Opioid use disorder is often a chronic, relapsing condition associated with increased morbidity and death; however, with appropriate treatment and follow-up, individuals can reach sustained long-term ...remission. This guideline strongly recommends opioid agonist treatment with buprenorphine-naloxone as the preferred first-line treatment when possible, because of buprenorphine's multiple advantages, which include a superior safety profile in terms of overdose risk. Withdrawal management alone is not recommended, because this approach has been associated with elevated risks (e.g., syringe sharing) and death from overdose in comparison to providing no treatment, and high rates of relapse when implemented without immediate transition to long-term evidence-based treatment. Here, Bruneau et al discuss management of opioid use disorders.
Background Esophageal strictures resulting from eosinophilic esophagitis present management challenges, and high rates of rents and perforation have been reported. Objective To assess the safety of ...esophageal dilation in eosinophilic esophagitis and to characterize predictors of both clinical response and complications of the procedure. Design Retrospective study of the University of North Carolina eosinophilic esophagitis database. Setting Tertiary care referral center. Patients Cases of eosinophilic esophagitis were defined as per consensus guidelines. Intervention Dilation with either Savary or through-the-scope balloon techniques. Main Outcome Measurements Complications (deep mucosal rents, contained or free perforation, and chest pain requiring medical attention or hospitalization) and the global clinical symptom response. Results Of 130 eosinophilic esophagitis cases identified, 70 dilations (12 Savary, 58 balloon) were performed in 36 patients. Esophageal size improved from 12 to 16 mm ( P < .001), with an overall symptom response rate of 83%. The only predictor of clinical response was final dilation diameter. There were 5 complications (7%): 2 deep mucosal rents and 3 episodes of chest pain. There were no perforations. There was one hospitalization for chest pain. All complications occurred in patients being treated with topical steroids, who underwent balloon dilation. Complications were associated with younger age (23 vs 42; P = .02) and more dilations (4 vs 1.7; P = .009). Limitations Single center, retrospective study. Conclusions Esophageal dilation can be performed in eosinophilic esophagitis with low rates of tears, chest pain, and hospitalization. No perforations were found in our database. The effectiveness of dilation was best when a larger esophageal caliber was achieved, but patients undergoing more procedures was associated with complications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Human immunodeficiency virus (HIV)-positive injection drug users (IDUs) are known to be at risk for multiple medical problems that may necessitate emergency department (ED) use; ...however, the relative contribution of HIV disease vs. injection-related complications has not been well described. Objectives We examined factors associated with ED use among a prospective cohort of HIV-positive IDUs in a Canadian setting. Methods We enrolled HIV-positive IDUs into a community-recruited prospective cohort study. We modeled factors associated with the time to first ED visit using Cox regression to determine factors independently associated with ED use. In sub-analyses, we examined ED diagnoses and subsequent hospital admission rates. Results Between December 5, 2005 and April 30, 2008, 428 HIV-positive IDUs were enrolled, among whom the cumulative incidence of ED use was 63.7% (95% confidence interval CI 59.1–68.3%) at 12 months after enrollment. Factors independently associated with time to first ED visit included: unstable housing (hazard ratio HR 1.5; 95% CI 1.1–2.0) and reporting being unable to obtain needed health care services (HR 2.2; 95% CI 1.2–4.1), whereas CD4 count and viral load were non-significant. Skin and soft tissue infections accounted for the greatest proportion of ED visits (17%). Of the 2461 visits to the ED, 419 (17%) were admitted to the hospital. Conclusions High rates of ED use were observed among HIV-positive IDUs, a behavior that was predicted by unstable housing and limited access to primary care. Factors other than HIV infection seem to be driving ED use among this population in the post-highly active antiretroviral therapy era.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Purpose Illicit drug overdose is a leading cause of premature mortality. We sought to examine fatal overdose trends from 2001 to 2005 in urban and nonurban areas of British Columbia, Canada. Methods ...We conducted a review of all provincial coroner files in which drug overdose was the cause of death between January 1, 2001, and December 31, 2005. We compared cocaine and noncocaine-related overdoses and examined temporal changes in cocaine-related mortality rates in urban and nonurban areas. Multilevel mixed effects models were used to determine the independent risk factors for cocaine-related death. Spatial analyses were conducted to identify clusters of these cases. Results During the study period, 904 illicit drug overdoses were recorded, including 369 (40.8%) in nonurban areas and 532 (58.9%) related to cocaine consumption. In a multilevel model, we observed a significant interaction ( p = .010) between population density and year, indicating a considerable and differential increase in the likelihood of cocaine-related deaths in nonurban areas. Cocaine-related deaths were clustered in the southeast region of the province. Conclusions Cocaine-related overdoses in nonurban areas should be a public health concern. Evidence-based interventions to reduce the risks associated with cocaine consumption and reach drug users in nonurban settings are needed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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