Prevalence of Opioid Use Disorder and Opioid Overdose Rates Among People With Mental Illness

OBJECTIVE

The authors examined the prevalence and correlates of co-occurring opioid use disorder and opioid overdose among individuals receiving psychiatric services.

METHODS

This was a cross-sectional study of adults with continuous enrollment in New York State Medicaid who received at least one psychiatric service in 2020 (N=523,885). Logistic regression models were used to examine the correlates of both opioid use disorder and overdose.

RESULTS

In the study sample, the prevalence rate of opioid use disorder was 8.1%; within this group, 7.7% experienced an opioid overdose in the study year. Opioid use disorder rates were lower among younger (18-24 years; 2.0%) and older (≥65 years; 3.1%) adults and higher among men (11.1%) and among those residing in rural areas (9.9%). Compared with Whites (9.4%), opioid use disorder rates were lower for Asian Americans (2.0%, adjusted odds ratio [AOR]=0.22) and Blacks (6.8%, AOR=0.76) and higher for American Indians (13.2%, AOR=1.43) and Hispanics (9.6%, AOR=1.29). Individuals with any substance use (24.9%, AOR=5.20), posttraumatic stress (15.7%, AOR=2.34), bipolar (14.9%, AOR=2.29), or anxiety (11.3%, AOR=2.18) disorders were more likely to have co-occurring opioid use disorder; those with conduct (4.5%, AOR=0.51), adjustment (7.4%, AOR=0.88), or schizophrenia spectrum (7.4%, AOR=0.87) disorders were less likely to have opioid use disorder. Those with suicidality (23.9%, AOR=3.83) or economic instability (23.7%, AOR=3.35) had higher odds of having opioid use disorder. Overdose odds were higher among individuals with suicidality (34.0%, AOR=6.82) and economic instability (16.0%, AOR=2.57).

CONCLUSIONS

These findings underscore the importance of providing opioid use disorder screening and treatment for patients receiving psychiatric services.

Clinical Implications of the Relationship Between Naltrexone Plasma Levels and the Subjective Effects of Heroin in Humans

BACKGROUND

Extended-release naltrexone (NTX) is an opioid antagonist approved for relapse prevention after medical withdrawal. Its therapeutic effect is dependent on the NTX plasma level, and as it decreases, patients may lack protection against relapse and overdose. Therefore, identifying the minimally effective NTX level needed to block opioid-induced subjective effects has important clinical implications.

METHODS

This secondary, individual-level analysis of data collected in a human laboratory study was conducted to evaluate the relationship between NTX levels and subjective effects of an intravenously administered 25-mg challenge dose of heroin in non-treatment-seeking participants with opioid use disorder (N = 12). Subjective ratings of drug liking using a 100-mm visual analog scale (VAS) and NTX levels were measured across 6 weeks after participants received a single injection of either extended-release NTX 192 mg (N = 6) or 384 mg (N = 6). Cubic spline mixed-effects models were used to provide 95% prediction intervals for individual changes in liking scores as a function of NTX levels.

RESULTS

Naltrexone levels above 2 ng/mL blocked nearly all VAS ratings of drug liking after intravenous heroin administration. Participants with NTX levels ≥ 2 ng/mL had minimal (≤20 mm) changes from placebo in VAS ratings of drug liking based on 95% prediction intervals. In contrast, NTX levels < 2 ng/mL were associated with greater variability in individual-level subjective responses.

CONCLUSIONS

In clinical practice, a plasma level range of 1 to 2 ng/mL is considered to be therapeutic in providing heroin blockade. The current findings suggest that a higher level (>2 ng/mL) may be needed to produce a consistent blockade.

Individual-Level Risk Prediction of Return to Use During Opioid Use Disorder Treatment

Importance

No existing model allows clinicians to predict whether patients might return to opioid use in the early stages of treatment for opioid use disorder.

Objective

To develop an individual-level prediction tool for risk of return to use in opioid use disorder.

Design, Setting, and Participants

This decision analytical model used predictive modeling with individual-level data harmonized in June 1, 2019, to October 1, 2022, from 3 multicenter, pragmatic, randomized clinical trials of at least 12 weeks' duration within the National Institute on Drug Abuse Clinical Trials Network (CTN) performed between 2006 and 2016. The clinical trials covered a variety of treatment settings, including federally licensed treatment sites, physician practices, and inpatient treatment facilities. All 3 trials enrolled adult participants older than 18 years, with broad pragmatic inclusion and few exclusion criteria except for major medical and unstable psychiatric comorbidities.

Intervention

All participants received 1 of 3 medications for opioid use disorder: methadone, buprenorphine, or extended-release naltrexone.

Main Outcomes and Measures

Predictive models were developed for return to use, which was defined as 4 consecutive weeks of urine drug screen (UDS) results either missing or positive for nonprescribed opioids by week 12 of treatment.

Results

The overall sample included 2199 trial participants (mean [SD] age, 35.3 [10.7] years; 728 women [33.1%] and 1471 men [66.9%]). The final model based on 4 predictors at treatment entry (heroin use days, morphine- and cocaine-positive UDS results, and heroin injection in the past 30 days) yielded an area under the receiver operating characteristic curve (AUROC) of 0.67 (95% CI, 0.62-0.71). Adding UDS in the first 3 treatment weeks improved model performance (AUROC, 0.82; 95% CI, 0.78-0.85). A simplified score (CTN-0094 OUD Return-to-Use Risk Score) provided good clinical risk stratification wherein patients with weekly opioid-negative UDS results in the 3 weeks after treatment initiation had a 13% risk of return to use compared with 85% for those with 3 weeks of opioid-positive or missing UDS results (AUROC, 0.80; 95% CI, 0.76-0.84).

Conclusions and Relevance

The prediction model described in this study may be a universal risk measure for return to opioid use by treatment week 3. Interventions to prevent return to regular use should focus on this critical early treatment period.

Integration of T-cell clonality screening using TRBC-1 in lymphoma suspect samples by flow cytometry

BACKGROUND

The diagnosis of T-cell non-Hodgkin lymphomas (NHL) is challenging. The development of a monoclonal antibody specific for T-cell receptor β constant region 1 (TRBC1) provides an alternative to discriminate clonal T cells. The aim of this study was to evaluate the diagnostic potential of an anti-TRBC1 mAb for the identification of T-NHL.

METHODS

We performed a cross-sectional diagnostic analytic study of samples tested for lymphoma. All samples sent for lymphoma screening were first evaluated using the standard Euroflow LST, to which a second additional custom-designed T-cell clonality assessment tube was added CD45/TRBC1/CD2/CD7/CD4/TCRγδ/CD3. Flow cytometry reports were compared with morphological and molecular tests.

RESULTS

Fifty-nine patient samples were evaluated. Within the T-cell population, cut-off percentages in the CD4+ cells were from 29.4 to 54.6% and from 23.9 to 52.1% in CD8+ cells. Cut-off ratios in CD4+ T cells were from 0.33 to 1.1, and in CD8+ cells between 0.22 and 1.0. Using predefined normal cut-off values, 18 of 59 (30.5%) samples showed a restricted expression of TRBC1. A final diagnosis of a T-NHL was confirmed clinically and/or by histopathological studies in 15 of the 18 cases (83.3%). There were no cases of T-NHL by morphology/IHC with normal TRBC1 expression. Non-neoplastic patient samples behaved between predefined TRBC1 cut-off values.

CONCLUSIONS

Expression of TRBC1 provides a robust method for T-cell clonality assessment, with very high sensitivity and good correlation with complementary methods. TRBC1 can be integrated into routine lymphoma screening strategies via flow cytometry.

Timing of umbilical cord occlusion, delayed vs early, in preterm babies: A randomized controlled trial (CODE-P Trial)

INTRODUCTION

Our hypothesis was that delayed cord clamping (DCC) (not earlier than 30 s; at 30-60 s) in premature neonates (born between 26.0 and 32.6 weeks of gestation), as compared with the usual early cord clamping (ECC), significantly reduces the need for blood transfusions and incidence of intraventricular haemorrhage (IVH) without an increased rate of maternal postpartum haemorrhage.

MATERIAL AND METHODS

A prospective, open-label, randomized, controlled trial was conducted at Vall d'Hebron Hospital from July 2014 to December 2018. All pregnant women at risk of impending preterm birth (≥26.0-<33.0 weeks of gestation) who were admitted to the obstetrics emergency department were evaluated for eligibility. If they met the eligibility criteria, they were invited to participate in the study and, if they agreed, they signed an informed consent. Patients were randomly assigned to one of two groups: ECC group and DCC group.

RESULTS

Our study included a total of 57 patients: 30 in the ECC group and 27 in the DCC group. Due to a lack of funding and low recruitment rates, the study was discontinued in 2018. Maternal characteristics and obstetric outcomes were similar between both groups. The intention-to-treat analysis did not reveal any differences between groups for neonatal red blood cell transfusions, neonatal IVH or maternal postpartum haemorrhage. There were no differences for secondary outcomes. Similarly, no differences were observed in the as-treated analysis.

CONCLUSION

The primary and secondary outcomes of our study were not achieved. Therefore, more meta-analysis and trials are needed to evaluate the appropriate timing of cord clamping in preterm birth.

Risks of returning to opioid use at treatment entry and early in opioid use disorder treatment: Role of non-opioid substances

OBJECTIVE

Patients in treatment with medications for opioid use disorder (MOUD) often report use of other substances in addition to opioids. Few studies exist that examine the relationship between use at treatment entry and early non-opioid use in opioid treatment outcome.

METHODOLOGY

We combined and harmonized three randomized, controlled MOUD clinical trials from the National Institutes of Drug Abuse (NIDA) Clinical Trials Network (CTN) (N=2197) and investigated the association of non-opioid substance use at treatment entry and during early treatment with a return to opioid use. The trials compared MOUD treatment (buprenorphine, methadone, extended-release naltrexone) in populations with opioid use disorder (OUD). Non-opioid substances were identified through harmonizing self-reported use. The primary outcomes were markers of return to opioid use by 12 weeks.

RESULTS

When treatment cohorts were adjusted, no association between self-reported treatment entry use of non-opioid substances and week-12 opioid use was detected. During the first month of treatment, higher use of cocaine (OR 1.41 [1.18-1.69]) and amphetamine (OR 1.70 [1.27-2.26]) was found to be associated with higher likelihood of illicit opioid use by week 12. Exploratory analyses of potential treatment cohort-by-predictor interactions showed that those with heavier cocaine use had a lower rate of returning to opioid use in the extended-release naltrexone group than in the methadone group.

CONCLUSION

Substance use other than opioids at treatment entry is not associated with relapse. Use of cocaine or amphetamines during the first few weeks of MOUD treatment may signal a worse outcome, suggesting a need for additional interventions.

A pilot study investigating cognitive impairment associated with opioid overdose

BACKGROUND

In 2021, while overdose (OD) deaths were at the highest in recorded history, it is estimated that >80% of ODs do not result in a fatality. While several case studies have indicated that opioid-related ODs can result in cognitive impairment, the possible association has not yet been systematically investigated.

METHODS

78 participants with a history of OUD who reported experiencing an OD in the past year (n=35) or denied a lifetime history of OD (n=43) completed this study. Participants completed cognitive assessments including the Test of Premorbid Functioning (TOPF) and the NIH Toolbox Cognition Battery (NIHTB-CB). Comparisons were made between those who experienced an opioid-related OD in the past year versus those who denied a lifetime OD history while controlling for factors including age, premorbid functioning, and number of prior ODs.

RESULTS

When comparing those who experienced an opioid-related OD within the past year to those without a history of OD, uncorrected standard scores were generally comparable; however, differences emerged in the multivariable model. Specifically, compared to those without a history of OD, those who experienced a past year OD evidenced significantly lower total cognition composite scores (coef. = -7.112; P=0.004), lower crystalized cognition composite scores (coef. = -4.194; P=0.009), and lower fluid cognition composite scores (coef. = -7.879; P=0.031).

CONCLUSIONS

Findings revealed that opioid-related ODs may be associated with, or contribute to, reduced cognition. Extent of the impairment appears contingent upon individuals' premorbid intellectual functioning and the cumulative number of past ODs. While statistically significant, clinical significance may be limited given that performance differences (∼4 - 8 points) were not particularly robust. More rigorous investigation is warranted, and future studies must also account for the many other variables possibly contributing to cognitive impairment.

Factors Associated with Medical Cannabis Use After Certification: A Three-Month Longitudinal Study

Background: Over the past decade, there has been increased utilization of medical cannabis (MC) in the United States. Few studies have described sociodemographic and clinical factors associated with MC use after certification and more specifically, factors associated with use of MC products with different cannabinoid profiles. Methods: We conducted a longitudinal cohort study of adults (N=225) with chronic or severe pain on opioids who were newly certified for MC in New York State and enrolled in the study between November 2018 and January 2022. We collected data over participants' first 3 months in the study, from web-based assessment of MC use every 2 weeks (unit of analysis). We used generalized estimating equation models to examine associations of sociodemographic and clinical factors with (1) MC use (vs. no MC use) and (2) use of MC products with different cannabinoid profiles. Results: On average, 29% of the participants used predominantly high delta-9-tetrahydrocannabinol (THC) MC products within the first 3 months of follow-up, 30% used other MC products, and 41% did not use MC products. Non-Hispanic White race, pain at multiple sites, and past 30-day sedative use were associated with a higher likelihood of MC use (vs. no MC use). Current tobacco use, unregulated cannabis use, and enrollment in the study during the COVID-19 pandemic were associated with a lower likelihood of MC use (vs. no MC use). Among participants reporting MC use, female gender and older age were associated with a lower likelihood of using predominantly high-THC MC products (vs. other MC products). Conclusion: White individuals were more likely to use MC after certification, which may be owing to access and cost issues. The findings that sedative use was associated with greater MC use, but tobacco and unregulated cannabis were associated with less MC use, may imply synergism and substitution that warrant further research. From the policy perspective, additional measures are needed to ensure equitable availability of and access to MC. Health practitioners should check patients' history and current use of sedative, tobacco, and unregulated cannabis before providing an MC recommendation and counsel patients on safe cannabis use. clinicaltrials.gov (NCT03268551).

Risk of Experiencing an Overdose Event for Patients Undergoing Treatment With Medication for Opioid Use Disorder

OBJECTIVE

Overdose risk during a course of treatment with medication for opioid use disorder (MOUD) has not been clearly delineated. The authors sought to address this gap by leveraging a new data set from three large pragmatic clinical trials of MOUD.

METHODS

Adverse event logs, including overdose events, from the three trials (N=2,199) were harmonized, and the overall risk of having an overdose event in the 24 weeks after randomization was compared for each study arm (one methadone, one naltrexone, and three buprenorphine groups), using survival analysis with time-dependent Cox proportional hazard models.

RESULTS

By week 24, 39 participants had ≥1 overdose event. The observed frequency of having an overdose event was 15 (5.30%) among 283 patients assigned to naltrexone, eight (1.51%) among 529 patients assigned to methadone, and 16 (1.15%) among 1,387 patients assigned to buprenorphine. Notably, 27.9% of patients assigned to extended-release naltrexone never initiated the medication, and their overdose rate was 8.9% (7/79), compared with 3.9% (8/204) among those who initiated naltrexone. Controlling for sociodemographic and time-varying medication adherence variables and baseline substance use, a proportional hazard model did not show a significant effect of naltrexone assignment. Significantly higher probabilities of experiencing an overdose event were observed among patients with baseline benzodiazepine use (hazard ratio=3.36, 95% CI=1.76, 6.42) and those who either were never inducted on their assigned study medication (hazard ratio=6.64, 95% CI=2.12, 19.54) or stopped their medication after initial induction (hazard ratio=4.04, 95% CI=1.54, 10.65).

CONCLUSIONS

Among patients with opioid use disorder seeking medication treatment, the risk of overdose events over the next 24 weeks is elevated among those who fail to initiate or discontinue medication and those who report benzodiazepine use at baseline.

[Esclerosis multiple. Lactancia. Lactante. Planificacion familiar. Posparto. Tratamiento modificador de la enfermedad.]

INTRODUCTION

Multiple sclerosis mainly affects women of childbearing age, and the pregnancy and postpartum period is of special interest because of the peculiarities of the disease course and the therapeutic consequences that derive from it. During the period of breastfeeding (BF), the choice of treatment strategy must weigh up the well-established benefits of BF for both the newborn and the mother against the safety profile and potential adverse effects on the infant resulting from exposure to disease-modifying drugs transferred through breast milk.

DEVELOPMENT

The study reviews the current evidence on the safety of disease-modifying drugs available for the treatment of multiple sclerosis during the BF period, and gathers data on the transfer of the different drugs into breast milk, as well as the potential adverse effects described in the infant. The drugs of first choice during this period are interferon beta and glatiramer acetate. The rest of the disease modifying drugs are not accepted for use in the BF period according to their summary of product characteristics. However, in recent years, data from studies of clinical practice and case series have been published suggesting that some of these drugs could be used safely during this period.

CONCLUSIONS

Given the recognised health benefits of BF for both mother and infant, exclusive breastfeeding is recommended whenever possible. It is essential to carry out an individualised assessment prior to pregnancy and to evaluate the different treatment options depending on each patient.

Preliminary attitudes on medications for opioid use disorders (MOUDs) in Southeastern Switzerland and New York City

The United States (US) and Switzerland are affluent countries with different responses to surges in opioid use disorder (OUD) cases over the last thirty years. The Swiss "PROVE" trail implemented heroin-assisted treatment (HAT) for OUD alongside other medications for opioid use disorder (MOUD). In contrast, heroin remains highly controlled, HAT is inaccessible, and MOUD programs are generally more restrictive in the US than in Switzerland. We conducted a survey to compare practitioners' attitudes toward HAT across sites in both countries. Surveys were distributed electronically for voluntary, uncompensated completion (N = 120) at two mental health delivery sites, Psychiatrische Dienste Graubünden (PDGR) in Graubünden, Switzerland and Montefiore Medical Center (MMC) in the Bronx, NY. The survey instrument included 10 demographic and 19 "beliefs" questions measuring agreement level with a statement on a 5-point scale. Analysis included 79 PDGR respondents (mean age = 43.2, 59.5% women) and 41 MMC respondents (mean age = 44.7, 63.4% women), and did not show differences in confidence to treat OUD, addictions, and psychiatric disorders. For belief in HAT, Swiss respondents had a significantly more favorable view (b = 0.62) than those in New York (p = 0.00027). This study shows a difference in attitudes toward HAT among demographically similar staff treating OUD patients across sites. The cohorts demonstrate an overall positive attitude toward HAT but a more robust positive attitude was evident in Switzerland. Previously unreported attitude comparisons across sites with dissimilar OUD treatment availability may explain differences in practices and success in reducing harm from this disorder.

Gabapentin increases the abuse liability of alcohol alone and in combination with oxycodone in participants with co-occurring opioid and alcohol use disorder

BACKGROUND

People who have co-occurring Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD) carry a higher risk of adverse outcomes, including drug overdose. Early clinical and preclinical studies suggested that gabapentin may be effective in treating both disorders. The present study was designed to assess the effects of gabapentin on the subjective and physiological effects of oxycodone (OXY) and alcohol (ALC), alone and in combination.

METHODS

During an 8-week, inpatient, within-subject, randomized, double-blind, placebo-controlled crossover study, non-treatment seeking participants (N = 13; 12 M/1F; 44.1 ± 3 years of age) with OUD and AUD were maintained on oral morphine (120 mg daily). Under gabapentin (1800 mg/day) and placebo (0 mg/day) maintenance, participants completed nine separate test sessions (three sessions per week) during which they received an oral solution containing 0, 15, or 30 mg/70 kg OXY in combination with 0, 0.5, or 0.75 g/kg ALC. During test sessions, subjective effects and physiological responses were assessed repeatedly on 100-mm visual analog scales (VAS). The primary outcome variable was the VAS rating of drug liking after receiving the drug challenge.

RESULTS

Alcohol alone (but not oxycodone alone) produced dose-related increases in several positive subjective responses, including drug liking. Gabapentin significantly increased drug liking when given in combination with ALC and OXY + ALC (p < 0.05). Gabapentin did not clinically compromise respiration or other vital functions.

CONCLUSIONS

Gabapentin may increase the abuse liability of ALC and OXY + ALC in those with co-occurring OUD and AUD.

A randomized clinical trial of the effects of brief versus extended opioid overdose education on naloxone utilization outcomes by individuals with opioid use disorder

BACKGROUND

Overdose education and naloxone distribution (OEND) trains people who use opioids (PWUO) in how to intervene in cases of opioid overdose but best practices have not been assessed empirically.

METHODS

PWUO along with a significant other (SO) were randomized to one of three training conditions. In the Treatment-as-Usual (TAU) condition, participants were randomized to receive minimal overdose-related education. In the extended training (ET) condition, PWUO received an extended training, while their SO received no overdose training. In the final condition, both the participant and SO received the extended overdose training (ETwSO). Outcome measures were naloxone use and overdose knowledge and competency assessed immediately before and after training, and at 1-, 3-, 6-, and 12-month timepoints following training.

RESULTS

Three hundred and twenty-one PWUO (w/ a SO) were randomized. All intensities of OD training were associated with sustained increases in OD knowledge/ competency (versus pre-training baseline p's < 0.01). PWUO intervened in 166 ODs. The 12-month incidence of naloxone use did not significantly differ between groups. Extended training (ET + ETwSO) compared to TAU resulted in significantly greater naloxone utilization by: 30 days (10.1% vs 4.1%, p = 0.041), 60 days (16.4% vs 5.2%, p<0.001) and 90 days (17.9% vs 9.5%, p = 0.039).

CONCLUSIONS

All intensities of OD training were associated with sustained increases in OD knowledge and competency, and equivalent rates of successful naloxone use. More extensive training increased naloxone utilization during the first 3 months. However, the benefits of more comprehensive training should be balanced against feasibility.

The effects of acute oral naltrexone pretreatment on the abuse potential of intranasal methamphetamine, and the relationship between reward/punishment sensitivity and methamphetamine's effects

One potential medication for treating methamphetamine use disorder is the opioid antagonist naltrexone (NLTX). Despite encouraging preclinical findings, the results of clinical studies have been mixed. The primary aim of the current trial was to examine the effects of acute NLTX pretreatment on the subjective and reinforcing effects of intranasal methamphetamine. Nonmedical psychostimulant users completed outpatient testing sessions in which they received oral placebo (0 mg) or NLTX (50 mg) before intranasal methamphetamine (30 mg/70 kg). Primary outcome measures were peak positive subjective effects (e.g. drug 'Liking') assessed on a visual analog scale (0-100), and methamphetamine self-administration using an operant self-administration task. Participants also completed a probabilistic categorization task to assess reward and punishment learning sensitivity. Complete data were available from 13 male and 1 transgender (male-to-female) participant (age: 33.4 ± 7.6 years). Intranasal methamphetamine significantly increased subjective ratings of drug 'Liking', 'Good Effect' and 'High' from baseline (P's < 0.01), but did not significantly vary as a function of placebo or NLTX pretreatment. Similarly, methamphetamine self-administration did not vary between the placebo and NLTX pretreatment conditions. This sample did not demonstrate a significant 'bias' in learning from positive and negative outcomes (i.e. reward and punishment sensitivity), and reward/punishment sensitivity was not correlated with the effects of methamphetamine or the effects of NLTX on methamphetamine. The current study argues against the use of NLTX as a stand-alone medication for treating methamphetamine use disorder.

The feasibility of masks and face shields designed by 3D printing makers; some considerations of their use against the COVID-19

The use of mask and face shield has been established as one of the main preventive measures for the control of COVID 19 spread. In Mexico, as well as in other regions of the world, 3D printing has been employed for the design and production of masks and face shields as personal protective equipment (PPE). These models have been fabricated mainly by the makers, industries, and university communities; therefore, it is necessary to analyze the feasibility of the 3D printed PPE to understand its advantages and limitations. In this work, some characteristics of masks and face shields fabricated by additive manufacturing were studied to explore their viability as protection against flow fluids similar to human sneeze. In the present paper, the PPE was designed, and 3D printed utilizing three types of polylactic acid (PLA) as base material. The morphology and the surface elemental analyses of sectioned samples were analyzed by scanning electron microscopy (SEM) and energy dispersion x-ray spectroscopy (EDS). Showing spacing between printed layers, porous areas, and dispersed copper particles. On the other hand, a computational fluid dynamics (CFD) simulation was carried out, the results demonstrated the importance of using PPE for protection of a possible exposure to a “contaminated” aerosol and human sneeze. Based on the abovementioned results, it is possible to consider the commercial PLA as suitable material for the manufacturing of PPE due to its capability to be disinfected employing isopropanol, ethanol, or commercial disinfectants.

Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses: A systematic review

BACKGROUND

Non-fatal opioid-related overdoses have increased significantly over the past two decades and there have been increasing reports of brain injuries and/or neurocognitive impairments following overdose events. Limited preclinical research suggests that opioid overdoses may cause brain injury; however, little is known about such injuries in humans. The purpose this systematic review is to summarize existing studies on neurocognitive impairments and/or brain abnormalities associated with an opioid-related overdose in humans.

METHODS

PubMed, Web of Science, Ovid MEDLINE and PsyINFO were searched, without year restrictions, and identified 3099 articles. An additional 24 articles were identified by reviewing references. Articles were included if they were published in English, reported study findings in humans, included individuals 18 years of age or older, and reported an objective measure of neurocognitive impairments and/or brain abnormalities resulting from an opioid-related overdose. Six domains of bias (selection, performance, attrition, detection (two dimensions) and reporting were evaluated and themes were summarized.

RESULTS

Seventy-nine journal articles, published between 1973-2020, were included in the review. More than half of the articles were case reports (n = 44) and there were 11 cohort studies, 18 case series, and 6 case-control studies. All of the studies were categorized as at-risk of bias, few controlled for confounding factors, and methodological differences made direct comparisons difficult. Less than half of the studies reported toxicology results confirming an opioid-related overdose; 64.6 % reported brain MRI results and 27.8 % reported results of neuropsychological testing. Only two studies had within subject comparative data to document changes in the brain possibly associated with an overdose. Despite these limitations, existing publications suggest that brain injuries and neurocognitive impairments are associated with opioid overdose. Additional research is needed to establish the incidence of overdose-related brain injuries and the potential impact on functioning, as well as engagement in treatment of substance use disorders.

CONCLUSIONS

Respiratory depression is a defining characteristic of opioid overdose and prolonged cerebral hypoxia may cause brain injuries and/or neurocognitive impairments. The onset, characteristics, and duration of such injuries is variable and additional research is needed to understand their clinical implications.

P–358 Characteristics of patients with inherited thrombophilia and anticoagulant treatment in repeated implantation failure (RIF) and recurrent pregnancy loss (RPL)

Study question

Do patients with inherited thrombophilia associated to RIF and RPL benefit from anticoagulant therapy?

Summary answer

Low molecular weight heparin (LMWH) in patients with medium and high risk of hereditary thrombophilia, associated with RIF could improve the reproductive prognosis.

What is known already

Thrombophilia is a condition that can be acquired and/or inherited genetically, that is characterized by the predisposition of patients to form venous and arterial thromboembolic events. Inherited thrombophilia has been associated with different complications during pregnancy, such as RPL. Genetic variants linked to hereditary thrombophilia can be classified by the thromboembolic risk: low (F12, F13A1, FGB), medium (MTHFR, PROCR, PROS1, SERPINC1, SERPINC1 PAI–1) and high (F2, F5, GP1BA), according to Martinez - Zamora. RPL rate may reduce with anticoagulant therapy. However, there is no conclusive evidence that prophylactic treatment improves the pregnancy rate in infertile women during IVF.

Study design, size, duration

We performed a prospective observational study which included patients referred to Ceras Clinic between March 2018 and March 2020, due to RPL (n = 38) and RIF (n = 40). All patients underwent genetic analysis for hereditary thrombophilia(F13, F2, F5, FGB, GP1BA, MTHFR C677T, MTHFR A1298C, PAI1,, PROCR, SERPIN1 CM910058, SERPIN 1 CM920113 ,F12, PROS1) by Sanger sequencing. The characteristics of anticoagulant therapy with clinical pregnancy rate and LBR were analyzed, using chi-squared test with STATA version 16.

Participants/materials, setting, methods

Patients have been included in the study according to their past medical history (stroke or myocardial infarction, personal or familiar history of deep vein thrombosis or pulmonary embolism, smoking, hormone replacement therapy), and reproductive history. Two groups were formed, the first group (n = 40) corresponds to RIF, and the second (n = 38), RPL. Genetic study of hereditary thrombophilia (11 genes) was performed to examine the genetic risk and assess the administration of anticoagulant therapy.

Main results and the role of chance

The prevalence of pathological antecedents in patients with RIF and RPL was not statistically significant (p &gt; 0,05), indicating that the factors that contribute to poor reproductive outcomes in these two groups of patients could be similar. Patients with RIF had a medium risk of thrombophilia in 65%, followed by low risk in 32.5% and high risk in 2.5%. RPL group presented 78.95%, 15.79% and 5.26%, respectively. All patients with medium and high risk for trombophilia received anticoagulation. Clinical pregnancy rate (69.7%) and live birth rate (63.64%) were not statistically significant (p &gt; 0.05) in RPL with anticoagulant therapy, compared to RPL group who did not received treatment (clinical pregnancy rate and live birth rate in 60%). Therefore, it is proposed that there may be other factors associated with abortions that require investigation. However, clinical pregnancy rate (77.14%) and live birth rate (74.29%) were statistically significant (p &lt; 0.05) in RIF with anticoagulant therapy, compared to RIF group that did not received treatment (clinical pregnancy rate and live birth rate in 20%). This suggests that there could be a beneficial factor due to anticoagulation. Further studies are needed to assess that anticoagulant treatment could improve obstetric outcomes in patients with RIF and RPL.

Limitations, reasons for caution

The small number of patients assessed is the main limitation of this work. Larger studies must be designed to accurately determine participation of each mutation associated with recurrent implantation failure and recurrent pregnancy loss. The role of anticoagulant therapy should be evaluated in randomized clinical trials.

Wider implications of the findings: Establishing a stronger evidence base implies that future studies should include large population groups. It is primordial to assess whether it is cost-effective to determine the risk of inherited thrombophilia in RIL and RPL, to increase the live birth rate by anticoagulant therapy. The information is controversial to this day.

Trial registration number

‘not applicable’

Gallbladder cancer who is really cured?

BACKGROUND

Although gallbladder cancer (GBCA) is characterized by a dismal prognosis, there is a proportion of patients who are cured. The aim of this study was to analyze the profile of these patients.

METHODS

A database was queried for patients who underwent curative resection with a follow-up of at least 5 years. Patients were prospectively treated and registered by the same surgical team. A multivariate regression analysis was used to identify factors associated with long-term survival.

RESULTS

From 1988 to 2013, 461 patients were evaluated and 112 who underwent resection were analyzed. Among the patients, five year survival was 57% while lymph node and liver compromise were the only independent factors associated with survival. On the other hand, the elapsed time between the cholecystectomy and the resection, the differentiation grade and the level of wall invasion did not have an independent effect on the prognosis.

CONCLUSION

Despite its poor prognosis, a subset of patients can be cured of GBCA. R0 resection of patients without lymph and liver infiltration are key to GBCA survival.

A qualitative study of repeat naloxone administrations during opioid overdose intervention by people who use opioids in New York City

BACKGROUND

Take-home naloxone (THN) kits have been designed to provide community members (including people who use drugs, their families and/or significant others) with the necessary resources to address out-of-hospital opioid overdose events. Kits typically include two doses of naloxone. This 'twin-pack' format means that lay responders need information on how to use each dose. Advice given tends to be based on dosage algorithms used by medical personnel. However, little is currently known about how and why people who use drugs, acting as lay responders, decide to administer the second dose contained within single THN kits. The aim of this article is to explore this issue.

METHODS

Data were generated from a qualitative semi-structured interview study that was embedded within a randomised controlled trial examining the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training in New York City (NYC). Analysis for this article focuses upon the experiences of 22 people who use(d) opioids and who provided repeat naloxone administrations (RNA) during 24 separate overdose events. The framework method of analysis was used to compare the time participants believed had passed between each naloxone dose administered ('subjective response interval') with the 'recommended response interval' (2-4 minutes) given during OEND training. Framework analysis also charted the various reasons and rationale for providing RNA during overdose interventions.

RESULTS

When participants' subjective response intervals were compared with the recommended response interval for naloxone dosing, three different time periods were reported for the 24 overdose events: i. 'two doses administered in under 2 minutes' (n = 10); ii. 'two doses administered within 2-4 minutes' (n = 7), and iii. 'two doses administered more than 4 minutes apart' (n = 7). A variety of reasons were identified for providing RNA within each of the three categories of response interval. Collectively, reasons for RNA included panic, recognition of urgency, delays in retrieving naloxone kit, perceptions of recipients' responsiveness/non-responsiveness to naloxone, and avoidance of Emergency Response Teams (ERT).

CONCLUSION

Findings suggest that decision-making processes by people who use opioids regarding how and when to provide RNA are influenced by factors that relate to the emergency event. In addition, the majority of RNA (17/24) occurred outside of the recommended response interval taught during OEND training. These findings are discussed in terms of evidence-based intervention and 'evidence-making intervention' with suggestions for how RNA guidance may be developed and included within future/existing models of OEND training.

Tickbite-associated chronic pruritic lesions in an Afro-descendant population in the Cauca Department, Colombia. I. Clinical features and impact on health

BACKGROUND

During a health survey in a remote area in southwest Colombia, it became apparent that a high percentage of the population suffered from chronic pruritus in association with high numbers of ticks and tickbites.

OBJECTIVE

To determine the clinical features and severity of tickbite-associated pruritus.

METHOD

At twotime points - 8 weeks apart to account for seasonal effects - a cross-sectional study was conducted encompassing physical examination of the population, histological analysis of skin biopsies, and determining serum for antibodies against spotted fever (SFG) rickettsiae and typhus group (TG) rickettsiae. Ticks were identified using morphological criteria, and infection by rickettsiae was determined by PCR.

RESULTS

About 94.5% of the population (95% CI 92-97%) showed clinical signs of a pruritic arthropod reaction and of chronic pruritus with lichenoid papules and hyper- and hypopigmented nodules on otherwise noninflamed skin. Pruritus markedly impaired the quality of life in terms of sleeping disturbances. No signs for other diseases were observed. Chronic pruritus appeared to be because of repeated tickbites and scratching, but not because of other dermatological or medical conditions. Antibodies against SFG and TG-rickettsiae were detected at 79.0% (95% CI 73-86) and 3.6% (95% CI 0.7-6), respectively. Ticks were identified as Amblyomma cajennense.

CONCLUSION

Remarkably high exposure to tick bites caused an unusually high rate of acute and chronic pruritus and markedly impaired quality of life of the investigated rural community. This underlines the necessity of public health measures and surveillance of rickettsial disease.

Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: Exploratory mixed methods analysis

INTRODUCTION

Take-home naloxone (THN) is a clinically effective and cost-effective means of reducing opioid overdose fatality. Nonetheless, naloxone administration that successfully saves a person's life can still produce undesirable and harmful effects.

AIM

To better understand factors associated with two widely reported adverse outcomes following naloxone administration; namely the person resuscitated displays: i. withdrawal symptoms and ii. anger.

METHODS

A mixed methods study combining a randomized controlled trial of overdose education and naloxone prescribing to people with opioid use disorder and semi-structured qualitative interviews with trial participants who had responded to an overdose whilst in the trial. All data were collected in New York City (2014-2019). A dataset (comprising demographic, pharmacological, situational, interpersonal, and overdose training related variables) was generated by transforming qualitative interview data from 47 overdose events into dichotomous variables and then combining these with quantitative demographic and overdose training related data from the main trial. Associations between variables within the dataset and reports of: i. withdrawal symptoms and ii. anger were explored using chi-squared tests, t-tests, and logistic regressions.

RESULTS

A multivariate logistic regression found that people who had overdosed were significantly more likely to display anger if the person resuscitating them criticized, berated or chastised them during resuscitation (adjusted OR = 27 [95% CI = 4.0-295]). In contrast, they were significantly less likely to display anger if the person resuscitating them communicated positively with them (OR = 0.10 [95% CI = 0.01-0.78]). Both positive and negative communication styles were independently associated with anger, and communication was associated with 59% of the variance in anger. There was no evidence that people who displayed withdrawal symptoms were more likely to display anger than those not displaying withdrawal symptoms, and neither displaying withdrawal symptoms nor displaying anger were associated with using more drugs after resuscitation.

CONCLUSIONS

Contrary to common assumptions, withdrawal symptoms and anger following naloxone administration may be unrelated phenomena. Findings are consistent with previous research that has suggested that a lay responder's positive or reassuring communication style may lessen anger post overdose. Implications for improving THN programmes and naloxone administration are discussed.

Intervention in an opioid overdose event increases interest in treatment among individuals with opioid use disorder

BACKGROUND

This study sought to explore whether intervening in suspected cases of opioid overdose alters interest in treatment for opioid use disorder (OUD). Data were collected as a part of a trial comparing the effects of different overdose education and naloxone distribution (OEND) training curricula on overdose outcomes. Methods: Following OEND training, participants completed four in-person follow-up visits at 1-, 3-, 6- and 12-months. Participants were also regularly contacted to inquire about overdose events they responded to, witnessed, or experienced themselves. Other assessments included the Addiction Severity Index that queries participants' perceived importance of drug treatment on a scale of: 0 (Not at All) to 4 (Extremely). For the current secondary data analysis, treatment importance was assessed at the time points most immediately preceding and following participant intervention in an overdose event using naloxone. Results: The sample reported a mean duration of opioid use of 14.9 (± 11.5) years, with 67% having witnessed an overdose event prior to the study. Of the 321 enrolled, 92 participants used naloxone in response to 166 suspected cases of an opioid overdose. For the entire sample, mean treatment importance did not significantly change throughout the study. Among participants who utilized naloxone, treatment importance increased following the event (Before: 3.03, After: 3.39, p = 0.02). Due to the amount of time between the overdose event and assessment of post-event treatment importance (40.5 days, ±40.2), the current study most likely underestimates this effect. Conclusions: The current study suggests that responding to an overdose event increases interest in OUD treatment. Currently only considered an acute intervention to reduce overdose morbidity and mortality, OEND may have the potential to increase enrollment in medications to treat OUD. However, a prospective investigation needs to determine if the impact of an overdose event could be utilized to increase treatment engagement.

Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study

BACKGROUND

Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches.

METHODS

Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016-2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals.

RESULTS

People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) 'rage' (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) 'withdrawal symptoms,' and (iii) 'not rage, not withdrawal' (i.e., a wide range of short-lived, 'harmless' conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms).

CONCLUSION

Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with 'mediated toxicity' (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to 'rage' associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.

Comparison of oncological outcomes after open and laparoscopic re-resection of incidental gallbladder cancer

BACKGROUND

The safety and oncological efficacy of laparoscopic re-resection of incidental gallbladder cancer have not been studied. This study aimed to compare laparoscopic with open re-resection of incidentally discovered gallbladder cancer while minimizing selection bias.

METHODS

This was a multicentre retrospective observational cohort study of patients with incidental gallbladder cancer who underwent re-resection with curative intent at four centres between 2000 and 2017. Overall survival (OS) and recurrence-free survival (RFS) were analysed by intention to treat. Inverse probability of surgery treatment weighting using propensity scoring was undertaken.

RESULTS

A total of 255 patients underwent re-resection (190 open, 65 laparoscopic). Nineteen laparoscopic procedures were converted to open operation. Surgery before 2011 was the only factor associated with conversion. Duration of hospital stay was shorter after laparoscopic re-resection (median 4 versus 6 days; P < 0·001). Three-year OS rates for laparoscopic and open re-resection were 87 and 62 per cent respectively (P = 0·502). Independent predictors of worse OS were residual cancer found at re-resection (hazard ratio (HR) 1·91, 95 per cent c.i. 1·17 to 3·11), blood loss of at least 500 ml (HR 1·83, 1·23 to 2·74) and at least four positive nodes (HR 3·11, 1·46 to 6·65). In competing-risks analysis, the RFS incidence was higher for laparoscopic re-resection (P = 0·038), but OS did not differ between groups. Independent predictors of worse RFS were one to three positive nodes (HR 2·16, 1·29 to 3·60), at least four positive nodes (HR 4·39, 1·96 to 9·82) and residual cancer (HR 2·42, 1·46 to 4·00).

CONCLUSION

Laparoscopic re-resection for selected patients with incidental gallbladder cancer is oncologically non-inferior to an open approach. Dissemination of advanced laparoscopic skills and timely referral of patients with incidental gallbladder cancer to specialized centres may allow more patients to benefit from this operation.

Development and evaluation of a pilot overdose education and naloxone distribution program for hospitalized general medical patients

Background: Overdose education and naloxone distribution (OEND) to people at risk of witnessing or experiencing an opioid overdose has traditionally been provided through harm reduction agencies. Expanding OEND to inpatient general medical settings may reach at-risk individuals who do not access harm reduction services and have not been trained. An OEND program targeting inpatients was developed, piloted, and evaluated on 2 general medicine floors at Montefiore Medical Center, a large urban academic medical center in Bronx, New York. Methods: The planning committee consisted of 10 resident physicians and 2 faculty mentors. A consult service model was piloted, whereby the primary inpatient care team paged the consult team (consisting of rotating members from the planning committee) for any newly admitted patient who had used any opioid in the year prior to admission. Consult team members assessed patients for eligibility and provided OEND to eligible patients through a short video training. Upon completion, patients received a take-home naloxone kit. To evaluate the program, a retrospective chart review over the first year (April 2016 to March 2017) of the pilot was conducted. Results: Overall, consults on 80 patients were received. Of these, 74 were eligible and the consult team successfully trained 50 (68%). Current opioid analgesic use of ≥50 morphine milligram equivalents daily was the most common eligibility criterion met (38%). Twenty-four percent of patients were admitted for an opioid-related adverse event, the most common being opioid overdose (9%), then opioid withdrawal (8%), skin complication related to injecting (5%), and opioid intoxication (2%). Twenty-five percent had experienced an overdose, 35% had witnessed an overdose in their lifetime, and 83% had never received OEND previously. Conclusions: Integrating OEND into general inpatient medical care is possible and can reach high-risk patients who have not received OEND previously. Future research should identify the optimal way of implementing this service.

Th1/Th17/Th22 immune response and their association with joint pain, imagenological bone loss, RANKL expression and osteoclast activity in temporomandibular joint osteoarthritis: A preliminary report

It is well accepted that the presence of cytokines belonging to the Th1/Th17/Th22 axis of immuno-inflammatory response in the joint environment, such as IL-1β, IL-17 and IL-22, respectively, are associated with pathogenesis of several synovial joint degenerative disorders. During temporomandibular joint osteoarthritis (TMJ-OA), IL-1β and IL-17 have been implicated in the inflammation and resorption of sub-chondral bone; however, the role of Th22 response in the TMJ-OA pathophysiology has not been established. This study aimed to compare the expression of Th1/Th17/Th22-type cytokines, chemokines and chemokine receptors in synovial fluid samples obtained from TMJ-OA or disk displacement with reduction (DDWR) patients. In addition, it aimed to associate these levels with joint pain, imagenological signs of bone degeneration, RANKL production, osteoclastogenesis and osteoclast-induced bone resorption. Higher levels of IL-1β, IL-17 and IL-22 were expressed in TMJ-OA compared with DDWR subjects, and these increased levels significantly correlated with RANKL expression, joint pain and articular bone degeneration. Higher levels of CCR5, CCR6 and CCR7, as well as their respective ligands CCL5 and CCL20, responsible for recruitment of IL-1β, IL-17 and IL-22-producing cells, were over-expressed in TMJ-OA compared with DDWR subjects. Osteoclastogenesis and osteoclast-induced bone resorption were significantly greater in presence of synovial fluid from TMJ-OA compared with DDWR subjects. These data demonstrate that cytokines, CCLs and CCRs associated with the Th1/Th17/Th22 axis of immuno-inflammatory response are involved in TMJ-OA pathogenesis. These findings suggest that IL-22 is involved in the RANKL expression in TMJ-OA, which in turn induces differentiation of osteoclasts and subsequent resorption of sub-chondral bone.

Serologic control against hepatitis B virus among dental students of the University of Granada, Spain

Background

To evaluate the immunological situation against hepatitis B virus (HBV) of a cohort of dentistry students, to analyze the behavior of the levels of hepatitis B surface antigen (anti-HBs) after the administration of one or three vaccine doses, and to determine the influence of age and sex on the immune response.

Material and Methods

This retrospective cohort study included students attending the School of Dentistry of the institution where the study was performed from 2005 to 2012 who had completed the public health vaccination calendar for HBV at the age of 12-13. Data on age, sex, basal anti-HBs levels, post-vaccination anti-HBs results and final anti-HBs levels were collected. Comparisons of the basal and final levels, as well as associations regarding age and sex, were performed by means of the Student t and Chi-square tests.

Results

Of the 359 students, 97 (27.02%) had basal antibody concentrations <10 mIU/ml, whereas in 262 the levels of anti-HBs were ≥10 mIU/ml (72.98%). Of the 288 participating students who completed the School´s protocol for immunization, 287 (99.65%) attained a level of protection ≥10 mIU/ml. Globally, there were statistically significant differences between the basal antibody levels and those achieved after administration of the vaccine and booster, but no association with age or sex was observed.

Conclusions

About 70% of dental students vaccinated as preadolescents had serologic evidence of protection against HBV. Administering a booster is associated with the presence of an excellent immune memory. There is clearly a need to reinforce control of the antibody levels in groups at risk, such as Dentistry students.

Key words:Dental students, hepatitis B virus, serologic control.

Cochlear implantation outcomes in advanced otosclerosis

INTRODUCTION

Several studies support the use of cochlear implants (CI) in far-advanced otosclerosis (FAO).

MATERIAL AND METHODS

We compared our results of CI in patients with FAO and unknown origin hearing loss (UOHL) and our incidence of facial electrical stimulation and difficult insertion of the electrode bundle up to 3 to 5 years from surgery.

RESULTS

We found 17 patients with CI in FAO and UOHL. FAO patients achieved better results on the pure tone average (PTA) and recognition of monosyllables by GEE test (p=0.022; p=0.006), and particularly at 1 year on the PTA (p=0.002), at 6 months and a year in monosyllables (p=0.002; p=0.001), and at 6 months in disyllables (p=0.004). There were no differences toward complications.

CONCLUSION

In our experience, placement of CI in FAO has proven successful, with results comparable to other similar cohorts, and with low complications.

Nitrite Inhibition of Bacterial Dinitrogen Fixation

Dinitrogen fixation by crude extracts from Rhodopseudomonas palustris and Rhodomicrobium vannielii and by purified nitrogenase preparations from Azotobacter vinelandii and Clostridium pasteurianum is inhibited by nitrite, whereas in the same preparations nitrate is without effect. In Clostridium nitrite seems to interact with dinitrogenase reductase component of the bacterial nitrogenase complex.

Nitrate Photo-Assimilation by the Phototrophic Bacterium Rhodopseudomonas capsulata E1F1

Rhodopseudomonas capsulata E1F1 bacteria photo-assimilated nitrate under anaerobic conditions, but were incapable of reducing it in the dark. The bacteria utilized dissolved N2 as nitrogen source, but the growth in the presence of nitrate was 5-fold higher. Nitrite was excreted to the medium, but not stoichiometrically with respect to nitrate consumption. Nitrate reductase is particulate and used reduced viologens or flavins as electron donors for nitrate reduction. The enzyme was inhibited in vitro by KCN, NaN3, dithioerythritol and mercurials. Ammonia and other sources of reduced nitrogen repressed nitrate reductase synthesis.

Small plasma focus as neutron pulsed source for nuclides identification

In this paper, we present preliminary results on the feasibility of employing a low energy (2 kJ, 31 kV) plasma focus device as a portable source of pulsed neutron beams (2.45 MeV) generated by nuclear fusion reactions D-D, for the "in situ" analysis of substances by nuclear activation. This source has the relevant advantage of being pulsed at requirement, transportable, not permanently radioactive, without radioactive waste, cheap, among others. We prove the feasibility of using this source showing several spectra of the characteristic emission line for manganese, gold, lead, and silver.

Cadmium tolerance and antibiotic resistance in Escherichia coli isolated from waste stabilization ponds

The incidence pattern of cadmium tolerance and antibiotics resistance by Escherichia coli was examined periodically from the samples of water, sludge and intestine of fish raised in waste stabilization ponds in a sewage treatment plant. Samples of water and sludge were collected from all the selected ponds and were monitored for total counts of fecal coliform (FC), total coliform (TC) and the population of Escherichia coli, which was also obtained from the intestine of fishes. Total counts of both FC and TC as well as counts of E. coli were markedly reduced from the facultative pond to the last maturation pond. Tolerance limit to cadmium by E. coli tended to decline as the distance of the sewage effluent from the source increased; the effective lethal concentration of cadmium ranged from 0.1 mM in split chamber to 0.05 mM in first maturation pond. E. coli isolated from water, sludge and fish gut were sensitive to seven out of ten antibiotics tested. It appears that holistic functions mediated through the mutualistic growth of micro algae and heterotrophic bacteria in the waste stabilization ponds were responsible for the promotion of water quality and significant reduction of coliform along the sewage effluent gradient.

The lithopedion - an unusual cause of an abdominal mass

We report the rare case of a lithopedion in an asymptomatic 69-year-old woman with poor antenatal history. Diagnosis was confirmed by plain abdominal X-ray. In view of the patient's age and symptomatology, we opted for conservative management with regular abdominal examination and imaging.

Algorithm for phase extraction from a set of interferograms with arbitrary phase shifts

The generalized analytical quadrature filter from a set of interferograms with arbitrary phase shifts is obtained. Both symmetrical and non symmetrical algorithms for any order are reported. The analytic expression is obtained through the convolution of a set of two-frame algorithms and expressed in terms of the combinatorial theory. Finally, the solution is applied to obtain several generalized tunable quadrature filters.

Sex differences in striatal dopamine release in young adults after oral alcohol challenge: a positron emission tomography imaging study with [¹¹C]raclopride

BACKGROUND

We used a positron emission tomography paradigm with the D2/3 radiotracer [¹¹C]raclopride and an alcohol challenge to examine the magnitude of alcohol-induced dopamine release and compare it between young men and women.

METHODS

Twenty-one nonalcohol-dependent young social drinkers completed two positron emission tomography scans on separate days following ingestion of a juice mix containing either ethanol (.75 mg/kg body water) or trace ethanol only. The extent of dopamine released after alcohol was estimated by the percentage difference in [¹¹C]raclopride binding potential (ΔBP(ND)) between days.

RESULTS

Alcohol administration significantly displaced [¹¹C]raclopride in all striatal subregions, indicating dopamine release, with the largest effect observed in the ventral striatum. Linear mixed model analysis across all striatal subregions of regional ΔBP(ND) with region of interest as repeated measure showed a highly significant effect of sex (p < .001). Ventrostriatal dopamine release in men, but not in women, showed a significant positive correlation to alcohol-induced measures of subjective activation. Furthermore, we found a significant negative correlation between the frequency of maximum alcohol consumption per 24 hours and ventrostriatal ΔBP(ND) (r = .739, p = .009) in men.

CONCLUSIONS

This study provides definitive evidence that oral alcohol induces dopamine release in nonalcoholic human subjects and shows sex differences in the magnitude of this effect. The ability of alcohol to stimulate dopamine release may contribute to its rewarding effects and, thereby, to its abuse liability in humans. Our report further suggests several biological mechanisms that may mediate the difference in vulnerability for alcoholism between men and women.

Alkaline cyanide degradation by Pseudomonas pseudoalcaligenes CECT5344 in a batch reactor. Influence of pH

Water containing cyanide was biologically detoxified with the bacterial strain Pseudomonas pseudoalcaligenes CECT5344 in a batch reactor. Volatilization of toxic hydrogen cyanide (HCN) was avoided by using an alkaline medium for the treatment. The operational procedure was optimized to assess cyanide biodegradation at variable pH values and dissolved oxygen concentrations. Using an initial pH of 10 without subsequent adjustment allowed total cyanide to be consumed at a mean rate of approximately 2.81 mg CN(-) L(-1) O.D.(-1) h(-1); however, these conditions posed a high risk of HCN formation. Cyanide consumption was found to be pH-dependent. Thus, no bacterial growth was observed with a controlled pH of 10; on the other hand, pH 9.5 allowed up to 2.31 mg CN(-) L(-1) O.D.(-1) h(-1) to be converted. The combination of a high pH and a low dissolved oxygen saturation (10%) minimized the release of HCN. This study contributes new basic knowledge about this biological treatment, which constitutes an effective alternative to available physico-chemical methods for the purification of wastewater containing cyanide or cyano-metal complexes.

[Indicators of quality in the critical patient]

The utility of using quality indicators as a tool to measure the common practice and evaluate efficacy of measures established to improve quality has been demonstrated, making it possible to identify and make known the improvements carried out. The project "Quality indicators in the critical patient" has been conducted by the Spanish Society of Intensive and Critical Medicine (SEMICYUC) under the methodological management of the Foundation Avedis Donabedian (FAD) of Barcelona. Its objective was to develop key indicators in the care of the critical patient, considering the following as added values: reaching an agreement on the quality criteria in these patients and providing the professionals with a potent and reliable instrument for clinical evaluation and management, introducing common evaluation methods that make it possible to unify the measure, making a comparative evaluation (benchmarking), having information that makes it possible to develop quality plans (quantitative, objective, reliable and valid data) and having a system that assures total quality of care to the critical patient.