Methadone-maintained patients in primary care have higher rates of chronic disease and multimorbidity, and use health services more intensively than matched controls.

BACKGROUND: Methadone maintenance treatment in primary care is cost-effective and improves outcomes for opiate-dependent patients. A more developed understanding of the evolving needs of this important cohort will facilitate further improvements in their integrated care within the community. OBJECTIVES: The aim of this study was to compare the burden of chronic disease, multi-morbidity and intensity of health-service use between methadone-maintained patients (MMPs) and matched controls in primary care. METHODS: This is a retrospective matched case-control design. Data on chronic disease and health service use was collected in 13 computerized GP surgeries on 414 patients (207 MMPs and 207 controls). Twelve months of records were examined. MMPs were compared with controls matched by gender, age, socio-economic status (SES) and GP surgery. RESULTS: MMPs suffered more chronic disease (OR = 9.1, 95% CI: 5.4-15.1, P < 0.001) and multi-morbidity (OR = 6.6, 95% CI: 4.3-10.2, P < 0.001). They had higher rates of respiratory, psychiatric and infectious disease. MMPs of lower SES had more chronic disease than their peers (OR = 7.2, 95% CI: 2.4-22.0, P < 0.001). MMPs attended the doctor more often with medical problems (OR = 15.4, 95% CI: 8.2-28.7, P < 0.001), with a frequent requirement to have medical issues addressed during methadone-management visits. Their care generated more telephone calls (OR = 4.4, 95% CI: 2.8-6.8, P < 0.001), investigations (OR = 1.8, 95% CI: 1.2-2.7, P = 0.003), referrals (2.6, 95% CI: 1.7-4.0, P < 0.001), emergency department visits (2.1, 95% CI: 1.3-3.6, P = 0.004), outpatient attendances (2.3, 95% CI: 1.51-1.43, P < 0.001) and hospital admissions (3.6, 95% CI: 1.6-8.1, P = 0.001). CONCLUSION: Correcting for routine methadone care and drug-related illnesses, MMPs had a higher burden of chronic disease and used both primary and secondary health services more intensively than matched controls.

Comprehensive vestibular and balance testing in the dizzy pediatric population.

OBJECTIVE: To describe the spectrum of balance disease in a large population of children presenting to a tertiary care vestibular and balance laboratory. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care pediatric hospital. MAIN OUTCOME MEASURES: Results of audiometric, vestibular, and balance tests and final diagnosis. SUBJECTS AND METHODS: Retrospective review of audiometric, vestibular, balance testing, and final diagnosis from a patient database. RESULTS: Between September 2003 and September 2007, 132 children were evaluated at the Alfred I. duPont Hospital for Children Vestibular Disorders Program. Sixty-nine of the patients were boys and 63 were girls. The average age was 9.7 ± 5.0 years (range, 1-17 years). Although not all were able to complete the entire test battery (99 children completed at least 50% of the tests in the protocol), a diagnosis was achieved in most cases. The most common diagnoses were peripheral vestibulopathy (29.5%), migraine/benign recurrent vertigo of childhood (24.2%), motor/developmental delay (10.6%), traumatic brain injury (9.8%), and central nervous system structural lesion (9.1%). CONCLUSIONS: Peripheral vestibular deficits and migraine disease account for most of the pathology in the pediatric population. With a multidisciplinary approach, diagnosis of the source of vertigo and imbalance is possible in most children.

A novel approach for patients at risk for ovarian hyperstimulation syndrome: elective transfer of a single zona-free blastocyst on day 5.

In this preliminary prospective randomized study of 420 patients undergoing ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI), 17 patients (4%) developed moderate to severe ovarian hyperstimulation syndrome (OHSS). Re-evaluation for OHSS on day 4 and 6 after oocyte retrieval identified one patient with continuous risk for severe OHSS, resulting in cancellation of the transfer (1/17, 5.8%). Prospectively, two of three patients had the zona pellucida of the blastocyst removed by pronase exposure prior to transfer. Significantly more patients became pregnant when a zona-free blastocyst was transferred in comparison to transfer of a single zona-intact embryo (9/11 or 82% versus 1/5 or 20%; P < 0.01). Higher ongoing singleton pregnancy rates were obtained when the zona pellucida was removed prior to the transfer (6/11 and 1/5 respectively). This preliminary prospective randomized study indicates that by prolonging the evaluation time for patients at risk of developing OHSS for up to 6 days after the oocyte retrieval, those patients at risk for developing severe OHSS can be identified. Transferring a single zona-free day 5 embryo (blastocyst) and freezing of the supernumerary embryos offers the patient with moderate OHSS an optimal chance for a singleton pregnancy, while avoiding the serious maternal complications of ovarian hyperstimulation syndrome.