Journal of general internal medicine
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Methadone is highly effective in treating opioid dependence, and it is also used as an analgesic for second-line management of chronic pain. However, recent increases in methadone-related deaths have instigated controversy about the use of this medication. In this paper, we evaluate risk factors for methadone mortality in opioid dependent and pain populations and present guidelines for initiating methadone treatment in these two populations to minimize the risk of death. ⋯ Recent reports of methadone deaths emphasize chronic pain populations, methadone-related QTc prolongation, and the possibility of inducing Torsade de pointes (TdP), a potentially fatal ventricular arrhythmia. Retrospective analyses of these deaths show that patients who develop TdP often present with multiple risk factors, including high methadone doses, use of other medications that cause QTc prolongation, and electrolyte abnormalities. To minimize fatalities, guidelines are presented for initiating methadone in opioid treatment and pain populations that consider the drug's pharmacology along with behavioral, medical and psychiatric risk factors.
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Multicenter Study
Supervising the supervisors--procedural training and supervision in internal medicine residency.
At teaching hospitals, bedside procedures (paracentesis, thoracentesis, lumbar puncture, arthrocentesis and central venous catheter insertion) are performed by junior residents and supervised by senior peers. Residents' perceptions about supervision or how often peer supervision produces unsafe clinical situations are unknown. ⋯ Residents report low levels of comfort and experience with procedures, and frequently report supervising prior to feeling comfortable. Our findings suggest a need to examine best practices for procedural supervision of trainees.
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Comparative Study
Relationship of opioid use and dosage levels to fractures in older chronic pain patients.
Opioids have been linked to increased risk of fractures, but little is known about how opioid dose affects fracture risk. ⋯ Higher doses (>or=50 mg/day) of opioids for chronic non-cancer pain were associated with a 2.00 increase in risk of fracture confirmed by medical record review. Clinicians should consider fracture risk when prescribing higher-dose opioid therapy for older adults.
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Renin-angiotensin-aldosterone system (RAAS) inhibitors are associated with hyperkalemia, but there is little evidence demonstrating patients who receive potassium monitoring have a lower rate of hyperkalemia. ⋯ Patients prescribed RAAS inhibitors who have both diabetes and chronic kidney disease and receive potassium monitoring are less likely to experience a serious hyperkalemia-associated adverse event compared to similar patients who did not receive potassium monitoring. This evidence supports existing consensus-based guidelines.
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Comparative Study
Disparities in service quality among insured adult patients seen in physicians' offices.
To examine racial disparities in health care service quality. ⋯ There are substantial racial/ethnic disparities in satisfaction with care, and these are related to objective quality measures that can be improved.