Publications

OBJECTIVE

The United States is amidst an opioid epidemic, including synthetic opioids that may result in rapid death, leaving minimal opportunity for bystander rescue. We pilot tested a behavioral intervention to reduce the occurrence of opioid overdose among opioid dependent persons at high-risk for subsequent overdose.

MATERIALS AND METHODS

We conducted a single-blinded randomized-controlled trial of a repeated dose motivational interviewing intervention (REBOOT) to reduce overdose versus treatment as usual, defined as information and referrals, over 16 months at the San Francisco Department of Public Health from 2014-2016. Participants were 18-65 years of age, had opioid use disorder by Structured Clinical Interview, active opioid use, opioid overdose within 5 years, and prior receipt of naloxone kits. The intervention was administered at months 0, 4, 8, and 12, preceded by the assessment which was also administered at month 16. Dual primary outcomes were any overdose event and number of events, collected by computer-assisted personal interview, as well as any fatal overdose events per vital records.

RESULTS

A total of 78 persons were screened and 63 enrolled. Mean age was 43 years, 67% were born male, 65% White, 17% African-American, and 14% Latino. Ninety-two percent of visits and 93% of counseling sessions were completed. At baseline, 33.3% of participants had experienced an overdose in the past four months, with a similar mean number of overdoses in both arms (p = 0.95); 29% overdosed during follow-up. By intention-to-treat, participants assigned to REBOOT were less likely to experience any overdose (incidence rate ratio [IRR] 0.62 [95%CI 0.41-0.92, p = 0.019) and experienced fewer overdose events (IRR 0.46, 95%CI 0.24-0.90, p = 0.023), findings that were robust to sensitivity analyses. There were no differences between arms in days of opioid use, substance use treatment, or naloxone carriage.

CONCLUSIONS

REBOOT reduced the occurrence of any opioid overdose and the number of overdoses.

TRIAL REGISTRATION

clinicaltrials.gov NCT02093559.

BACKGROUND

Chemical irritants used in crowd control, such as tear gases and pepper sprays, are generally considered to be safe and to cause only transient pain and lacrimation. However, there are numerous reports that use and misuse of these chemicals may cause serious injuries. We aimed to review documented injuries from chemical irritants to better understand the morbidity and mortality associated with these weapons.

METHODS

We conducted a systematic review using PRISMA guidelines to identify injuries, permanent disabilities, and deaths from chemical irritants worldwide between January 1, 1990 and March 15, 2015. We reviewed injuries to different body systems, injury severity, and potential risk factors for injury severity. We also assessed region, context and quality of each included article.

RESULTS

We identified 31 studies from 11 countries. These reported on 5131 people who suffered injuries, two of whom died and 58 of whom suffered permanent disabilities. Out of 9261 total injuries, 8.7% were severe and required professional medical management, while 17% were moderate and 74.3% were minor. Severe injuries occurred to all body systems, with the majority of injuries impacting the skin and eyes. Projectile munition trauma caused 231 projectile injuries, with 63 (27%) severe injuries, including major head injury and vision loss. Potentiating factors for more severe injury included environmental conditions, prolonged exposure time, and higher quantities of chemical agent in enclosed spaces.

CONCLUSIONS

Although chemical weapons may have a limited role in crowd control, our findings demonstrate that they have significant potential for misuse, leading to unnecessary morbidity and mortality. A nuanced understanding of the health impacts of chemical weapons and mitigating factors is imperative to avoiding indiscriminate use of chemical weapons and associated health consequences.

BACKGROUND AND OBJECTIVES

The natural history of kidney disease among blacks who carry the high-risk variants varies, with only a subgroup progressing to ESRD. We aimed to determine whether the risk variants are associated with incident proteinuria in the context of hypertension-attributed CKD, and whether subsequent kidney function decline after the onset of proteinuria differs by risk status.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using Cox models, we studied the association between risk status and incident proteinuria (defined as a doubling of urine protein-to-creatinine ratio to a level ≥0.22 g/g creatinine) among African-American Study of Kidney Disease and Hypertension (AASK) trial participants with genotyping and without proteinuria at baseline.

RESULTS

Of the 480 participants in our study, 82 (17%) had the high-risk genotypes (2 alleles), and 254 (53%) developed proteinuria over a median follow-up of 6.8 years. At baseline, mean eGFR was lower in the high-risk group compared with the low-risk group (0 or 1 allele; 49.6 versus 53.2 ml/min per 1.73 m, respectively; =0.02), but median proteinuria was similar (0.04 g/g creatinine for both groups; =0.43). Individuals with the high-risk genotypes were 1.72-fold more likely to develop incident proteinuria compared with those with the low-risk genotypes (95% confidence interval, 1.27 to 2.32), independent of age, sex, ancestry, baseline eGFR, baseline systolic BP, and randomized treatment groups. Although eGFR declined faster after the onset of proteinuria, this rate did not differ significantly by risk status.

CONCLUSIONS

Among blacks with established moderate CKD, the high-risk variants are associated with greater risk of incident proteinuria. After proteinuria onset, kidney function declines more rapidly but does not differ by risk status. This suggests that factors that lead to proteinuria, beyond , may additionally drive CKD progression.

Cytokine-producing CD4 T cells have important roles in immunity against malaria. However, the factors influencing functional differentiation of specific CD4 T cells in naturally exposed children are not well understood. Moreover, it is not known which CD4 T-cell cytokine-producing subsets are most critical for protection. We measured specific IFNγ-, IL10-, and TNFα-producing CD4 T-cell responses by multi-parametric flow cytometry in 265 children aged 6 months to 10 years enrolled in a longitudinal observational cohort in a high malaria transmission site in Uganda. We found that both age and parasite burden were independently associated with cytokine production by CD4 T cells. IL10 production by IFNγ CD4 T cells was higher in younger children and in those with high-parasite burden during recent infection. To investigate the role of CD4 T cells in immunity to malaria, we measured associations of -specific CD4 cytokine-producing cells with the prospective risk of infection and clinical malaria, adjusting for household exposure to -infected mosquitos. Overall, the prospective risk of infection was not associated with the total frequency of specific CD4 T cells, nor of any cytokine-producing CD4 subset. However, the frequency of CD4 cells producing IL10 but not inflammatory cytokines (IFNγ and TNFα) was associated with a decreased risk of clinical malaria once infected. These data suggest that functional polarization of the CD4 T-cell response may modulate the clinical manifestations of malaria and play a role in naturally acquired immunity.