Housing and overdose: an opportunity for the scale-up of overdose prevention interventions?

Background

North America is currently experiencing an overdose epidemic due to a significant increase of fentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergency given the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people who use drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to 90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and response interventions have yet to be widely implemented in a range of housing settings.

Overdose prevention interventions

There are few examples of overdose prevention interventions in housing environments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at some housing environments. There are also “supervised” spaces such as overdose prevention sites (similar to supervised consumption sites (SCS)) located in some housing environments; however, their coverage remains limited and the impacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number of SCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is known about the design or effectiveness, as they remain under-evaluated.

Conclusions

Implementing SCS and other overdose prevention interventions across a range of housing sites provides multiple opportunities to address overdose risk and drug-related harms for marginalized people who use drugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationship between housing and overdose, the continued implementation and evaluation of novel overdose prevention interventions in housing environments should be a public health priority. A failure to do so will simply perpetuate what has proven to be a devastating epidemic of preventable death.

     

Electroconvulsive Therapy and Chronic Subdural Hematoma

An elderly female patient with major depression was found to have an asymptomatic chronic subdural hematoma. Electroconvulsive therapy (ECT) resulted in full remission of her depression without neurological deterioration. The use of ECT in patients with cerebral lesions is discussed.     

Endobronchial nocardial infection.

The rare presentation of nocardial infection as an endobronchial "tumour" is reported. Haematogenous dissemination occurred after fibreoptic bronchoscopy and biopsy, a phenomenon not previously described in nocardial infections. This case highlights the difficulties in diagnosing pulmonary nocardial infection and the potential for invasive procedures to disseminate the disease.     

Metabolomics of the Bio-Degradation Process of Aflatoxin B1 by Actinomycetes at an Initial pH of 6.0

Contamination of food and feed by Aflatoxin B1 (AFB1) is a cause of serious economic and health problems. Different processes have been used to degrade AFB1. In this study, biological degradation of AFB1 was carried out using three Actinomycete species, Rhodococcus erythropolis ATCC 4277, Streptomyces lividans TK 24, and S. aureofaciens ATCC 10762, in liquid cultures. Biodegradation of AFB1 was optimised under a range of temperatures from 25 to 40 °C and pH values of 4.0 to 8.0. An initial concentration of 20 µg/mL of AFB1 was used in this study. The amount of AFB1 remaining was measured against time by thin layer chromatography (TLC) and high-performance liquid chromatography (HPLC), coupled with UV and mass spectrometry (LC-MS). All species were able to degrade the AFB1, and no significant difference was found between them. AFB1 remained in the liquid culture for R. erythropolis, S. lividans and S. aureofaciens were 0.81 µg/mL, 2.41 µg/mL and 2.78 µg/mL respectively, at the end of the first 24 h. Degradation occurred at all incubation temperatures and the pH with the optimal conditions for R. erythropolis was achieved at 30 °C and pH 6, whereas for S. lividans and S. aureofaciens the optimum conditions for degradation were 30 °C and pH 5. Analysis of the degradative route indicated that each microorganism has a different way of degrading AFB1. The metabolites produced by R. erythropolis were significantly different from the other two microorganisms. Products of degradation were identified through metabolomic studies by utilizing high-resolution mass spectral data. Mass spectrometric analysis indicated that the degradation of AFB1 was associated with the appearance of a range of lower molecular weight compounds. The pathway of degradation or chemical alteration of AFB1 was followed by means of high resolution Fourier transform mass spectrometry (HR-FTMS) analysis as well as through the MS² fragmentation to unravel the degradative pathway for AFB1. AFB1 bio-degradation was coupled with the accumulation of intermediates of fatty acid metabolism and glycolysis. A plausible mechanism of degradation of AFB1 by Rhodococcus was hypothesized.     

Acute gout management during hospitalization: a need for a protocol

Aim: To review systematically the management of acute gout during hospitalization. Methods: Case‐file review of all episodes of acute gout occurring in a large tertiary hospital over a 20‐month period. Results: Of 134 acute gout episodes identified, the large majority (118) occurred in patients not admitted under the rheumatology unit. Baseline anti‐gout medications were frequently ceased on admission and in 9% of episodes, no pharmacotherapy was prescribed. Delays in initiation of treatment occurred in up to 29% of patients. Acute management included anti‐inflammatory monotherapy, or combinations of colchicine, non‐steroidal anti‐inflammatory drugs (NSAIDs) and corticosteroids. Of patients prescribed colchicine, 26% received >1.5 mg/day and a strong correlation was found between colchicine dose and the occurrence of diarrhoea. NSAIDs were prescribed in 29% of patients with pre‐existing renal impairment. Overall, 25% of patients received inappropriate pharmacological management. In patients not under the direct care of the rheumatology unit, in‐hospital rheumatology consultation was sought by the treating unit in 34% of episodes. Consultation was sought more frequently in patients with multiple joint involvement, but there were no other obvious differences in baseline clinical characteristics between cases with or without rheumatology involvement. In cases with rheumatology involvement, patients were investigated more frequently, they received more pharmacotherapeutic intervention, in particular combination anti‐inflammatory therapy, and they achieved better symptomatic relief and long‐term follow up. Conclusion: Acute gout episodes in hospital are variably investigated and treated with frequent suboptimal management. We recommend establishment of a hospital‐wide protocol to support decision‐making regarding investigations, treatment and follow up.     

Sepsis-associated microvascular dysfunction measured by peripheral arterial tonometry: an observational study

Introduction  

Sepsis has a high mortality despite advances in management. Microcirculatory and endothelial dysfunction contribute to organ failure, and better tools are needed to assess microcirculatory responses to adjunctive therapies. We hypothesised that peripheral arterial tonometry (PAT), a novel user-independent measure of endothelium-dependent microvascular reactivity, would be impaired in proportion to sepsis severity and related to endothelial activation and plasma arginine concentrations.