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.

Co-prescribing of atypical and typical antipsychotics – prescribing sequence and documented outcome

AIMS AND METHOD

To evaluate patterns of antipsychotic co-prescription and to establish documented outcome, we reviewed 1441 in-patient and community prescriptions written in a large mental health trust. For patients co-prescribed regular atypical and typical antipsychotics for longer than 6 weeks, medication histories were taken and case notes examined to determine sequence of prescribing, documented outcome and reasons for co-prescription.

RESULTS

Fifty-three patients had been co-prescribed aytpical and typical antipsychotics for more than 6 weeks. In 62% of cases the atypical drug had been prescribed first and a typical drug added later. The most frequently documented reason for co-prescription was that symptoms persisted when prescribed a single antipsychotic. Clinical outcome was documented for 64% of patients: 45% of the total number treated showed some improvement, with seven of 53 patients noted to have shown improvements in psychotic symptoms.

CLINICAL IMPLICATIONS

Co-prescription of aytpical and typical antipsychotics often occurs as a consequence of poor outcome with single drug treatment. In this study there was minimal evidence to suggest that co-prescription improved outcome to an important extent. There remains little support for co-prescription of antipsychotics but considerable evidence to suggest that such practice worsens adverse effect burden. Co-prescription of atypical and typical antipsychotics should be avoided in all but very exceptional circumstances.

Antipsychotic use and unexpected death: a hospital-based case-control study

OBJECTIVE

To examine the risk of unexpected death in patients prescribed an antipsychotic. Unexpected death was defined as death occurring within 7 days of the onset of acute symptoms.

METHOD

A case-control study conducted on events occurring between July 2009 and January 2011 in a UK mental health trust providing in-patient and out-patient services.

RESULTS

The study included 100 cases (deaths) and 436 unmatched controls. Current users of antipsychotics had a lower risk of unexpected death than non-users--adjusted odds ratio (OR) 0.48 (95% CI 0.24-0.94, P = 0.033). A significant reduction in risk was seen for second-generation [adjusted OR 0.42 (95% CI 0.21-0.86, P = 0.018)], but not first-generation agents [adjusted OR 0.83 (95% CI 0.31-2.20, P = 0.706)]. Treatment with antipsychotics for any duration was associated with reduced risk. Dose and route of administration did not affect risk. In a planned secondary analysis not adjusting for cardiovascular disease, prescription of an antipsychotic was not associated with increased risk of unexpected death [adjusted OR 0.56 (95% CI 0.28-1.08, P = 0.084)].

CONCLUSION

Our findings do not support an association between current antipsychotic use and increased risk of unexpected death.

[Megaesophagus in the dog and cat]

Megaesophagus is a disorder of the esophagus characterized by diffuse dilation and decreased peristalsis. It is classified into congenital and acquired forms. Gastrointestinal, endocrine, immune-mediated, neuromuscular, paraneoplastic, and toxic disorders have been associated with acquired megaesophagus. Common clinical signs of megaesophagus are regurgitation, weight loss, coughing, and halitosis. Most cases of megaesophagus can be diagnosed using thoracic radiography; however, diagnosing the underlying cause requires a thorough history and additional diagnostics. The treatment, management, and prognosis of megaesophagus vary greatly depending on the underlying cause.

Ammonia influence in anaerobic digestion of OFMSW

The anaerobic digestion of the organic fraction of municipal solid wastes is taking increasing importance in the recent years. The main problem of some anaerobic digestion process is the large quantity of ammonia that is released, especially when high solid digestion is implemented. A fraction of the supernatant is treated and the remaining is recirculated to maintain the reactor in the optimum solids concentration. The question arising is if this recirculation stream should also be treated to improve biogas production. However, when doing the latter the quantity of ammonia inside the reactor increases too which could lead to inhibit the reactor operation. In this paper it appears that not only free ammonia affects the methanogenic fermentation but also ammonium ion concentration. Biogas production profiles are estimated using the Gompertz model. On the other hand, inhibition constants are fitted using a non-competitive inhibition model equation Thus, 50% inhibition of biomethane production was observed at level of 215 and 468 mg NH3_N/L under mesophilic and thermophilic conditions. However, the methane generation under mesophilic and thermophilic conditions was reduced by 50% when ammonium ion reach concentrations of 3,860 and 5,600 mg NH4+_N/L respectively. Under mesophilic conditions, pH higher than 7 impacted the methanogens bacteria negatively. This threshold pH limit, is variable under thermophilic conditions, depending on the total ammonia concentration.

Dry anaerobic digestion of differently sorted organic municipal solid waste: a full-scale experience

This paper presents a comparison of dry anaerobic digestion reactors fed with differently sorted municipal organic solid wastes. One reactor was fed with source sorted organic wastes and a second reactor was fed with mixed organic wastes consisting of grey wastes, mechanically selected municipal solid wastes and sludge. The two reactors utilised the same process (Valorga) and operational conditions at full scale. The results of the study emphasise the influence of the kind of treated material on the process performances, especially in terms of biogas and methane production, thus, energy reclamation. The reactor treating the source sorted organic waste and the reactor treating the mixed organic wastes generated some 200 m3 and 60 m3 of biogas per ton of waste treated, respectively, while the specific methane production was some 0.40 and 0.13 m3CH4/kgTVS, respectively. The mass balance and the final fate of the digested material from the two reactors were also clearly different. As for the costs, these were some 29 Euro per ton of treated waste (50% for personnel) and 53 Euro/ton for disposing of the rejected materials. Incomes were some 100 Euro/ton (on average) and an other 15 Euro/ton came from green certificates. The initial investment was 16 million Euros.

Association studies in candidate genes: strategies to select SNPs to be tested

OBJECTIVE

When numerous single nucleotide polymorphisms (SNPs) have been identified in a candidate gene, a relevant and still unanswered question is to determine how many and which of these SNPs should be optimally tested to detect an association with the disease. Testing them all is expensive and often unnecessary. Alleles at different SNPs may be associated in the population because of the existence of linkage disequilibrium, so that knowing the alleles carried at one SNP could provide exact or partial knowledge of alleles carried at a second SNP. We present here a method to select the most appropriate subset of SNPs in a candidate gene based on the pairwise linkage disequilibrium between the different SNPs.

METHOD

The best subset is identified through power computations performed under different genetic models, assuming that one of the SNPs identified is the disease susceptibility variant.

RESULTS

We applied the method on two data sets, an empirical study of the APOE gene region and a simulated study concerning one of the major genes (MG1) from the Genetic Analysis Workshop 12. For these two genes, the sets of SNPs selected were compared to the ones obtained using two other methods that need the reconstruction of multilocus haplotypes in order to identify haplotype-tag SNPs (htSNPs). We showed that with both data sets, our method performed better than the other selection methods.

A Study in vitro of the Abrasive Effect of the Tongue on Enamel and Dentine Softened by Acid Erosion

The palatal aspect of upper anterior teeth appears to be one site of predilection for erosion. This raises the question of whether abrasion of softened enamel and dentine by the tongue has a role in this process. The aim of this study in vitro was to determine whether enamel and dentine specimens licked by the tongue after exposure to acid lost more tissue than when exposed to acid alone. Flat enamel and dentine specimens were prepared from human third molars and taped to expose a window of tissue. Three groups of specimens were exposed to citric acid for 10 min followed by 60 s tongue licking, ultrasonication or immersion in water. Two further groups of enamel specimens were placed in a low erosive drink for 10 min with or without licking. At the end of 5, 10 and 15 treatment cycles tissue loss was measured by profilometry. Enamel loss was significantly greater with licking and ultrasonication compared to water immersion. Dentine loss was greater with licking and ultrasonication compared to water immersion, but differences only reached significance for ultrasonication. The low erosive drink produced one third of the citric acid erosion and licking had no effect. The results suggest that the tongue could exert an abrasive effect on dental tissues softened by erosion, thereby increasing the overall loss of tooth substance.

Comparison of the biodegradability of the grey fraction of municipal solid waste of Barcelona in mesophilic and thermophilic conditions

The results of the start-up of two digesters in mesophilic and thermophilic conditions, together with its steady results at several organic loading rates are described. A kinetic study is also carried out which allows one to estimate the ultimate methane production, together with the first-order kinetic constant. Operation at thermophilic temperature yields better results as it allows a more loaded reactor and the methane production is slightly higher.

Selective serotonin reuptake inhibitors: a review of efficacy and tolerability in depression

Selective serotonin reuptake inhibitors (SSRIs) are now generally regarded as effective and better tolerated alternatives to tricyclic antidepressants (TCAs) for the treatment of depression. SSRIs also seem to be as well tolerated as moclobemide, mirtazapine, venlafaxine, reboxetine and nefazodone and show comparable efficacy. Minor differences have been observed between some SSRIs and some of the newer antidepressants but these findings are far from conclusive. Widespread use of the SSRIs has highlighted some unforseen adverse effects associated with SSRIs, namely hyponatraemia, EPSE and sexual dysfunction. Overall, differences in efficacy and tolerability between individual SSRIs are small and clinically insignificant.

A nursing career in the RAF

In 1918, the Royal Air Force (RAF) nursing service was formed. Today, the Princess Mary's Royal Air Force Nursing Service (PMRAFNS) has 291 qualified trained nurses and provides invaluable nursing and aeromedical support to the RAF wherever it serves. In addition, the PMRAFNS offers qualified nurses a wide variety of professional and personal opportunities both within the UK and abroad.

Anaphylactic shock induced by intraarticular injection of methylprednisolone acetate

There are numerous reports of hypersensitivity reactions to corticosteroids. However, cases of anaphylactic shock after intraarticular injection of corticosteroids are exceedingly rare. We describe a case of anaphylaxis in a 31-year-old woman after intraarticular injection of synthetic methylprednisolone acetate. Immediately after injection she developed sneezing, angioedema, tachycardia, and marked hypotension. She responded promptly to treatment with subcutaneous epinephrine. She had received uneventfully one intraarticular injection of the same compound 4 years earlier. Intradermal skin testing showed strong reactivity to methylprednisolone acetate suspension, moderate reactivity to hydrocortisone, and weak reactivity to betamethasone. Tests with dexamethasone, triamcinolone, lidocaine, latex and nonsteroid constituents of the injected suspension including polyethylene glycol, polysorbate 80, mono and dibasic sodium phosphate, and myristyl-gamma-picolinium chloride were negative. This patient had developed anaphylaxis due to methylprednisolone acetate alone. Although such events are very rare, it is advisable to keep injectable epinephrine in the offices of rheumatologists.

Hepatic dysfunction and cardiovascular abnormalities. Occurrence in infants, children, and young adults

In infants and children, the effect of heart failure and/or cyanotic heart disease on the liver has not been well documented, nor has there been any comparison between the degree of liver dysfunction and hemodynamic factors. Sixty-five patients with cardiovascular abnormalities were examined. Hepatic function, as indicated by laboratory data and histologic liver studies, was compared with the following categories of cardiovascular dysfunction: hypoxemia, systemic venous congestion, and low cardiac output. If any one of these factors was present, or any combination, abnormalities of liver function were usually noted. Patients with both hypoxemia and systemic venous congestion had marked hepatic dysfunction. Those with low cardiac output had the most severe abnormalities. Serial studies indicated that liver function correlated with cardiac status.

Hypertensive encephalopathy. A cause of neonatal seizures

Hypertensive encephalopathy is rare in newborns. The few reported cases of malignant hypertension in newborns have been secondary to renovascular disease. We studied an infant with hypertensive encephalopathy secondary to isolated coarctation of the aorta. Infants with this condition are generally asymptomatic; to our knowledge, this is the youngest patient to have had neurologic complications secondary to isolated coarctation of the aorta.

Vagal control of heart period in alloxan diabetic rats

Autonomic neuropathies are a frequent complication to diabetes in humans. Similar neuropathies have not been well-documented in animal models. To determine if diabetic rats would develop parasympathetic neuropathies, rats were made diabetic by the injection of alloxan into the tail vein and then maintained on daily injections of insulin. At various times subsequent to the induction of diabetes (3-5 weeks, 7-9 weeks, and 14 weeks), the effect of constant frequencies of vagal stimulation on the efferent cardiac chronotropic response was evaluated using analysis of variance techniques. It was found that the vagal parasympathetic effect was accentuated in diabetic rats. That is, at a given frequency of supramaximal vagal stimulation, the heart rate slowed more in diabetic rats than in nondiabetic rats. Whether a similar phenomenon exists in humans is not known.

Echocardiographic abnormalities in infants of diabetic mothers

In order to evaluate the presence of myocardial hypertrophy and/or abnormalities of postnatal cardiovascular adaptation, echocardiograms were performed on 34 infants of diabetic mothers. Based on cardiopulmonary assessment, the IDM were divided into three groups: Group I with congestive heart failure predominating: Group II with respiratory distress predominating: Group III asymptomatic. Hypertrophy of the interventricular septum and of the walls of left and right ventricles was frequently present in IDM: this change was most notable in association with clinical CHF. Six IDM, four of whom were found to have CHF, had additional echocardiographic signs of subaortic stenosis. All IDM had normal indices of left ventricular performance, despite the presence of CHE. In IDM with respiratory distress, the right ventricular pre-ejection period to ventricular ejection time ratio was elevated, suggesting an abnormality of the transitional pulmonary circulation. Poor maternal diabetes control and maternal systemic hypertension were closely correlated with evidence of myocardial hypertrophy in the infants.