Exploring trends in benzodiazepine-positive fatal drug overdoses in Tennessee, 2019-2021

BACKGROUND

Benzodiazepine-positive overdoses increased between 2019 and 2021 in Tennessee. We sought to determine the changes in the number and characteristics of prescription and illicit benzodiazepine-positive fatal drug overdoses during this period.

MATERIALS AND METHODS

A statewide study was conducted to determine changes in the number and characteristics of benzodiazepine-positive drug overdose decedents using 2019-2021 data from the Tennessee State Unintentional Drug Overdose Reporting System. The analyses were limited to Tennessee residents aged ≥ 18 years. A benzodiazepine-positive overdose was defined as any benzodiazepine on toxicology, regardless of the presence of other substances. Frequencies were generated to compare demographics, circumstances, prescription history, and toxicology between 2019 and 2021 for illicit and prescription benzodiazepine-positive fatal overdoses.

RESULTS

Between 2019 and 2021, 1666 benzodiazepine-positive unintentional or undetermined fatal drug overdoses out of 5916 total overdoses that occurred among adult Tennessee residents with available toxicological information. Prescription benzodiazepines were identified in 80.7% of deaths, whereas illicit benzodiazepines were identified in 12.0% of deaths. Many decedents had an anxiety disorder (45.5%), while over half of all decedents had a history of substance use disorder (52.3%). Most benzodiazepine-positive overdoses involved fentanyl (71.3%).

CONCLUSIONS

This analysis can inform local and regional public health workers to implement focused prevention and intervention efforts for people with co-occurring mental health conditions and substance use disorders to curb overdose epidemics among persons using benzodiazepines in Tennessee. Public health campaigns should focus on educating people on appropriate prescription medication use and the dangers of obtaining substances illicitly. Given the high proportion of opioids in this population, further education also is needed on the dangers of polysubstance drug use. The differences between prescription and illicit benzodiazepine-positive fatal overdoses indicate the need to develop substance-specific prevention and treatment strategies.

Oncology provider experiences during the COVID-19 pandemic

Purpose

The COVID-19 pandemic upended nearly all aspects of daily life and of medical care, placing a double burden of professional and personal concerns on those who provide medical care. We set out to assess the burden of the pandemic on provider outlook and understand how cancer survivorship providers experienced rapid changes to practice.

Methods

We distributed a survey through the American College of Surgeons Commission on Cancer (CoC) to its accredited organizations in mid-October 2020. We included questions on provider characteristics, changes in patient care practices resulting from the pandemic, worry about COVID-19, and concern about impact on cancer survivors.

Results

Of the n = 607 participants, three-quarters were female and three-quarters were White. Only 2.1% of participants reported having had COVID-19, but 43% reported anxiety about getting COVID-19 and over a quarter experienced sadness or depression, anxiety about the future, changes to sleep, difficulty concentrating, or social isolation. Approximately half of providers also expressed significant concern about progression of cancer in patients who experienced care delays or were afraid of accessing in-person care. In terms of changes to survivorship care, respondents reported changes to visitor policies, delays or cancellations, and efforts to reduce in-person visits.

Conclusions

COVID-19 has taken a significant toll on front-line healthcare professionals, including oncologists and cancer care allied health professionals. Findings support proactive mental health support of healthcare professionals as well as emergency preparedness to manage delays to care for cancer patients in the event of future unexpected pandemics.

Cancer Provider and Survivor Experiences With Telehealth During the COVID-19 Pandemic

PURPOSE

The COVID-19 pandemic led to rapid shifts in cancer survivorship care, including the widespread use of telehealth. Given the swift transition and limited data on preferences and experiences around telehealth, we surveyed oncology providers and post-treatment survivors to better understand experiences with the transition to telehealth.

METHODS

We distributed provider (MD, PA or NP, nurse, navigator, and social worker) and survivor surveys through the American College of Surgeons Commission on Cancer in mid-October 2020. Survivor surveys were also disseminated through patient advocacy organizations. We included questions on demographics, experiences with telehealth, and preferences for future telehealth utilization.

RESULTS

Among N = 607 providers and N = 539 cancer survivors, there was overwhelmingly more support from providers than from survivors for delivery of various types of survivorship care via telehealth and greater comfort with telehealth technologies. The only types of appointments deemed appropriate for survivorship care by both > 50% of providers and survivors were discussion of laboratory results or imaging, assessment and/or management of cancer treatment symptoms, nutrition counseling, and patient navigation support. Only a quarter of survivors reported increased access to health care services (25.5%), and 32.0% reported that they would use telehealth again.

CONCLUSION

Although there have been drastic changes in technological capabilities and billing reimbursement structures for telehealth, there are still concerns around delivery of a broad range of survivorship care services via telehealth, particularly from the patient perspective. Still, offering telehealth services, where endorsed by providers and if available and acceptable to cancer survivors, may provide more efficient and accessible care following the COVID-19 pandemic.

Strategies for the Identification and Prevention of Survey Fraud: Data Analysis of a Web-Based Survey

BACKGROUND

To assess the impact of COVID-19 on cancer survivors, we fielded a survey promoted via email and social media in winter 2020. Examination of the data showed suspicious patterns that warranted serious review.

OBJECTIVE

The aim of this paper is to review the methods used to identify and prevent fraudulent survey responses.

METHODS

As precautions, we included a Completely Automated Public Turing test to tell Computers and Humans Apart (CAPTCHA), a hidden question, and instructions for respondents to type a specific word. To identify likely fraudulent data, we defined a priori indicators that warranted elimination or suspicion. If a survey contained two or more suspicious indicators, the survey was eliminated. We examined differences between the retained and eliminated data sets.

RESULTS

Of the total responses (N=1977), nearly three-fourths (n=1408) were dropped and one-fourth (n=569) were retained after data quality checking. Comparisons of the two data sets showed statistically significant differences across almost all demographic characteristics.

CONCLUSIONS

Numerous precautions beyond the inclusion of a CAPTCHA are needed when fielding web-based surveys, particularly if a financial incentive is offered.

Characteristics of fatal opioid overdoses with stimulant involvement in Tennessee: A descriptive study using 2018 State Unintentional Drug Overdose Reporting System Data

PURPOSE

Opioid overdose deaths involving stimulants are on the rise. Demographic characteristics for these deaths to be used in prevention efforts have not been established.

METHODS

We conducted a statewide retrospective study to evaluate the characteristics of fatal opioid overdoses with stimulant involvement using 2018 Tennessee State Unintentional Drug Overdose Reporting System data. Data sources included death certificates, autopsy reports, toxicology, and prescription drug monitoring program data. Frequencies were generated to compare demographics, circumstances, opioid history, death scene information, bystander intervention, and toxicology between fatal opioid overdoses with and without stimulant involvement.

RESULTS

A total of 1183 SUDORS opioid overdose deaths occurred in Tennessee in 2018 of which 434 (36.7%) involved a stimulant. Fatal opioid overdoses involving stimulants had higher frequencies of illicit drugs on toxicology specifically marijuana, fentanyl, and heroin compared to fatal opioid overdoses without stimulants. Fatal opioid overdoses involving stimulants had higher frequencies of scene indications of injection drug use compared to fatal opioid overdoses without stimulant involvement.

CONCLUSIONS

Fatal overdoses are shifting from mainly opioid to multidrug involvement and over one-third include use of stimulants. This analysis can help public health practitioners understand the circumstances around fatal opioid overdoses involving stimulants to inform tailored prevention strategies.

P6518Radial artery dilatation to improve access and lower complication rates during coronary angiography (RADIAL): a randomized controlled trial

Background

Transradial catheterization has become the preferred access site for coronary angiography. The transradial approach is however not without challenges and complications. Cannulation is technically challenging and may require multiple cannulation attempts or access may fail. Local access site complications may occur postprocedurally.

Purpose

To explore the use of prolonged occlusion flow mediated dilatation (PO-FMD) to dilate the radial artery prior to cannulation to reduce puncture attempts, increase cannulation success and reduce access site complications in transradial coronary angiography.

Methods

1156 patients undergoing transradial coronary angiography were randomized into PO-FMD and sham PO-FMD groups. PO-FMD was achieved by a 10 minute inflation of a blood pressure cuff on the arm to above systolic pressure, followed by deflation with resultant radial artery dilation. In the sham PO-FMD group the cuff was not inflated. The operators were blinded to the intervention.

Results

580 patients were randomized to the sham PO-FMD group and 576 to the PO-FMD group. The number of puncture attempts were reduced with the use of PO-FMD, with a median number of attempts of 1 in the PO-FMD group and 2 in the sham PO-FMD group (p<0.001). Cannulation failure was reduced with PO-FMD FMD with cannulation failure rates of 2.7% in the PO-FMD group and 5.8% in the sham PO-FMD group (p=0.01). Radial artery pulsation loss (RAPL) was reduced with PO-FMD with 1.4% in the PO-FMD group and 3.8% in the sham PO-FMD group (p=0.02).

Conclusion

PO-FMD decreases puncture attempts, reduces cannulation failure rates and decreases RAPL during transradial coronary angiography.

A-65 Verbal Abilities May Influence Performance in Assessment of Verbal Short-Term Memory Tasks

Objective

Examine whether verbal abilities may help explain the learning strategies people employ when completing a short-term verbal memory task.

Methods

The assessment records of 296 American Veterans with diverse neuropsychiatric conditions were analyzed using Exploratory Factor Analyses. There were no exclusion criteria. All participants completed the Benton Serial Digit Learning Test – 9 Digits (SDL-9) and Visual Naming (VisNam), Sentence Repetition (SenRep), Controlled Word Association (COWA), and Token Tests of the Multilingual Aphasia Examination (MAE). Individual assessment instruments were factored using Principal Component Analyses (PCA). A three-factor solution of the SDL-9 was co-factored with the verbal components of the MAE to identify common sources of variance.

Results

A three-factor solution of the SDL-9 separated trials into three overlapping factors consisting of early (SDL-9_Early), middle (SDL-9_Middle), and late (SDL-9_Late) trials. Co-factoring the three new scales with the verbal components of the MAE produced a four-factor model explaining 67.85% of the shared variance: 1) SenRep loaded with SDL-9_Early, 2) COWAT loaded with SDL-9_Middle and SDL-9_Late, 3) Token loaded with SDL-9_Late, and 4) Vis Nam loaded with SDL-9_Late.

Conclusions

The results suggest that individuals may engage verbal abilities differently as they progress from simpler to more difficult verbal short-term memory tasks. It appears performance in early trials is mostly associated with rote repetition and performance on middle trials is mostly associated with verbal fluency, while performance on the late trials is associated with a combination of verbal fluency, auditory comprehension, and conceptual organization/naming. This may therefore indicate a shift in learning strategy to meet increased cognitive demands.

A-49 Visual Memory Errors and Intelligence: The Role of Verbal Mediation

Objective

Examine the relationship of verbal mediation with visual memory errors and intelligence to understand the role of spoken language on other assessment measures.

Method

Assessment records were obtained from a Veteran Affairs clinic for veterans (n=100) with diverse neuropsychiatric conditions who completed the Wechsler Adult Intelligence Scale, third edition (WAIS-III), Multilingual Aphasia Examination (MAE), and Benton Visual Retention Test (BVRT). A Principal Component Analysis (PCA) was used to examine the interrelationship among these assessments. The components of spoken language, types of errors on the BVRT, and the four factors of the WAIS-III were factored using the PCA to identify common sources of variance.

Results

A principal component analysis revealed a six-factor model explaining 68.16% of the shared variance among the WAIS-III factors, MAE components, and BVRT Errors. Omission errors loaded with Processing Speed and Controlled Word Association. Distortions and size errors loaded with Perceptual Organization. Size errors also loaded with Verbal Comprehension and Visual Naming. Misplacements loaded with Working Memory and Sentence Repetition. Misplacements, perseverations, and omissions loaded with the Token Test (a measure associated with auditory comprehension). Rotation errors loaded with Perceptual Organization.

Conclusions

Results indicated significant shared variance between visual memory errors, spoken language, and intelligence factors. This suggests that spoken language is involved in the process of visual memory, and deficits in spoken language may result in increased errors on visual memory tasks. Therefore, treatment recommendations for visual memory difficulties should take into consideration verbal capabilities and intelligence factors to better individualize treatment.

A-44 Categorical Errors on the Benton Visual Retention Test are Systemically Related to Specific Factorial Components of Intelligence

Objective

We investigated the factorial relationship of the six categories of memory errors of the BVRT to the four factorial variables of the WAIS to determine the relationship between cognitive and nonverbal memory variables.

Methods

A sample of 134 diagnostically mixed ambulatory American Veteran patients with a wide variety of mixed neuropsychiatric diagnoses and with or without general medical problems who had completed the WAIS-3, and the BVRT were examined. There were no demographic or diagnostic exclusion criteria.

Results

The 6 types of BVRT memory errors (omissions, distortions, perseverations, rotations, misplacements, and size errors) were factored using principal component analysis. The four WAIS 3 and six BVRT components were jointly factored to examine for systematic relationships between memory and cognitive domains. The analysis identified specific factorial relationships of BVRT error type to each of the four factorial components of the WAIS. POI was related to rotation errors, VCI was related to size errors, PSI specifically related to omissions and WMI to distortions. Misplacement and perseveration errors were related to each other but not to factorial constructs of the WAIS.

Conclusions

There are specific and robust relationships among BVRT errors and dimensional cognitive variables.

A-53 Exploring the Relationship between Spoken Language and Verbal Short-term Memory Assessment Tasks

Objective

Examine whether performance on spoken language assessment measures may be associated with performance at different phases of verbal learning and recall tasks.

Method

The assessment records of 222 American Veterans with diverse neuropsychiatric conditions were analyzed using Exploratory Factor Analyses. There were no exclusion criteria. All participants completed the Visual Naming (VisNam), Sentence Repetition (SenRep), Controlled Word Association (COWA), and Token Tests of the Multilingual Aphasia Examination (MAE), and Benton Serial Digit Learning Test – 8 Digits (SDL8). Individual assessment instruments were factored using Principal Component Analyses (PCA). A three-factor solution of the SDL-8 was co-factored with the spoken language components of the MAE to identify common sources of variance.

Results

A three-factor solution of the SDL8 separated trials into three overlapping factors consisting of early (SDL8_Early), middle (SDL8_Middle), and late (SDL8_Late) trials. Co-factoring the three new scales with the verbal components of the MAE produced a five-factor model explaining 84.563% of the shared variance: 1) SDL8_Early loaded with SenRep, 2) SDL8_Middle loaded with SenRep, 3) SDL8_Late loaded with Token, 4) SDL8_Late loaded with COWA, and 5) VisNam alone formed the fifth factor.

Conclusions

The results suggest that rote repetition is largely associated with early trials and slightly associated with middle trials, while late trials are largely associated with auditory comprehension and slightly associated with verbal fluency. This may be indicative of a shift in use of spoken language abilities to accommodate increasing levels of complexity in presented verbal short-term memory tasks and thus reflective of a change on learning strategy to optimize performance.

A-43 Factorial Relationships Among Copy and Memory Trials of the Benton Visual Retention Test

Objective

We investigated the factorial relationships among categorical error groups on the Benton Visual Retention Test (BVRT) copy and memory trials.

Methods

A sample of 523 ambulatory American Veteran patients who presented for clinical evaluation with a wide variety of mixed neuropsychiatric diagnoses and general medical diagnoses were studied. There were no demographic or diagnostic exclusion criteria.

Results

Frequency summary scores for the six types of BVRT errors (omission, misplacement, size, distortion, perseveration, and rotation errors) were factored jointly by means of principal component analysis. Omission, misplacement, and size errors grouped factorially across copy and memory domains by error type. Results showed the factorial relationships are primarily defined by the type of error. Omission, size, and misplacement errors were grouped together regardless of whether they occurred on copy or memory trials. Rotation, distortion, and perseveration errors were factorially grouped on both the copy and memory trials, but the groupings of these similar error groups formed independent factors for the copy and memory trials. The copy error factor explained the most variance and the memory error factor o explained the least variance.

Conclusions

Omission, size, and misplacement errors on the BVRT copy and memory trials appear to be due to similar encoding process errors. Distortion, rotation, and perseveration errors on the BVRT copy and memory trials are related to each other within each trial type but different cognitive processes account for errors of this kind on the copy and memory trials.

A-45 Systematic Relationships of the Benton Visual Retention Test to Intelligence, Language and Demographics

Objective

We investigated the factorial relationships of WAIS 3, BVRT, Visual Naming and demographic variables to better understand factorial relationships among those variables.

Methods

A sample of 126 ambulatory American Veteran patients who presented for clinical evaluation with a wide variety of mixed neuropsychiatric diagnoses and general medical diagnoses were studied. There were no demographic or diagnostic exclusion criteria.

Results

Our first analysis demonstrated robust independent relationships of age to a late occurring BVRT item group and education to an early occurring BVRT item group. A two factor solution for the items of the multilingual aphasia exam visual naming subtest from previous research showed systematic and robust relationships of one visual naming factor to VCI and the other visual naming factor to PSI only. Factor scales were computed to represent the orthogonal factors for the new variables in each of these analyses. Factor scales from the first two analyses were factored together to produce a four-part solution that explained 86% of the variance. POI was related to the late BVRT item group and age. The early BVRT item grouping was related to educational level, VCI, PSI and both visual naming components. WMI was independent of demographic, linguistic and BVRT variables.

Conclusions

There are factorial relationships between factorial components of nonverbal memory, intelligence, naming and demographic variables.

A-52 An Exploratory Factor Analysis Investigation of the Role of Verbal Mediation in the Interaction between Intelligence and Visual Memory Tasks

Objective

Examine whether verbal mediation may play a role in the interaction between visual memory tasks and the four-factor model of intelligence as operationalized by standard neuropsychological assessment instruments.

Method

The assessment records of 101 American Veterans with diverse neuropsychiatric conditions were examined using Exploratory Factor and Principal Component Analyses (EFA and PCA respectively). There were no exclusion criteria. All participants completed the Wechsler Adult Intelligence Scale, third edition (WAIS-III), Benton’s Visual Retention Test (BVRT), and Multilingual Aphasia Examination (MAE). Individual assessment instruments were factored using PCA. The factor solution of the BVRT was co-factored with the scales of the WAIS-III, then the resulting factor scales were again factored with the verbal components of the MAE to identify common sources of variance.

Results

A three-step analysis revealed a four-factor model explaining 69.44% of the shared variance: 1) Items 1-4 of the BVRT (BVRT-E) loaded with Verbal Comprehension and Visual Naming. 2) BVRT-E also loaded with Processing Speed and Controlled Word Association. 3) Items 5-10 of the BVRT (BVRT-L) loaded with Perceptual Organization and the Token Test. 4) Working Memory loaded with Sentence Repetition on a fourth factor.

Conclusions

The results indicate a strong relationship between assessed performance on visual memory tasks and performance on measures based on the four-factor model of intelligence. The results also appear to support the idea that verbal mediation plays a role in the interaction between visual memory and intelligence, particularly when comparing performance on simple versus more complex visual memory tasks.

Current controversies over bioresorbable scaffolds

The field of coronary intervention has made great strides since the first balloon angioplasty performed by Andreas Gruentzig in Zurich in 1977.1 Starting with that case, coronary interventional data has been rigorously generated through single-center and multicenter registries and randomized trials, allowing for remarkably broad-sweeping, evidence-based, leapfrog improvements in technology and outcomes in just a few decades. In this paper we outline the natural evolution from "plain old balloon angioplasty" (POBA) to bioresorbable scaffolds (BRS) and other novel therapies, and discuss the emerging data regarding the promise of BRS as well as controversies and residual concerns regarding this technology.

Coherent synthesis of ultra-broadband optical parametric amplifiers

We report on coherent synthesis of two ultra-broadband optical parametric amplifiers, each compressed by chirped mirror pairs, resulting in almost-octave-spanning (520-1000 nm) spectra supporting nearly single-cycle sub-4 fs pulse duration. Synthesized pulse timing is locked to less than 30 as by a balanced optical cross-correlator. The synthesized pulse is characterized by two-dimensional spectral interferometry and has a 3.8 fs duration.

Self-injurious behavior and foreign body entrapment in the root canal of a mandibular lateral incisor

Self-injurious behavior is a deliberate alteration or damage without suicidal intent. Herein, we report a patient who had caused intentionally self-trauma to his left lower permanent canine and placed a long metallic foreign body into the root canal. History revealed a habit of placing metallic objects in the form of stapler pins into the mouth, but closer examination revealed the habit to be more as a method of self-injurious behavior. Following an episode of severe pain, the tooth was endodontically treated after removal of the foreign body that was corroding. Clinical significance of the case report is that the patient may just be put off as having a habit of inserting foreign objects into the mouth, but the behavior was more self-injurious in nature.

Optical Cherenkov radiation by cascaded nonlinear interaction: an efficient source of few-cycle energetic near- to mid-IR pulses

When ultrafast noncritical cascaded second-harmonic generation of energetic femtosecond pulses occur in a bulk lithium niobate crystal optical Cherenkov waves are formed in the near- to mid-IR. Numerical simulations show that the few-cycle solitons radiate Cherenkov (dispersive) waves in the λ = 2.2 - 4.5 μm range when pumping at λ₁ = 1.2 - 1.8 μm. The exact phase-matching point depends on the soliton wavelength, and we show that a simple longpass filter can separate the Cherenkov waves from the solitons. The Cherenkov waves are born few-cycle with an excellent Gaussian pulse shape, and the conversion efficiency is up to 25%. Thus, optical Cherenkov waves formed with cascaded nonlinearities could become an efficient source of energetic near- to mid-IR few-cycle pulses.

Comparative evaluation of the efficacy of different concentrations of chlorhexidine mouth rinses in reducing the mutans streptococci in saliva: an in vivo study

BACKGROUND

Is low-concentration chlorhexidine effective against reducing the mutans streptococci (MS) in saliva?

AIM

To compare the efficacy of different concentrations of chlorhexidine mouth rinses, i.e. 0.02%, 0.06% and 0.12%, in reducing the mutants streptococci count in saliva.

DESIGN

Forty subjects in the age group of 12-14 years were selected from the schools of Chennai and were equally divided into four groups. The first three were study groups and the fourth group was the control group. The subjects were instructed to rinse with a measured amount of mouth rinse for 1 min, twice-daily, for 1 week. Salivary samples were collected at baseline and 1 week after mouth rinsing with various concentrations and were cultured on MSB agar. The number of MS colonies was counted on agar medium under anaerobic conditions.

RESULTS

The results of the study confirmed that children using chlorhexidine of concentration 0.12% showed the maximum reduction in MS when compared with subjects using 0.02% and 0.06% concentrations. But, children using chlorhexidine of concentration 0.06% also showed significant reduction in MS when compared with the control group.

CONCLUSION

From the above study, we conclude that chlorhexidine used in different concentrations (0.02%, 0.06%, 0.12%) efficiently reduced the mutans count.