Association between Individual versus Community-level Social Vulnerability and Neonatal Opioid Withdrawal Syndrome among Pregnant Individuals Receiving Buprenorphine for Opioid Use Disorder

OBJECTIVE

 Individual patient-level measures of adverse social determinants of health are associated with neonatal opioid withdrawal syndrome (NOWS), but the relative impact of community-level adverse social determinants of health remains to be defined. We examined the association between community-level social vulnerability and NOWS among pregnant individuals receiving buprenorphine for opioid use disorder.

STUDY DESIGN

 We conducted a secondary analysis of an established cohort of pregnant individuals and their infants participating in a multidisciplinary prenatal/addiction care program from 2013 to 2021. Addresses were geocoded using ArcGIS and linked at the census tract to the Centers for Disease Control and Prevention 2018 Social Vulnerability Index (SVI), incorporating 15 census variables. The primary exposure was the SVI as a composite measure of community-level social vulnerability, and secondarily, individual scores for four thematic domains (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation). The primary outcome was a clinical diagnosis of NOWS defined as withdrawal requiring pharmacological treatment following buprenorphine exposure.

RESULTS

 Among 703 pregnant individuals receiving buprenorphine, 39.8% (280/703) of infants were diagnosed with NOWS. Among our patinets, those who were nulliparous, had post-traumatic stress disorder, a term birth (≥ 37 weeks) and had a male infant were more likely to have an infant diagnosed with NOWS. Individuals with and without an infant diagnosed with NOWS had similarly high community-level social vulnerability per composite SVI scores (mean [standard deviation]: 0.6 [0.4-0.7] vs. 0.6 [0.4-0.7], p = 0.2]. In adjusted analyses, SVI, as a composite measure as well as the four domains, was not associated with NOWS diagnosis.

CONCLUSION

 Among pregnant persons receiving buprenorphine enrolled in a multidisciplinary prenatal and addition care program, while individual risk factors that measure adverse social determinants of health were associated with an NOWS diagnosis in the infant, community-level social vulnerability as measured by the SVI was not associated with the outcome.

KEY POINTS

· Community-level SVI was not associated with neonatal opioid use disorder.. · Certain individual risk factors were identified as being associated with NOWS.. · Homogeneity of composite SVI scores may have led to lack of significant findings..

Regression of Metastatic Breast Cancer in a Patient Treated with the Anti-Angiogenic Drug Tnp-470

Background

Solid tumors in general, and breast cancer in particular, depend on angiogenesis to grow and metastasize. Multiple agents have been developed in order to inhibit this phenomenon of tumor-induced angiogenesis. TNP-470 is one of the most potent of these drugs. We report here a case of regression of metastatic lesions from breast cancer due to the administration of the anti-angiogenic drug TNP-470.

Methods

A 44-year-old woman with a history of stage 2 breast cancer developed metastases at four sites: eye, lung, liver, and bone. She had been treated with radiation, megace, adriamycin, Cytoxan, and 5-fluorouracil with disease stabilization. After she completed her radiation and chemotherapy, she was started on TNP-470.

Results

In response to TNP-470, her disease showed a partial response at the three-month follow-up and stabilization at the five-month follow-up. There were no side effects, and her quality of life was good.

Conclusions

To our knowledge, this patient is the first reported case of regression of breast cancer metastases as a result of treatment with TNP-470. Anti-angiogenic drugs hold promise for the future therapy of breast cancer, and possibly of many other solid tumors as well.

Program for the use of antipsychotics with metabolic monitoring in North Carolina medicaid children

Introduction

Children are at greater risk than adults for weight gain and metabolic disorders including hyperlipidemia and diabetes with newer antipsychotics. A web-based safety-monitoring program using a prior documentation model required submission of patient safety data (prior documentation) for insurance coverage at the pharmacy point of sale. This program launched in April of 2011, covering all NC Medicaid and Health Choice recipients under age 18. Clinical monitoring parameters and interactive educational features were developed with pediatric psychiatric experts and key mental health stakeholder groups.

Objectives

Using a four-year run in period and a full 9 months of post implementation claims data, evaluate the rates of antipsychotic prescribing and safety monitoring before and after the implementation of the A + KIDS program.

Results

Implementation of this program was associated with a consistent monthly decrease in overall antipsychotic use and increases in patient monitoring of glucose and lipid (Figure. 1, Table 1).

Conclusions

The prior documentation registry was effective in decreasing antipsychotic use and increasing safety monitoring. The impact of changing to more traditional prior authorization on the same clinical endpoints is currently under evaluation.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Munchausen syndrome presenting in a patient who has undergone temporomandibular joint surgery

Munchausen syndrome is a rare psychiatric disorder. Patients with Munchausen syndrome insist on and repeatedly undergo unnecessary investigations and operative treatments. No organic pathosis is demonstrated, and treatment consistently fails to alleviate the symptoms. This article presents a case report and a brief discussion to facilitate recognition and management techniques.

Trial of vitamin A supplementation in very low birth weight infants at risk for bronchopulmonary dysplasia

We performed a randomized, double-blind, controlled trial to determine whether vitamin A supplementation in a group of very low birth weight infants would reduce the incidence of bronchopulmonary dysplasia. Forty-nine infants (birth weight 700 to 1100 gm) requiring mechanical ventilation and supplemental oxygen at 96 hours age were randomly assigned to receive either 2000 IU retinyl palmitate (n = 27) or saline placebo (n = 22) intramuscularly every other day for up to 14 doses. There were no differences between treatment groups in the incidences of bronchopulmonary dysplasia at 31 days of postnatal age (vitamin A group 48%, placebo group 55%; p = 0.776), supplemental oxygen requirement at 34 weeks of postconceptional age, or other complications of prematurity. The vitamin A group had higher mean plasma vitamin A concentrations than the placebo group, but mean plasma vitamin A concentrations were greater than 20 micrograms/dl (suggesting sufficiency) in both groups after the first study week. By study day 28, only one fourth of the infants in either group had plasma vitamin A concentrations less than 20 micrograms/dl. In contrast to an earlier report, we found no change in the incidence of BPD with vitamin A supplementation. Our findings may reflect a low baseline incidence of vitamin A deficiency in the study population and recent changes in the respiratory care of very low birth weight infants. The latter may have lessened the potential impact of vitamin A deficiency on lung disease.