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de Paula Meirelles G, Pereira E Silva J, Paranhos BAPB, Yonamine M. Development of a dispersive liquid-liquid microextraction method for the evaluation of maternal-fetal exposure to cocaine employing human umbilical cord tissue. J Anal Toxicol 2024; 48:263-272. [PMID: 38551067 DOI: 10.1093/jat/bkae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 06/12/2024] Open
Abstract
Illicit drug use is a serious and complex public health problem, not only due to the severity of the health damage but also to the social implications, such as marginalization and drug trafficking. Currently, cocaine (COC) is among the most abused drugs worldwide with about 22 million users. Drug abuse has also been found in women during the pregnancy period, which has shed light on a new group for epidemiology. The diagnosis of COC use in these cases usually depends largely on the mother's reports, which in several cases omit or deny consumption. Therefore, considering physical-chemical methods of sample preparation and exposure biomarkers, the development of analytic toxicological methods can help to confirm drug use during pregnancy. Thus, the objective of the present work was to develop an analytical method based on dispersive liquid-liquid microextraction for the determination of COC analytes, using umbilical cord tissue as an alternative biological matrix, and detection by gas chromatography coupled to mass spectrometry. Therefore, after optimization, the dispersive liquid-liquid microextraction method was fully validated for quantification of COC, benzoylecgonine, cocaethylene, ecgonine, ecgonine methyl ester and norcocaine. The limits of detection were between 15 and 25 ng/g, the limits of quantification were 30 ng/g for ecgonine and 25 ng/g for the other analytes. Linearity ranged from the limits of quantification to 1,000 ng/g. Coefficients of variation for intra-assay precision were <18.5%, inter-assay was <8.75% and bias was <16.4% for all controls. The developed method was applied in 10 suspected positive samples, based on the mother's report and maternal urine screening and confirmation. COC, benzoylecgonine, ecgonine and ecgonine methyl ester were quantified in four umbilical cords with concentrations that ranged from 39.6 to 420.5 ng/g.
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Affiliation(s)
- Gabriela de Paula Meirelles
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580, 13B, Sao Paulo, SP 05508-000, Brazil
| | - Jefferson Pereira E Silva
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580, 13B, Sao Paulo, SP 05508-000, Brazil
| | - Beatriz Aparecida Passos Bismara Paranhos
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580, 13B, Sao Paulo, SP 05508-000, Brazil
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Martinez NG, Roberts SCM, Achu-Lopes RA, Samura TL, Seidman DL, Woodhams EJ. Reconsidering the use of urine drug testing in reproductive settings. Am J Obstet Gynecol MFM 2023; 5:101206. [PMID: 37871695 DOI: 10.1016/j.ajogmf.2023.101206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Abstract
The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.
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Affiliation(s)
- Noelle G Martinez
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Martinez).
| | - Sarah C M Roberts
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, CA (Dr Roberts)
| | - Rachel A Achu-Lopes
- Department of Anesthesia, Boston Medical Center, Boston University School of Medicine, Boston, MA (Dr Achu-Lopes)
| | - Tirah L Samura
- Los Angeles County Department of Health Services, Harbor-University of California Los Angeles Medical Center, Los Angeles, CA (Dr Samura); Los Angeles County Department of Health Services, Martin Luther King, Jr. Outpatient Center, Los Angeles, CA (Dr Samura)
| | - Dominika L Seidman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA (Dr Seidman)
| | - Elisabeth J Woodhams
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, MA (Dr Woodhams)
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Tran EL, England LJ, Park Y, Denny CH, Kim SY. Systematic Review: Polysubstance Prevalence Estimates Reported during Pregnancy, US, 2009-2020. Matern Child Health J 2023; 27:426-458. [PMID: 36752906 PMCID: PMC10521102 DOI: 10.1007/s10995-023-03592-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The objective of this systematic review is to describe polysubstance studies and their prevalence estimates among pregnant people in the US. METHODS This review was not subject to protocol preparation or registration with the International Prospective Register of Systematic Reviews (PROSPERO) because outcome data were not reported. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist was followed. Four scientific literature databases were used to identify articles published from January 1, 2009 to June 3, 2020 reporting prenatal exposure to two or more substances in the US. A standardized process of title and abstract screening followed by a two-phase full-text review was used to assess study eligibility. RESULTS A total of 119 studies were included: 7 case-control studies, 7 clinical trials, 76 cohort studies, and 29 cross-sectional studies. Studies varied with respect to study design, time period, region, sampling and participant selection, substances assessed, and method of exposure ascertainment. Commonly reported polysubstance prevalence estimates among studies of pregnant people included combinations with alcohol, marijuana, and/or tobacco/nicotine. The range of prevalence estimates was wide (alcohol 1-99%; marijuana 3-95%; tobacco/nicotine 2-95%). DISCUSSION Polysubstance use during pregnancy is common, especially with alcohol, marijuana, and/or tobacco/nicotine. Future research to assess polysubstance use during pregnancy could help better describe patterns and ultimately help mitigate its effects on maternal and infant health outcomes.
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Affiliation(s)
- Emmy L Tran
- Division of Birth Defects and Infant Disorders, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway, NE MS S106-3, Atlanta, GA, 30341, USA.
- Eagle Global Scientific, LLC, 2835 Brandywine Rd, Suite 200, Atlanta, GA, 30341, USA.
| | - Lucinda J England
- Division of Birth Defects and Infant Disorders, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway, NE MS S106-3, Atlanta, GA, 30341, USA
| | - Youngjoo Park
- Division of Birth Defects and Infant Disorders, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway, NE MS S106-3, Atlanta, GA, 30341, USA
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, TN, USA
| | - Clark H Denny
- Division of Birth Defects and Infant Disorders, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway, NE MS S106-3, Atlanta, GA, 30341, USA
| | - Shin Y Kim
- Division of Birth Defects and Infant Disorders, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway, NE MS S106-3, Atlanta, GA, 30341, USA
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4
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Langman LJ, Rushton AM, Thomas D, Colbourne P, Seiden-Long I, Brun MM, Colantonio D, Jannetto PJ. Drug testing in support of the diagnosis of neonatal abstinence syndrome: The current situation. Clin Biochem 2023; 111:1-10. [PMID: 36379240 DOI: 10.1016/j.clinbiochem.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/21/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Illicit drug use during pregnancy is a concern worldwide, with many international studies describing attempted strategies to mitigate this problem. Drug misuse during pregnancy is associated with significant maternal as well as perinatal complications, which include a high incidence of stillbirths, fetal distress, neonatal abstinence syndrome (NAS) and increased neonatal mortality. Unfortunately, the identification of a drug-exposed mother or neonate is challenging. Maternal disclosure of drug use is often inaccurate, principally due to psychosocial factors including behavioral denial or the fear of the consequences resulting from such admissions. Likewise, many infants who have been exposed to drugs in utero may appear normal at birth and initially show no overt manifestations of drug effects. Thus, the identification of the drug-exposed infant requires a high index of clinical suspicion. Conversely, analytical testing is an objective means of determining drug exposure when it may be necessary to document proof of the infant's exposure to illicit drugs. The review will discuss the different matrices that are most commonly used for testing (e.g., maternal urine, neonatal urine, meconium, and umbilical cord), the strengths and limitations for each matrix, which drugs and metabolites are appropriate for testing, the various testing methods, and the advantages and disadvantages of each method.
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Affiliation(s)
- Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Alysha M Rushton
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Dylan Thomas
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Penny Colbourne
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Isolde Seiden-Long
- Alberta Precision Laboratories and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Miranda M Brun
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - David Colantonio
- Eastern Ontario Regional Laboratory Association and Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Karr AJ, Rayens MK, Scott LK. Neonatal abstinence syndrome: Effectiveness of targeted umbilical cord drug screening. J Perinatol 2022; 42:1038-1043. [PMID: 35810246 DOI: 10.1038/s41372-022-01457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/24/2022] [Accepted: 06/30/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study sought to determine if targeted drug screening of newborns was effective in identifying a positive drug test result. STUDY DESIGN This was a retrospective cross-sectional study. A total of 340 infants met criteria for drug screening. Sensitivity and specificity were used to evaluate each of the potential risk factors in terms of their ability to predict a positive drug test result. Two-sample t-tests were used to compare differences in Finnegan scores between babies with a positive drug test result and those with a negative one. RESULT The risk factor with the highest sensitivity was maternal history of drug use. The difference in the Finnegan scores between groups was statistically significant. CONCLUSION The risk factors associated with this study were not very sensitive. The only way to identify all infants at risk of NAS is to standardize the screening process and apply to all infants.
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Affiliation(s)
- Alecia J Karr
- Division of Neonatology, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,Baptist Hardin Health, Elizabethtown, KY, USA. .,University of Kentucky College of Nursing, Lexington, KY, USA.
| | - Mary Kay Rayens
- University of Kentucky College of Nursing, Lexington, KY, USA
| | - Leslie K Scott
- University of Kentucky College of Nursing, Lexington, KY, USA
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Simpson EA, Skoglund DA, Stone SE, Sherman AK. A Prediction Model for Positive Infant Meconium and Urine Drug Tests. Am J Perinatol 2022; 39:1104-1111. [PMID: 33336348 DOI: 10.1055/s-0040-1721688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study aimed to determine the factors associated with positive infant drug screen and create a shortened screen and a prediction model. STUDY DESIGN This is a retrospective cohort study of all infants who were tested for drugs of abuse from May 2012 through May 2014. The primary outcome was positive infant urine or meconium drug test. Multivariable logistic regression was used to identify independent risk factors. A combined screen was created, and test characteristics were analyzed. RESULTS Among the 3,861 live births, a total of 804 infants underwent drug tests. Variables associated with having a positive infant test were (1) positive maternal urine test, (2) substance use during pregnancy, (3) ≤ one prenatal visit, and (4) remote substance abuse; each p-value was less than 0.0001. A model with an indicator for having at least one of these four predictors had a sensitivity of 94% and a specificity of 69%. Application of this screen to our population would have decreased drug testing by 57%. No infants had a positive urine drug test when their mother's urine drug test was negative. CONCLUSION This simplified screen can guide clinical decision making for determining which infants should undergo drug testing. Infant urine drug tests may not be needed when a maternal drug test result is negative. KEY POINTS · Many common drug screening criteria are not predictive.. · Four criteria predicted positive infant drug tests.. · No infant urine drug test is needed if the mother tests negative..
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Affiliation(s)
- Elizabeth A Simpson
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - David A Skoglund
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Sarah E Stone
- Department of Population Health, Inova Fairfax Hospital for Children, Falls Church, Virginia
| | - Ashley K Sherman
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Pandya V, Wilker C, McMillin GA. Can Umbilical Cord and Meconium Results Be Directly Compared? Analytical Approach Matters. J Anal Toxicol 2022; 47:96-105. [PMID: 35707888 PMCID: PMC9942436 DOI: 10.1093/jat/bkac037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 12/26/2022] Open
Abstract
Maternal drug use during pregnancy is a significant concern. Drug-exposed newborns are often born premature and may suffer from birth defects, neonatal abstinence syndrome and cognitive and developmental delays. Because of this, testing of neonatal specimens is carried out to assess fetal drug exposure during pregnancy. Umbilical cord tissue (UC) and meconium are commonly used specimens for this purpose. However, comprehensive studies comparing drug positivity rates and concentration in the two specimen types are lacking. To this end, 4,036 paired UC and meconium specimens originating from 13 states within the USA were identified, and retrospective analysis of drug positivity rates and drug concentration was performed for 31 analytes in 5 drug classes. Testing for 11-Nor-9-carboxy-tetrahydrocannabinol (THC-COOH) is a separate orderable for UC specimen at our laboratory, so a second data set was created for evaluation of this drug analyte with 2,112 paired UC and meconium specimens originating from 11 states. Testing of UC was performed by semi-quantitative liquid chromatography-tandem mass spectrometry (LC-MS-MS) assays, whereas, for meconium, an immunoassay-based screening preceded LC-MS-MS confirmation tests. Results generated for UC and meconium specimens were therefore compared for a total of 32 drug analytes from 6 drug classes. Drug concentrations for analytes were higher in meconium compared to UC, with the exception of phencyclidine. Despite this, the positivity rates for individual analytes were higher in UC, with the exception of THC-COOH and cocaine. Furthermore, analysis for multidrug positivity revealed that THC-COOH and opioids were the most common multidrug combination detected in both matrices. In conclusion, this study suggests that for most drug compounds, UC was more analytically sensitive to assess neonatal drug exposure by current methodologies. Additionally, by demonstrating that meconium has higher drug concentrations for most compounds, this study sets the stage for developing more sensitive assays in meconium.
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Affiliation(s)
- Vrajesh Pandya
- Department of Pathology, University of Utah Health, Salt Lake City, UT 84112, USA,ARUP Laboratories, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Chase Wilker
- ARUP Laboratories, 500 Chipeta Way, Salt Lake City, UT 84108, USA,ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
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Mark K, Pace L, Temkin SM, Crimmins S, Terplan M. Concordance and discordance between maternal and newborn drug test results. Am J Obstet Gynecol MFM 2021; 3:100366. [PMID: 33831588 DOI: 10.1016/j.ajogmf.2021.100366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Screening for substance use is recommended during pregnancy, and many clinicians rely on urine drug screening to identify newborns at potential risk for withdrawal. OBJECTIVE This study aimed to determine the concordance and discordance rates between maternal and neonatal drug testing at or near the time of delivery. STUDY DESIGN This retrospective chart review was performed at a single institution that employs universal testing for those who consent. Results of maternal and neonatal urine drug testing via immunoassay at delivery were compared. RESULTS Of 1573 singleton pregnancies, 233 mothers (14.8%) had a positive test result for any substance and 102 of their newborns (43.8%) had concordant positive test results. Of the 285 positive maternal test results for individual substances, 133 (46.7%) were concordant with newborn test results. After removing iatrogenic positives, there were 84 truly discordant pairs representing 5.9% of the total cohort of test pairs, but 29.5% of the pairs with maternal positive test results. When considering the outcome of a newborn positive test result, the overall sensitivity and specificity for the maternal test were 21.1% and 85.8%, respectively. The positive and negative predictive values were 46.7% and 96.4%, respectively. After excluding iatrogenic positive test results, the sensitivity and specificity for maternal testing were 97.8% and 99.4%, respectively, and the negative predictive value of maternal testing for all substances approached 100%. A total of 11 pairs of twins had at least 1 twin with a positive drug test result, and of these, 6 twin pairs (54.5%) had drug test results that were discordant from each other. CONCLUSION There is a high rate of iatrogenic discrepancy in maternal and neonatal drug testing. After adjusting for iatrogenic positive test results, the negative predictive value of maternal testing is high. Many discrepancies, such as those in twins, remained unexplained by medication administration, and potential reasons for these discrepancies warrant further investigation.
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Affiliation(s)
- Katrina Mark
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins).
| | - Lauren Pace
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins)
| | | | - Sarah Crimmins
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins)
| | - Mishka Terplan
- Friend Social Research Institute, Baltimore, MD (Dr Terplan)
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Roth D, Loudin S, Andrews L, Evans J, Davies TH. Inclusion of Positive Self-reporting by Mothers of Substance Exposed Neonates Increases the Predictability of NAS Severity Over Toxicology Alone. Matern Child Health J 2020; 24:340-350. [PMID: 31916143 DOI: 10.1007/s10995-019-02871-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The rise in opioid use among pregnant women has resulted in an increase in the incidence of neonatal abstinence syndrome (NAS). Despite the focus on opioid use, prenatal polysubstance exposure is often associated with NAS diagnosis and severity. Drug toxicology screens such as urine drug screens and umbilical cord toxicology are dependent upon the substance, timing, frequency, and dose to detect substances present and can underestimate the neonatal exposure. The aim of this study was to identify the predictability of the consequences of prenatal polysubstance exposure versus opioid only exposure based on toxicology and toxicology plus self-report. METHODS Neonates > 35 weeks gestation with prenatal opioid exposure were included in this retrospective data analysis. NAS was identified using maternal urine drug screen (UDS) toxicology, self-reported exposure during pregnancy, and neonatal toxicology. Analysis was conducted using Stata 15.1 utilizing McNemar's test, chi-square for categorical outcomes, and Wilcoxon test for numerical outcomes. RESULTS A statistically significant difference in length of stay and length of treatment with poly-exposed neonates was observed when maternal self-report was considered with toxicology, but not with toxicology alone. This trend was observed for cumulative hospital length of stay as well as length and dose of treatment. CONCLUSIONS FOR PRACTICE The findings in this report demonstrate that self-report is important for identifying substance of exposure. Three substances in particular that often require a change in treatment paradigm went undetected by toxicology were Gabapentin (20.9% of the population), Heroin (20.5% of the population), and Benzodiazepines (8.5% of the population). A healthy rapport with patients is often critical to effective clinical practice. Women with substance use disorder anticipate negative reactions from healthcare providers. Empathetic interview techniques to facilitate accurate disclosure may be more important to the treatment of the exposed neonate.
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Affiliation(s)
- Danielle Roth
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - Sean Loudin
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - Lacey Andrews
- Division of Addiction Sciences, Family and Community Health, Joan C Edwards School of Medicine of Marshall University, 1600 Medical Center Drive, Huntington, WV, 25701, USA
| | - Joseph Evans
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - Todd H Davies
- Division of Addiction Sciences, Family and Community Health, Joan C Edwards School of Medicine of Marshall University, 1600 Medical Center Drive, Huntington, WV, 25701, USA.
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Abstract
A 13-year-old girl presents to the emergency department for the second time with an unresponsive episode. She has a GCS (Glasgow Coma Scale) score of 11 on arrival and all other observations are normal. The story is unclear, but there are ongoing safeguarding concerns and the family are known to social services. All investigations are normal. After a period of observation on the ward, her GCS returns to normal and she appears well. Both on the first presentation and this presentation ingestion of a toxin was suspected. However, this was denied by the patient and urine toxicology screen was negative. Does this rule out toxin ingestion? Will this change your management?
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Affiliation(s)
- Emma M Dyer
- Evelina London Children's Healthcare, London, UK
| | - Sormeh Salehian
- Paediatric Department, Addenbrooke's Hospital, Cambridge, UK
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11
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Singh S, Filion KB, Abenhaim HA, Eisenberg MJ. Prevalence and outcomes of prenatal recreational cannabis use in high-income countries: a scoping review. BJOG 2019; 127:8-16. [PMID: 31529594 DOI: 10.1111/1471-0528.15946] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND With expanding recreational cannabis legalisation, pregnant women and their offspring are at risk of potentially harmful consequences. OBJECTIVES To assess the prevalence of recreational cannabis use among pregnant women, health outcomes associated with prenatal recreational cannabis use, and the potential impact of recreational cannabis legalisation on this population. SEARCH STRATEGY Five databases and the grey literature were systematically searched (2000-2019). SELECTION CRITERIA Human studies published in English or French reporting on the prevalence of prenatal recreational cannabis use in high-income countries. DATA COLLECTION AND ANALYSIS Data on study characteristics, prenatal substance use, and health outcomes were extracted and qualitatively synthesised. MAIN RESULTS Forty-one publications met our inclusion criteria. The overall prevalence of prenatal cannabis use varied substantially (min-max: 0.24-22.6%), with the greatest use in the first trimester. In the three studies with temporal data available, rates of prenatal cannabis use increased across years. Only 7/41 and 5/41 studies provided information on gestational age of exposure and frequency of use, respectively. The concomitant use of alcohol, illicit drugs, and tobacco was higher among cannabis users than nonusers. Prenatal cannabis use was associated with select neonatal, but not maternal, health outcomes. There were insufficient data to compare prenatal cannabis use between the pre- and post-legalisation periods. CONCLUSION Cannabis use among pregnant women is prevalent and may be associated with adverse neonatal outcomes. Future studies should assess the gestational age and frequency of cannabis exposure, and usage patterns prior to and following legalisation. TWEETABLE ABSTRACT Women who consume cannabis during pregnancy could risk predisposing their newborns to poor birth outcomes.
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Affiliation(s)
- S Singh
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - K B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - H A Abenhaim
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - M J Eisenberg
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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12
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Abstract
Substance and alcohol use disorders impose large health and economic burdens on individuals, families, communities, and society. Neither prevention nor treatment efforts are effective in all individuals. Results are often modest. Advances in neuroscience and addiction research have helped to describe the neurobiological changes that occur when a person transitions from recreational substance use to a substance use disorder or addiction. Understanding both the drivers and consequences of substance use in vulnerable populations, including those whose brains are still maturing, has revealed behavioral and biological characteristics that can increase risks of addiction. These findings are particularly timely, as law- and policymakers are tasked to reverse the ongoing opioid epidemic, as more states legalize marijuana, as new products including electronic cigarettes and newly designed abused substances enter the legal and illegal markets, and as "deaths of despair" from alcohol and drug misuse continue.
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Affiliation(s)
- George R. Uhl
- New Mexico VA Healthcare SystemAlbuquerqueNew Mexico
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13
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Wood KE, McMillin GA, Krasowski MD. Risk-Based Newborn Drug Testing in a Setting With a Low Prevalence of Maternal Drug Use. Hosp Pediatr 2019; 9:593-600. [PMID: 31278167 DOI: 10.1542/hpeds.2018-0256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Our objective in this study was to determine the predictive value of an institutional risk-based newborn drug-testing tool for detecting maternal drug use during pregnancy. METHODS For 5.5 months, the umbilical cords of all newborns born at the study institution were collected and analyzed at a national reference laboratory. In the context of usual clinical care, the decision to perform newborn drug testing is based on an institutional risk assessment tool. For the cohort without clinical indication for testing, cords were deidentified during the study period. Chart review was not performed. Study data were compared with a national data set during the same time period and to previous institutional data. RESULTS We tested 857 newborns, 257 of which had 1 or more identified risk factors. There were no drugs or drug metabolites that were significantly more common in the cohort without risk factors than in the clinical cohort. Alprazolam, methamphetamine, hydrocodone, and oxycodone were all significantly more commonly found in the risk-identified cohort. Amphetamine, methamphetamine, and cocaine were not detected in umbilical cords from any of the 600 newborns that would not have been identified for testing. Tetrahydrocannabinol (1.0%; n = 6) was the only illegal substance in the institution's state that would not have been detected. CONCLUSIONS Performing universal newborn drug testing in the study population would have identified an additional 6 newborns who were exposed prenatally to tetrahydrocannabinol out of 600 who were additionally tested. In areas with a low prevalence of maternal drug use, universal testing may not be cost-effective.
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Affiliation(s)
- Kelly E Wood
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa;
| | - Gwendolyn A McMillin
- Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City, Utah; and
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Abstract
Drug testing commonly involves serum, blood, or urine. More recently, alternative specimens for drug testing have been increasingly used for clinical and forensic toxicology. Examples include oral fluid (saliva), hair, meconium, and umbilical cord tissue. Each of these matrices has unique properties that provide advantages for certain applications. Oral fluid has easier and less invasive collection requirements than urine, the most common specimen for drug screening. Oral fluid drug testing is common in Europe and steadily gaining popularity in the United States. Hair accumulates drugs and drug metabolites and provides a much longer window of detection than blood or urine. Meconium and umbilical cord tissue each allow for assessment of prenatal drug exposure over the course of months. Limitations of these alternative matrices include need for laboratory-developed tests (exception being some oral fluid immunoassays), challenges with the specimen matrix, and incomplete understanding of drug incorporation and kinetics. This chapter briefly describes each of the above alternative specimens in terms of their utility, advantages, and limitations.
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Price HR, Collier AC, Wright TE. Screening Pregnant Women and Their Neonates for Illicit Drug Use: Consideration of the Integrated Technical, Medical, Ethical, Legal, and Social Issues. Front Pharmacol 2018; 9:961. [PMID: 30210343 PMCID: PMC6120972 DOI: 10.3389/fphar.2018.00961] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/03/2018] [Indexed: 01/01/2023] Open
Abstract
North America is currently suffering from one of the worst epidemics of illicit drug use in recent history: the opioid crisis. Pregnant women are not immune to the ravages of substance misuse which affects themselves, their pregnancies, and the wider community. The prevalence of drug misuse in pregnancy is not well quantified due to the lack of good validated tests, cooperation between clinicians and scientists developing tests, and consensus as to who should be tested and how results should be used. A wide range of tissues can be tested for drug use, including maternal blood, urine, and hair; neonatal meconium, urine, and hair; and placenta and umbilical cord tissues. Testing methods range from simple spectrophotometry and clinical chemistry to sophisticated analytical HPLC or mass spectrometry techniques. The drive for ever greater accuracy and sensitivity must be balanced with the necessities of medical practice requiring minimally invasive sampling, rapid turnaround, and techniques that can be realistically utilized in a clinical laboratory. Better screening tests have great potential to improve neonatal and maternal medical outcomes by enhancing the speed and accuracy of diagnosis. They also have great promise for public health monitoring, policy development, and resource allocation. However, women can and have been arrested for positive drug screens with even preliminary results used to remove children from custody, before rigorous confirmatory testing is completed. Balancing the scientific, medical, public health, legal, and ethical aspects of screening tests for drugs in pregnancy is critical for helping to address this crisis at all levels.
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Affiliation(s)
- Hayley R Price
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Abby C Collier
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Tricia E Wright
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, United States.,Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, United States
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Historical and clinical factors associated with positive urine toxicology screening on labor and delivery. Eur J Obstet Gynecol Reprod Biol 2018; 228:261-266. [PMID: 30041147 DOI: 10.1016/j.ejogrb.2018.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Illicit drug use in pregnancy may lead to adverse outcomes. Although the American College of Obstetricians and Gynecologists recommends that all pregnant women be screened for substance use by questionnaire or conversation, it remains unclear how well these methods identify women with illicit drug use. Drug use may also be suspected based on clinical complications, such as fetal demise or placental abruption. There are currently no formal recommendations to guide targeted laboratory testing in women perceived to be at risk based on historical or clinical factors. Our objective was to determine which historical and clinical factors are associated with positive urine toxicology screens in women admitted to labor and delivery. STUDY DESIGN Historical cohort study of all women admitted to labor and delivery at our county hospital over a 5-year period (2010-2014). All patients underwent historical and clinical risk assessment and women perceived to be at increased risk of illicit drug use and who consented to testing had urine toxicology performed. We conducted a detailed chart review on all women with a positive test during this 5-year period and compared them to all women with a negative test in 2014, reporting values significant at a p-value of ≤0.05. RESULTS Amongst the 19,604 admissions during this period, 850 women underwent urine toxicology testing, accounting for 4.8% of all admissions. We compared the 83 women who tested positive for illicit drugs (9.8% of all women tested) to the 179 women who tested negative in 2014. Historical drug use was the factor most strongly associated with a positive test. Other historical and demographic factors associated with a positive test included single relationship status, lack of employment, lack of high school education, nulliparity and history of a prior sexually-transmitted or blood-borne infection. Regarding clinical risk factors, maternal medical complications were not associated with a positive test, and obstetrical complications, like preterm labor, were associated with a negative test. CONCLUSIONS A positive urine toxicology test was most strongly associated with maternal historical factors, especially known drug use. No clinical risk factor was associated with a positive test. The implications of our findings in guiding targeted laboratory testing are discussed.
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Perceptions, Practices, and Mother’s Willingness to Provide Meconium for Use in the Assessment of Environmental Exposures among Children in Mukono and Pallisa Districts, Uganda. ADVANCES IN PUBLIC HEALTH 2018. [DOI: 10.1155/2018/5691323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Presence of biomarkers or metabolites is assessed in various human biospecimens including meconium in the investigation of exposures to environmental contaminants. This study gathered data on the perceptions and practices of mothers in two rural districts of Uganda concerning meconium and their willingness to provide meconium from their babies for research purposes. The study reveals a wide range of perceptions and beliefs around meconium as well as a number of associated taboos and practices. Many participants noted that meconium could be used to detect ailments among newborns based on its appearance. Practices and beliefs included using it to prevent stomach discomfort and other ailments of newborns, as a means to confirm paternity and initiate the child into the clan as well as facilitating father-child bonding that included ingestion of meconium by the fathers. Most mothers indicated scepticism in accepting to provide meconium for research purposes and had fears of unscrupulous people disguising as researchers and using meconium to harm their children. However, some were willing to provide meconium, if it helped to detect ailments among their children. These perceptions and practices may negatively influence mothers’ willingness to participate in meconium study. However, through provision of educational and behaviour change interventions, mothers’ willingness to participate in a meconium study can be improved.
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Palmer KL, Wood KE, Krasowski MD. Evaluating a switch from meconium to umbilical cord tissue for newborn drug testing: A retrospective study at an academic medical center. Clin Biochem 2017; 50:255-261. [DOI: 10.1016/j.clinbiochem.2016.11.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/16/2016] [Accepted: 11/22/2016] [Indexed: 11/27/2022]
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Colby JM. Comparison of umbilical cord tissue and meconium for the confirmation of in utero drug exposure. Clin Biochem 2017; 50:784-790. [PMID: 28288850 DOI: 10.1016/j.clinbiochem.2017.03.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Drug screening in neonates is traditionally performed using meconium, but cord tissue has been proposed as an alternative specimen. This study compares the detection of drugs in a large number of paired meconium and umbilical cord tissue samples from subjects at risk of in utero drug exposure. DESIGN AND METHODS Physician-ordered toxicology results and clinical information were collected in a retrospective review of subject medical records. All toxicology testing was performed by a national reference laboratory using a combination of immunoassays and chromatography-mass spectrometry. The comparison was limited to drugs present in both cord and meconium panels. RESULTS Overall agreement between cord and meconium ranged from 76% (cannabinoids) to 100% (barbiturates), but Cohen's kappa was <65% for 5 of the 6 drug classes we studied. Considering meconium as the gold standard, cord was less sensitive for the detection of 5 of the 6 drug classes, and for the detection of all 5 individual opioids. For 3 of the 5 individual opioids, the concentration of drug measured in meconium did not correlate well with qualitative detection in cord. CONCLUSIONS This study reveals different sensitivities of drug detection in umbilical cord tissue and meconium. For the drugs studied here, meconium provides greater sensitivity, and is likely to remain the specimen of choice when sensitivity is of greatest importance. These results can help clinicians, laboratorians, and epidemiologists to (1) select the most appropriate test to confirm a suspected drug exposure and (2) interpret discordant results when testing is performed in multiple matrices.
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Affiliation(s)
- Jennifer M Colby
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4918B TVC, Nashville, TN 37232, USA.
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Krasowski MD, Ford BA, Klutts JS, Jensen CS, Briggs AS, Robinson RA, Bruch LA, Karandikar NJ. Using Focused Laboratory Management and Quality Improvement Projects to Enhance Resident Training and Foster Scholarship. Acad Pathol 2017; 4:2374289517722152. [PMID: 28913416 PMCID: PMC5590695 DOI: 10.1177/2374289517722152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/26/2017] [Accepted: 06/28/2017] [Indexed: 11/22/2022] Open
Abstract
Training in patient safety, quality, and management is widely recognized as an important element of graduate medical education. These concepts have been intertwined in pathology graduate medical education for many years, although training programs face challenges in creating explicit learning opportunities in these fields. Tangibly involving pathology residents in management and quality improvement projects has the potential to teach and reinforce key concepts and further fulfill Accreditation Council for Graduate Medical Education goals for pursuing projects related to patient safety and quality improvement. In this report, we present our experience at a pathology residency program (University of Iowa) in engaging pathology residents in projects related to practical issues of laboratory management, process improvement, and informatics. In this program, at least 1 management/quality improvement project, typically performed during a clinical chemistry/management rotation, was required and ideally resulted in a journal publication. The residency program also initiated a monthly management/informatics series for pathology externs, residents, and fellows that covers a wide range of topics. Since 2010, all pathology residents at the University of Iowa have completed at least 1 management/quality improvement project. Many of the projects involved aspects of laboratory test utilization, with some projects focused on other areas such as human resources, informatics, or process improvement. Since 2012, 31 peer-reviewed journal articles involving effort from 26 residents have been published. Multiple projects resulted in changes in ongoing practice, particularly within the hospital electronic health record. Focused management/quality improvement projects involving pathology residents can result in both meaningful quality improvement and scholarly output.
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Affiliation(s)
- Matthew D. Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Bradley A. Ford
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - J. Stacey Klutts
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Pathology and Laboratory Medicine, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Chris S. Jensen
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Angela S. Briggs
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Robert A. Robinson
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Leslie A. Bruch
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Nitin J. Karandikar
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Wood KE, Smith P, Krasowski MD. Newborn drug testing practices in Iowa birthing hospitals. J Neonatal Perinatal Med 2017; 10:445-450. [PMID: 29286931 DOI: 10.3233/npm-16153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Federal law mandates states to have policies and procedures to identify newborns exposed to maternal substance use during pregnancy. National guidelines for newborn drug testing are lacking; therefore, procedures are variable and determined by state law and local practices. In Iowa, maternal substance use during pregnancy is considered child abuse and must be reported.The objective of this study was to identify newborn drug testing policies and procedures among birthing hospitals in Iowa. METHODS This was a cross sectional survey of all birthing hospitals in Iowa identified via the Statewide Perinatal Care Program. An electronic survey was sent to the representative at each affiliated hospital. RESULTS Sixty-nine of 76 hospitals completed the survey for a 90.8% response rate. Newborn drug testing is ordered in 97.1% of responding hospitals with most testing 25% or less of newborns annually. The majority utilized a risk assessment tool (89.6%), although many (62.7%) also allowed for provider discretion. No hospital performed universal testing of all newborns. 86.6% of hospitals reported all positive newborn drug test results including illicit and/or prescription drugs to child protective services. 35.0% of hospitals notified mothers of the report and 45.5% offered substance abuse services and/or treatment to the mothers. CONCLUSIONS Most Iowa birthing hospitals perform newborn drug testing and report all positive test results to child protective services. The majority use risk assessment tools. Maternal notification practices and referral for substance use disorder treatment are suboptimal and represent an area for future improvement.
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Affiliation(s)
- K E Wood
- Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA
| | - P Smith
- Iowa Statewide Perinatal Care Program, Iowa Department of Public Health, Des Moines, IA, USA
| | - M D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Stauffer SL, Wood SM, Krasowski MD. Diagnostic yield of hair and urine toxicology testing in potential child abuse cases. J Forensic Leg Med 2015; 33:61-7. [DOI: 10.1016/j.jflm.2015.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 04/20/2015] [Indexed: 02/08/2023]
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Saunders NR, Dreifuss JJ, Dziegielewska KM, Johansson PA, Habgood MD, Møllgård K, Bauer HC. The rights and wrongs of blood-brain barrier permeability studies: a walk through 100 years of history. Front Neurosci 2014; 8:404. [PMID: 25565938 PMCID: PMC4267212 DOI: 10.3389/fnins.2014.00404] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 11/20/2014] [Indexed: 12/16/2022] Open
Abstract
Careful examination of relevant literature shows that many of the most cherished concepts of the blood-brain barrier are incorrect. These include an almost mythological belief in its immaturity that is unfortunately often equated with absence or at least leakiness in the embryo and fetus. The original concept of a blood-brain barrier is often attributed to Ehrlich; however, he did not accept that permeability of cerebral vessels was different from other organs. Goldmann is often credited with the first experiments showing dye (trypan blue) exclusion from the brain when injected systemically, but not when injected directly into it. Rarely cited are earlier experiments of Bouffard and of Franke who showed methylene blue and trypan red stained all tissues except the brain. The term “blood-brain barrier” “Blut-Hirnschranke” is often attributed to Lewandowsky, but it does not appear in his papers. The first person to use this term seems to be Stern in the early 1920s. Studies in embryos by Stern and colleagues, Weed and Wislocki showed results similar to those in adult animals. These were well-conducted experiments made a century ago, thus the persistence of a belief in barrier immaturity is puzzling. As discussed in this review, evidence for this belief, is of poor experimental quality, often misinterpreted and often not properly cited. The functional state of blood-brain barrier mechanisms in the fetus is an important biological phenomenon with implications for normal brain development. It is also important for clinicians to have proper evidence on which to advise pregnant women who may need to take medications for serious medical conditions. Beliefs in immaturity of the blood-brain barrier have held the field back for decades. Their history illustrates the importance of taking account of all the evidence and assessing its quality, rather than selecting papers that supports a preconceived notion or intuitive belief. This review attempts to right the wrongs. Based on careful translation of original papers, some published a century ago, as well as providing discussion of studies claiming to show barrier immaturity, we hope that readers will have evidence on which to base their own conclusions.
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Affiliation(s)
- Norman R Saunders
- Department of Pharmacology and Therapeutics, University of Melbourne Parkville, VIC, Australia
| | | | | | - Pia A Johansson
- Institute for Stem Cell Research, Helmholtz Center Munich Munich, Germany
| | - Mark D Habgood
- Department of Pharmacology and Therapeutics, University of Melbourne Parkville, VIC, Australia
| | - Kjeld Møllgård
- Department of Cellular and Molecular Medicine, University of Copenhagen Copenhagen, Denmark
| | - Hans-Christian Bauer
- Institute of Tendon and Bone Regeneration, Paracelsus Medical University Salzburg, Austria ; Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University Salzburg, Austria
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