Cannabis is a common drug of abuse that is associated with various long-term and short-term adverse effects. The nature of its association with vomiting after chronic abuse is obscure and is underrecognised by clinicians. In some patients this vomiting can take on a pattern similar to cyclic vomiting syndrome with a peculiar compulsive hot bathing pattern, which relieves intense feelings of nausea and accompanying symptoms. In this case report, we describe a twentytwo year-old-male with a history of chronic cannabis abuse presenting with recurrent vomiting, intense nausea and abdominal pain. In addition, the patient reported that the hot baths improved his symptoms during these episodes. Abstinence from cannabis led to resolution of the vomiting symptoms and abdominal pain. We conclude that in the setting of chronic cannabis abuse, patients presenting with chronic severe nausea and vomiting that can sometimes be accompanied by abdominal pain and compulsive hot bathing behaviour, in the absence of other obvious causes, a diagnosis of cannabinoid hyperemesis syndrome should be considered.

Background Recent policy clarifications by the Centers for Medicare and Medicaid Services have changed access to outpatient dialysis care at end stage renal disease (ESRD) facilities for individuals with acute kidney injury in the United States. Tools to predict “ESRD” and “acute” status in terms of kidney function recovery among patients who previously initiated dialysis in the hospital could help inform patient management decisions. Study Design Historical cohort study Setting & Participants Incident hemodialysis patients in the Mayo Clinic Health System who initiated in-hospital RRT and continued outpatient dialysis following hospital dismissal (2006 to 2009) Predictor Baseline estimated glomerular filtration rate (eGFR), sepsis/surgery acute tubular necrosis (ATN), heart failure, intensive care unit, and dialysis access. Outcomes Kidney function recovery defined as sufficient kidney function for outpatient hemodialysis discontinuation. Results Cohort consisted of 281 patients with mean age 64 years, 63% men, 45% heart failure, and baseline eGFR ≥30 mL/min/1.73m2 in 46%. Over a median 8 months, 52 (19%) recovered, most (94%) within 6 months. Higher baseline eGFR (Hazard Ratio 1.27 per 10 ml/min/1.73m2; 95% CI 1.16–1.39; p<0.001), ATN from sepsis or surgery (HR 3.34; CI 1.83- 6.24; p<0.001), and heart failure (HR 0.40; CI 0.19–0.78, p=0.007) were independent predictors of recovery within 6 months while first RRT in the intensive care unit and a catheter dialysis access were not. There was a positive interaction between absence of heart failure and eGFR≥30 ml/min/1.73m2 for predicting kidney function recovery (p<0.001). Limitations Sample size. Conclusions Kidney function recovery in the outpatient hemodialysis unit following in-hospital RRT initiation is not rare. As expected, higher baseline eGFR is an important determinant of recovery. However, patients with heart failure are less likely to recover even with higher baseline eGFR. Consideration of these factors at hospital discharge informs decisions on “ESRD” status designation and long-term hemodialysis care.

Background/Aims: The incidence of adverse events (AEs) in adults who receive continuous renal replacement therapy (CRRT) is unknown. We report the incidence of mechanical, metabolic, and hemodynamic CRRT AEs. Methods: This is a retrospective study of all consecutive adult patients (≥18 years) who underwent CRRT from January 1, 2007 to December 31, 2009. Results: Out of 595 patients who underwent CRRT, 366 (62%) were male and 500 (84%) were Caucasian. Regional citrate anticoagulation was used in 98.6% of all patients. The most common clinically significant electrolyte derangements were ionized hypocalcemia (22%), ionized hypercalcemia (23%), and hyperphosphatemia (44%). Almost all (97%) patients had at least one additional AE including new onset hypotension (within the first hour after CRRT initiation) (43%), hypothermia (44%), new onset arrhythmias (29%), new onset anemia (31%) and thrombocytopenia (40%). Conclusions: ICU patients who require CRRT have a high incidence of AEs. Although the extent to which these complications are attributable to CRRT is not known, clinicians need to be cautious and aware of their high prevalence in this patient population.

Hospitalizations are common in older incident haemodialysis patients. Access preparation and overall burden of illness leading to the initial hospitalization appear to play a role. Identification of additional factors associated with hospitalization will allow for focused interventions to reduce hospitalization rates and increase the value of care.

The increasing use of opioids to manage pain in the United States over the last decade has resulted in a subset of our population developing opioid tolerance. While the management of opioid tolerant patients during acute episodes of care is well known to be a challenge amongst health care providers, there is little in the literature that has studied opioid tolerance as a predictor of outcomes. We conducted a review on all admissions to Massachusetts General Hospital over a period of 6 months, from January 2013 to June 2013, and identified opioid tolerant patients at admission using the FDA definition of opioid tolerance. To compare risk adjusted groups, we placed opioid tolerant patients and control patients into groups determined by expected length of stay of less than 2 days, 2 to 5 days, 5 to 10 days, and greater than 10 days. Opioid tolerant patients were then compared to the control for outcomes measures including observed length of stay and readmission rates. Our results show that all opioid tolerant patients have a significantly longer length of stay and a greater 30 day all cause readmission rate than the control group (P < 0.01). This trend was found in the first 3 risk adjusted groups, but not in the fourth group where expected length of stay was greater than 10 days. The opioid tolerant population is at risk given the poorer outcomes and higher health care costs associated with their care. It is imperative that we identify opportunities for improvement and delineate specific pathways for the care of these patients. Key words: Opioid tolerance, opioid tolerant patient population, opioid tolerant patients, readmission rates, length of stay