Vancouver Clinic

Methadone is a widely used opioid for the management of chronic pain and opioid use disorder. Despite its safety profile, it is complicated by rare but significant side effects that can be easily overlooked in patients with multiple comorbidities. This case report details a challenging scenario of persistent hypoglycemia in a patient with a complex history of chronic pain syndrome, failed back surgery, and type 2 diabetes mellitus, who was maintained on high-dose methadone for pain control. Despite persistent hyperglycemia (glucose = 165-245 mg/dL, hemoglobin A1c = 7.0-8.1%) and the need for frequent insulin dose adjustments due to poor glycemic control, the patient experienced recurrent episodes of overnight hypoglycemia despite insulin administration for carbohydrate intake. The paradox of hyperglycemia with intermittent hypoglycemia was attributed to methadone use, with hypoglycemia episodes noted to be dose-dependent at methadone doses exceeding 40 mg daily. The patient’s endocrine comorbidities, including hypothyroidism and hypogonadism, further complicated glucose homeostasis and counter-regulatory responses. This case signifies the importance of maintaining a high index of suspicion of opioid-induced hypoglycemia in patients with diabetes and chronic pain, especially in the context of escalating methadone therapy. It highlights the need for individualized management strategies when multiple risk factors are present.

Abstract Community-based aging resources, like Area Agencies on Aging (AAA), are often underutilized. Establishing partnerships with healthcare providers can promote better awareness and use of available services/supports. We evaluated a community partnership between a primary care clinic and an AAA; both community partners were committed to reducing adverse health outcomes. This exploratory intervention study assessed social determinants of health (SDH) needs of Medicare-eligible primary care patients (n = 385) during an annual visit (Mage=72.5; 89.6% White) and connected patients to appropriate supportive aging services. There were 284 participants with identified unmet SDH needs, but only 36 participants accepted referral to AAA resources. We analyzed Medicare’s Risk Adjustment Factor (RAF) score at baseline and participants’ use of advanced care (i.e., ER visits/hospital readmissions/institutionalizations), urgent care, and primary care, over a 6-month period. Descriptive, bivariate, and multivariate analyses revealed positive associations between RAF score with age (p< 0.001) and number of SDH needs (p< 0.001), advanced care with SDH needs (p=0.004) and RAF score (p< 0.001), and primary care visits with SDH needs (p=0.003) and RAF score (p< 0.001). The screening revealed that older adults’ SDH needs are often unmet and underrecognized. Cross-sector partnerships between medical and social models of health can reduce risk and meet needs of community-dwelling older adults. Policy provisions that encourage such partnerships are needed to improve community-dwelling older adults’ wellbeing, independence, and ability to age-in-place.

This study investigated treatment-engagement fears, self-efficacy, and accommodating and enabling in mothers and fathers of adolescent and adult children with eating disorders. This study involved a secondary analysis of pre-treatment data from a subsample of 143 parents (95 mothers; 48 fathers) from a Canada-wide multi-site study. Parents completed the Caregiver Traps Scale, Parents Versus Anorexia Scale, and the Accommodation and Enabling Scale for Eating Disorders. Data were analysed using factorial Multivariate Analysis of Variance and mediation via multiple regression. Mothers reported higher levels of treatment-engagement fears than fathers. Among mothers, higher fear predicted lower self-efficacy and more accommodating and enabling behaviours. Among fathers, neither fear nor self-efficacy predicted accommodating and enabling. No differences in treatment-engagement fear or self-efficacy between parents of adolescent child and adult children were found at pre-treatment. Mothers' and fathers' experience different levels of fear related to their involvement in their ill-child's treatment at pre-treatment, and that fear is uniquely related to variables that impact treatment outcomes. There is a need to support parents even when their child is an adult. This study can inform family-based treatments vis-a-vis tailoring interventions for mothers and fathers and providing support to parents of children with eating disorders across the lifespan.

Background: Refractory angina is defined as a chronic condition characterized by the presence of angina due to coronary insufficiency which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. Prevalence in the United States is estimated to be between 300,000-900,000. Spinal cord stimulation for refractory angina pain relief was first described in 1987 but is still not widely used in North America. We report our experience with this treatment. Methods: A retrospective review of patients referred to the St Pauls Hospital neuromodulation program for consideration of SCS for refractory angina was conducted. Patients underwent implantation using a either a two stage approach (percutaneous or permanent lead trial followed by full system implantation) or full system implantation. Results: Bewtween 2004-2020 36 patients underwent full system implantation (2 patients failed the trial and were not implanted). Of the 36 patients undergoing full system implantation, 33 (92%) experienced significant reduction of angina, increased exercise tolerance and/or medication reduction and were considered successful implantation. Most common lead placement location was at C7 T1. Conclusions: Spinal cord stimulation is an effective therapy for patients suffering from crippling angina pain despite medical optimization.

In the global coronavirus disease 2019 (COVID-19) pandemic, to date, delivery of critically ill pregnant patients has predominantly been by cesarean. A 27-year-old pregnant woman was admitted to a 166-bed community hospital at 33 weeks of gestation with acute hypoxemic respiratory failure secondary to COVID-19. She underwent mechanical ventilation for 9 days. While ventilated, she underwent induction of labor, resulting in a successful forceps assisted-vaginal birth. She was extubated on postpartum day 5 and discharged on postpartum day 10. The neonate was intubated for 24 hours but was otherwise healthy and discharged home at 36 2/7 weeks postmenstrual age. Critically ill patients requiring mechanical ventilation, in this case due to COVID-19, may undergo induction of labor and vaginal delivery when carefully selected.

In this chapter readers are introduced to the choices of emergency (battery and UPS) systems, battery room maintenance, essential for plant operation as well as for maintaining the critical systems in readiness for recovery following plant outages.