Guidance for Handling the Increasing Prevalence of Drugs Adulterated or Laced With Fentanyl

The use of fentanyl and its analogs is the primary driver of deaths related to the opioid overdose crisis. In fall 2021, the U.S. Drug Enforcement Administration issued its first public safety alert in 6 years to raise awareness of the escalating prevalence of fentanyl in counterfeit pills and in other opioids, such as heroin, and nonopioids, such as methamphetamine. In addition to increased public awareness, specific actions are needed to remediate the risk for fentanyl overdose. The authors endorse four principles to address the opioid overdose crisis and provide guidance for remediating its impacts: an incremental approach to behavior change or harm reduction; engagement strategies for individuals with substance use disorder; an integrated care approach to ensure better access to treatment programs and effective interventions; and vigilance among clinicians, program staff, and patients to the threat of fentanyl-adulterated drugs. The authors offer specific recommendations on how to apply these principles effectively within health care systems, communities, and law enforcement agencies across the United States.

Inositol treatment raises CSF inositol levels

Inositol is a key precursor for synthesis of phosphatidylinositol in a major second messenger signalling system. It is biologically active in syndromes such as respiratory distress syndrome but has been thought to be excluded from CNS by the blood-brain barrier. Oral inositol treatment of 8 patients is shown to significantly increase CSF inositol by almost 70%, suggesting possible CNS therapeutic applications of this compound and possible CNS side-effects of systemic therapy.

Cervical soft tissue metastasis of typical carcinoid tumor preceding diagnosis of ileal primary by 4 years

A solitary cervical metastasis of a typical carcinoid tumor was found in the subcutaneous tissue of an asymptomatic 38-yr-old woman. Investigations failed to disclose the primary site until the 5th yr, when she presented with carcinoid syndrome. Multifocal ileal carcinoid tumors were resected and debulking of abdominal metastases performed. Interferon and somatostatin analogue treatment resulted in remission. Solitary cervical metastasis is an exceedingly rare initial manifestation of a mid-gut carcinoid tumor, and poses a therapeutic dilemma. There are no directions in the literature as to whether a "wait-and-see" approach or exploration surgery is the preferred management when one is confronted by a cervical metastasis of typical carcinoid tumor of unknown primary site.

Ischemic heart disease precipitated by occult cancer

The hypothesis was tested that cancer, by virtue of it being a thrombotic diathesis, may enhance ischemic heart disease. Because cancer therapy may precipitate thromboembolism, the authors focused on patients with occult neoplasia before therapy. Occult cancer was defined as a time period of 2 years before a cancer diagnosis was established. Data obtained from the files of patients with the diagnosis of malignant tumors and admitted to a general hospital during a 3-year period were reviewed for coronary risk factors, coronary events, and characteristics of cancer. Indices of coronary instability were studied: the incidence of first coronary events, the incidence of all coronary events, and the coronary events burden. These indices were calculated for 366 patients with cancer (from the Department of Medicine files of 166 consecutive patients with cancer of several primary sites and from the surgical ward files of 100 consecutive patients with colorectal cancer and 100 consecutive patients with cancer of the prostate or bladder) and for 100 patients with benign prostatic hypertrophy. The patients with benign prostatic hypertrophy served as controls. A steep and statistically significant increase in coronary instability indices was observed in all groups of patients with cancer in the 2-year period before cancer diagnosis in comparison with the coronary instability indices of control patients (P less than or equal to 0.05 to 0.0001). Patients with colorectal cancer presented the highest indices in the 2-year period before cancer diagnosis, with unstable ischemic heart disease being reported in 18% and first coronary events in 10%. The coronary events burden was 0.92. The lowest indices among patients with cancer were recorded in those with prostatic and bladder cancer. Unstable ischemic heart disease occurred in 6% and first coronary events in 4%. The coronary events burden was 0.36. The indices were several times lower for control patients than for patients with cancer. Unstable ischemic heart disease occurred in 3% of control patients, and first coronary events in 2%. The coronary events burden was 0.15. Other possible etiologic factors, particularly the known coronary risk factors and anemia, were not statistically related with an increased risk of coronary events in the 2-year period before cancer diagnosis. Based on these epidemiologic data, it appears that there may be an association between occult cancer and coronary events.

Humoral antibody response of rabbits to experimental infection with Encephalitozoon cuniculi

Six female rabbits (Oryctolagus cuniculus) were experimentally infected intravenously with approximately 1.5 X 10(7) live spores of Encephalitozoon cuniculi. Head tilt was observed as the single clinical sign in only one of the six animals. Antibody response was registered over 68 days postinfection using the indirect immunofluorescence test (IFT) for IgM and IgG, and the carbon immunoassay (CIA). IgG titers reached a level of 160-2560 after a latent phase of 13-28 days, followed by a 2-4 week relatively steep increase. The IgM seroconversion was faster than that of IgG and occurred at the beginning of the antibody response. Thus, simultaneous detection of both IgM and IgG allowed the infection to be identified as recent. Long, short, and episodic antibody responses could be distinguished: the IgG titer continued to increase on Day 68 in one animal (long response) and began to decrease between Days 45 and 63 in three other animals (short response). In two additional animals the seroconversion was very short, occurring between Days 13 and 41, and 28 and 52, respectively (episodic response). The CIA proved to be specific, reliable, and simple to perform; titers were slightly higher than in the IFT. Parasite pseudocysts were detected scattered throughout the brain on Day 68 in four of the six rabbits. The persistence of antigen in the brain did not correlate with antibody response, which in most cases was shorter.

[Combination chemotherapy in metastatic breast cancer]

Combination chemotherapy was administered to 62 patients with metastatic breast cancer in the years 1977-9. The combination consisted of cyclophosphamide, methotrexate and 5-fluorouracil. The average age was 52.5 years, and the range from 27-76. Complete or partial remission for a period of 11.5 months (median) was achieved in 56.5%. Among 23 cases of lung metastases 48% had partial or complete remissions, among 16 cases of lymph node metastases 81%, and among 32 cases of bone metastases, 37.5%. Of six cases of local recurrence, 33.3% had partial remissions. Among four cases of liver metastases, 50% had objective responses. Among five cases of miscellaneous metastases, all had complete or partial responses. The median survival of the complete responders was 17 months, while that of the nonresponders was only 11 months. Side effected were tolerable and no deaths were attributed to the treatment.

Long survival following combined treatment of inoperable cholangiocarcinoma: surgery, radiotherapy, and chemotherapy

A jaundiced patient due to inoperable bile duct carcinoma was treated by a combination of surgery, radiotherapy, and chemotherapy. At the operation an intra-abdominal, extra-choledochal bypass of the tumor was performed with a T-tube obstruction 10 months after diagnosis, and no evidence of malignancy was seen. The T-tube was replaced by an Argyle tube. One year later jaundice reappeared, due to displacement of the tube, and islets of metastatic tumor ce and additional cytotoxic treatment was given. Three months later, after the patient's demise due to an unrelated cause, no evidence of the disease was found. This case demonstrates the importance of palliative by-passing of the tumor in order to relieve obstruction, thus enabling further oncological treatment, which may be, as in the present case, highly effective.

Computer-aided tumour classification and treatment selection in breast cancer

In order to provide a common basis for treatment decisions and the future evaluation of breast cancer therapy, the breast cancer protocol used in our clinic was formulated for the computer. A system for the simulation of clinical reasoning was used which allows the physician to express the medical logic as a series of inferences to be confirmed or rejected on the basis of Boolean combinations of medical criteria. The system enables the physician to rearrange these criteria into a questionnaire for complete and accurate recording of patient data. These data are then fed into the computer to produce a patient status report and treatment recommendations. The data from 26 patients in various stages of breast cancer have been processed by the computer and the computer's conclusions compared to the assessment made by a junior physician in our department. In three cases the staging was not identical, in 15 cases the treatment decisions were not identical and in all cases investigations were left out by the physician. The system has been of considerable value in standardising patient examination and treatment and in training inexperienced physicians.