IntroductionEffective chronic pain management is a core competency of internal medicine. Opioid use in the United States, both therapeutic and nonmedical in origin, has dramatically increased, as has the number of deaths due to opioid overdose. Despite this, formal training in pain management and responsible opioid prescribing is lacking for internal medicine residents.MethodsOur educational workshop for PGY 1-PGY 3 internal medicine residents was designed to provide a functional knowledge base and improve motivation to change behaviors in chronic pain management and responsible opioid prescribing. A secondary aim was to align our intervention with our new clinic opioid-prescribing protocol with the goal of increasing the adoption of opioid risk-reduction strategies in our resident clinic, specifically, use of urine drug screening (UDS). We collected data using pre- and postsession knowledge and motivation to change questionnaires as well as pre- and postintervention data regarding UDS in our ambulatory clinic.ResultsSixty-three residents participated in a workshop session. Based on pre- to posttest results, medical knowledge of principles of responsible opioid prescribing increased overall (p = .01). Most residents reported high motivation to change behaviors around management of chronic pain and opioid prescribing. There was also a significant postintervention ordering of UDS in patients on long-term opioid therapy.DiscussionOur workshop resulted in a short-term improvement in knowledge of principles of responsible opioid prescribing, a significant motivation to change behaviors, and increased adoption of opioid risk-reduction strategies in our resident clinic.
Classic Lemierre's syndrome is a septic internal jugular venous (IJV) thrombophlebitis secondary to oropharyngeal anaerobic infection in adolescent and young adult. Though upper respiratory tract infection is the most common antecedent, it has also been described following skin, soft tissues, genitourinary and gastrointestinal infections. Fusobacteria necrophorum is the commonest pathogen isolated from blood and tissue cultures but other bacteria like Eikenella correndens, Bacteroides melaninogenicus and Non Group A Streptococcal species have also been reported. The overall incidence of Lemierre's and Lemierre's like syndromes has declined since the first case report in 1936. There is however, a resurgence of cases in recent years due to more judicious use of antibiotics for treatment of upper respiratory tract infection among medical practitioners. The main stay of treatment of complete Lemierre's syndrome is prolonged antibiotic coverage and surgical drainage of nonresolving abscesses. Currently, there is no consensus opinion on the use of anticoagulation in patient with complete Lemierre's syndrome complicated by septic internal jugular thrombosis and embolism. High index of suspicion is required for early diagnosis of Lemierre's and Lemierre's like syndromes. Early and effective antibiotics therapy may prevent the development full spectrum of the syndrome and its associated complication.
Meconium drug analysis is a new and sensitive test for detecting the intrauterine exposure of infants to drugs of abuse. To explore other potential, diagnostic use of the test, we studied, in timed pregnant rats, the relationship between timing, dosage, and duration of morphine administration to the dam and the concentration of morphine, analyzed by radioimmunoassay, in their pups’ meconium. The term ‘meconium’ refers to both the intestine and its contents. Due to the minute size of the pups’ intestines, the intestinal contents were not separated from the intestines. The mean morphine concentration in meconium was found to be significantly (p < 0.05) higher in the groups treated with a higher morphine dose (10 vs. 5 mg/ kg/day), longer duration of treatment (7–20 vs. 18–20 days), or treated during the last week of gestation (14–20 vs. 1–6 or 7–13 days). We conclude that the concentration of a drug in the meconium is related to amount, timing, or duration of the drug exposure of the fetus, in utero. The quantitative analysis of drugs in the meconium, therefore, provides added information which enhances the diagnostic use of the test.
Background Regular cocaine and/or heroin use is associated with major health risks, especially cardiovascular disease, but confounded by other factors. We examined effects of chronic (years regular use) and recent (past-month) cocaine and heroin use, controlling for other factors, on resting cardiovascular function. Methods In a sample of 292 cocaine and/or heroin users, we assessed demographics, body mass index (BMI), substance use history, electrocardiogram, heart rate (HR) and blood pressure (BP). Three-block (1: demographics, BMI; 2: tobacco, alcohol, cannabis; 3: cocaine, heroin) regression analyses were conducted to predict cardiovascular measures. Results Higher BMI predicted increased systolic and diastolic BP (as did older age), increased supine HR, and longer QRS duration, QTc interval, PR interval, and P-wave duration. Past-month cannabis-use days predicted higher systolic BP, lower supine HR, and greater likelihood of early repolarization and ST elevation; average daily cannabis use predicted shorter QTc interval. Average daily alcohol use predicted higher diastolic BP, higher supine HR and lower likelihood of sinus bradycardia (HR < 60 bpm). Past-month tobacco-use days predicted shorter QTc interval and lower lower likelihood of profound bradycardia (HR < 50 bpm). Past-month heroin-use days predicted lower seated HR, greater likelihood of sinus bradycardia and lower likelihood of left ventricular hypertrophy. More years of regular cocaine use and past-month cocaine-use days predicted longer QTc interval. Conclusions Cocaine and heroin use incrementally predicted modest variance in resting bradycardia and QTc interval. Clinicians should first consider demographics and recent use of tobacco, alcohol and cannabis before assuming cocaine and heroin affect these measures.
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