National trends in reported past year opioid misuse among black women

BACKGROUND

The opioid crisis within the United States has been widely studied; however, some gaps within the literature still exist. There is limited information on trends in opioid misuse as it relates to income among a national sample of Black Women. Given the recent increase in opioid overdose deaths in Black Americans and the vulnerability of women who misuse opioids, research in this population is important.

OBJECTIVE

The objective of this study is to evaluate trends of past year opioid misuse (PYOM) among Black women by income over the study period.

METHODS

A cross-sectional study among adult aged Black women captured in the National Survey on Drug Use and Health (NSDUH) from 2015 to 2019 was conducted. Descriptive statistics for all study variables was conducted. Weighted logistic regression analyses were conducted to evaluate predictors of PYOM. A stratified analysis was also conducted to examine possible differences between income strata on predictors of PYOM.

RESULTS

A total of 15,196 Black women were included in the study (16,008,921 weighted visits). Among the women included, 41.5% were age 50+, 57.7% were unemployed, 63.8% reported very good/good health, 59.5% had past year alcohol use, 44.1% had never been married, 39.1% received government assistance, and 90.1% resided in a metro area. An estimated 3.14% of Black women reported PYOM. Findings from the regression analysis showed that Black women who were between 18 and 25, had past year major depressive episode, had alcohol use, illicit drug use, and who received government assistance had significantly greater odds of PYOM. Those reporting an excellent general health rating and higher education had significantly lower odds of PYOM. Income was not associated with PYOM in this study.

CONCLUSION

Overall, income was not found to be a significant predictor of PYOM. However, income was found to modify the effects of major depressive episode and alcohol use on PYOM, especially among Black women who reported earning ≥$75,000/year. These findings suggest that high-earning Black women may be just as at risk for opioid misuse as low-earning Black women. Further studies are warranted to explore these effects among other gender/racial groups to determine if this trend is unique to Black women.

Frequency of the Dopamine Receptor D3 (rs6280) vs. Opioid Receptor µ1 (rs1799971) Polymorphic Risk Alleles in Patients with Opioid Use Disorder: A Preponderance of Dopaminergic Mechanisms?

While opioids are a powerful class of drugs that inhibit transmission of pain signals, their use is tarnished by the current epidemic of opioid use disorder (OUD) and overdose deaths. Notwithstanding published reports, there remain gaps in our knowledge of opioid receptor mechanisms and their role in opioid seeking behavior. Thus, novel insights into molecular, neurogenetic and neuropharmacological bases of OUD are needed. We propose that an addictive endophenotype may not be entirely specific to the drug of choice but rather may be generalizable to altered brain reward circuits impacting net mesocorticolimbic dopamine release. We suggest that genetic or epigenetic alterations across dopaminergic reward systems lead to uncontrollable self-administration of opioids and other drugs. For instance, diminished availability via knockout of dopamine D3 receptor (DRD3) increases vulnerability to opioids. Building upon this concept via the use of a sophisticated polymorphic risk analysis in a human cohort of chronic opioid users, we found evidence for a higher frequency of polymorphic DRD3 risk allele (rs6280) than opioid receptor µ1 (rs1799971). In conclusion, while opioidergic mechanisms are involved in OUD, dopamine-related receptors may have primary influence on opioid-seeking behavior in African Americans. These findings suggest OUD-targeted novel and improved neuropharmacological therapies may require focus on DRD3-mediated regulation of dopaminergic homeostasis.

Metastasis-directed Therapy in Prostate Cancer: Prognostic Significance of the ESTRO/EORTC Classification in Oligometastatic Bone Disease

AIMS

Oligometastatic disease (OMD) represents a spectrum of clinical scenarios and various classification systems have been proposed. Bone-only OMD can occur in patients with advanced prostate cancer and validated decision-making tools are needed to assist patient selection for metastasis-directed therapy. The aim of the present study was to determine the prognostic utility of a classification system for OMD.

MATERIALS AND METHODS

A retrospective review was conducted of all patients with bone-only oligometastatic prostate cancer treated with stereotactic body radiotherapy (SBRT) since November 2011. SBRT was delivered using CyberKnife® and gantry-based linear accelerator platforms. All patients were classified into oligometastatic states based on the European Society for Radiotherapy and Oncology/European Organisation for Research and Treatment of Cancer (ESTRO/EORTC) classification system. Kaplan-Meier and Cox regression analyses were carried out to determine the prognostic utility of this classification system.

RESULTS

In total, 105 patients with 145 osseous metastases were treated over 119 sessions. The median follow-up after SBRT was 23 months (interquartile range 10-39.8). Twelve patients had died after a median time of 31 months. The 3-year metastatic progression-free survival was 23% (95% confidence interval 13-32) and the 3-year overall survival was 88% (95% confidence interval 80-96). Patients in a metachronous oligometastatic state were 4.50 (95% confidence interval 1.19-17.10, P = 0.03) times more likely to experience metastatic progression compared with those with synchronous oligometastases, and 6.69 (95% confidence interval 1.05-42.50, P = 0.04) times more likely to experience any failure. Hazard ratio magnitudes increased for patients in a repeat oligometastatic state. The multivariate model for both metastatic progression-free survival and failure-free survival found prostate-specific antigen doubling time <4 months (P = 0.002; P = 0.05) to independently predict for progression.

CONCLUSION

The ESTRO/EORTC classification of OMD predicts for progression in patients treated with SBRT for bone-only oligometastatic prostate cancer at our institution. Further validation in prospective series over multiple tumour sites is needed. These characterisation factors should be assessed in patients considered for metastasis-directed therapy together with established prognostic features.

Genetic addiction risk score (GARS) ™, a predictor of vulnerability to opioid dependence

The interaction of neurotransmitters and genes that control the release of dopamine is the Brain Reward Cascade (BRC). Variations within the BRC, whether genetic or epigenetic, may predispose individuals to addictive behaviors and altered pain tolerance. This discussion authored by a group of concerned scientists and clinicians examines the Genetic Addiction Risk Score (GARS), the first test to accurately predict vulnerability to pain, addiction, and other compulsive behaviors, defined as Reward Deficiency Syndrome (RDS). Innovative strategies to combat epidemic opioid, iatrogenic prescription drug abuse and death, based on the role of dopaminergic tone in pain pathways, are proposed. Sensitivity to pain may reside in the mesolimbic projection system, where genetic polymorphisms associate with a predisposition to pain vulnerability or tolerance. They provide unique therapeutic targets that could assist in the treatment of pain, and identify risk for subsequent addiction. Pharmacogenomic testing of candidate genes like CB1, mu receptors, and PENK might result in pharmacogenomic, personalized solutions, and improved clinical outcomes. Genetically identifying risk for all RDS behaviors, especially in compromised populations, may be a frontline tool to assist municipalities to provide better resource allocation.

Pharmacogenomics-guided policy in opioid use disorder (OUD) management: An ethnically-diverse case-based approach

INTRODUCTION

Opioid use disorder (OUD) is characterized by a problematic pattern of opioid use leading to clinically-significant impairment or distress. Opioid agonist treatment is an integral component of OUD management, and buprenorphine is often utilized in OUD management due to strong clinical evidence for efficacy. However, interindividual genetic differences in buprenorphine metabolism may result in variable treatment response, leaving some patients undertreated and at increased risk for relapse. Clinical pharmacogenomics studies the effect that inherited genetic variations have on drug response. Our objective is to demonstrate the impact of pharmacogenetic testing on OUD management outcomes.

METHODS

We analyzed a patient who reported discomfort at daily buprenorphine dose of 24 mg, which was a mandated daily maximum by the pharmacy benefits manager. Regular urine screenings were conducted to detect the presence of unauthorized substances, and pharmacogenetic testing was used to determine the appropriate dose of buprenorphine for OUD management.

RESULTS

At the 24 mg buprenorphine daily dose, the patient had multiple relapses with unauthorized substances. Pharmacogenetic testing revealed that the patient exhibited a cytochrome P450 3A4 ultrarapid metabolizer phenotype, which necessitated a higher than recommended daily dose of buprenorphine (32 mg) for adequate OUD management. The patient exhibited a reduction in the number of relapses on the pharmacogenetic-based dose recommendation compared to standard dosing.

CONCLUSION

Pharmacogenomic testing as clinical decision support helped to individualize OUD management. Collaboration by key stakeholders is essential to establishing pharmacogenetic testing as standard of care in OUD management.

Molecular Assessment of Microcirculation Injury in Formalin-Fixed Human Cardiac Allograft Biopsies With Antibody-Mediated Rejection

Precise diagnosis of antibody-mediated rejection (AMR) in cardiac allograft endomyocardial biopsies (EMBs) remains challenging. This study assessed molecular diagnostics in human EMBs with AMR. A set of 34 endothelial, natural killer cell and inflammatory genes was quantified in 106 formalin-fixed, paraffin-embedded EMBs classified according to 2013 International Society for Heart and Lung Transplantation (ISHLT) criteria. The gene set expression was compared between ISHLT diagnoses and correlated with donor-specific antibody (DSA), endothelial injury by electron microscopy (EM) and prognosis. Findings were validated in an independent set of 57 EMBs. In the training set (n = 106), AMR cases (n = 70) showed higher gene set expression than acute cellular rejection (ACR; n = 21, p < 0.001) and controls (n = 15, p < 0.0001). Anti-HLA DSA positivity was associated with higher gene set expression (p = 0.01). Endothelial injury by electron microscopy strongly correlated with gene set expression, specifically in AMR cases (r = 0.62, p = 0.002). Receiver operating characteristic curve analysis for diagnosing AMR showed greater accuracy with gene set expression (area under the curve [AUC] = 79.88) than with DSA (AUC = 70.47) and C4d (AUC = 70.71). In AMR patients (n = 17) with sequential biopsies, increasing gene set expression was associated with inferior prognosis (p = 0.034). These findings were confirmed in the validation set. In conclusion, biopsy-based molecular assessment of antibody-mediated microcirculation injury has the potential to improve diagnosis of AMR in human cardiac transplants.

Vitrectomy with subretinal tissue plasminogen activator and ranibizumab for submacular haemorrhages secondary to age-related macular degeneration: retrospective case series of 45 consecutive cases

PurposeTo assess the efficacy of small-gauge vitrectomy with subretinal recombinant tissue plasminogen activator (rtPA) and ranibizumab for submacular haemorrhages secondary to neovascular age-related macular degeneration (nAMD), and to identify the factors associated with visual outcome.MethodsA retrospective case series was performed, including all patients who had small-gauge vitrectomy with subretinal rtPA and ranibizumab for submacular haemorrhages secondary to nAMD. All patients received three consecutive monthly injections of ranibizumab after the surgery, and were reviewed monthly and treated on a pro re nata regime.ResultsA total of 45 eyes of 45 patients were included in the study. Mean age was 77.07±9.67 years, and 32 of 45 patients (71.1%) were women. Surgery was performed on average 6.98±5.70 days after the onset of symptoms, and patients were observed for a follow-up period of 12.9±10.8 months. On average, visual acuity improved -0.59±0.61 LogMAR between presentation and last follow-up. Visual acuity improved in 33 patients (73.3%), remained unchanged in 10 patients (22.2%), and worsened in 2 patients (4.4%). Multiple linear regression showed that patients with smaller haemorrhages (P=0.012) and prompt surgery (P=0.008) had better final visual acuities. A haemorrhage area of ≤30 mm(2) had 91.3% sensitivity and 73.3% specificity for predicting a final visual acuity ≥6/60.ConclusionSmall-gauge vitrectomy with subretinal rtPA and ranibizumab is effective for improving visual acuity in patients with submacular haemorrhages secondary to nAMD. Small haemorrhage area and prompt surgery are associated with better final visual acuity.

Fourteen years of surveillance of HIV-1 prevalence among pregnant women attending antenatal care clinics in western Uganda

This study monitored long-term temporal trends in HIV-1 prevalence in antenatal clinic attendees living in western Uganda. Semi-annual data collection was done from 1991 to 2004. For each woman the following data were recorded: HIV-1 status, age, educational status, marital status, occupation and parity. The results show that the overall HIV-1 prevalence was 15.3% during the entire time period (urban 21.3%, semi-urban 12.7% and rural 7.1%). Between 1991 and 2004, we observed a gradual decline in the HIV-1 prevalence. The decline was most pronounced in urban women aged 15-19 years old and least pronounced in rural women aged 20-24 years. Women above 25 years of age did not show any decline in HIV-1 prevalence over time. The declining HIV-1 prevalence in the younger age groups (15-24 years) likely represents a declining risk for acquiring HIV infection as we have previously shown in the urban sub-sample of this data set.

Conditioned medium from Ad-IFN-alpha-infected bladder cancer and normal urothelial cells is cytotoxic to cancer cells but not normal cells: further evidence for a strong bystander effect

We have reported earlier that a bystander effect is seen in cancer cells that are resistant to high concentrations of the interferon-alpha protein (Intron A) when treated with adenoviral-mediated interferon-alpha (Ad-IFN-alpha). We now provide further evidence for this bystander effect using conditioned medium (CM) collected from Ad-IFN-alpha-infected cancer and normal urothelial cells. The CMs collected from UC-9 and KU7 bladder cancer cells as well as normal urothelial cells following transfection with Ad-IFN produce cell death when added to various cancer cell types in culture but not to normal urothelial cells. The CM could be filtered, frozen and thawed, and diluted to at least one part Ad-IFN CM to five parts fresh control medium and the diluted CM still shows a similar cytotoxicity as a 100% concentration of Ad-IFN CM. This cytotoxicity was observed by both flow cytometry and MTT assays as well as by phase microscopy, and a significant sub-G1 population was seen whether the CM was collected 48, 72 or 96 h after initial Ad-IFN treatment. In addition, the CM could be partially inactivated by exposure to 65 degrees C for 30 min and totally inactivated by placement at 92 degrees C for 3 min, whereas Intron A was not inactivated under the same conditions. Importantly, although significant caspase 8 and caspase 9 cleavage occurred in Ad-IFN-treated cells as a direct effect of Ad-IFN transfection, the Ad-IFN CM produced no activation of caspase 8 and caspase 9, indicating that a different mechanism of cell death was produced by the bystander factor(s) than the direct effect of Ad-IFN. This bystander effect in turn may play an important role in the efficacy of the current Ad-IFN clinical trial for superficial bladder cancer now underway.

The importance of quality management in fetal measurement

OBJECTIVES

The aims of this study were to evaluate factors contributing to inaccuracy in fetal measurements and to assess the clinical importance of measurement quality.

METHODS

One hundred images of biparietal diameter (BPD), head circumference (HC) and abdominal circumference (AC) measurements were collected from six centers (1800 measurements); the proportion meeting quality criteria was assessed. Four hundred images of AC were collected from one center, each image measured by ellipse fitting and tracing methods; clinical agreement between the methods was assessed. Fetal weight estimation (EFW) errors were compared between quality controlled and non-quality controlled studies. Images of three ACs on each of 400 fetuses were collected; where one measurement failed to meet quality criteria, it was compared with an optimal measurement on the same fetus.

RESULTS

Eighty-nine percent, 87% and 60% of BPD, HC and AC, respectively, met all quality criteria. Limits of agreement between ellipse and traced AC were -4.7 mm to 12.5 mm; 22% of sections were non-elliptical. EFW errors were significantly different but were confounded by differences in time to delivery. Limits of agreement between optimal and suboptimal AC measurements were -15.1 mm to 7.7 mm.

CONCLUSIONS

AC quality criteria are less easily recognized and obtained than those for head measurements; training, adherence to protocols and audit are important. Differences between ellipse and traced AC may not justify the use of separate charts; the number of non-elliptical sections suggests that ellipse fitting is not appropriate. Comparison between EFW errors is not a suitable tool for audit. Failure to meet quality criteria results in clinically significant errors.

Regeneration of PAPS for the enzymatic synthesis of sulfated oligosaccharides

This paper describes the study of 3'-phosphoadenosine-5'-phosphosulfate (PAPS) regeneration from 3'-phosphoadenosine-5'-phosphate (PAP) for use in practical syntheses of carbohydrate sulfates which are catalyzed by sulfotransferases. Among the regeneration systems, the one with recombinant aryl sulfotransferase proved to be the most practical. This regeneration system was coupled with a sulfotransferase-catalyzed reaction, using a recombinant Nod factor sulfotransferase, for the synthesis of various oligosaccharide sulfates that were further glycosylated using glycosyltransferases.

Homeopathic treatment of acute childhood diarrhea: results from a clinical trial in Nepal

OBJECTIVE

To investigate whether the finding in a previous study that homeopathic medicines decrease the duration of acute diarrhea in children could be replicated in a different study population.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Private, charitable health clinic in Kathmandu, Nepal.

SUBJECTS

A consecutive sample of 126 children, 6 months to 5 years of age, who presented during April through June, 1994, with more than three unformed stools in the previous 24 hours.

INTERVENTION

Children received either an individualized homeopathic medicine or placebo, to be taken one dose after each unformed stool for 5 days. Parents recorded daily stools on diary cards, and health workers made home visits daily to monitor children.

OUTCOME MEASURES

Predefined measures were based on the previous study: (1) duration of diarrhea, defined as the time until there were fewer than three unformed stools per day, for two consecutive days, and (2) Average number of stools per day for each group.

RESULTS

Of the 126 children initially enrolled, 116 completed treatment. The mean number of stools per day over the entire 5-day treatment period was 3.2 for the treatment group and 4.5 for the placebo group (P = 0.023). A Kaplan-Meier survival analysis of the duration of diarrhea, which included data from all patient visits, showed an 18.4% greater probability that a child would be free of diarrhea by day 5 under homeopathic treatment (P = 0.036).

CONCLUSIONS

These results are consistent with the finding from the previous study that individualized homeopathic treatment decreases the duration of diarrhea and number of stools in children with acute childhood diarrhea.

In praise of ivory towers

Mrs Gillian Shepherd, during her tenure as the United Kingdom's Secretary of State responsible for education, announced proposals for a national curriculum for the preparation of teachers--prescribing, for the first time in the United Kingdom, the skills that all teachers should be taught. It seems timely, therefore, to reflect on exactly what is happening to education in general and nursing education in particular in the United Kingdom. The developing climate of opinion (at least from the politician's viewpoint, and perhaps the general public's) is that education should be skills-based--that is, that certain actions and behaviours should be taught that will produce an end product that is 'marketable' and competent to carry out certain 'tasks'. These tasks may be mathematical skills, applying a wound dressing, writing correct English, or any precise measurable activity. The philosophical foundation of this approach is two-fold: (a) with limited resources, it is right to target education towards the vocational needs of an industrial and commercial society improving competitiveness; and (b) that which produces practical end results has more moral worth than pure academic pursuits, no matter how intrinsically valuable they may seem to be.

Nurse education: a feminist approach

Nursing is predominantly a female profession. This paper seeks to explore the implications of this for curriculum design and suggests that insights from feminist theory should be applied to curricula. To insert the 'subject' of feminism into the curriculum is different from allowing its theories to affect the design of the curriculum itself. The paper seeks to justify such a change and asks what the resulting characteristics would be. Would such a curriculum change succeed and what would be its limitations? The paper concludes by highlighting the implications for nurse education.

Prevalence of Cyclospora species and other enteric pathogens among children less than 5 years of age in Nepal

Stools from 124 Nepalese children aged 6 to 60 months with diarrhea were examined for organisms of the coccidian genus Cyclospora and for other enteric pathogens. Enterotoxigenic Escherichia coli, Giardia Lamblia, Campylobacter species, Cyclospora species, and Cryptosporidium species were the most common pathogens identified. Cyclospora species were detected in none of 74 children < 18 months of age compared with 6 (12%) of 50 children > or = 18 months of age (P = 0.004).

Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee

BACKGROUND

Peak flow based asthma self-management plans have been strongly advocated in consensus statements, but convincing evidence for the effectiveness of this approach has been largely lacking.

METHODS

A randomised controlled trial was conducted in 25 general practices comparing an asthma self-management programme based on home peak flow monitoring and surgery review by a general practitioner or practice nurse with a programme of planned visits for surgery review only over a six month period.

RESULTS

Seventy two subjects (33 in the self-management group and 39 in the planned visit group) completed the study protocol, but diary card data for at least three months were available on a total of 84 (39 in the self-management group and 45 in the planned visit group). Teaching self-management took longer than the planned visit review. In the self-management group home peak flow monitoring was felt to be useful by doctors and patients in 28 (85%) and 27 (82%) cases, respectively. There were no between group differences during the study period in terms of lung function, symptoms, quality of life, and prescribing costs. Only within the self-management group were improvements noted in disturbance of daily activities and quality of life. Possible explanations for these negative results include small numbers of subjects, the mild nature of their asthma, and inappropriate self-management strategies for such patients.

CONCLUSIONS

Rigid adherence to long term daily peak flow measurement in the management of mild asthma in general practice does not appear to produce large changes in outcomes. Self-management and the use of prescribed peak flow meters need to be tailored to individual circumstances.

Asthma at the interface: bridging the gap between general practice and a district general hospital

A clinic supervised by a nurse, using principles originally developed in general practice, was established in the paediatric department of a district general hospital. A randomised controlled study was conducted comparing children admitted with asthma or attending outpatients who were given a patient education programme and self management plan (intervention group) with a control group. The study comprised 91 patients aged 3-14 years admitted for asthma or attending a hospital outpatient department from November 1989 to November 1990. Seventy seven patients completed the study and kept diaries for a median of 283 days. Patients in the intervention group had significantly less restriction of activity (95% confidence interval (CI) -0.27 to -0.01) and fewer episodes of peak flow below 30% of best (95% CI 0.03 to 1.17). Patients in the intervention group were more likely to make the correct response to an acute exacerbation of their asthma than the control group (71% v 47%, 95% CI 9.51 to 39.1). The intervention group had fewer school absences and fewer home visits by a general practitioner. There was an increase in the readmission rate for the intervention group. A subgroup of patients who self managed by doubling their use of inhaled steroids during an exacerbation performed better than those patients who only increased their bronchodilator or were managed on salbutamol or sodium cromoglycate alone. Improvements in patient follow up and the structure of the self management plans used, particularly changing the peak flow level at which inhaled steroids are doubled, may further improve the outcome of patients attending the asthma clinic.

Leading the change process. Interview by Michael L. Laughlin and Carolyn Dunbar

'Change or cease to exist.' In interviews with Computers in Healthcare six industry leaders agree that increasing market pressures will force many organizations to drastically modify the way they do business. Those that don't will eventually fail.

Hospitals and prisons. An action plan for the liberation of our patients

Each day about 24,000 people are imprisoned in America's penal institutions. The experience for those people is humiliating, disturbing, and degrading. I know. I used to put them there. When I resigned from the United States District Attorney's office in 1975 after serving for three years as a federal prosecutor (and later as a night court judge) and started my new role as a hospital executive, I thought I was leaving the process of imprisonment behind. In the winter of 1975-76, as I went about the task of learning how hospitals functioned, I visited the emergency room. I visited the admitting area. I visited the floors. I watched doctors, nurses, and X-ray technologists at work. Gradually, a disturbing thought came to me: Hospital patients are treated much like convicted felons.