Prolonged detection of urine norfentanyl in individuals enrolled in a medication for opioid use disorder in pregnancy and postpartum program: a case series

BACKGROUND

Although urine drug testing can have vast legal and social ramifications, its interpretation during pregnancy and after birth remains not well understood. Fentanyl metabolism is altered by an individual's genetics, history of opioid use, and liver function. However, little is known about the clearance of fentanyl or its primary metabolite, norfentanyl, in the peripartum period.

OBJECTIVE

We sought to identify and describe cases of delayed urine norfentanyl clearance in the pregnancy and postpartum period within our institution.

STUDY DESIGN

This study described 3 cases of delayed urine norfentanyl clearance in pregnant and postpartum individuals in a colocated obstetrics, postpartum, and addiction medicine program. This program included prescriptions for medication for opioid use disorder and weekly urine drug testing with fentanyl immunoassay with reflex confirmation testing with liquid chromatography-tandem mass spectrometry for positive results with a limit of detection of 2.5 ng/mL.

RESULTS

Low levels of norfentanyl (<16.3 ng/mL) were detected in urine 294 days, 126 days, and 231 days after the last fentanyl use. Patient self-reported abstinence was supported by consistently negative urine fentanyl levels throughout the collection period, compliant weekly urine drug tests that were otherwise only positive for buprenorphine, and negative fentanyl and norfentanyl in umbilical cord toxicology.

CONCLUSION

Despite compliance in a medication for opioid use disorder program, the presence of norfentanyl in urine has significant consequences on the maternal-child dyad in the postpartum period. Caution should be used when using low levels of norfentanyl to determine an individual's abstinence, as it can lead to further discrimination against women in medication for opioid use disorder programs.

Maternal obesogenic diet regulates offspring bile acid homeostasis and hepatic lipid metabolism via the gut microbiome in mice

Mice exposed in gestation to maternal high-fat/high-sucrose (HF/HS) diet develop altered bile acid (BA) homeostasis. We hypothesized that these reflect an altered microbiome and asked if microbiota transplanted from HF/HS offspring change hepatic BA and lipid metabolism to determine the directionality of effect. Female mice were fed HF/HS or chow (CON) for 6 wk and bred with lean males. 16S sequencing was performed to compare taxa in offspring. Cecal microbiome transplantation (CMT) was performed from HF/HS or CON offspring into antibiotic-treated mice fed chow or high fructose. BA, lipid metabolic, and gene expression analyses were performed in recipient mice. Gut microbiomes from HF/HS offspring segregated from CON offspring, with increased Firmicutes to Bacteriodetes ratios and Verrucomicrobial abundance. After CMT was performed, HF/HS-recipient mice had larger BA pools, increased intrahepatic muricholic acid, and decreased deoxycholic acid species. HF/HS-recipient mice exhibited downregulated hepatic Mrp2, increased hepatic Oatp1b2, and decreased ileal Asbt mRNA expression. HF/HS-recipient mice exhibited decreased cecal butyrate and increased hepatic expression of Il6. HF/HS-recipient mice had larger livers and increased intrahepatic triglyceride versus CON-recipient mice after fructose feeding, with increased hepatic mRNA expression of lipogenic genes including Srebf1, Fabp1, Mogat1, and Mogat2. CMT from HF/HS offspring increased BA pool and shifted the composition of the intrahepatic BA pool. CMT from HF/HS donor offspring increased fructose-induced liver triglyceride accumulation. These findings support a causal role for vertical transfer of an altered microbiome in hepatic BA and lipid metabolism in HF/HS offspring.NEW & NOTEWORTHY We utilized a mouse model of maternal obesogenic diet exposure to evaluate the effect on offspring microbiome and bile acid homeostasis. We identified shifts in the offspring microbiome associated with changes in cecal bile acid levels. Transfer of the microbiome from maternal obesogenic diet-exposed offspring to microbiome-depleted mice altered bile acid homeostasis and increased fructose-induced hepatic steatosis.

Distinct iron architecture in SF3B1-mutant myelodysplastic syndrome patients is linked to an SLC25A37 splice variant with a retained intron

Perturbation in iron homeostasis is a hallmark of some hematologic diseases. Abnormal sideroblasts with accumulation of iron in the mitochondria are named ring sideroblasts (RS). RS is a cardinal feature of refractory anemia with RS (RARS) and RARS with marked thrombocytosis (RARS/-T). Mutations in SF3B1, a member of the RNA splicing machinery are frequent in RARS/-T and defects of this gene were linked to RS formation. Here we showcase the differences in iron architecture of SF3B1-mutant and wild-type (WT) RARS/-T and provide new mechanistic insights by which SF3B1 mutations lead to differences in iron. We found higher iron levels in SF3B1 mutant vs WT RARS/-T by transmission electron microscopy/spectroscopy/flow cytometry. SF3B1 mutations led to increased iron without changing the valence as shown by the presence of Fe(2+) in mutant and WT. Reactive oxygen species and DNA damage were not increased in SF3B1-mutant patients. RNA-sequencing and Reverse transcriptase PCR showed higher expression of a specific isoform of SLC25A37 in SF3B1-mutant patients, a crucial importer of Fe(2+) into the mitochondria. Our studies suggest that SF3B1 mutations contribute to cellular iron overload in RARS/-T by deregulating SLC25A37.

Neurokinin-1 receptor antagonists as novel antidepressants: trials and tribulations

Based upon animal experiments and early clinical trials, neurokinin-1 receptor antagonists showed promise as novel antidepressants. Subsequently, however, more extensive clinical trials did not reveal evidence of efficacy in depression. The development of novel antidepressants will require a better understanding of the neural basis of antidepressant action in humans.

Recognition, assessment, and treatment of anxiety in the critical care patient

A multidisciplinary group of experts involved in the treatment of critically ill patients participated in a workshop conference designed to develop practice recommendations for the recognition, assessment, and treatment of anxiety in the critical care environment. Anxiety was identified as a ubiquitous problem in critical care that may interfere with healing and recovery. The faculty agreed that clinicians should be familiar with the signs and symptoms of anxiety and should be able to determine when interventions are necessary. Whenever possible, nonpharmacologic methods for anxiolysis should be incorporated into intensive care protocols. Intensive care personnel should be trained in those interventions that require specialized expertise, and they should become familiar with the drugs available for the treatment of anxiety. Protocols for determining the best agents to be used in a given setting and their most appropriate method of administration should be established. Pharmacologic and nonpharmacologic treatments are not mutually exclusive but should be complementary. Finally, procedures for obtaining psychiatric consultation, when necessary, should be in place.

Pulmonary embolism in the critically ill: strategies for prevention and treatment

Most ICU patients are at high risk for developing deep venous thrombosis; thus, they should be considered candidates for prophylaxis against pulmonary emboli (PE). If early ambulation is not an option, give low-dose heparin or apply lower extremity pneumatic compression. When PE cannot be prevented, rapid treatment is mandatory. Inotropic agents can be used to improve right ventricular contractility; however, the role of volume loading for augmenting preload is controversial. Heparin is the first-line therapy for halting ongoing thrombosis; administer a 5,000- to 10,000-U bolus, followed by a continuous infusion of about 35,000 U/d. Thrombolysis, embolectomy, and occlusive devices are other therapeutic options.

Late presentation of vitamin D-dependent rickets

An 8 1/2-year-old girl presented with rickets. This had developed despite a normal diet and in the absence of symptoms, signs, or laboratory evidence of malabsorption, hepatic or renal disease. The rickets healed with physiological doses of 1-alpha-hydroxy-cholecalciferol. It is suggested that this case provides evidence for genetic and metabolic heterogeneity in vitamin D-dependent rickets.

Absorption of chlorhexidine from the intact skin of newborn infants

34 newborn infants who had been bathed in a standard manner with Hibiscrub were studied to find out whether it was absorbed percutaneously. Low levels of chlorhexidine were found in the blood of all 10 babies sampled by heel prick, and 5 of 24 from whom venous blood was taken. The detection of chlorhexidine varied greatly with the method and timing of sampling, and no correlation was found between gestational or postnatal age and chlorhexidine levels.

Group B streptococcal infection in a maternity unit

Neonatal infection due to Group B streptococci is described in a maternity unit. Six babies were affected and two died. Three of the babies were born at term, and weighed more than 2.5 kg. Tachypnoea was the earliest clinical sign in each case, and we suggest that newborn infants with persistent tachypnoea and evidence of maternal or infant colonization with Group B streptococci should receive antibiotics. Alternative approaches to the diagnosis and management of infection with Group B streptococci are discussed and rejected.

Spontaneous abortion and fetal abnormality in subsequent pregnancy

In a prospective survey neural tube defects and other congenital abnormalities were studied in the babies born to 510 mothers ascertained during pregnancy. The women were divided into two groups according to the outcome of their immediately preceding pregnancy. Those whose preceding pregnancy had resulted in a spontaneous abortion (256 women) formed the index cases; those in whom the outcome had been a normal baby (254 women) served as controls. There was a highly significant increased number of congenital abnormalities in the index cases. This may possibly be explained by the trophoblastic "rest" hypothesis and suggests that spontaneous abortions are more relevent to congenital abnormalities than has been thought.

Two cases of Meckel's diverticulum shown by technetium scanning

Images

The effect of protein deficiency and calorie deficiency on the reproduction of rats

1. Groups of twelve female rats were fed from 4 weeks of age on four different experimental dietary regimens, and on a stock diet containing 18% protein givenad lib.as a control (group 1). The rats in two of the experimental groups were malnourished either by being given a low-protein (9%) dietad lib.(group 2), or the stock diet containing 18% protein in limited amounts to maintain weight as in group 2. These animals were designated calorie-deficient (group 3). Two other groups of twelve rats were more severely malnourished from 4 to 13 weeks of age by being given a low-protein (6%) dietad lib.(group 4) or the stock diet in limited amounts to maintain weight as in group 4 (group 5). From 13 weeks all the rats in groups 4 and 5 were rehabilitated on stock dietad lib.

2. Well-nourished males were introduced into the cages 1 week after the vaginas opened, and again immediately after the females had suckled successive litters. This was repeated until the females were 60 weeks old and had reared up to six litters.

3. Chronic deprivation of protein or of calories delayed puberty, reduced fertility and gave rise to smaller numbers in the litters. It also interfered with lactation.

4. More severe malnutrition for 9 weeks further delayed puberty, but when these animals were rehabilitated they produced as many young as those that had been well-nourished throughout. They lactated well and there was no carry-over of the effects of the early deficiencies.