2545 Jetport Road
Kinston, NC 28504
Phone 800 735-9111
Louisville Pharmacy
13040 East Gate Parkway
Suite 105
Louisville, KY 40223
Phone 866-601-2982
Mooresville Pharmacy
947 N. Main Street
Mooresville, NC 28115
Phone 800 578-6506
To all the Pharm Notes Family,
With all the negativity in the news…..I thought I would end the newsletter this month on a light-
hearted note. So, I will leave you with……
Things to Ponder
1. If the No. 2 pencil is the most popular, why is it sill No. 2?
2. Why do we press harder on the remote control when we know the batteries are getting weak?
3. Why are you “in” a movie, but “on” TV?
4. What was the best thing BEFORE sliced bread?
5. Why do we drive on parkways & park on driveways?
6. Why do “fat chance” and “slim chance” mean the same thing but “wise man” and “wise guy”
are opposites?
7. Why do feet smell and noses run?
8. Why is QUITE A FEW the same as QUITE A LOT?
9. When does it stop being partly cloudy & start being partly sunny?
10. When French people swear, do they say “Pardon my English?”
11. Why do people say “heads up” when you should duck?
12. How does a building BURN UP as it BURNS DOWN?
13. Why is it called a HAMburger when its made of beef?
14. Why do psychics have to ask you for your name?
15. Why doesn't glue stick to the inside of the bottle?
Till next time……
Cathy Fuquay
Pharm Notes Editor
Pharm Notes is a bimonthly publication by Neil
Medical Group Pharmacy Services Division.
Articles from all health care disciplines pertinent
to long-term care are welcome. References for
articles in Pharm Notes are available upon request.
Your comments and suggestions are appreciated.
Contact: Cathy Fuquay ([email protected])
1-800-735-9111 Ext 23489
...a note from the Editor
Thank you for allowing Neil Medical Group to partner with
you in the care of your residents!