Referral quality was influenced by letter format but not by urgency of the patient's condition. Omission of information from referral letters potentially risks patient safety. Handwritten referrals should be abandoned. Comprehensive electronic letter templates and regular updating of medications, comorbidities and allergies are encouraged.

Objective To compare short and long term cardiovascular disease (CVD) risk scores and prevalence of metabolic syndrome in HIV-infected adults receiving and not receiving antiretroviral therapy (ART) to HIV-negative controls. Methods A cross-sectional study including: 151 HIV-infected, ART-naive, 150 HIV-infected on ART and 153 HIV-negative adults. Traditional cardiovascular risk factors were determined by standard investigations. The primary outcome was ACC/AHA ASCVD Risk Estimator lifetime CVD risk score. Secondary outcomes were ASCVD 10-year risk, Framingham risk scores, statin indication and metabolic syndrome. Results Compared to HIV-negative controls, more HIV-infected adults on ART were classified as high lifetime CVD risk (34.7% vs 17.0%, p<0.001) although 10-year risk scores were similar, a trend which was similar across multiple CVD risk models. In addition, HIV-infected adults on ART had a higher prevalence of metabolic syndrome vs HIV-negative controls (21.3% vs 7.8%, p=0.008), with 2 common clusters of risk factors. More than one-quarter (28.7%) of HIV-infected Tanzanian adults on ART meet criteria for statin initiation. Conclusions HIV-infected ART-treated individuals have high lifetime cardiovascular risk, and this risk seems to develop rapidly in the first 3–4 years of ART as does the development of clusters of metabolic syndrome criteria. These data identify a new subgroup of low short-term/high lifetime risk HIV-infected individuals on ART who do not currently meet criteria for CVD risk factor modification but require further study.

The incidence of fentanyl in forensic toxicology analyses in the U.S. has dramatically increased over the past several years. The increase in death cases has been well studied, however little has been reported on the impact to drug impaired driving. Fentanyl driving under the influence of drugs (DUID) case data from 2014 to 2019 is presented. The data was obtained from three toxicology laboratories in the Northeast, Southeast, and Midwest regions of the U.S. Fentanyl whole blood concentrations ranged from 0.1 ng/mL to 157 ng/mL in living drivers with a 466% to 524% increase in fentanyl positive DUID cases from 2014 to 2019 depending on the U.S. region. The vast majority of fentanyl cases involved poly-drug use. Twenty case histories are presented where fentanyl was the only drug identified. The mean (SD) fentanyl concentration for these cases was 5.2 ± 3.8 ng/mL with a median of 3.7 ng/mL and the concentrations ranged from 2.0 to 16 ng/mL. Naloxone administration was documented in exactly half of these cases similar to another study involving carfentanil impaired driving. The case histories also demonstrate that some recreational opioid users may display limited signs of impairment either due to tolerance or naloxone administration. The top three observations in common among the cases were the driver was found unresponsive behind the wheel, the vehicle left the travel lane or roadway, and the driver was involved in a crash. The increase in fentanyl use not only poses a risk for overdose and death, but is also a significant concern for traffic safety. This study supports the movement of fentanyl from a Tier II drug to Tier I due to its significant potential for impairment and increase in prevalence in impaired driving cases.