"That's why we're speaking up today": exploring barriers to overdose fatality prevention in Indianapolis' Black community with semi-structured interviews

BACKGROUND

Opioid overdose deaths are of great concern to public health, with over one million lives lost since 1999. While many efforts have been made to mitigate these, Black communities continue to experience a greater burden of fatalities than their white counterparts. This study aims to explore why by working with Black community members in Indianapolis through semi-structured interviews.

METHODS

Semi-structured one-on-one in-depth interviews were conducted in spring and summer of 2023 with Black residents (N = 23) of zip codes 46202, 46205, 46208, and 46218 in Indianapolis. Ten interview questions were used to facilitate conversations about opioid overdoses, recovery, fatality prevention tools such as calling 911 and naloxone, law enforcement, and racism. Data were analyzed using grounded theory and thematic analysis.

RESULTS

Interviews revealed access barriers and intervention opportunities. Racism was present in both. Mental access barriers such as stigma, fear, and mistrust contributed to practical barriers such as knowledge of how to administer naloxone. Racism exacerbated mental barriers by adding the risk of race-based mistreatment to consequences related to association with substance use. Participants discussed the double stigma of substance use and being Black, fear of being searched in law enforcement encounters and what would happen if law enforcement found naloxone on them, and mistrust of law enforcement and institutions that provide medical intervention. Participants had favorable views of interventions that incorporated mutual aid and discussed ideas for future interventions that included this framework.

CONCLUSIONS

Racism exacerbates Blacks' mental access barriers (i.e., help-seeking barriers), which, in turn, contribute to practical barriers, such as calling 911 and administering naloxone. Information and resources coming from people within marginalized communities tend to be trusted. Leveraging inter-community relationships may increase engagement in opioid overdose fatality prevention. Interventions and resources directed toward addressing opioid overdose fatalities in Black communities should use mutual aid frameworks to increase the utilization of the tools they provide.

Mutational analysis of MAdCAM-1/alpha4beta7 interactions reveals significant binding determinants in both the first and second immunuglobulin domains

The selective emigration of blood born leukocytes into tissues is mediated, in part by interactions of Ig-like cell adhesion molecules (IgCAMs) expressed on vascular endothelium and their cognate ligands, the leukocyte integrins. Within mucosal lymphoid tissues and gastrointestinal sites the mucosal vascular addressin. MAdCAM-1 is the predominant IgCAM, mediating specific lymphocyte homing via interactions with its ligand on lymphocytes, the integrin alpha4beta7. Previous studies have shown that an essential binding motif resides in the first Ig domain of all IgCAMs, containing an acidic residue (D or E) preceded by an aliphatic residue (L or I) that resides in strand C or the CD loop. However, domain swap experiments with MAdCAM-1 and VCAM-1 have shown a requirement for both Ig domains 1 and 2 for efficient integrin binding. We describe the use of chimeric MAdCAM-1/VCAM-1 receptors and point mutations in MAdCAM-1 to define other sites that are required for binding to the integrin alpha4beta7. We find that, in addition to critical CD loop residues, other regions in both domain one and two contribute to MAdCAM-1/alpha4beta7 interactions, including a buried arginine residue in the F strand of domain one and several acidic residues in a highly extended DE ribbon in domain 2. These mutations, when placed in the recently solved crystal structure of human MAdCAM-1 give insight into the integrin binding preference of this unique receptor.

The impact of early clinical training in medical education: a multi-institutional assessment

With funding from The Robert Wood Johnson Foundation's Generalist Physician Initiative, Dartmouth Medical School (DMS), New York Medical College (NYMC), and Virginia Commonwealth University School of Medicine (VCU-SOM) adopted early community-based training models for longitudinal clinical experiences. These schools developed different evaluation strategies to assess these models. This paper describes each program, the method used to evaluate an aspect of the program, lessons learned about early clinical teaching and learning, and challenges encountered. Each program used cross-sectional evaluation, and the analysis methods included descriptive statistics, chi-square, t-tests, analysis of variance, and generalized linear models. Dartmouth determined that the type of preceptor does not greatly influence the development of clinical skills, although case-specific differences were discovered. NYMC learned that students taught clinical skills in community-based settings performed as well as or better than their peers who received early patient experience on hospital wards. Virginia Commonwealth discovered that community experiences contributed positively to students' education, critical thinking, and problem-solving skills. Students value early clinical experiences and make important achievements in clinical skills and knowledge development, although logistic challenges exist in conducting these courses. Evaluations are critical to ensure competency, and faculty development must be linked to the evaluation process.

How medical students can bring about curricular change

Traditionally, medical school committees have been charged with curricular improvement and modification, while medical students have had little or no involvement in reform efforts. However, medical students can sometimes be ahead of faculty in recognizing new topics that need to be covered, and their energy, commitment, and vision can be a very important impetus for curricular change. In 1995-96, as part of a general curricular restructuring effort, faculty at Dartmouth Medical School began to design and offer new electives in innovative topics, with the idea that electives might become part of the required curriculum if the material presented in them were deemed to be "core." Students were invited to organize their own electives if a topic in which they were interested was not being covered. The authors (two were second-year medical students and the third was their faculty sponsor) developed an elective in women's health. This paper describes the development and implementation of this elective, and the process by which the course was later made part of the required curriculum at Dartmouth. The success of the authors' efforts highlights the crucial role students can play in reforming medical curricula.

Structure-function analysis of the integrin beta 7 subunit: identification of domains involved in adhesion to MAdCAM-1

Beta 7 integrins serve special roles in mucosal immunity. Alpha 4 beta 7-mediated adhesion to mucosal addressin cell adhesion molecule-1 (MAdCAM-1) directs lymphocyte homing to the gut, and alpha E beta 7 mediates binding of lymphocytes to E-cadherin on epithelial cells. Since alpha 4 beta 7 mediates adhesion to MAdCAM-1 but alpha 4 beta 1 does not, we used beta 7/beta 1 chimeras to directly assess the importance of specific regions of beta 7 in MAdCAM-1 binding. We found a region of beta 7 (residues 46-386) that accounts for specificity of alpha 4 beta 7 binding to MAdCAM-1. We also used human/mouse and human/rat chimeric beta 7 subunits to map epitopes recognized by fifteen anti-beta 7 mAbs. Six of seven Abs that block adhesion to MAdCAM-1 and E-cadherin (Fib 21, 22, 27, 30, 504; Act-1) mapped to amino acid residues 176-250. Residues 176-250 lie within the region of beta 7 that specifies MAdCAM-1 binding and also within a region that has a predicted structure homologous to the metal ion-dependent adhesion site (MIDAS) domains of the integrin subunits alpha L and alpha M. Three new Abs that recognize beta 7 in the presence of Mn2+, but not Ca2+, and promote adhesion to MAdCAM-1, mapped to amino acids 46-149. One blocking and five other Abs mapped to other regions (amino acids 387-725). We conclude that a MIDAS-like domain serves a critical role in beta 7 integrin-mediated adhesion.

Structure-function analysis of the integrin beta 7 subunit: identification of domains involved in adhesion to MAdCAM-1

Beta 7 integrins serve special roles in mucosal immunity. Alpha 4 beta 7-mediated adhesion to mucosal addressin cell adhesion molecule-1 (MAdCAM-1) directs lymphocyte homing to the gut, and alpha E beta 7 mediates binding of lymphocytes to E-cadherin on epithelial cells. Since alpha 4 beta 7 mediates adhesion to MAdCAM-1 but alpha 4 beta 1 does not, we used beta 7/beta 1 chimeras to directly assess the importance of specific regions of beta 7 in MAdCAM-1 binding. We found a region of beta 7 (residues 46-386) that accounts for specificity of alpha 4 beta 7 binding to MAdCAM-1. We also used human/mouse and human/rat chimeric beta 7 subunits to map epitopes recognized by fifteen anti-beta 7 mAbs. Six of seven Abs that block adhesion to MAdCAM-1 and E-cadherin (Fib 21, 22, 27, 30, 504; Act-1) mapped to amino acid residues 176-250. Residues 176-250 lie within the region of beta 7 that specifies MAdCAM-1 binding and also within a region that has a predicted structure homologous to the metal ion-dependent adhesion site (MIDAS) domains of the integrin subunits alpha L and alpha M. Three new Abs that recognize beta 7 in the presence of Mn2+, but not Ca2+, and promote adhesion to MAdCAM-1, mapped to amino acids 46-149. One blocking and five other Abs mapped to other regions (amino acids 387-725). We conclude that a MIDAS-like domain serves a critical role in beta 7 integrin-mediated adhesion.

Human mucosal addressin cell adhesion molecule-1 is preferentially expressed in intestinal tract and associated lymphoid tissue

Lymphocyte homing to normal tissues and recruitment to inflammatory tissue sites are controlled, in part, by the selective expression of chemokines, pro-inflammatory cytokines and mediators, and various adhesion proteins and molecules. In the mouse, mucosal addressin cell adhesion molecule-1 (MAdCAM-1) is selectively expressed on endothelium of high endothelial venules in gut and gut-associated lymphoid tissue. By interaction with its integrin ligand, alpha 4 beta 7, lymphocytes presumed to be involved in mucosal immunity are selectively recruited to these intestinal sites. After generating monoclonal antibodies against a murine cell line expressing recombinant human MAdCAM-1, we qualitatively and semiquantitatively assessed MAdCAM-1 expression in human tissue sections from various normal and inflammatory disorders. We found that human MAdCAM-1, as in the mouse, is expressed in a tissue-selective manner. In normal tissues, MAdCAM-1 is constitutively expressed to endothelium of venules of intestinal lamina propria. Interestingly, using computer-assisted morphometric analysis, the proportion of venular endothelium within lamina propria that expresses MAdCAM-1 is increased, compared with normal tissues, at inflammatory foci associated with ulcerative colitis and Crohn's disease. Moreover, for the most part, MAdCAM-1 is not detected in the majority of normal or inflamed extra-intestinal tissues, including those with mucosal surfaces. These results are consistent with a role, as originally defined in the mouse, for human MAdCAM-1 in the localization of alpha 4 beta 7+ lymphocytes in the gastrointestinal tract and associated lymphoid tissue. As such, the pathway defined by MAdCAM-1/alpha 4 beta 7 may be a relevant tissue-specific therapeutic target for the modulation of inflammatory bowel disease activity.

Enzymatic and organizational difference in expression of a Burkitt lymphoma-associated antigen (globotriaosylceramide) in Burkitt lymphoma and lymphoblastoid cell lines

In our previous study, a Burkitt lymphoma-associated antigen defined by a monoclonal antibody, designated 38.13, was characterized as globotriaosylceramide (Gb3, Gal alpha 1----4 Gal beta 1----4 Glc beta 1----1 Cer) (Nudelman, E., Kannagi, R., Hakomori, S., Parsons, M., Lipinski, M., Wiels, J., Fellous, M., and Tursz, T. (1983) Science (Wash. D.C.) 220, 509-511). Consequently, we have studied the enzymatic basis and organization of Gb3 expression in Burkitt as compared with non-Burkitt lymphoblastoid cell lines. Burkitt lymphoma cell lines (Ramos, Daudi, Put) were characterized by a high chemical quantity of Gb3, high enzyme activity for synthesis of Gb3 (UDP-Gal:LacCer alpha-galactosyltransferase), and a high degree of surface exposure of Gb3, as determined by galactose oxidase/NaB[3H]4 and by cytofluorometry with the monoclonal antibody to Gb3 (38.13). Non-Burkitt lymphoblastoid cell lines (Priess, Remb1, and ARH77) were characterized by the absence of Gb3 at the cell surface detected by cytofluorometry or cell-surface labeling. The cell lines Priess and Remb1 did not contain Gb3 and showed a low alpha-galactosyltransferase activity for Gb3 synthesis. However, the cell line ARH77, though it did not express Gb3 at the cell surface, was found to contain a large chemical quantity of Gb3 and a high level of alpha-galactosyltransferase activity for Gb3 synthesis. However, Gb3 of ARH77 cells was exposed by sialidase treatment, but not by protease treatment, although Gb3 itself was not sialylated. The crypticity of Gb3 in ARH77 cells could be associated with an adjacent sialosyl residue of a second glycoconjugate at the cell surface, in the same way as Gg3 in mouse lymphoma L5178 (Urdal, D. L., and Hakomori, S. (1983) J. Biol. Chem. 258, 6869-6874). Thus, the expression in Burkitt and non-Burkitt lymphoma is dependent on (i) Gb3 synthesis due to alpha-galactosyltransferase activity and (ii) membrane organization of Gb3, which may be controlled through interaction with the sialosyl residue of a second glycoconjugate.

Novel fucolipids accumulating in human adenocarcinoma. II. Selective isolation of hybridoma antibodies that differentially recognize mono-, di-, and trifucosylated type 2 chain

A series of glycolipids having the X determinant (Gal beta 1----4 [Fuc alpha----3]GlcNAc) at the terminus and a fucosyl alpha 1----3 residue at the internal GlcNAc residue have been isolated and characterized from tumor tissues (Hakomori, S., Nudelman, E., Levery, S.B., and Kannagi, R. (1984) J. Biol. Chem. 259, 4672-4680. A series of monoclonal antibodies that differentially recognize glycolipids with mono-, di-, and trifucosylated type 2 chain have been isolated and characterized. The antibody FH4 shows a remarkable preferential reactivity towards di-/or trifucosylated type 2 chain, i.e. it does not react with monofucosylated structures, including lactofucopentaosyl (III) ceramide (III3FucnLc4), monofucosyl neolactonorhexaosylceramide (y2, V3FucnLc6), and monofucosyl neolactonoroctaosylceramide (Z1, VII3FucnLc8), but reacts well with di- and trifucosylated type 2 chain structures such as difucosyl neolactonorhexaosylceramide (III3V3Fuc2nLc6) and trifucosyl neolactonoroctaosylceramide (III3V3VII3Fuc3nLc8). Two other monoclonal antibodies, FH5 and ACFH18, preferentially react with trifucosylated type 2 chain structure (III3V3VII3Fuc3nLc8), although cross-reactivity with difucosylated type 2 chain (III3V3Fuc2nLc6) was observed. They showed a minimal cross-reaction with monofucosylated type 2 chain. In contrast, the antibody FH1 does not react with III3FucnLc4 but reacts with V3FucnLc6, III3V3Fuc2nLc6, and III3V3VII3Fuc3nLc8. Two monoclonal antibodies, FH2 and FH3, do not discriminate among various glycolipids having fucosylated type 2 chain, and their reactivities are essentially similar to previously established antibodies directed to the X determinant, such as anti-SSEA-1, WGHS 29, VEP8 and 9, My-1, etc. This series of antibodies will be useful to detect the specific type of glycolipid with fucosylated type 2 chain accumulating in human cancer and in undifferentiated cells.

Measuring preferences for hierarchical control: an attitude scale for contemporary times

A concern for understanding patterns of social control in contemporary society led to the development of an attitude scale measuring preferences for Hierarchical Control ( ns = 473, 510). The scale distinguished situations where decisions were associated with those having power or authority from situations where decisions were made by people most affected by the decision, regardless of status. Statistical characteristics of the 34-item forced-choice questionnaire included (1) moderately high item-total score correlations, (2) a wide distribution of scores, and (3) reliabilities of approximately .80. The scale did not duplicate the I-E Scale, Dogmatism, or the control subscales of FIRO-B, not was it significantly related to social desirability. Data from police officers, army enlisted men, and teachers with differing educational approaches supported the validity of the scale.