A young patient with biliary and urinary disease: What's the unifying diagnosis?

Left Ventricular Assist Device in Patients With Alcohol Abuse or Illicit Drug Use

Background Several reports suggest that illicit drug use may be a major cause of acute myocardial infarction (AMI) independently of smoking habits, and associated with a poorer prognosis. Purpose We sought to determine the frequency of history of illicit drug use in an AMI population and its impact on short- and mid-term prognosis. Methods Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2018 in France. We identified patients with history of illicit drug use and the adverse outcomes were investigated during follow-up. Results Among 797,212 patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI (mean age 69 years, 66% male), 3827 patients (0.5%) had a known history of illicit drug use (cannabis, cocaine or opioid). Patients with illicit drug use were younger and had less comorbidities. They presented more frequently with STEMI and anterior localization compared to those with no history of illicit drug use. In univariate analysis, patients with illicit drug use had lower short-term mortality rates compared to those without history of illicit drug use: 4.9% vs 10.1% at one month (p<0.0001), respectively. However, this might be attributed to a younger age at the time of presentation. Using logistic multivariable analysis with adjustment on age, gender, other cardiovascular and non-cardiovascular comorbidities, type and localisation of MI and procedures of revascularization, history of illicit drug use was associated with a non-significant higher risk of death at one year (adjusted odds ratio OR 1.12 95% CI 0.98–1.29). This trend was supported by a significantly higher risk of death at one year in patients with a history of opioid use (OR 1.27 95% CI 1.04–1.29, p=0.01). Conclusion In a large and systematic nationwide analysis of patients with AMI, history of illicit drug use was associated with a non-significant higher overall odds of mortality, which was significant among those with opioid use. Funding Acknowledgement Type of funding source: None

History of illicit drug use in adults with acute myocardial infarction: Temporal trends from the French national hospital discharge database

Background: Obstructive jaundice is a common clinical condition requiring accurate imaging for prompt diagnosis and management. Ultrasonography (USG) is often the first-line modality, whereas magnetic resonance cholangiopancreatography (MRCP) offers non-invasive high-resolution visualization of the biliary and pancreatic ducts. This study aimed to compare the diagnostic accuracy of USG and MRCP in obstructive jaundice and assess the efficacy of MRCP in detecting ancillary biliary and pancreatic abnormalities.Methods: A hospital-based prospective study was conducted on 30 adult patients (age 18-75 years) with obstructive jaundice at P.D.U. Government Medical College, Rajkot, India, between November 2020 and November 2022. All participants underwent both USG and MRCP. Diagnostic performance was evaluated against the reference standard of intraoperative, histopathological, or endoscopic retrograde cholangiopancreatography findings. Sensitivity, specificity, positive and negative predictive values, accuracy, and Cohen’s kappa coefficient (κ) were calculated. Chi-square test and receiver operating characteristic curve analysis were used to compare modalities.Results: MRCP demonstrated superior diagnostic performance compared with USG in detecting intrahepatic biliary dilatation (14 (46.7%) vs. 6 (20%), p < 0.05), common bile duct (CBD) dilatation (25 (83.3%) vs. 18 (60%), p < 0.05), and level of obstruction ((26 (86.7%) vs. 19 (63.3%), p = 0.04). For benign biliary pathologies, MRCP achieved higher sensitivity (95.6% vs. 92.3%), specificity (78.9% vs. 50%), and overall accuracy (87.2% vs. 71.1%) compared to USG. In CBD stones, MRCP outperformed USG in sensitivity (96.8% vs. 91.6%), specificity (84.9% vs. 55%), and accuracy (90.8% vs. 73.3%). MRCP demonstrated perfect diagnostic performance in bile duct dilatation, benign strictures, and tumors, with higher concordance to reference standards (κ = 0.92) than USG (κ = 0.56). Overall, MRCP provided more precise detection and characterization of biliary pathology across all parameters.Conclusion: MRCP significantly outperforms USG in the evaluation of obstructive jaundice, particularly in detecting biliary strictures, ductal dilatation, and tumors. MRCP should be considered the preferred non-invasive diagnostic modality for comprehensive assessment of patients with obstructive jaundice, complementing USG in clinical decision-making.

The study sought to assess if there is an association between emotional intelligence (EI) with illicit drug use in adolescents, and if this link is independent of social and parental variables. In this cross-sectional study, 990 randomly selected adolescents (age 15 - 17) from public high schools in Tehran, Iranian capital, were interviewed in 2006. The independent data consisted of EI (measured by the Bar-On Emotional Quotient Inventory) and also demographic characteristics (age and sex), family-related data (number of siblings and having an intact family), education-related data (attitude towards school and school achievement), parental and environmental data of illicit drug use and the outcome was “a history of illicit drug use amongst adolescents”. Our logistic regression model showed that the correlates of a history of illicit drug use in the adolescents were “the Bar-On Emotional Quotient Inventory score” (P < 0.001) alongside “family history of illicit drug use” (P < 0.001), “witnessing illicit drug use” (P < 0.014), “peer encouragement of illicit drug use” (P = 0.006), “school achievement” (P < 0.001), and “attitude towards school” (P = 0.007). Our results indicated a link between EI and a history of illicit drug use in Iranian adolescents, independent of other social factors. It is advisable that policymakers pay heed to this association in devising preventive measures against illicit drug use amongst adolescents. Key words: Adolescents, Illicit drug use, emotional intelligence, social risk factors.

Biliary dilatation in the asymptomatic patient is a frequent incidental finding in the work-up for which there are no current guidelines. The purpose of this study was to determine the yield of magnetic resonance cholangiopancreatography (MRCP) in asymptomatic patients with an incidental finding of biliary duct dilatation. The study included 68 consecutive patients for evaluation of biliary duct dilatation found incidentally on computed tomography (CT) or ultrasound (US). MRCP scans were reviewed, and data were retrospectively collected on demographics and laboratory work-up. Patients were divided by the presence of a significant or non-significant MRCP findings explaining the biliary duct dilatation and compared for normal or abnormal liver function. Liver function was normal in 47 patients and abnormal in 21 patients. MRCP identified the cause of the bile duct dilatation in 41 patients (60.3%). Rates of insignificant causes were 51% in the normal-liver-function group and 7% in the abnormal-function group. Corresponding rates of significant causes were 27.7% and 61.9% (p = 0.007). MRCP is a valuable tool in the work-up of biliary duct dilatation. Although significantly more significant causes of bile dilatation are identified in patients with abnormal liver function, almost one-third of patients with normal liver function need further work-up. This has important implications for establishing criteria for the use of MRCP in asymptomatic patients with biliary dilatation.

Association Between Tobacco Use, Symptom Expression, and Alcohol and Illicit Drug Use in Advanced Cancer Patients

154 Background: Our aim was to determine the association between smoking status and symptom expression, opioid use, alcoholism, and illicit drug use in advanced cancer patients. Methods: We retrospectively reviewed 560 consecutive charts from the outpatient Supportive Care Center and identified 300 advanced cancer patients who completed a comprehensive smoking questionnaire. Data on the Edmonton Symptom Assessment Scale (ESAS), morphine equivalent daily dose (MEDD), CAGE (Cut Down, Annoyed, Guilty, Eye Opener) questionnaire for alcoholism screening, and history of illicit drug use were collected. Results: Among 300 advanced cancer patients, 119 (40%) were never-smokers, 148 (49%) were former smokers, and 33 (11%) were current smokers. Compared with never-smokers, current smokers were more likely to be men (58% vs. 29%, P=0.004), report a higher pain expression (median 7.0 vs. 5.0 by the ESAS, P=0.007), be CAGE positive (≥2 yes response) (42% vs. 3%, P&lt;0.001), and have a history of illicit drug use (33% vs. 3%, P&lt;0.001). Compared with never-smokers, former smokers were more likely to be men (60% vs. 29%, P&lt;0.001), have head and neck cancer or lung cancer (30% vs. 13%, P=0.001), be CAGE positive (21% vs. 3%, P&lt;0.001), and have a history of illicit drug use (16% vs. 3%, P&lt;0.001). Current smokers reported a higher pain expression than former smokers (median 7.0 vs. 6.0 by the ESAS, P=0.01), had higher CAGE positivity (42% vs. 21%, P=0.01) and more frequent illicit drug use (33% vs. 16%, P=0.03). The MEDD and the timing of palliative care referral were not significantly different between current or former smokers compared with never-smokers. However, a higher proportion of current smokers were receiving opioids with MEDD ≥30mg at the time of palliative care consultation compared with never-smokers (70% vs. 52%, P=0.08). Conclusions: Our study suggests that current tobacco use is associated with a higher pain expression. In addition, any history of tobacco use is associated with a history of illicit drug use and alcoholism. Advanced cancer patients who smoked cigarettes may be at an increased risk for chemical coping or stronger opioid utilization and further studies are needed.

Outcomes in patients with acute myocardial infarction and a history of illicit drug use

Several reports suggest that illicit drug use may be a major cause of acute myocardial infarction (AMI) independently of smoking habits and associated with a poorer prognosis. The aim of our study was to evaluate the impact of illicit drug use on (i) the risk of AMI and (ii) its prognosis. This French longitudinal cohort study was based on the administrative hospital-discharge database from the entire population. First, we collected data for all patients admitted in hospital in 2013 with at least 5 years of follow-up to identify potential predictors of AMI. In a second phase, we collected data for all patients admitted with AMI from January 2010 to December 2018. We identified patients with a history of illicit drug use (cannabis, cocaine, or opioid). These patients were matched with patients without illicit drug use to assess their prognosis. In 2013, 3 381 472 patients were hospitalized with a mean follow-up of 4.7 ± 1.8 years. In multivariable analysis, among all drugs under evaluation, only cannabis use was significantly associated with a higher risk of AMI [HR 1.32 (95% CI 1.09-1.59), P = 0.004]. Between January 2010 and December 2018, we then identified 738 899 AMI patients. Among these patients, 3827 (0.5%) had a known history of illicit drug use. These patients were younger, most often male and had less comorbidities. After 1:1 propensity score matching, during a mean follow-up of 1.9 ± 2.3 years, there was no significant difference between patients without illicit drug use and patients with illicit drug use regarding all-cause death, cardiovascular death, stroke, or heart failure. In a large and systematic nationwide analysis, cannabis use was an independent risk factor for the incidence of AMI. However, the prognosis of illicit drug users presenting with AMI was similar to patients without illicit drug use.

BackgroundHomelessness, HIV, and substance use are interwoven problems. Furthermore, homeless individuals are frequent users of emergency services. The main purpose of this study was to identify risk factors for frequent emergency room (ER) visits and to examine the effects of housing status and HIV serostatus on ER utilization. The second purpose was to identify risk factors for frequent ER visits in patients with a history of illicit drug use.MethodsA retrospective analysis was performed on 412 patients enrolled in a Boston-based health care for the homeless program (HCH). This study population was selected as a 2:1 HIV seronegative versus HIV seropositive match based on age, sex, and housing status. A subgroup analysis was performed on 287 patients with history of illicit drug use. Chart data were analyzed to compare demographics, health characteristics, and health service utilization. Results were stratified by housing status. Logistic models using generalized estimating equations were used to predict frequent ER visits.ResultsIn homeless patients, hepatitis C was the only predictor of frequent ER visits (OR 4.49, p<0.01). HIV seropositivity was not predictive of frequent ER visits. In patients with history of illicit drug use, mental health (OR 2.53, 95% CI 1.07–5.95) and hepatitis C (OR 2.85, 95% CI 1.37–5.93) were predictors of frequent ER use. HIV seropositivity did not predict ER use (OR 0.45, 95% CI 0.21 – 0.97).ConclusionsIn a HCH population, hepatitis C predicted frequent ER visits in homeless patients. HIV seropositivity did not predict frequent ER visits, likely because HIV seropositive HCH patients are engaged in care. In patients with history of illicit drug use, hepatitis C and mental health disorders predicted frequent ER visits. Supportive housing for patients with mental health disorders and hepatitis C may help prevent unnecessary ER visits in this population.

To investigate the added value of diffusion-weighted imaging (DWI) when used with conventional T2-weighted magnetic resonance (MR) imaging (T2WI) and MR cholangiopancreatography (MRCP) for diagnosing bile duct dilatations. Our institutional review board approved this retrospective study protocol and waived the informed consent requirement. The study included 151 consecutive patients (70 men, 81 women) with intra- and/or extra-hepatic bile duct dilatation examined using MR imaging. Two radiologists independently and randomly reviewed 3 image sets (A: MRCP and T2WI; B: DWI; and C: combined T2WI, MRCP, and DWI) at different occasions to differentiate between malignancy, biliary lithiasis, and benign dilatation. The sensitivity, specificity, and diagnostic accuracy of these imaging sets were calculated and compared. For both readers, combined T2WI, MRCP, and DWI exhibited significantly higher sensitivity and diagnostic accuracy for malignant dilatation, compared with conventional T2WI and MRCP (P<0.01 for both readers). However, DWI did not significantly affect the sensitivity and diagnostic accuracy for biliary lithiasis or benign dilatation. The addition of DWI to T2WI and MRCP sequences yields significantly higher sensitivity and diagnostic accuracy when examining bile duct dilatations, particularly malignant dilatations.

Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our objective was to determine the patterns of storage, utilization, and disposal of opioids among cancer outpatients. We surveyed 300 adult cancer outpatients receiving opioids in our supportive care center and collected information regarding opioid use, storage, and disposal, along with scores on the CAGE (cut down, annoyed, guilty, eye-opener) alcoholism screening questionnaire. Unsafe use was defined as sharing or losing opioids; unsafe storage was defined as storing opioids in plain sight. The median age was 57 years. CAGE was positive in 58 of 300 patients (19%), and 26 (9%) had a history of illicit drug use. Fifty-six (19%) stored opioids in plain sight, 208 (69%) kept opioids hidden but unlocked, and only 28 (9%) locked their opioids. CAGE-positive patients (p = .007) and those with a history of illicit drug use (p = .0002) or smoking (p = .03) were more likely to lock their opioids. Seventy-eight (26%) reported unsafe use by sharing (9%) or losing (17%) their opioids. Patients who were never married or single (odds ratio: 2.92; 95% confidence interval: 1.48-5.77; p = .006), were CAGE positive (40% vs. 21%; p = .003), or had a history of illicit drug use (42% vs. 23%; p = .031) were more likely to use opioids unsafely. Overall, 223 of 300 patients (74%) were unaware of proper opioid disposal methods, and 138 (46%) had unused opioids at home. A large proportion of cancer patients improperly and unsafely use, store, and dispose of opioids, highlighting the need for establishment of easily accessed patient education and drug take-back programs.

ContextCancer prevalence is increasing, with many patients requiring opioid analgesia. Clinicians need to ensure patients receive adequate pain relief. However, opioid misuse is widespread, and cancer patients are at risk.ObjectivesThis study aims (1) to identify screening approaches that have been used to assess and monitor risk of opioid misuse in patients with cancer; (2) to compare the prevalence of risk estimated by each of these screening approaches; and (3) to compare risk factors among demographic and clinical variables associated with a positive screen on each of the approaches.MethodsMedline, Cochrane Controlled Trial Register, PubMed, PsycINFO, and Embase databases were searched for articles reporting opioid misuse screening in cancer patients, along with handsearching the reference list of included articles. Bias was assessed using tools from the Joanna Briggs Suite.ResultsEighteen studies met the eligibility criteria, evaluating seven approaches: Urine Drug Test (UDT) (n = 8); the Screener and Opioid Assessment for Patients with Pain (SOAPP) and two variants, Revised and Short Form (n = 6); the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) tool and one variant, Adapted to Include Drugs (n = 6); the Opioid Risk Tool (ORT) (n = 4); Prescription Monitoring Program (PMP) (n = 3); the Screen for Opioid-Associated Aberrant Behavior Risk (SOABR) (n = 1); and structured/specialist interviews (n = 1). Eight studies compared two or more approaches. The rates of risk of opioid misuse in the studied populations ranged from 6 to 65%, acknowledging that estimates are likely to have varied partly because of how specific to opioids the screening approaches were and whether a single or multi-step approach was used. UDT prompted by an intervention or observation of aberrant opioid behaviors (AOB) were conclusive of actual opioid misuse found to be 6.5–24%. Younger age, found in 8/10 studies; personal or family history of anxiety or other mental ill health, found in 6/8 studies; and history of illicit drug use, found in 4/6 studies, showed an increased risk of misuse.ConclusionsYounger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinical suspicion of opioid misuse may be raised by data from PMP or any of the standardized list of AOBs. Clinicians may use SOAPP-R, CAGE-AID, or ORT to screen for increased risk and may use UDT to confirm suspicion of opioid misuse or monitor adherence. More research into this important area is required.Significance of resultsThis systematic review summarized the literature on the use of opioid misuse risk approaches in people with cancer. The rates of reported risk range from 6 to 65%; however, true rate may be closer to 6.5–24%. Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinicians may choose from several approaches. Limited data are available on feasibility and patient experience.PROSPERO registration number.CRD42020163385.

BACKGROUND Acute pancreatitis (AP) is a disease associated with sudden onset of abdominal and back pain in a band-like pattern, nausea, and vomiting. In patients with AP, the gold standard, i.e., the initial imaging modality to be used is ultrasonography (US). However, in cases where evaluation is insufficient, computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) are other modalities to be applied. In this study, we aimed to demonstrate the diagnostic accuracy of CT and MRCP in patients with acute pancreatitis. METHODS Seventy-five patients diagnosed with acute pancreatitis were evaluated using CT and, as well as patients who underwent contrast-enhanced MRCP within 48 hours. CT and MRCP were examined in terms of the biliary tract and pancreatic duct structure, gallbladder, common bile duct stones and complications. Chi-square test and the Mann-Whitney U test were used to analyze the data at significance level of p<0.05. RESULTS Of all the included patients, 44 were male (58.7%), and the mean age was 59.27 ± 17.37 years. In CT findings, the percentage of AP complication findings such as pancreatic necrosis, extrapancreatic complications, the pancreatic or peripancreatic fluid collection was significantly higher than the MRCP group (p<0.05). MRCP showed biliary tract findings such as cholelithiasis, gallstone, common bile duct dilatation, intrahepatic bile duct dilatation, choledochal stone and pancreatic duct dilatation at a higher percentage than CT. CONCLUSION MRCP was superior to CT in gallbladder and choledochal stone and biliary tract dilatation but not in AP complications. Therefore, non-invasive and radiation-free MRCP can be used more widely in AP patients, especially in emergency departments.