Introduction:Medications to treat opioid use disorder (MOUD) has been associated with improved maternal-fetal outcomes when compared with illicit opioid use during pregnancy. However, there remains ambiguity surrounding optimal strategies for initiating and rotating MOUD for pregnant patients. This manuscript aims to introduce a novel approach to rotating a patient from methadone to sublingual buprenorphine/naloxone during pregnancy, followed by a rapid macrodosing titration to depot buprenorphine in the immediate postpartum period.Methods:This is a case report. It follows one patient's experience with illicit opioid use and MOUD in the peripartum period.Results:While the patient completed an uncomplicated intrapartum in-hospital rotation from methadone to sublingual buprenorphine/naloxone at 26 weeks gestation, she discontinued MOUD and resumed illicit opioid use 1 week later. The patient successfully completed a macroinduction of depot buprenorphine immediately postpartum and has since remained adherent to monthly depot injections and abstinent from illicit opioids for 5 months and counting.Conclusions:This manuscript details a unique and effective approach to a rotation of a pregnant patient from methadone to sublingual buprenorphine/naloxone via low-dose initiation, plus rapidly initiating depot buprenorphine immediately postpartum via macrodosing. Details of these protocols may aid future obstetrical addiction providers in optimizing opioid management for their patients. Introduction:M & eacute;dicaments pour traiter les troubles li & eacute;s & agrave; la consummation d'opiac & eacute;s a & eacute;t & eacute; associ & eacute; & agrave; une am & eacute;lioration des r & eacute;sultats maternels-f oe taux par rapport & agrave; la consommation d'opio & iuml;des illicites pendant la grossesse. Cependant, l'ambigu & iuml;t & eacute; demeure quant aux strat & eacute;gies optimales d'instauration et de rotation du m & eacute;dicaments pour traiter les troubles li & eacute;s & agrave; la consummation d'opiac & eacute;s chez les patientes enceintes. Ce manuscrit vise & agrave; pr & eacute;senter une nouvelle approche pour faire passer une patiente de la m & eacute;thadone & agrave; la bupr & eacute;norphine/naloxone sublinguale pendant la grossesse, suivie d'une titration rapide par macrodosage & agrave; la bupr & eacute;norphine par d & eacute;p & ocirc;t dans la p & eacute;riode post-partum imm & eacute;diate.M & eacute;thodes:Il s'agit d'un rapport de cas. Il retrace l'exp & eacute;rience d'une patiente qui a fait usage d'opio & iuml;des illicites et de son m & eacute;dicaments pour traiter les troubles li & eacute;s & agrave; la consummation d'opiac & eacute;s pendant la p & eacute;riode p & eacute;ri-partum.R & eacute;sultats:Bien que la patiente ait effectu & eacute; une rotation intra-partum sans complication de la m & eacute;thadone & agrave; la bupr & eacute;norphine sublinguale/naloxone & agrave; la 26e semaine de gestation, elle a interrompu le m & eacute;dicaments pour traiter les troubles li & eacute;s & agrave; la consummation d'opiac & eacute;s et repris l'usage d'opio & iuml;des illicites une semaine plus tard. La patiente a r & eacute;ussi une macro-induction de bupr & eacute;norphine par d & eacute;p & ocirc;t imm & eacute;diatement apr & egrave;s l'accouchement et est rest & eacute;e depuis lors fid & egrave;le aux injections mensuelles par d & eacute;p & ocirc;t en s'abstenant de consommer des opio & iuml;des illicites depuis maintenant cinq mois.Conclusions:Ce manuscrit d & eacute;crit une approche unique et efficace pour faire passer une patiente enceinte de la m & eacute;thadone & agrave; la bupr & eacute;norphine/naloxone sublinguale par initiation & agrave; faible dose, en plus de l'initier rapidement & agrave; la bupr & eacute;norphine par d & eacute;p & ocirc;t imm & eacute;diatement apr & egrave;s l'accouchement par macrodosage. Les d & eacute;tails de ces protocoles peuvent aider les futurs prestataires de soins obst & eacute;triques aux toxicomanes & agrave; optimiser la gestion des opio & iuml;des pour leurs patientes.

Background: Emergency shelters offer temporary sleeping accommodation to people deprived of housing and connect them to services. Service restriction is the practice of limiting or denying someone access to emergency shelters. This parallel convergent mixed methods study describes the characteristics, healthcare utilization, and morbidity of people experiencing service restrictions in Hamilton, Ontario, and explores the relationship between health and service restriction. Methods: We recruited 20 people who had experienced service restriction and accessed healthcare from the Shelter Health Network clinic. We conducted semi-structured interviews and performed reflexive thematic analysis. We reviewed participants' medical records from January 1, 2018 to December 31, 2021 to calculate simple descriptive statistics. Mixing our qualitative and quantitative results, we generated narrative metainferences. We employed community-based research principles, including a research team with lived and living experiences of being service restricted, implementing service restrictions, or providing care to people experiencing service restrictions. Results: We generated six themes: 1) Losing your home shouldn't mean losing your humanity, 2) Where am I supposed to go?, 3) The snakes and ladders of service restrictions, 4) Abandoned to survive, 5) Constantly criminalized, 6) Harnessing the wisdom of community. Participants averaged 17.4 primary care visits, 11 emergency department visits, and 4 hospital admissions over 4 years. The most common reasons for visit were infections, traumatic injuries, and substance use-related concerns. Narrative metainferences highlighted how people experience dehumanization when accessing shelters or healthcare; how service restrictions and encampment living contribute to infections; the lack of practical supports for people using substances in shelters; the ubiquitous criminalization of people experiencing homelessness; and the care people practice for one another to reduce substance-related harms. Conclusions: Participants' high healthcare need and utilization was shaped by criminalization, stigma, societal abandonment, and abstinence-based substance use policies. Participants practiced care for themselves and others to navigate these barriers. Shelters should have a transparent service restriction process and employ harm reduction practices. Healthcare should provide affirming and accessible treatment for common conditions. Social and health services must contend with broader social forces while building on the strengths of people with lived experience to improve the health of people who are service restricted.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementFunding support was provided by Hamilton Community Foundation Education & Research Fund 2021-2022. The funders played no role in study design, data collection, data analysis, decision to publish, or writing of the manuscript. ### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Ethics approval was obtained from the Hamilton Integrated Research Ethics Board [Project #14035].I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll de-identified data produced in the present study are available upon reasonable request to the corresponding authors.

Homelessness is an emergencyOn any given night, about 35,000 people experience homelessness in Canada [1].Homelessness is associated with substantially higher mortality, with rates up to eight times higher for men [2] and 32 times higher for women compared to people of similar age (Table 1) [3].Despite this risk, homelessness remains underrecognized.As first responders in public health crises and working at a critical intersection of health systems, emergency department (ED) care providers are in a unique position to intervene.ED visits are often related to acute exacerbations of chronic health conditions or medical complications of being homeless

The original article can be found online.

The original article can be found online.

A 38-year-old man presents to your emergency department (ED) via emergency medical services (EMS).History obtained by paramedics indicates that he became unresponsive after smoking fentanyl.When 0.4 mg of intramuscular naloxone administered by bystanders was ineffective, they called EMS and initiated CPR.Paramedics arrived and administered another 0.8 mg of intramuscular naloxone at the scene, at which point the patient's respiratory rate improved to 10 breaths/min.He was mildly sedated upon arrival to the ED, but after a period of observation, he became awake and alert and developed diaphoresis, nausea, and myalgias.You identify these symptoms as opioid withdrawal.Your patient reports using opioids daily for several years and has been smoking 1 g of fentanyl per day for the past several months.He has experienced multiple opioid overdoses in the past year, but this was his first overdose requiring presentation to hospital.He has no other medical conditions and has never received treatment for his opioid use disorder.

A shortcut review was carried out to establish the incidence of arrhythmia after prescription of a fluoroquinolone antibiotic. 332 papers were found using the reported searches, of which 14 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that the incidence of arrhythmia after prescription of a fluoroquinolone antibiotic is low (<3%), but estimates are imprecise.