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A large proportion of individuals who use heroin report initiating opioid use with prescription opioids. However, patterns of prescription opioid use preceding heroin-related overdose have not been described.

To describe prescription opioid use in the year preceding heroin overdose.

Case-control study comparing prescription opioid use with a heroin-involved overdose, non-heroin-involved opioid overdose, and non-overdose controls from 2015 to 2017.

Oregon Medicaid beneficiaries with linked administrative claims, vital statistics, and prescription drug monitoring program data.

Opioid, benzodiazepine, and other central nervous system depressant prescriptions preceding overdose; among individuals with one or more opioid prescription, we assessed morphine milligram equivalents per day, overlapping prescriptions, prescriptions from multiple prescribers, long-term use, and discontinuation of long-term use.

We identified 1458 heroin-involved overdoses (191 fatal) and 2050 non-heroin-involved opioid overdof long-term prescription opioid use was not associated with heroin-involved overdose.

Although individuals with a heroin-involved overdose were less likely to receive prescribed opioids in the year preceding their overdose relative to non-heroin opioid overdose cases, prescription opioid use was relatively common and increased with age. Discontinuation of long-term prescription opioid use was not associated with heroin-involved overdose.

Spine conditions are costly and a major cause of disability. A growing body of evidence suggests that healthcare utilization and spending are driven by provider availability, which varies geographically and is a topic of healthcare policy debate.

To estimate the effect of provider availability on spine spending.

Retrospective cohort study using relocation as a natural experiment.

Fee-for-service Medicare beneficiaries over age 65 who relocated to a new hospital referral region between 2010 and 2014.

We used generalized linear models to evaluate how changes in per-beneficiary availability of three types of healthcare providers (primary care physicians, spine surgeons, and chiropractors) affected annual per-beneficiary spine spending. We evaluated increases and decreases in provider availability separately. To account for the relative sizes of the provider workforces, we alsocalculated estimates of the effects of changes in national workforce size on changes in national spine spending.

The associatispending.

Provider availability affects individual spine spending, with substantial changes observed at the national level. The effect depends on provider type and whether availability increases or decreases. Policymakers should consider how changes in the size of the physician workforce affect healthcare spending.The management of high-utilizing patients is an area of active research with broad implications for the healthcare system. There are significant operational challenges to designing primary care models for these medically complex, high-needs patients. Although it is crucial to provide a high degree of continuity of care for this population, managing a cohort of these patients can lead to provider over-work and attrition. This may be magnified by the lack of training dedicated to addressing the unique care needs of these patients. While academic medical centers would seem well suited to care for individuals with multimorbidity needing intensive and specialized treatment, primary care providers in this setting need additional support to be clinically available for patients while pursuing scholarship and teaching. Formally recognizing intensive outpatient care as a specialty within internal medicine would help overcome some of these challenges. This would require a committed effort to high-level systems changes including a new focus on graduate medical education, the creation of division-level infrastructure within academic departments of medicine, and realistic levels of financial support to make this a viable career path.

Differentiating the etiology of ACTH-dependent Cushing's syndrome (CS) has remained challenging due to the limited accuracy of noninvasive assays. Nowadays, bilateral inferior petrosal sinus sampling (BIPSS) with corticotropin-releasing hormone (CRH) is the gold standard method in the diagnostic work-up of complex CS. However, this method is as yet far from being widespread. The limited utility of this method could be due to many factors such as limited availability of an experienced interventionist, limited availability of CRH, and cost of the procedure. So far, very few studies have been conducted using desmopressin instead of CRH. In this study, we report the use of BIPSS with desmopressin as a diagnostic tool in a series of patients with suspected Cushing's disease (CD) and equivocal imaging in a tertiary referral center in Iran.

A total of 13 patients with ACTH-dependent CS and no significant lesions in their pituitary MRI participated in this retrospective case series. All patients underwent BIPSS wd. click here The sensitivity of BIPSS in the diagnosis of CD was high, whereas it has moderate accuracy in tumor lateralization.

No significant benefits of adding desmopressin to BIPSS were observed. The sensitivity of BIPSS in the diagnosis of CD was high, whereas it has moderate accuracy in tumor lateralization.The concept of metamorphosis (change of form, structure, or substance) is very frequently encountered in Ancient Greek and Roman literature. One of the most striking types of metamorphosis described in many myths is gender transformation, where a man becomes a woman or vice versa. Herein, we present a case of pubertal gender inversion, the marvelous story of the Cretan Leucippus, which not only inspired many ancient writers but also led to the development of a distinct, local, religious cult. A medical interpretation of the myth, whereby we attempt to establish a diagnosis for this case of heterosexual puberty, is also provided.

Estrogens have beneficial effects on the cardiovascular system, promoting vasodilation, endothelial cells growth, relaxation, and regulation of blood pressure. Some of these effects could be associated with the purinergic system known for the control of vasodilation, inflammation, and platelet function. The aim of our study was the evaluation of ATP, AMP, and adenosine extracellular catabolism, catalyzed by ectonucleoside triphosphate diphosphohydrolase-1 (CD39), ecto-5'-nucleotidase (CD73), and ecto-adenosine deaminase (eADA) in mouse aortas.

Extracellular hydrolysis of ATP, AMP, and adenosine was estimated on the aortic surface of 3-month-old female and male C57BL/6J wild-type (WT) mice, in female WT mouse aortas incubated for 48h in the presence or absence of 100nM estradiol, and in WT female mouse and ApoE-/-LDL-R-/- aortas. The conversion of substrates to products was analyzed by high-pressure liquid chromatography (HPLC).

We demonstrated significantly higher adenosine deamination rate in WT male vs.