The Optimal Initial Dose and Route of Naloxone Administration for Successful Opioid Reversal: A Systematic Literature Review

This systematic literature review aims to determine the optimal initial dose of naloxone for successful opioid overdose reversal across different administration routes. Types of participants included adults who have opioid overdoses and adults who are suspected to have opioid overdoses. Pregnant women, children, animals, and populations outside the US were excluded. The interventions included were intranasal (IN), intramuscular (IM), and intravenous (IV) naloxone administration. The data collected for this systematic review were studies from PubMed, CINAHL, PsyINFO, and Cochrane Central Register of Controlled Trials registers between January 2015 and July 2021. The risk of bias was assessed via the Review Manager application. Six studies met the inclusion criteria. A meaningful statistical analysis was unable to be conducted with such few studies. The studies reveal 2 mg IN as the most popular dosing for initial naloxone for successful opioid reversal. The most common route of naloxone administration for successful reversal could not be studied but most studies revealed successful initial naloxone dosing in IN equivalents. With minimal studies emerging from our review, further research is warranted in naloxone dosing for optimal opioid reversal in order to fully treat patients. Healthcare workers must be vigilant of potential withdrawal from high naloxone dosing as well as the inefficiency of lower naloxone dosing for adequate opioid overdose reversal in order to treat patients with opioid overdoses properly.

Scrutinizing the therapeutic response of Phyllanthus exmblica's different doses to restore the immunomodulation potential in immunosuppressed female albino rats

OBJECTIVE

Immunosuppression and microbial resistance are the major drawbacks in conventional pharmaceutics. The present research work was planned to screen and characterize phytochemical constituents present in Phyllanthus emblica and to explore the immunomodulation potential of P. emblica by evaluating stress markers and different biochemical parameters in animals.

MATERIALS AND METHODS

The phytochemical analysis explored the presence of antioxidant profiles and revealed the radical scavenging activities. In the second phase, an animal trial was performed using female albino rats. Female rats (n=18) were administered three different doses of P. emblica (low dose 100 mg/kg, intermediate 200 mg/kg, and high dose 300 mg/kg) for three weeks. After a significant change (p<0.05) in antioxidant status i.e., TOS and TAS, hematological, biochemical parameters, and immunoregulation i.e., IgM and IgG were elevated. Statistical analysis (ANOVA) illustrates that these selected plants have a great impact on microbial resistance and immunosuppression and have shown highly significant results.

RESULTS

The results of all in vitro and in vivo assays conducted as part of the recent research work offer considerable evidence that the chosen medicinal plant has the ability to induce specific hormone release and boost the immune system.

CONCLUSIONS

Based on our findings, it is proposed that medicinal herbs may be isolated using cutting-edge approaches to tackle the issues of immunosuppression and microbial resistance.

The First Case of Bridge-Enhanced Anterior Cruciate Ligament (ACL) Repair (BEAR) Procedure in Mississippi

In the past, surgical treatment of anterior cruciate ligament (ACL) tears has mainly involved reconstruction using allografts and autografts. The relatively new FDA-approved bridge-enhanced ACL repair (BEAR) procedure allows the body to use its innate healing properties to help repair the ACL using an absorbable protein-based implant. The procedure is currently being offered by surgeons in 44 states. This case describes the first BEAR procedure performed in the state of Mississippi. A 47-year-old female of normal BMI presented to the orthopedic clinic with a chief complaint of right knee pain. The patient stated that she felt unstable on the injured knee, and the patient had positive anterior drawer and Lachman's tests on physical examination. MRI of the knee one month after injury revealed full-thickness ACL rupture. The patient underwent arthroscopic bridge-enhanced ACL repair in the right knee 43 days after the initial injury. The patient reported positive progress in her healing process at her three-month follow-up, and MRI at the three-month follow-up showed successful repair of the patient's ACL. At six months post-operatively, the patient reported that she is still doing well, and she feels that the stability of her right knee has improved. This case highlights an early trend towards repairs instead of reconstructions in ACL injuries for candidates that meet the following requirements: within 50 days of injury and have an intact tibial stump as recommended by the implant manufacturers.

Spontaneous Non-Traumatic Mediastinal Hematoma in a Patient on Imatinib Therapy for a Gastrointestinal Stromal Tumor (GIST)

Mediastinal hematomas are thoracic complications often resulting from direct trauma or aortic dissections. Spontaneous non-traumatic mediastinal hematomas are rare. We present a case of spontaneous non-traumatic mediastinal hematoma in a patient on Imatinib therapy for a gastrointestinal stromal tumor (GIST). A 67-year-old female presented to the ER with the chief complaint of constant sharp right shoulder pain that progressed to her chest. The patient was not on any anticoagulants and had not complained of shortness of breath. Under suspicion of a pulmonary embolism, a CT chest scan was performed, and a diagnosis of non-traumatic anterior mediastinal hematoma was confirmed. This case may warrant further investigation into the links between Imatinib use and the formation of mediastinal hematomas.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Galanin-like peptide (GALP) neurone-specific phosphoinositide 3-kinase signalling regulates GALP mRNA levels in the hypothalamus of males and luteinising hormone levels in both sexes

Galanin-like peptide (GALP) neurones participate in the metabolic control of reproduction and are targets of insulin and leptin regulation. Phosphoinositide 3-kinase (PI3K) is common to the signalling pathways utilised by both insulin and leptin. Therefore, we investigated whether PI3K signalling in neurones expressing GALP plays a role in the transcriptional regulation of the GALP gene and in the metabolic control of luteinising hormone (LH) release. Accordingly, we deleted PI3K catalytic subunits p110α and p110β via conditional gene targeting (cKO) in mice (GALP-p110α/β cKO). To monitor PI3K signalling in GALP neurones, these animals were also crossed with Cre-dependent FoxO1GFP reporter mice. Compared to insulin-infused control animals, the PI3K-Akt-dependent FoxO1GFP nuclear exclusion in GALP neurones was abolished in GALP-p110α/β cKO mice. We next used food deprivation to investigate whether the GALP-neurone specific ablation of PI3K activity affected the susceptibility of the gonadotrophic axis to negative energy balance. Treatment did not affect LH levels in either sex. However, a significant genotype effect on LH levels was observed in females. By contrast, no genotype effect on LH levels was observed in males. A sex-specific genotype effect on hypothalamic GALP mRNA was observed, with fed and fasted GALP-p110α/β cKO males having lower GALP mRNA expression compared to wild-type fed males. Finally, the effects of gonadectomy and steroid hormone replacement on GALP mRNA levels were investigated. Compared to vehicle-treated mice, steroid hormone replacement reduced mediobasal hypothalamus GALP expression in wild-type and GALP-p110α/β cKO animals. In addition, within the castrated and vehicle-treated group and compared to wild-type mice, LH levels were lower in GALP-p110α/β cKO males. Double immunofluorescence using GALP-Cre/R26-YFP mice showed androgen and oestrogen receptor co-localisation within GALP neurones. Our data demonstrate that GALP neurones are direct targets of steroid hormones and that PI3K signalling regulates hypothalamic GALP mRNA expression and LH levels in a sex-specific fashion.

Accumulation of chromium in pak choi ( L.) grown on representative chinese soils

Anthropogenic chromium (Cr) pollution in soils poses a great threat to human health through the food chain. It is imperative to understand Cr accumulation properties in common vegetables because the proportion of vegetables consumed has increased with the improvement of living standards. This study investigated Cr accumulation in pak choi ( L.) grown on six representative agricultural soils in China. Chromium concentration in the edible parts of pak choi generally increased with soil Cr concentrations following the order: Ustic Cambosols > Periudic Argosols > Mollisols > Calcaric Regosols > Stagnic Anthrosols > Udic Ferrisols. Simple correlation analysis indicated that Cr concentration in pak choi was significantly correlated with the total Cr, Mehlich-3-extractable Cr, and Cr(VI). Stepwise multiple regression analysis also demonstrated that the phytoavailability of Cr was strongly correlated with the extractable fraction by Mehlich-3, total Cr concentration, soil organic matter, and Fe(II). Critical Cr concentrations in these six soils were evaluated for pak choi based on the maximum safe level for daily intake of Cr. Total soil Cr can be used as Cr thresholds for potential dietary toxicity in pak choi. Mehlich-3-extractable Cr is most suitable to be used as Cr thresholds for Periudic Argosols, Udic Ferrisols, Mollisols, and Ustic Cambosols, with values of 20.7, 15.8, 21.2, and 20.4 mg kg, respectively, whereas Cr(VI) is most suitable for Calcaric Regosols and Stagnic Anthrosols, with values of 26.5 and 28.0 mg kg, respectively.

P3-07-29: Validating the Lymph Node Ratio as a Prognostic Indicator among South East Asian Breast Cancer Patients

Background: Several studies in Caucasian settings have suggested that the lymph node ratio (LNR, i.e. the ratio of the number of positive nodes to the total number of nodes excised) is a superior prognostic indicator for breast cancer as compared to the absolute number of nodes involved (pN stage). This study validates the prognostic performance of LNR in the South East Asian setting.

Methods: All patients diagnosed with non-metastatic invasive breast cancer at the National University Hospital (Singapore) or University of Malaya Medical Center (Kuala Lumpur) between 1990 and 2007 and with information on axillary nodes removed and involved were included for analysis (n = 1589). Multivariate Cox regression analysis was performed to evaluate the prognostic value of the LNR [low (&gt; 0 and &lt;0.2), intermediate (0.2 to 0.65) and high risk (&gt;0.65 to 1)] and pN staging [pN1, pN2 and pN3] for all cause mortality. Patients staged pN0/LNR 0 were excluded from analysis.

Results: According to the LNR classification, 758 patients were categorized as low risk, 574 as intermediate risk and 257 as high risk LNR. For classic pN staging, 879 were pN1, 447 pN2 and 263 pN3. Women in the intermediate risk category (0.2 to 0.65) had a 1.5 fold increased risk of death [Adjusted hazard ratio [HRadj] of 1.5 (95%CI, 1.2 to 1.9]), and women with high risk (&gt;0.65 to 1) LNR had a 3.2 fold increased risk of death [HRadj of 3.2 (95%CI, 2.6 to 4.1)] as compared to the low risk women (&gt;0 and &lt;0.2). Similarly, women with pN2 disease had a 1.9 fold increased risk of death [HRadj of 1.9 (95%CI, 1.5 to 2.4)], and women with pN3 disease had 3.1 fold increased risk of death [HRadj 3.1 (95%CI, 2.5 to 3.9)] compared to pN1 patients.

Conclusion: Among South East Asian breast cancer patients, both the Lymph Node Ratio and the pN Staging system seem to be equally good at predicting all cause mortality.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-29.

Outcome of Pregnancy in Renal Allograft Recipients: SIUT Experience

The course of pregnancy and its outcome was studied in renal allograft recipients. Between November 1985 and November 2005, a total of 1481 renal transplants were carried out at the Sindh Institute of Urology and Transplantation (SIUT); among them were 348 females, with 73 potential females for pregnancy. All patients received cyclosporine and prednisolone, with 82% also receiving azathioprine and 4 patients mycophenolate mofetil as a third immunosuppressant drug. We evaluated incidence of hypertension, diabetes, pre-eclampsia, urinary tract infection (UTI), rejection during pregnancy and during 3 months' postdelivery as well as outcomes of pregnancy. Among 73 potential candidates, 31 had 47 pregnancies, after an average of 31 months (8-86 months). Of 31 subjects, 21 subjects were hypertensive on one or two drugs prior to conception. A rise in blood pressure during pregnancy was noticed in 7 patients. Albuminuria from trace to 3+ appeared in 13 patients and glycosuria in one other. Blood sugar levels remained within normal range in all subjects. UTIs occurred during pregnancy in 7 patients. Among 47 pregnancies, 9 had abortions (7 spontaneous, 2 therapeutic) and 6 had preterm deliveries. The others were full-term deliveries: 12 via a lower segment caesarean section and 20 were normal vaginal deliveries. Average birth weight was 4.8 lbs. At an average follow-up of 38 months the serum creatinine values ranged from 0.94 to 2.3 mg %. One patient developed acute irreversible graft dysfunction soon after delivery. Our study demonstrated that pregnancy did not reduce renal graft survival, but newborns are at greater risk of premature birth and low birth weight.

Recruiting the community for supporting end-stage renal disease management in the developing world

Although the incidence of new end-stage renal disease (ESRD) patients in Pakistan is estimated at 100 patients per million (ppm), the prevalence of those alive on renal replacement therapy (RRT) is around 40 ppm, reflecting the severe shortage of facilities. A national program was launched in 1998 to provide free RRT, but the funds were extremely limited, leading to the flourishing of suboptimal treatment in private dialysis and transplant centers. The Sindh Institute of Urology and Transplantation (SIUT), started as a small unit in 1975, took the lead in recruiting nongovernmental funds for RRT. Through the devotion of several groups, it was possible to raise funds from individuals, pharmaceutical firms, and other organizations, which permitted the development of SIUT into an independent, large, and fully equipped institution that provides free RRT including dialysis and transplantation to many thousands of patients. This prompted the government to increase its contributions to encourage SIUT to pursue its unique path.

A randomized double-blind comparative study of terbinafine for 1, 2 and 4 weeks in tinea capitis

We report a randomized, double-blind study, comparing the relative efficacy and tolerability of oral terbinafine, given for 1, 2 or 4 weeks, in tinea capitis. Of 161 evaluable patients, 53 were treated with terbinafine for 1 week, 51 for 2 weeks and 57 for 4 weeks. Isolated pathogens included Trichophyton violaceum (71.5%), T. tonsurans (14.9%), T. verrucosum (4.3%), Microsporum audouinii (4.3%), M. canis (2.5%), T. schoenleinii (1.9%) and T. mentagrophytes (0.6%). The final evaluation, at 12 weeks, showed cure rates of 73.6, 80.4 and 85.9%, in the respective groups. The adverse effects noted, were not drug related. In our opinion, terbinafine given for 1, 2 or 4 weeks, is equally effective for most cases of tinea capitis.