Opioid overdose prevention education for medical students: Adopting harm reduction into mandatory clerkship curricula

Abstract

Background: Opioid overdose deaths constitute a public health crisis in the United States. Strategies for reducing opioid-related harm are underutilized due in part to clinicians’ low knowledge about harm reduction theory and limited preparedness to prescribe naloxone. Educational interventions are needed to improve knowledge and attitudes about, and preparedness to address, opioid overdoses among medical students. Methods: Informed by the Department of Veterans Affairs’ Overdose Education and Naloxone Distribution (OEND) program and narrative medicine, we developed and led a mandatory workshop on harm reduction for clerkship medical students. Using validated scales, we assessed students’ knowledge and attitudes about, and preparedness to address, opioid overdoses before the workshop and 6 weeks after. Results: Of 75 participating students from February through December 2017, 55 (73%) completed pre-workshop and 38 (51%) completed both pre- and post-workshop surveys. At baseline, 40 (73%) encountered patients with perceived at-risk opioid use in the previous 6 weeks, but only 11 (20%) recalled their teams prescribing naloxone for overdose prevention. Among those completing both surveys, knowledge about and preparedness to prevent overdose showed large improvement (Cohen’s d?=?0.85, P?<?.001; Cohen’s d?=?1.24, P?<?.001, respectively) and attitudes showed moderate improvement (Cohen’s d?=?0.32, P = .04). Discussion: Educational interventions grounded in harm reduction theory can increase students’ knowledge and attitudes about, and preparedness to address, opioid overdoses.     

High-dose corticosteroid therapy for Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

Overwhelming Pneumocystis carinii pneumonia (PCP) in patients with acquired immunodeficiency syndrome (AIDS) carries a poor prognosis. Patients who require mechanical ventilation have up to a 90% mortality rate despite vigorous treatment. Although there are theoretic contraindications to steroid use in severely immunocompromised individuals, case reports of AIDS patients with PCP either inadvertently or intentionally given steroids have shown benefit. We report a series of seven patients whose AIDS and PCP worsened with conventional therapy and who subsequently received high-dose intravenous steroid therapy. All patients required intubation or a high inspired oxygen concentration. Four patients with uncomplicated PCP had a rapid and sustained response to steroids. Three patients with mixed infections (cytomegalovirus, Legionella pneumophila, and Pneumococcus) had transient improvement in gas exchange, though two of these patients subsequently died. Our experience is similar to that of others and suggests that corticosteroids may be of benefit in patients with AIDS and overwhelming PCP. We postulate that pulmonary inflammation is a major determinant of the severity of PCP in AIDS, and that this inflammation may be diminished by high-dose corticosteroid therapy.     

Taxodione and arenarone inhibit farnesyl diphosphate synthase by binding to the isopentenyl diphosphate site

We used in silico methods to screen a library of 1,013 compounds for possible binding to the allosteric site in farnesyl diphosphate synthase (FPPS). Two of the 50 predicted hits had activity against either human FPPS (HsFPPS) or Trypanosoma brucei FPPS (TbFPPS), the most active being the quinone methide celastrol (IC₅₀ versus TbFPPS ∼20 µM). Two rounds of similarity searching and activity testing then resulted in three leads that were active against HsFPPS with IC₅₀ values in the range of ∼1–3 µM (as compared with ∼0.5 µM for the bisphosphonate inhibitor, zoledronate). The three leads were the quinone methides taxodone and taxodione and the quinone arenarone, compounds with known antibacterial and/or antitumor activity. We then obtained X-ray crystal structures of HsFPPS with taxodione+zoledronate, arenarone+zoledronate, and taxodione alone. In the zoledronate-containing structures, taxodione and arenarone bound solely to the homoallylic (isopentenyl diphosphate, IPP) site, not to the allosteric site, whereas zoledronate bound via Mg²⁺ to the same site as seen in other bisphosphonate-containing structures. In the taxodione-alone structure, one taxodione bound to the same site as seen in the taxodione+zoledronate structure, but the second located to a more surface-exposed site. In differential scanning calorimetry experiments, taxodione and arenarone broadened the native-to-unfolded thermal transition (T_m), quite different to the large increases in ΔT_m seen with biphosphonate inhibitors. The results identify new classes of FPPS inhibitors, diterpenoids and sesquiterpenoids, that bind to the IPP site and may be of interest as anticancer and antiinfective drug leads.Farnesyl diphosphate synthase (FPPS) catalyzes the condensation of isopentenyl diphosphate (IPP; compound 1 in Fig. 1) with dimethylallyl diphosphate (DMAPP; compound 2 in Fig. 1) to form the C₁₀ isoprenoid geranyl diphosphate (GPP; compound 3 in Fig. 1), which then condenses with a second IPP to form the C₁₅ isoprenoid, farnesyl diphosphate (FPP; compound 4 in Fig. 1). FPP then is used in a wide range of reactions including the formation of geranylgeranyl diphosphate (GGPP) (1), squalene (involved in cholesterol and ergosterol biosynthesis), dehydrosqualene (used in formation of the Staphylococcus aureus virulence factor staphyloxanthin) (2), undecaprenyl diphosphate (used in bacterial cell wall biosynthesis), and quinone and in heme a/o biosynthesis. FPP and GGPP also are used in protein (e.g., Ras, Rho, Rac) prenylation, and FPPS is an important target for the bisphosphonate class of drugs (used to treat bone resorption diseases) such as zoledronate (compound 5 in Fig. 1) (3). Bisphosphonates targeting FPPS have activity as antiparasitics (4), act as immunomodulators (activating γδ T cells containing the Vγ2Vδ2 T-cell receptor) (5), and switch macrophages from an M2 (tumor-promoting) to an M1 (tumor-killing) phenotype (6). They also kill tumor cells (7) and inhibit angiogenesis (8). However, the bisphosphonates in clinical use (zoledronate, alendronate, risedronate, ibandronate, etidronate, and clodronate) are very hydrophilic and bind avidly to bone mineral (9). Therefore, there is interest in developing less hydrophilic species (10) that might have better activity against tumors in soft tissues and better antibacterial (11) and antiparasitic activity.Open in a separate windowFig. 1.Chemical structures of FPPS substrates, products, and inhibitors.The structure of FPPS (from chickens) was first reported by Tarshis et al. (12) and revealed a highly α-helical fold. The structures of bacterial and Homo sapiens FPPS (HsFPPS) are very similar; HsFPPS structure (13, 14) is shown in Fig. 2A. There are two substrate-binding sites, called here “S1” and “S2.” S1 is the allylic (DMAPP, GPP) binding site to which bisphosphonates such as zoledronate bind via a [Mg²⁺]₃ cluster (15) (Fig. 2B). S2 is the homoallylic site to which IPP binds, Fig. 2B. Recently, Jahnke et al. (10) and Salcius et al. (16) discovered a third ligand-binding site called the “allosteric site” (hereafter the “A site”). A representative zoledronate+A-site inhibitor structure [Protein Data Bank (PDB) ID code 3N46] (Nov_980; compound 6 in Fig. 1) showing zoledronate in S1 and Nov_980 (compound 6) in the A site is shown in a stereo close-up view in Fig. 2B, superimposed on a zoledronate+IPP structure (PDB ID code 2F8Z) in S2. Whether the allosteric site serves a biological function (e.g., in feedback regulation) has not been reported. Nevertheless, highly potent inhibitors (IC₅₀ ∼80 nM) have been developed (10), and the best of these newly developed inhibitors are far more hydrophobic than are typical bisphosphonates (∼2.4–3.3 for cLogP vs. ∼−3.3 for zoledronate) and are expected to have better direct antitumor effects in soft tissues (10).Open in a separate windowFig. 2.Structures of human FPPS. (A) Structure of HsFPPS showing zoledronate (compound 5) and IPP (compound 1) bound to the S1 (allylic) and S2 (homoallylic) ligand-binding sites (PDB ID code 2F8Z). (B) Superposition of the IPP-zoledronate structure (PDB ID code 2F8Z) on the zoledronate-Nov_980 A-site inhibitor structure (PDB ID code 3N46). Zoledronate binds to the allylic site S1, IPP binds to the homoallylic site S2, and the allosteric site inhibitor binds to the A site. Active-site “DDXXD” residues are indicated, as are Mg²⁺ molecules (green and yellow spheres, respectively). The views are in stereo.In our group we also have developed more lipophilic compounds (e.g., compound 7 in Fig. 1) (17, 18) as antiparasitic (19) and anticancer drug leads (18) and, using computational methods, have discovered other novel nonbisphosphonate FPPS inhibitors (e.g., compound 8 in Fig. 1) that have micromolar activity against FPPS (20). In this study, we extended our computational work and tried to discover other FPPS inhibitors that target the A site. Such compounds would be of interest because they might potentiate the effects of zoledronate and other bisphosphonates, as reported for other FPPS inhibitors (21), and have better tissue distribution properties in general.     

Nervous system involvement in von Hippel–Lindau disease: pathology and mechanisms

Patients with von Hippel–Lindau disease carry a germline mutation of the Von Hippel–Lindau (VHL) tumor-suppressor gene. We discuss the molecular consequences of loss of VHL gene function and their impact on the nervous system. Dysfunction of the VHL protein causes accumulation and activation of hypoxia inducible factor (HIF) which can be demonstrated in earliest stages of tumorigenesis and is followed by expression of VEGF, erythropoietin, nitric oxide synthase and glucose transporter 1 in VHL-deficient tumor cells. HIF-independent functions of VHL, epigenetic inactivation of VHL, pVHL proteostasis, and links between loss of VHL function and developmental arrest are also described. A most intriguing feature in VHL disease is the occurrence of primary hemangioblastic tumors in the nervous system, the origin of which has not yet been entirely clarified, and current hypotheses are discussed. Endolymphatic sac tumors may extend into the brain, but originally arise from proliferation of endolymphatic duct/sac epithelium; the exact nature of the proliferating epithelial cell, however, also has remained unclear, as well as the question why tumors almost consistently develop in the intraosseous portion of the endolymphatic sac/duct only. The epitheloid clear cell morphology of both advanced hemangioblastoma and renal clear cell carcinoma can make the differential diagnosis challenging, recent developments in immunohistochemical differentiation are discussed. Finally, metastasis to brain may not only be caused by renal carcinoma, but may derive from VHL disease-associated pheochromocytoma/paraganglioma, or pancreatic neuroendocrine tumor.     

Dronedarone,an Amiodarone Analog with Improved Anti-Leishmania mexicana Efficacy

Dronedarone and amiodarone are cationic lipophilic benzofurans used to treat cardiac arrhythmias. They also have activity against the parasitic protozoan Trypanosoma cruzi, the causative agent of Chagas'' disease. They function by disrupting intracellular Ca²⁺ homeostasis of the parasite and by inhibiting membrane sterol (ergosterol) biosynthesis. Amiodarone also has activity against Leishmania mexicana, suggesting that dronedarone might likewise be active against this organism. This might be of therapeutic interest, since dronedarone is thought to have fewer side effects in humans than does amiodarone. We show here that dronedarone effectively inhibits the growth of L. mexicana promastigotes in culture and, more importantly, has excellent activity against amastigotes inside infected macrophages (the clinically relevant form) without affecting the host cell, with the 50% inhibitory concentrations against amastigotes being 3 orders of magnitude lower than those obtained previously with T. cruzi amastigotes (0.65 nM versus 0.75 μM). As with amiodarone, dronedarone affects intracellular Ca²⁺ homeostasis in the parasite, inducing an elevation of intracellular Ca²⁺ levels. This is achieved by rapidly collapsing the mitochondrial membrane potential and inducing an alkalinization of acidocalcisomes at a rate that is faster than that observed with amiodarone. We also show that dronedarone inhibits parasite oxidosqualene cyclase, a key enzyme in ergosterol biosynthesis known to be vital for survival. Overall, our results suggest the possibility of repurposing dronedarone as a treatment for cutaneous, and perhaps other, leishmaniases.     

Expression of the vascular permeability factor/vascular endothelial growth factor gene in central nervous system neoplasms.

Expression of the vascular permeability factor/vascular endothelial growth factor (VEGPF) gene was investigated in human central nervous system (CNS) neoplasms and normal brain. Adsorption of capillary permeability activity from human glioblastoma multiforme (GBM) cell conditioned medium and GBM cyst fluids by anti-VEGPF antibodies demonstrated that VEGPF is secreted by GBM cells and is present in sufficient quantities in vivo to induce vascular permeability. Cloning and sequencing of polymerase chain reaction-amplified GBM and normal brain cDNA demonstrated three forms of the VEGPF coding region (567, 495, and 363 nucleotides), corresponding to mature polypeptides of 189, 165, and 121 amino acids, respectively. VEGPF mRNA levels in CNS tumors vs. normal brain were investigated by the RNase protection assay. Significant elevation of VEGPF gene expression was observed in 81% (22/27) of the highly vascular and edema-associated CNS neoplasms (6/8 GBM, 8/8 capillary hemangioblastomas, 6/7 meningiomas, and 2/4 cerebral metastases). In contrast, only 13% (2/15) of those CNS tumors that are not commonly associated with significant neovascularity or cerebral edema (2/10 pituitary adenomas and 0/5 nonastrocytic gliomas) had significantly increased levels of VEGPF mRNA. The relative abundance of the forms of VEGPF mRNA was consistent in tumor and normal brain: VEGPF495 > VEGPF363 > VEGPF567. In situ hybridization confirmed the presence of VEGPF mRNA in tumor cells and its increased abundance in capillary hemangioblastomas. Our results suggest a significant role for VEGPF in the development of CNS tumor neovascularity and peritumoral edema.     

A dual CT‐MR dendrimer contrast agent as a surrogate marker for convection‐enhanced delivery of intracerebral macromolecular therapeutic agents

The feasibility of using Gd dendrimer‐based macromolecules (Gd‐G8 dendrimer) as a dual CT and MR contrast agent for monitoring convection‐enhanced delivery of therapy in the brain is evaluated both in vitro and in vivo with optimal dosing established. In vitro CT attenuation values of the Gd‐based agents (～6.0 HU mM ^?1) were ～1.6 times greater than iodine‐based agents and the attenuation of the Gd‐DTPA was comparable to Gd‐G8 dendrimer. Visible enhancement was observed on both CT and MR using Gd‐G8 dendrimer over a range of 23–78 mM ; however, a concentration of at least 47 mM in Gd was required for adequate delineation of the injection site on both CT and MR. MR offers greater sensitivity than CT in estimating the volume of distribution (V_d) and effectively quantified the agent's concentration and diffusion using T₁ mapping at much lower concentrations of Gd (<10 mM in [Gd]). Copyright © 2008 John Wiley & Sons, Ltd.     

The history of pituitary surgery for Cushing disease

Although he never performed a pituitary operation for the disease, Harvey Cushing was the first to describe and treat patients with Cushing disease (CD). Other surgeons at the time were reluctant to operate on the pituitary due to the normal sella on skull radiographs in CD and the unclear etiology of the disorder. To better define and understand factors influencing the history of pituitary surgery for CD, the authors analyzed historical texts related to CD biology, diagnosis, and treatment. Cushing's monograph on basophilic pituitary adenomas and cortisol excess appeared in 1932. One year later in 1933, Alfred Pattison performed the first successful pituitary operation for CD by implanting radon seeds in the sella. Resection of a pituitary adenoma for CD was attempted 1 month later in 1933 by Howard Naffziger, resulting in only transient improvement that corresponded to the lack of tumor in the resected tissue. Soon thereafter, Susman in 1935 and Costello in 1936 described pituitary basophilic adenomas at autopsy in patients without premorbid endocrinopathy. They concluded that the adrenal gland was the cause of CD, which resulted in a 3-decade abandonment of pituitary surgery for CD. Jules Hardy in 1963 used the operating microscope to perform the first selective removal of an adrenocorticotropic hormone (ACTH)-secreting microadenoma, which established a pituitary cause and defined the modern treatment of CD. Subsequent reports by Hardy, Laws, and Wilson resulted in widespread acceptance of pituitary surgery for CD. Initial reluctance to operate on the pituitary for CD was multifaceted and included general uncertainty surrounding the etiology of Cushing syndrome as well as a lack of early surgical success, both due to the small size of ACTH-secreting adenomas. Selective removal of ACTH-secreting adenomas identified the source of CD and ended the delay in acceptance of pituitary surgery for CD.