Addressing Perinatal Substance Use: A Triad Approach Led by the Colorado Perinatal Care Quality Collaborative

Unintentional overdose is a leading driver of maternal death in Colorado. The high volume of maternal deaths from preventable causes lends questions to failures in our clinical and community-based care for pregnant and postpartum people. The Colorado Maternal Mortality Review Committee identified 3 main contributors including stigma in the community and health care system, fragmentation of the health care system, and the need for more clinician training. The Colorado Perinatal Care Quality Collaborative led a 3-pronged intervention to address these challenges and improve perinatal care. The first intervention, the Colorado Alliance for Innovation on Maternal Health Substance Use Disorder quality improvement initiative, partnered with birthing hospitals statewide to institute universal screening and timely referral for individuals at risk of substance use disorder (SUD) and perinatal mood and anxiety disorders. The second intervention, the Improve Perinatal Access, Coordination, and Treatment for Behavioral Health initiative, established a perinatal support network within communities. This program assists individuals with SUD, perinatal mood and anxiety disorders, or social needs to navigate the perinatal period. The third intervention, the Colorado Maternal Overdose Matters Plus program, has enhanced in-hospital access to pharmacotherapy for pregnant and postpartum individuals with SUD through training and technical support. These collaborative initiatives aim to minimize barriers to care by integrating inpatient screening, treatment referrals, pharmacotherapy access, and community care support to mitigate maternal mortality in Colorado.

Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors

BACKGROUND

Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented.

METHODS

Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society of Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome.

RESULTS

There were 479 patients enrolled (mean age, 78 years; 54% male, 86% White; 81% anticoagulated for atrial fibrillation at a median time of 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 patients (10%); in 16 patients, this occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors.

CONCLUSIONS

In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02329327.

The impact of COVID-19 vaccination on patients with a history of heparin induced thrombocytopenia

The newly classified entity of vaccine induced thrombocytopenia and thrombosis (VITT) following AstraZeneca Vaccination is an area of ongoing investigation. The underlying pathophysiology is considered to have pathological similarities to heparin induced thrombocytopenia (HIT). It is unclear which cohorts may be particularly susceptible to developing VITT. In view of the underlying mechanism of action we undertook a retrospective analysis of patients with a history of HIT to assess whether they had been vaccinated and to assess whether any patients had experienced adverse reactions to the AstraZeneca vaccination. 20 out of 60 patients with a confirmed history of HIT received the AstraZeneca vaccination and none of these reported any features suggestive of VITT.

A multicentre longitudinal observational study of changes in self reported health status in people with Parkinson's disease left untreated at diagnosis

BACKGROUND

The issue of when to start treatment in Parkinson's disease (PD) remains controversial. Some favour treatment at diagnosis while others opt for a "wait and watch" policy. The effect of the latter policy on the self reported health status of people with PD is unknown.

AIMS

To record self reported health status through longitudinal use of a validated PD specific questionnaire (PDQ-39) in untreated PD patients in multiple centres in the UK. To compare patients who were left untreated with those who were offered treatment during follow-up.

METHODS

A multicentre, prospective, "real life" observational audit based study addressing patient reported outcomes in relation to self reported health status and other sociodemographic details.

RESULTS

198 untreated PD were assessed over a mean period of 18 months. During two follow-up assessments, the self reported health status scores in all eight domains of the PDQ-39 and the overall PDQ-39 summary index worsened significantly (p<0.01) in patients left untreated. In a comparative group in whom treatment was initiated at or soon after diagnosis, there was a trend towards improvement in self reported health status scores after treatment was started.

CONCLUSIONS

This study addresses for the first time self reported health status, an indicator of health related quality of life, in untreated PD. The findings may strengthen the call for re-evaluation of the policy to delay treatment in newly diagnosed patients with PD.

Proglacial succession of biological soil crusts and vascular plants: biotic interactions in the High Arctic

To evaluate the hypothesis that biological soil crusts facilitate the establishment and maintenance of vascular plants during succession, we studied the distribution patterns of crusts and vascular plants along a High Arctic glacier foreland and compared the success of plants growing in and out of crusted substrate. Multivariate analyses determined that distance from the glacier and crust cover were the most important variables, explaining 11% and 9% of the variance in the vegetation data, respectively. Surfaces colonized by biological soil crusts generally supported higher plant densities and showed positive associations with the most dominant, long-lived plant species such as Saxifraga oppositifolia L., Salix arctica Pall., and Dryas integrifolia Vahl. Crusts facilitate plant establishment and growth in early and midsuccession but may compete for available resources further along the chronosequence. This study recognizes subtle direct influences of crust on vegetation density but also draws attention to a much larger overall positive effect on community structure. Succession on this foreland proceeds via a “directional-replacement” model and supports a well-developed community of biological soil crusts and vascular plants with greater species richness, cover, and density compared with other glacier foreland vegetation communities previously investigated on Ellesmere Island, Nunavut.

Australian Medical Council: a view from the inside

Although it has an important role in maintaining medical standards, little is known about the work of the Australian Medical Council (AMC) by members of the medical profession. A non-statutory standards authority, the AMC accredits medical schools in Australia and New Zealand, examines overseas-trained doctors for registration purposes and advises Medical Boards and Health Ministers on registration issues. The AMC, in consultation with Specialist Medical Colleges and others, is currently working on a number of initiatives to ensure standards of medical training and practice, including procedures to recognize new specialties and to accredit externally specialist education and training courses.

Serum expression of sialyltransferase in normal and Down's syndrome-affected pregnancy

Human chorionic gonadotrophin (hCG) has been used as a serum biochemical marker of Down's syndrome (DS) pregnancies, and recent studies have reported an increase in a hyperglycosylated form of the protein associated with DS. In the present study, the activity of the combined soluble serum sialyltransferase (ST) enzymes was examined as a potential marker for the hyperglycosylated form of hCG. There were no changes in total ST activity during the course of the pregnancy in normal mothers and there was no difference in enzyme activity in the DS pregnancies when compared with controls. These results suggest that, although there may be an alteration in the activities of one or more of the glycosyltransferase enzymes in the placenta resulting in an alteration in hCG glycosylation, this is not reflected in the serum soluble enzyme activity.

On the ability of four flavonoids, baicilein, luteolin, naringenin, and quercetin, to suppress the Fenton reaction of the iron-ATP complex

Four flavonoids, baicilein, luteolin, naringenin, and quercetin were investigated for their ability to suppress the Fenton reaction characteristic of the iron-ATP complex. Absorption spectroscopy indicates that under the conditions of 18.75% aqueous methanol, 0.0625 mM HEPES pH 7.4 buffer and 1.5:1 quercetin/iron-ATP ratio a mix ligand complex formed. All four flavonoids were found to interfere with the voltammetric catalytic wave associated with the iron-ATP complex in the presence of H2O2. Quercetin and luteolin were able to completely suppress the catalytic wave of the iron-ATP/H2O2 system when a minimum ratio of 1.5:1 of the flavonoid to iron-ATP was reached. At this ratio, the ability of the studied series of flavonoids to suppress the Fenton reaction characteristic of iron-ATP follows as quercetin approximate to luteolin > naringenin approximate to baicilein. Both quercetin and luteolin contain catechol on the B ring, which may enhance the iron chelation of these species over baicilein and naringenin. The common structural feature of all of these flavonoids is the 4-keto, 5-hydroxy region, which may also contribute to the chelation of iron.

Intervening with everyday memory problems in dementia of Alzheimer type: an errorless learning approach

Dementia of Alzheimer Type (DAT) is increasingly detected at an earlier stage of the disorder, when interventions to assist with everyday memory difficulties might be most valuable. Some learning is possible in DAT and a number of factors have been identified which may facilitate performance, although applications to everyday memory problems have been limited. The concept of errorless learning has not previously been directly examined in relation to DAT, but might provide a useful additional strategy. In the present study, 6 participants with early stage DAT (MMSE scores 21 - 26) received individually tailored interventions, based on errorless learning principles and targeted at a specific everyday memory problem. Five of the participants showed significant improvement on the target measures, and maintained this improvement up to 6 months later. The results suggest that it is feasible to intervene with everyday memory problems in the early stages

Psychiatric aspects of parathyroid disease

Parathyroid diseases can present with psychiatric symptoms and can be recognized through determinations of serum electrolytes, especially the calcium level. Psychiatric evaluations should include a serum calcium concentration test, which is also essential in reassessment of patients poorly responsive to mental illness treatment. A magnesium and a phosphate assay may also be diagnostically helpful. Abnormality of divalent cation levels may provide evidence for consideration of, or ruling out, parathyroid disorders. Determinations of parathyroid hormone are performed if clinically indicated, and if abnormal divalent cation quantifications are confirmed. If parathyroid disease is identified, corrective endocrine therapies may diminish or even cure psychiatric aspects of parathyroid pathology. Failure to recognize a parathyroid disorder leaves an endocrine-induced mental dysfunction without proper treatment.

The relationship between irritable bowel syndrome and psychiatric illness. A family study

Although irritable bowel syndrome (IBS) is a common disorder among gastrointestinal clinic outpatients, it continues to be a diagnosis of exclusion. In treatment-seeking populations, IBS has been frequently associated with psychiatric illness, and this co-occurrence has added to controversy about the validity of the IBS diagnosis. This study is a preliminary effort to examine the nature of this relationship by using the family study design. The probands consisted of 20 patients with IBS and 20 patients who had undergone laproscopic cholecystectomy. Their first-degree relatives were interviewed to obtain lifetime diagnoses of functional gastrointestinal and psychiatric syndromes. Significantly more IBS probands had lifetime psychiatric illness than the cholecystectomy probands. The lifetime prevalence of IBS as well as other functional gastrointestinal syndromes was not significantly different between the groups of relatives. However, significantly more relatives of the IBS probands had lifetime psychiatric illness than the relatives of the cholecystectomy probands. Among the relatives with functional gastrointestinal disorders, significantly more had psychiatric illness. This preliminary study provides support for a relationship between IBS and psychiatric illness by the finding of an increased prevalence of psychiatric disorders among the relatives of patients who have IBS.

Impaired naming and preserved reading: a complete dissociation

This study examines the relationship between reading and naming in an anomic patient whose verbal comprehension skills were intact. In spite of very poor naming skills, his ability to read irregular words was well preserved. Moreover, his naming remained impaired in conditions when he had read the same word only a few minutes or even seconds before and there was unexpectedly little overlap between his performance on the two tasks. The implications of these results for current models of reading and naming are discussed.

A study of anomia: evidence for a distinction between nominal and propositional language

We describe our investigations of the word retrieval abilities of a patient (NOR) with a very severe anomia. NOR had the greatest difficulty naming even very common objects to confrontation yet his word comprehension, word repetition and reading skills were intact. We documented the efficacy of different types of cues for name retrieval. Phonological and semantic cues were either ineffective or had a minor effect. By contrast a sentence frame even a low probability sentence frame (e.g. I went to the shop to buy a ...?) had a very significant facilitatory effect for object naming. In a series of experiments we explored the basis of this facilitation. It was shown that neither a picture frame, an associated verb, nor a syntactically correct but semantically meaningless sentence frame were effective cues. Our findings challenge the orthodox linear models of object naming. We interpret our observations in the context of Luria's distinction between nominative and propositional language. It is suggested that there may be two 'routes' to name retrieval, one that utilises a nominative system and an alternative one that utilises an on-line language processor that constructs propositional speech. It is the integrity of this latter system that could account for the facilitation of naming by a sentence frame in NOR, and also for the frequently observed phenomenon of the preservation of fluent speech in patients with a grave anomia.

Increase in extracellular NCAM and amyloid precursor protein following induction of long-term potentiation in the dentate gyrus of anaesthetized rats

The extracellular concentrations of the amyloid precursor protein (APP) and neural-cell adhesion molecule (NCAM) in the dentate gyrus of the anaesthetized rat were assayed before and after the induction of long-term potentiation (LTP) in vivo. Levels of high molecular weight neurofilament protein and activity of the lysosomal enzyme arylsulphatase were measured as internal controls and indicators of neuronal damage. Ninety minutes after the induction of LTP, the concentrations of NCAM and APP increased, in an NMDA-dependent manner, in the absence of changes in neurofilament and arylsulphatase levels. The delayed changes in the extracellular concentration of these molecules may reflect events leading to morphological modifications following LTP.

A prospective study of septic complications of endoscopic retrograde cholangiopancreatography

Prophylactic antibiotics are used in an attempt to avoid the septic complications of endoscopic retrograde cholangiopancreatography (ERCP). We prospectively performed blood cultures and surveyed patients for complications. The aims were first, to determine the incidence of bacteraemia associated with ERCP, second, to assess the incidence of clinical sepsis following the procedure and third, to evaluate the effectiveness of our antibiotic prophylaxis. One hundred and fifty successive patients underwent 179 ERCP. Bacteraemia related to the procedure or the underlying pathology was found in nine procedures (5.2%). Bacteraemias were more likely to complicate therapeutic procedures (P = 0.015), biliary obstruction (P = 0.045) or underlying pathology (P = 0.022). Although 61% of ERCP received antibiotics, 22 septic events occurred. Five bacteraemic patients were septic despite antibiotics. Septic complications were associated with the same factors as bacteraemia. It was concluded that patients with biliary obstruction and undergoing therapeutic endoscopic procedures are at greatest risk of bacteraemia. Single dose prophylactic antibiotics may not prevent sepsis in these patients and longer-acting drugs or repeated dosing may be necessary.

Serum prolactin levels during extended cocaine abstinence

Following a report indicating almost a 100% risk for hyperprolactinemia in cocaine users after 1 month of abstinence, the authors determined the serum prolactin concentrations of 23 male inpatients who had abstained from cocaine for 2-43 weeks. None showed high prolactin levels; this places the incidence below 12.3% with 95% confidence. These results imply that persistent hyperprolactinemia requires a medical explanation other than cocaine abstinence itself.

Pharmacologic provocation and dexamethasone suppression test sensitivity

In expectation of improving sensitivity, the standard 1-mg dexamethasone suppression test (DST) was given to 10 depressed inpatients and repeated with theophylline or caffeine and again following 3 days of lorazepam with abrupt discontinuation. Two patients showed nonsuppression on the standard DST; 2 suppressors changed to nonsuppression after lorazepam discontinuation, and 1 also changed after theophylline. This increase from 20 to 40% sensitivity remains significantly less than a desirable minimum 80% sensitivity (p less than 0.001), which suggests that a consistent DST sensitivity of 80% in melancholia is unlikely to be attained.

Wernicke's encephalopathy in a metropolitan hospital. A prospective study of incidence, characteristics and outcome

Thirty-two cases of Wernicke's encephalopathy were admitted to hospital for treatment in a period of 33 months; this represented a relatively low incidence in total hospital admissions. Thiamin status was deficient, borderline and normal in 21 (66%), five (16%) and six (19%) patients, respectively, and responded immediately to treatment in those who had abnormal thiamin status. Ophthalmoplegia responded rapidly to treatment. Nystagmus, ataxia, disturbance of mental function and peripheral neuropathy responded incompletely to treatment in both the short-and the long-term. The overall setting for the development of Wernicke's encephalopathy appears to be chronic alcohol abuse, accompanied by cerebral "atrophy" and liver disease, but often without gross evidence of malnutrition.

A study of partial thiamin restriction in human volunteers

A double blind study of partial thiamin restriction was undertaken in 19 volunteer male medical students for a period of 4 to 5 weeks. Each day the subjects followed a diet supplying 500 micrograms thiamin and took 1 capsule randomly assigned to contain 5 mg thiamin hydrochloride or thiamin placebo. This capsule also supplied physiological doses of other vitamins. At the end of the study all were repleted with thiamin hydrochloride. Ten thiamin-depleted subjects were correctly identified by low urinary thiamin excretion, decreasing erythrocyte transketolase activity, and elevation of the thiamin pyrophosphate effect. The remaining nine subjects were controls. The degree of thiamin depletion induced varied between individuals and had no measurable ill effect on health as assessed by subjective feelings, physical findings, psychological testing, nerve conduction studies, and work performance. Subclinical thiamin deficiency is defined from this study as the presence of a low urinary thiamin level (27 microgram thiamin/g creatinine) together with a thiamin pyrophosphate effect above 14.2% and below 35.4%. However, when urinary thiamin excretion is unknown, the data indicate that a thiamin pyrophosphate effect above 9% and below 41.6% is likely but not certain to represent subclinical thiamin deficiency. These guidelines, developed under experimental conditions, are a reference framework for assessment of thiamin status in population groups but should be applied with caution to individuals and to people with disease.