Risk factors for opioid overdose among hospitalized patients.

WHAT IS KNOWN AND OBJECTIVE: Hospitalized patients are at risk for opioid overdose. Little is known about the risk factors for these events. METHOD: Opioid overdose cases were identified by naloxone orders in computerized order entry system from a single institution. For each case, two controls were randomly selected. Data were collected on factors including age, gender, weight, opioid dose, route of administration, concomitant CNS depressants, renal function and comorbid conditions. RESULTS AND DISCUSSION: Between 2010 and 2013, we identified 44 cases of opioid overdose (OD), none of which were fatal, and matched these to 88 controls (no OD). Patients with a history of substance use disorder were excluded from the study. Factors associated with opioid overdose included age of 65 or older (40.9% OD vs 29.5% no OD, P = .026), being in an ICU (MICU/CICU 27.3% OD vs. 3.4% no OD, P < .001; SICU 18.1% OD vs 5.7% no OD, P = .031) and renal impairment (eGFR ≤60, 50.0% OD vs 28.4% no OD, P = .034). Total 24-hour opioid dose was lower in OD group, but the difference was not statistically significant (71.9 vs 107.2 mg morphine equivalent, P = .116). OD cases were more likely to have received concomitant CNS depressants, but the difference was statistically significant only for those who received 3 or more (15.9% OD vs 0% no OD, P = <.001). Heart disease was the only comorbidity significantly associated with an increased risk of opioid overdose (43.2% vs 20.5%, P = .025). Patient's BMI, duration of opioid use, route of administration and history of COPD and/or psychiatry were not associated with opioid overdoses. WHAT IS NEW AND CONCLUSION: Among hospitalized patients, risk factors of opioid overdose include age of 65 or greater, being in an ICU, renal impairment and concomitant administration of CNS depressant medications. These findings may help with the development and implementation of measures to prevent overdose.

Highly active antiretroviral therapy outcomes in a primary care clinic.

This paper compares antiretroviral outcomes of patients at a primary care clinic with those previously reported at HIV specialty clinics and examines risk factors for treatment failure. A retrospective medical record review was undertaken at an academic primary care practice in Baltimore, Maryland. One hundred and twenty-three patients were included who had not previously received HAART and who were started on a regimen that included a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor and at least one other new antiretroviral medication. HIV RNA levels, CD4 lymphocyte counts, missed appointment rate, HAART regimen, demographic variables, and their association with the achievement of a viral RNA of 500 or less at 7-14 months were analyzed. Forty-seven per cent of the patients had an HIV RNA level of 500 or less at 7-14 months after initiation of HAART. Factors associated with treatment failure included missed appointment rate, injection drug use and previous exposure to antiretroviral medication. On multivariate analysis, only missed appointment rate and lower baseline CD4 lymphocyte count were independently associated with treatment failure. The antiretroviral outcomes of patients started on HAART by experienced health care providers in this primary care practice were comparable to those reported in specialty clinics. As with previous reports, most patients did not maintain viral suppression. Missed appointment rate was the most important risk factor for treatment failure.

A patient with primary human immunodeficiency virus infection who presented with acute rhabdomyolysis.

Primary human immunodeficiency virus (HIV) infection is usually symptomatic, and infected patients can present with a variety of symptoms. We describe a 51-year-old man who presented at our hospital with acute self-limited rhabdomyolysis and who was found to have primary HIV infection. Our case and other reports suggest that a diagnosis of primary HIV infection needs to be considered for patients who present with acute rhabdomyolysis.

Case report. Diagnosis of disseminated Mycobacterium avium complex infection by liver biopsy.

Mycobacterium avium complex (MAC) infection is a common complication of HIV/AIDS. Signs and symptoms of this infection are nonspecific and include fever, weight loss, diarrhea, and abnormal levels of liver enzymes, especially elevated alkaline phosphatase levels. Diagnosis can be achieved through several methods, but liver biopsy may be the most rapid and efficient. We present a case that illustrates the potential value of liver biopsy in diagnosing disseminated MAC infection.

A comparison of resource utilization in nurse practitioners and physicians.

CONTEXT: Nurse practitioners increasingly provide primary care in a variety of settings. Little is known about how resource utilization for patients assigned to nurse practitioners compares with that for patients assigned to physicians. OBJECTIVE: To compare health care resource utilization for adult patients assigned to a nurse practitioner with that for patients assigned to a resident or attending physician. DESIGN: Prospective, quasi-randomized study. SETTING: Primary care clinic at a Veterans Affairs medical center. PATIENTS: 450 new primary care patients: 150 were assigned to a nurse practitioner, 150 to a resident physician, and 150 to an attending physician. OUTCOME MEASURES: We collected data on laboratory and radiologic testing, specialty care, primary care, emergency or walk-in visits, and hospitalizations over a 1-year period. We also collected information on baseline chronic illnesses, blood pressure, and weight. RESULTS: Resource utilization for patients assigned to a nurse practitioner was higher than that for patients assigned to a resident in 14 of 17 utilization measures (3 were statistically significant) and higher in 10 of 17 measures when compared with patients assigned to an attending physician (3 were statistically significant). None of the utilization measures for patients in the nurse practitioner group was significantly lower than those for either physician group. CONCLUSIONS: In a primary care setting, nurse practitioners may utilize more health care resources than physicians.

Anomalous origin of the left coronary artery from the pulmonary artery associated with ventricular septal defect and mitral stenosis.

We report a case of a child with ventricular septal defect, mitral stenosis, and patent ductus arteriosus, who was also found to have anomalous origin of the left coronary artery from the pulmonary artery. Preoperative diagnosis allowed successful surgical correction.

Pericyte changes in branch retinal vein occlusion.

The model of experimental branch vein occlusion (BVO) in the monkey offers the opportunity to examine retinal capillaries under stress. Electron microscopic morphometry was done on 812 capillaries of 13 eyes of cynomolgus monkeys, comparing 579 capillary collaterals of 9 BVO eyes with 233 normal capillaries of 4 control eyes. The tissue underwent the myosin subfragment-1 technique to decorate and quantify bundles of actin filaments in capillary pericytes. The duration of BVO was 2-48 months. Capillary collaterals of BVO eyes had an enlarged caliber, endothelial hyperplasia, and pericyte hypertrophy, but no proportional increase in basement membrane area. Collaterals near the inner plexiform layer (IPL) had a greater wall thickness, pericyte coverage, and actin coverage than collaterals near the outer plexiform layer (OPL). Pericyte hypertrophy was proportionate to caliber increase in OPL vessels and exceeded caliber increase only in IPL vessels. Actin coverage was proportional with the vessel dilation and size of pericyte cytoplasm in all vessels. These findings indicate that capillary collaterals in BVO are not equipped morphologically for an increased regulatory role in microvascular flow beyond their normal function.