Laupacis relates the experience of a client of the Safer Alternatives for Emergency Response (SAFER) program. The client tried SAFER's powdered fentanyl program. So far it seems to be working pretty ...good. He has been on it for about 2 months. You can come to SAFER up to 4 times a day. Sometimes he come a couple of times, sometimes all 4. The nurses and doctors are all addiction-based, so they have a lot of experience dealing with people who are using drugs. They don't attach the stigma to it too much.
Laupacis shares a story of a long road to recovery following complications of sickle cell disease. A certain person has known people with sickle cell disease who are in and out of the hospital and he ...never had those issues. As a child growing up in the Islands, every time he went down into the sea they would literally have to carry him home because of pain. A doctor told him he had sickle cell trait, and he always went with that he remembers going into emergency 18 months ago because he noticed his eyeballs were yellow. Everything else he has no memory of until 2 months later. He was in the hospital for 6 months, then rehab for 2.5 months.
The pain in both shoulders started around midnight and got worse as the night went on. It felt like someone was stabbing me. No matter what position I was in, I couldn't sleep. In the morning, I went ...to work. The pain was bearable, but when I picked up something a little bit heavy, it felt like somebody was trying to pull my arm out of the socket. At that point, I realized, "Okay, this isn't just aches and pains." At the first hospital, they didn't really know what was wrong with me. The doctor was thinking maybe shingles. They gave me some steroids and Tylenol 3s and sent me home. The pain got worse throughout the day. Patients with neuralgic amyotrophy often have acute and severe pain. Multifocal weakness follows hours to days later. The pain is in the shoulder or arm, and patients typically rate it as 7 out of 10 or worse.
The relative risk of death for patients treated with peritoneal dialysis compared with those treated with hemodialysis appears to change with duration of dialysis therapy. Patients who start dialysis ...urgently are at high risk for mortality and are treated almost exclusively with hemodialysis, introducing bias to such mortality comparisons. To better isolate the association between dialysis treatment modality and patient mortality, we examined the relative risk for mortality for peritoneal dialysis compared with hemodialysis among individuals who received ≥4 months of predialysis care and who started dialysis electively as outpatients. From a total of 32,285 individuals who received dialysis in Ontario, Canada during a nearly 8-year period, 6,573 patients met criteria for elective, outpatient initiation. We detected no difference in survival between peritoneal dialysis and hemodialysis after adjusting for relevant baseline characteristics. The relative risk of death did not change with duration of dialysis therapy in our primary analysis, but it did change with time when we defined our patient population using the more inclusive criteria typical of previous studies. These results suggest that peritoneal dialysis and hemodialysis associate with similar survival among incident dialysis patients who initiate dialysis electively, as outpatients, after at least 4 months of predialysis care. Selection bias, rather than an effect of the treatment itself, likely explains the previously described change in the relative risk of death over time between hemodialysis and peritoneal dialysis.
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