Body

NEW YORK, NY (September 5, 2018)--Concerns about health and rising death rates may have helped tilt the 2016 presidential election in favor of Donald J. Trump, according to an analysis of voting patterns and mortality rates in counties across the U.S.

Findings from the study, at Columbia University Irving Medical Center (CUIMC), were published online today in the Journal of General Internal Medicine.

"Although life expectancy is increasing in many parts of the country, especially in urban areas, we're not seeing nearly the same gains in rural and middle America. We shouldn't underestimate the degree to which some portions of the country have been left behind in terms of their health. And it's not surprising that health disparities correspond with voting behavior," said study leader Lee Goldman, MD, MPH, the Harold and Margaret Hatch Professor, Dean of the Faculties of Health Sciences and Medicine, and Chief Executive, Columbia University Irving Medical Center.

Dr. Goldman and colleagues hypothesized that changes in health outlook may have affected the outcome of the 2016 presidential election. To test this hypothesis, they used publicly available data from each of the country's 3,112 counties to compare changes in presidential voting from 2008 to 2016 with changes in death rates. The analysis controlled for race/ethnicity, income, education, unemployment rates, health insurance rates, and other factors.

Both 2016 presidential candidates received fewer votes than the 2008 Republican and Democratic presidential candidates in 398 counties. And while President Trump fared better than Senator John McCain in 2,607 counties, Secretary Hillary Clinton surpassed President Obama's percentage of the vote in only 108 counties.

Counties with a net gain in the percentage of individuals who voted for the Republican candidate had a 15 percent higher 2015 age-adjusted death rate than counties with a net gain in Democratic voters. The increase in death rates due to alcohol, drugs, and suicide was also 2.5 times higher in counties where Republicans made gains compared with counties where Democrats made gains.

"It's commonly argued that President Trump won by receiving more votes from people who have been left behind economically--especially older, less-educated, and less-urban, white voters," said Dr. Goldman. "Based on our data, we can also say that changes in life expectancy were an independent factor in voting choices. Reduced health prospects are an important marker of dissatisfaction, discouragement, hopelessness, and fear--sentiments that may have resonated with voters who sided with President Trump. Although correlation does not imply causality, our findings also suggest that plausible improvements in life expectancy in Michigan, Pennsylvania, and Wisconsin might have shifted their electoral votes to Secretary Clinton.

"Regardless of your political persuasion, our paper suggests that if health disparities were important enough to influence presidential voting, they may have an even broader impact on our country's future than we had imagined," said Dr. Goldman. "It also highlights how much work remains to reduce health disparities."

The paper is titled, "Independent Relationship of Changes in Death Rates with Changes in U.S. Presidential Voting." The other contributors are: Maribel P. Lim, Qixuan Chen, Peng Jin,¬¬¬ Peter Muennig, and Andrew Vagelos (all at CUIMC).

The commonly used painkiller diclofenac is associated with an increased risk of major cardiovascular events, such as heart attack and stroke, compared with no use, paracetamol use, and use of other traditional painkillers, finds a study published by The BMJ this week.

The findings prompt the researchers to say that diclofenac should not be available over the counter, and when prescribed, should be accompanied by an appropriate front package warning about its potential risks.

Diclofenac is a traditional non-steroidal anti-inflammatory drug (NSAID) for treating pain and inflammation and is widely used across the world.

But its cardiovascular risks compared with those of other traditional NSAIDs have never been examined in large randomised controlled trials, and current concerns about these risks make such trials unethical to conduct.

So a research team, led by Morten Schmidt at Aarhus University Hospital in Denmark, examined the cardiovascular risks of starting diclofenac compared with no NSAIDS, starting other traditional NSAIDs, and starting paracetamol.

The results are based on national registry data for more than 6.3 million adults in Denmark with at least one year of continuous prescription records before study entry in January 1996.

Participants were split into low, moderate, and high baseline cardiovascular risk. Average age was 46-49 years among participants starting NSAIDs and 56 years among those starting paracetamol.

After taking account of potentially influential factors, starting diclofenac during the study period (1996-2016) was associated with an increased rate of major adverse cardiovascular events within 30 days compared with starting other traditional NSAIDs (ibuprofen or naproxen) or starting paracetamol.

Events included irregular heart beat or flutter, ischaemic stroke, heart failure, and heart attack. The increased risks applied to men and women of all ages and also at low doses of diclofenac.

Starting diclofenac was also associated with an increased rate of cardiac death compared with no NSAIDs, and an increased risk of upper gastrointestinal bleeding compared with no NSAIDs, starting ibuprofen or paracetamol, but not with naproxen.

The authors point out that, although the relative risk was increased, the absolute risk remained low for the individual patient.

When results were analysed by baseline cardiovascular risk, the absolute number of events per 1000 diclofenac starters per year also increased. For example, among patients at low baseline risk, diclofenac starters had one additional event versus ibuprofen starters, one additional event versus naproxen starters, three additional events versus paracetamol starters, and four additional events versus no NSAIDs. Among patients at moderate baseline risk, corresponding figures were seven, seven, eight, and 14 additional events, respectively, and for those at high baseline risk, corresponding numbers were 16, 10, one, and 39 additional events, respectively.

This is an observational study, so no firm conclusions can be drawn about cause and effect. However, the study's sample size is larger than most previous analyses of observational and randomised studies taken together and provides strong evidence to guide clinical decision making.

"Treatment of pain and inflammation with NSAIDs may be worthwhile for some patients to improve quality of life despite potential side effects," they write. "Considering its cardiovascular and gastrointestinal risks, however, there is little justification to initiate diclofenac treatment before other traditional NSAIDs," they conclude.

The amount of physical activity that women undertake is not linked to their risk of early menopause, according to the largest study ever to investigate this question.

Until now, there have been conflicting findings about the relation between physical activity and menopause, with some studies suggesting that women who are very physically active may be at lower risk of a menopause before the age of 45, while others have found evidence of the opposite effect.

However, the study that is published today (Wednesday) in Human Reproduction [1], one of the world's leading reproductive medicine journals, has analysed data from 107,275 women, who were followed prospectively from the time they joined the Nurses' Health Study II in 1989 until 2011, and found no association between physical activity at any age and early natural menopause.

Dr Elizabeth Bertone-Johnson, Professor of Epidemiology at the University of Massachusetts, USA, who directed the research, said: "Our study provides considerable information in helping us understand the relationship between activity and timing of menopause; this is because of its size, its focus on early menopause specifically, and because of its prospective design, which limited the likelihood of bias and allowed us to look at physical activity at different time periods.

"Several previous well-designed studies have found suggestions that more physical activity is associated with older age at menopause, but even in those studies the size of the effect was very small. Our results, in conjunction with other studies, provides substantial evidence that physical activity is not importantly associated with early menopause."

Female US registered nurses aged 25-42 were enrolled in the Nurses' Health Study II in 1989 and they completed questionnaires about lifestyles and medical conditions every two years thereafter. They were asked about the time they spent in recreational physical activities such as walking, running, cycling, racquet sports, swimming laps, aerobic activities, yoga, weight training and high intensity activities such as lawn mowing. The researchers also collected information on factors such as race, ethnicity, age, education, height, the age when the women had their first periods, whether or not they had been pregnant and how often, use of oral contraceptives and hormone therapy, whether or not they smoked, weight and body mass index (BMI), diet and use of dietary supplements.

In order to assess the frequency, duration and intensity of the activities, the researchers multiplied the hours per week of each activity by its metabolic equivalent (MET) score to create total MET hours per week. One MET equals one kilogram calorie per kilogram per hour (kcal/kg/h), which is the amount of energy expended by sitting quietly for an hour.

During the 20 years of follow-up, 2786 women experienced natural menopause before the age of 45. The researchers found no significant difference in the risk of early menopause between, for instance, women reporting less than three MET hours a week of physical activity and women reporting 42 or more hours a week (the equivalent to four or more hours of running or eight or more hours of brisk walking per week). The amount of physical activity that the women reported in their teenage years was also unrelated to the risk of early menopause.

The first author of the paper, Mingfei Zhao, a graduate student at the University of Massachusetts, said: "While our results do not suggest that more physical activity is associated with lower risk of early menopause, we would encourage premenopausal women to be physically active, as exercise is associated with a range of health benefits, such as a lower risk of heart disease, diabetes, breast cancer and other conditions. Our results in no way suggest that premenopausal women should not be physically active."

Researchers are still investigating other factors that might play a role in women experiencing an early menopause. Dr Bertone-Johnson said: "Our work has suggested that environmental factors are associated with early menopause. We found higher intake of calcium and vitamin D from dairy foods to be associated with lower risk. Higher intake of vegetable protein was associated with lower risk as well, though animal protein was not. Cigarette smoking is associated with higher risk, as is being underweight. We are currently investigating other factors as well."

Limitations of the study include the fact that women self-reported their physical activity and menopausal status, and the majority of the participants were white. However, the researchers say that the repeated assessment (every two years) of physical activity and menopausal status would have reduced the likelihood of any bias from self-reporting. They also think it unlikely that the physiological relation between activity and menopause varies by ethnicity.

Patients developing AFib after TAVR are at higher risk of death, stroke and heart attack compared to patients who already had AFib prior to the procedure, according to a study today in JACC: Cardiovascular Interventions. The paper is the first nationwide examination of patients who developed AFib for the first time following TAVR.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure to replace aortic valves by inserting a catheter into an artery in the leg to reach the patient's heart. Heart rhythm disorders, particularly atrial fibrillation (AFib), frequently complicate TAVR. Prior research has shown that if a patient has AFib before TAVR, they are much more likely to have worse outcomes after the procedure in comparison to patients who do not have pre-existing AFib. When it comes to patients who did not have AFib before TAVR, but developed it after the procedure, data has been limited until now.

"We found that about 8 percent of patients undergoing TAVR that did not have pre-existing AFib developed new-onset AFib after their procedure," said lead study author Amit N. Vora, MD, MPH, an interventional cardiologist and researcher from Duke University Medical Center and the Duke Clinical Research Institute. "When you combine patients that had AFib prior to the TAVR procedure and those that develop it after, more than one-half of all patients undergoing TAVR have to also deal with co-existing AFib."

The study looked at data from the STS/ACC TVT Registry, a collaboration of the Society of Thoracic Surgeons and the American College of Cardiology, linked with outcomes data from the Centers for Medicare and Medicaid Services. Researchers analyzed 13,356 patients undergoing TAVR at 381 sites across the U.S. From this group, 1,138 patients developed AFib for the first time after the procedure. The study focused on how often new AFib was occurring, how it was managed if it did happen, and what the outcomes were for patients who developed AFib after TAVR.

The analysis found that patients who developed new-onset AFib following TAVR were more likely to be female, older and have severe chronic obstructive pulmonary disease. TAVR that was not performed via transfemoral access was also shown to be associated with the development of new-onset Afib.

The study also examined short- and long-term outcomes among patients who developed new-onset AFib. Rates of in-hospital death, stroke and heart attack were all higher among new-onset AFib patients. Additionally, these patients were at a 37 percent higher risk of death one year after the TAVR procedure as well.

"Current guidelines are murky regarding the optimal treatment strategy for these patients, who often tend to be at high risk for stroke but also high risk for bleeding," Vora said. "Although there are a number of trials that are examining various strategies for this population, we need to continue to look very closely at this and determine the best care management for these high-risk patients."

Scientists have traditionally believed that combining more than two drugs to fight harmful bacteria would yield diminishing returns. The prevailing theory is that that the incremental benefits of combining three or more drugs would be too small to matter, or that the interactions among the drugs would cause their benefits to cancel one another out.

Now, a team of UCLA biologists has discovered thousands of four- and five-drug combinations of antibiotics that are more effective at killing harmful bacteria than the prevailing views suggested. Their findings, reported today in the journal npj Systems Biology and Applications, could be a major step toward protecting public health at a time when pathogens and common infections are increasingly becoming resistant to antibiotics.

"There is a tradition of using just one drug, maybe two," said Pamela Yeh, one of the study's senior authors and a UCLA assistant professor of ecology and evolutionary biology. "We're offering an alternative that looks very promising. We shouldn't limit ourselves to just single drugs or two-drug combinations in our medical toolbox. We expect several of these combinations, or more, will work much better than existing antibiotics."

Working with eight antibiotics, the researchers analyzed how every possible four- and five-drug combination, including many with varying dosages -- a total of 18,278 combinations in all -- worked against E. coli. They expected that some of the combinations would be very effective at killing the bacteria, but they were startled by how many potent combinations they discovered.

For every combination they tested, the researchers first predicted how effective they thought it would be in stopping the growth of E. coli. Among the four-drug combinations, there were 1,676 groupings that performed better than they expected. Among the five-drug combinations, 6,443 groupings were more effective than expected.

"I was blown away by how many effective combinations there are as we increased the number of drugs," said Van Savage, the study's other senior author and a UCLA professor of ecology and evolutionary biology and of biomathematics. "People may think they know how drug combinations will interact, but they really don't."

On the other hand, 2,331 four-drug combinations and 5,199 five-drug combinations were less effective than the researchers expected they would be, said Elif Tekin, the study's lead author, who was a UCLA postdoctoral scholar during the research.

Some of the four- and five-drug combinations were effective at least partly because individual medications have different mechanisms for targeting E. coli. The eight tested by the UCLA researchers work in six unique ways.

"Some drugs attack the cell walls, others attack the DNA inside," Savage said. "It's like attacking a castle or fortress. Combining different methods of attacking may be more effective than just a single approach."

Said Yeh: "A whole can be much more, or much less, than the sum of its parts, as we often see with a baseball or basketball team." (As an example, she cited the decisive upset victory in the 2004 NBA championship of the Detroit Pistons -- a cohesive team with no superstars -- over a Los Angeles Lakers team with future Hall of Famers Kobe Bryant, Shaquille O'Neal, Karl Malone and Gary Payton.)

Yeh added that although the results are very promising, the drug combinations have been tested in only a laboratory setting and likely are at least years away from being evaluated as possible treatments for people.

"With the specter of antibiotic resistance threatening to turn back health care to the pre-antibiotic era, the ability to more judiciously use combinations of existing antibiotics that singly are losing potency is welcome," said Michael Kurilla, director of the Division of Clinical Innovation at the National Institutes of Health/National Center for Advancing Translational Sciences. "This work will accelerate the testing in humans of promising antibiotic combinations for bacterial infections that we are ill-equipped to deal with today."

The researchers are creating open-access software based on their work that they plan to make available to other scientists next year. The software will enable other researchers to analyze the different combinations of antibiotics studied by the UCLA biologists, and to input data from their own tests of drug combinations.

Using a MAGIC framework

One component of the software is a mathematical formula for analyzing how multiple factors interact, which the UCLA scientists developed as part of their research. They call the framework "mathematical analysis for general interactions of components," or MAGIC.

"We think MAGIC is a generalizable tool that can be applied to other diseases -- including cancers -- and in many other areas with three or more interacting components, to better understand how a complex system works," Tekin said.

Savage said he plans to use concepts from that framework in his ongoing research on how temperature, rain, light and other factors affect the Amazon rainforests.

He, Yeh and Mirta Galesic, a professor of human social dynamics at the Santa Fe Institute, also are using MAGIC in a study of how people's formation of ideas is influenced by their parents, friends, schools, media and other institutions -- and how those factors interact.

"It fits in perfectly with our interest in interacting components," Yeh said.

Other co-authors of the new study are Cynthia White, a UCLA graduate who was a research technician while working on the project; Tina Kang, a UCLA doctoral student; Nina Singh, a student at the University of Southern California; Mauricio Cruz-Loya, a UCLA doctoral student; and Robert Damoiseaux, professor of molecular and medical pharmacology, and director of UCLA's Molecular Screening Shared Resource, a facility with advanced robotics technology where Tekin, White, and Kang conducted much of the research.

The research team reported in 2016 that combinations of three antibiotics can often overcome bacteria's resistance to antibiotics, even when none of the three antibiotics on its own -- or even two of the three together -- is effective. The biologists reported in 2017 two combinations of drugs that are unexpectedly successful in reducing the growth of E. coli bacteria.

1. Nalbuphine may help manage opioid-induced urine retention

Abstract: http://annals.org/aim/article/doi/10.7326/L18-0387

URLs go live when the embargo lifts

Nalbuphine may help to manage opioid-induced urine retention. Findings from a brief case report are published in Annals of Internal Medicine.

Urine retention is common in the hospital setting and is sometimes caused by the use of opioids. Once opioid-induced urine retention develops, resolving it without interfering with pain control can be problematic.

Clinicians from Southern Illinois University School of Medicine saw a patient with a history of alcoholic cirrhosis who was hospitalized for right-sided abdominal pain, and diagnosed with portal vein thrombosis and hepatocellular cancer. The patient was treated with hydromorphone for pain and quickly developed urine retention. The patient did not respond to α-1 blockers and found a catheter to be effective but inconvenient. The clinicians gave the patient a dose of intravenous nalbuphine, an opioid used to treat moderate to severe pain that has a different mechanism of action than other opioids. The patient responded well to the medication and was able to urinate within the first 6 hours.

According to the authors, these findings suggest that clinicians should consider offering nalbuphine to patients with opioid-induced urine retention that does not respond to α-1 blockers who prefer not to continue using bladder catheterization.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Abdisamad M. Ibrahim, MD, please contact him directly at qalbinoor@gmail.com

2. Cost a key consideration of WHO guidelines for diabetes treatment intensification

Recently published guidelines make recommendations on use of medicines for treatment intensification of type 2 diabetes and type of insulin in type 1 and type 2 diabetes

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1149

Editorial: http://annals.org/aim/article/doi/10.7326/M18-1148

URLs go live when the embargo lifts

The World Health Organization (WHO) recently issued guidelines on the selection of medicines for treatment intensification in patients with type 2 diabetes and on the use of insulin in patients with type 1 or 2 diabetes. A synopsis of the guidelines is published in Annals of Internal Medicine.

Type 2 diabetes is highly prevalent in most settings, and the increase in prevalence has been greatest in low- and middle-income countries in the past few decades. WHO develops guidelines for settings with limited health system resources where the health care budget can be quickly exhausted with widespread use of expensive brand-name medications. WHO guidelines also apply to high-income countries where patients with limited resources need evidence-based care that takes into account costs and value.

WHO made the following five recommendations:

Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control with metformin alone or who have contraindications to metformin.

Introduce human insulin treatment to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea.

If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, or a thiazolidinedione (TZD) may be added.

Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated.

Consider long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin.

The authors of an accompanying commentary by members of the High Value Care Committee of the American College of Physicians (ACP) consider the nuances of clinical decision-making in the face of limited evidence and limited resources. They also compare key differences between ACP and WHO guidelines. The authors suggest that the decision to name sulfonylureas as the single best second-line agent for type 2 diabetes largely reflects the prioritization of cost and the recognition that WHO guidelines must apply to low-resource settings. ACP also acknowledges cost in its guideline, but places a priority on shared decision making between physicians and patients and on quality of life. ACP's guideline recommends that clinicians and patients discuss benefits, adverse effects, and costs when considering second-line therapy options, including sulfonylureas, which present a higher risk for hypoglycemia, and the newer agents, which may have a more favorable side-effects profile but are more expensive.

Media contact: For an embargoed PDF or to interview the editorialist from ACP's High Value Care Committee, please contact Steve Majewski at smajewski@acponline.org.

3. Patient says ALS took away control over his body; court ruling took away control over his life

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1719

URLs go live when the embargo lifts

Michael Danielson (photo available), a terminally ill patient in San Diego, says that ALS took away control over his body and then the court's decision to overturn California's End of Life Option Act took away control over his life. Danielson's essay is published in Annals of Internal Medicine.

When Danielson was diagnosed with ALS, he was pragmatic about his prognosis. Knowing that the disease would eventually kill him, he told his friends and family that when the time came, he would end his life on his own terms. At the time, California was one of a handful of states that allowed physicians to legally assist patients in dying. The law was written so that a person's underlying illness and not "medical aid in dying" would be recorded as the cause of death on the death certificate. In Danielson's case, it would be ALS. This is a very important distinction for insurance companies, families, and patients going through a terminal illness.

On May 24, California's End of Life Option Act was overturned, a decision that has caused Danielson a great deal of anxiety knowing how much he will suffer. As for the Hippocratic oath doctors take that begins, 'First, do no harm,' Danielson says that doctors are doing more harm by keeping terminally ill patients alive needlessly than by allowing them to take control and have a dignified passing of their choice.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. For an interview with the patient, please contact Sara Gianella Weibel at gianella@uscd.edu. To speak with Dr. David Grube from Compassion and Choices, please contact him directly at dgrube@compassionandchoices.org.

Social media networks, which often foster partisan antagonism, may also offer a solution to reducing political polarization, according to new findings published in the Proceedings of the National Academy of Sciences from a team led by University of Pennsylvania sociologist Damon Centola.

The Penn researchers asked 2,400 Republicans and Democrats to interpret recent climate-change data on Arctic sea-ice levels. Initially, nearly 40 percent of Republicans incorrectly interpreted the data, saying that Arctic sea-ice levels were increasing; 26 percent of Democrats made the same mistake. However, after participants interacted in anonymous social media networks--sharing opinions about the data and its meaning for future levels of Artic sea ice--88 percent of Republicans and 86 percent of Democrats correctly analyzed it, agreeing that sea-ice levels were dropping.

Republicans and Democrats who were not permitted to interact with each other in social media networks but instead had several additional minutes to reflect on the climate data before updating their responses remained highly polarized and offered significantly less accurate forecasts.

"New scientific information does not change people's minds. They can always interpret it to match their beliefs," says Centola, director of Penn's Network Dynamics Group and author of the new book "How Behavior Spreads." "But, if you allow people to interact with each other in egalitarian social networks, in which no individual is more powerful than another, we find remarkably strong effects of bipartisan social learning on eliminating polarization."

To test this notion for politically charged topics like climate change, Centola, along with Penn doctoral student Douglas Guilbeault and recent Penn Ph.D. graduate Joshua Becker, constructed an experimental social media platform, which they used to test how different kinds of social media environments would affect political polarization and group accuracy.

Their study was motivated by NASA's 2013 release of new data detailing historical trends in monthly levels of Arctic sea ice. "NASA found, to its dismay, that a lot of people were misinterpreting the graph to say that there would actually be more Arctic sea ice in the future rather than less," Guilbeault explains. "Conservatives in particular were susceptible to this misinterpretation."

The researchers wondered how social media networks might alter this outcome, so they randomly assigned participants to one of three experimental groups: a political-identity setup, which revealed the political affiliation of each person's social media contacts; a political-symbols setup, in which people interacted anonymously through social networks but with party symbols of the donkey and the elephant displayed at the bottom of their screens; and a non-political setup, in which people interacted anonymously. Twenty Republicans and 20 Democrats made up each social network.

Once randomized, every individual then viewed the NASA graph and forecasted Arctic sea-ice levels for the year 2025. They first answered independently, and then viewed peers' answers before revising their guesses twice more. The study outcomes surprised the researchers in several respects.

"We all expected polarization when Republicans and Democrats were isolated," says Centola, who is also an associate professor in Penn's Annenberg School for Communication and School of Engineering and Applied Sciences, "but we were amazed to see how dramatically bipartisan networks could improve participants' judgments." In the non-political setup, for example, polarization disappeared entirely, with more than 85 percent of participants agreeing on a future decrease in Arctic sea ice.

"But," Centola adds, "the biggest surprise--and perhaps our biggest lesson--came from how fragile it all was. The improvements vanished completely with the mere suggestion of political party. All we did was put a picture of an elephant and a donkey at the bottom of a screen, and all the social learning effects disappeared. Participants' inaccurate beliefs and high levels of polarization remained."

That last finding reveals that even inconspicuous elements of a social media environment or of a media broadcast can hinder bipartisan communications. "Simple ways of framing a political conversation, like incorporating political iconography, can significantly increase the likelihood of polarization," Guilbeault says.

Instead, Centola says, put people into situations that remove the political backdrop. "Most of us are biased in one way or another. It's often unavoidable. But, if you eliminate the symbols that drive people into their political camps and let them talk to each other, people have a natural instinct to learn from one another. And that can go a long way toward lessening partisan conflict."

Researchers from Tokyo Metropolitan University and the FIRC Institute of Molecular Oncology (IFOM) in Italy have uncovered a previously unknown function of the DDX11 helicase enzyme. Mutations in the gene which codes for DDX11 are known to be implicated in Warsaw Breakage Syndrome. They showed that DDX11 plays an important role in DNA repair, and functions as a backup to the Fanconi Anemia (FA) pathway, whose malfunction is associated with another life-debilitating condition.

DNA plays a central role in the biological function of the cell, but it is constantly being damaged, both spontaneously and through environmental factors. Failure to successfully repair these lesions can lead to malignant tumors or cancer. Understanding how it is repaired is of the utmost importance; in fact, pioneering work on the subject was recognized with the 2015 Nobel Prize for Chemistry.

Warsaw Breakage Syndrome (WABS) is a genetic disorder; afflicted individuals suffer from mild to severe intellectual disability and growth impairment amongst other potential abnormalities. It was known that mutations in the DDX11 gene in Chromosome 12 in the human genome and the enzyme it codes for, the DDX11 helicase, were responsible for the onset of WABS, yet the mechanism by which DDX11 acted remained unclear. Thus, a collaboration led by Dr. Dana Branzei of IFOM, Italy and Prof. Kouji Hirota of Tokyo Metropolitan University set out to investigate the role played by DDX11 using avian cells, particularly noting similarities in the cells of WABS patients to those of Fanconi Anemia (FA).

What they found was that DDX11 played a vital role in DNA repair, acting together with the 9-1-1 checkpoint complex protein, which, as the name suggests, checks the integrity of DNA strands after replication. In doing so, DDX11 is critical in the repair of a wide-range of bulky lesions and also serves as a backup to the so-called FA pathway, specialized in the repair of interstrand crosslinks (ICLs), a harmful type of lesion that can lead to cell death and developmental problems. This finding explains the apparent similarity between WABS and FA cells exposed to ICLs, which caused WABS to be classified as a FA-like disorder. The researchers also discovered that DDX11 is involved in immunoglobulin-variable gene diversification, a key mechanism in the healthy function and adaptability of a healthy immune system. As immunoglobulin-variable gene diversification is induced by abasic sites, the most common endogenous lesion in mammalian cells, one implication is that DDX11 and 9-1-1 promote DNA damage tolerance of abasic sites, a finding that potentially explains the essential role of DDX11 and its similarity with 9-1-1 during development.

Besides shedding light on the mechanism underlying WABS, the study advances our understanding of the biological mechanisms behind genomic stability and how disorders arise at the cellular level. These results have profound medical significance for several conditions, including cancer and developmental disorders associated with DNA repair deficiency.

August 31, 2018 - Patient satisfaction after plastic surgery is most affected by surgeon-related factors, such as taking the time to answer questions and including patients in the decision-making process, reports a study in the September issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

By comparison, practice-related issues like waiting time and office staff have a much weaker effect on patient satisfaction scores, according to the new research by ASPS Member Surgeon Neil Tanna, MD, MBA, and colleagues of Hofstra Northwell Health School of Medicine, New York. They write, "In the outpatient plastic surgery setting, patients are more satisfied if they feel that their physician provides them with compassionate, coordinated care."

To Increase Patient Satisfaction, Spend More Quality Time with Patients

The researchers analyzed responses to a patient satisfaction questionnaire distributed to patients of nearly 700 plastic surgeons nationwide. Patient satisfaction is an increasingly used measure of healthcare quality and outcomes. The study included responses from nearly 37,000 patients, including more than 400 from the authors' plastic surgery department.

The study focused on two questionnaire items: patients' ratings of how likely they would be to recommend the plastic surgeon and the plastic surgery practice to others. These "likelihood to recommend" items have been identified as useful indicators of overall patient satisfaction and success of the medical practice.

The results suggested that several categories of practice-related factors did not have a major impact on the likelihood of recommending the surgeon or practice. Correlations were weak for items such as office hours or scheduling appointments, waiting times, interactions with nurses or staff other than the surgeon, or attention to patient privacy or safety.

In contrast, items specifically related to the plastic surgeon were strongly related to the likelihood of recommending the surgeon and practice. The strongest items were the patient's level of confidence in the surgeon and the surgeon's concern for the patient's questions and worries. Other important factors included the surgeon's explanations of the problem or condition and efforts to include the patient in decisions.

That pattern was consistent with previous studies - in plastic surgery and other medical specialties - showing that the perceived quality and among of time spent with the doctor or other healthcare provider has a major impact on patient satisfaction scores. "Patients are most likely to recommend plastic surgeons and their practices whose care is characterized by empathy and communication," Dr. Tanna and coauthors write. A recent study in Plastic and Reconstructive Surgery found that good communication was an important factor affecting online reviews of plastic surgeons.

Although practice-related factors - such as scheduling, office staff interactions, and waiting times - were still significantly related to patient satisfaction, the correlations were much weaker than for surgeon-related factors. While having an attractive, smooth-running practice is still important, "Resources may be better allocated to improving the time and quality of time spent with patients," according to the authors.

Dr. Tanna and colleagues believe their study has important implications for marketing the plastic surgery practice - particularly in improving patients' "likelihood to recommend" as a reflection of the patient's trust in the surgeon. The authors conclude: "In earning patients' trust, plastic surgeons can fulfill goals of a practicing provider and the goal of any medical professional: improving patient experience by meeting their needs."

WASHINGTON --First responders to major chemical exposure incidents in the United States can improve treatment protocols for at-risk casualties with better communication strategies, according to new analysis in Annals of Emergency Medicine.

The evaluation, Operation DOWNPOUR, was funded by the U.S. Department of Health and Human Services (HHS) Biomedical Advanced Research and Development Authority (BARDA), part of the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR).

The authors note that existing processes are nearly 100 percent effective. But, enhancing communication processes would better serve people with chronic illnesses, disabilities or language barriers. And, for the first time, experts endorsed revised guidelines that call for immediate disrobing to ensure optimal decontamination.

"Should a large-scale chemical exposure occur, clear communication from first responders can save lives. Making sure everyone can hear you, understand you, and is physically able to follow safety procedures will speed the decontamination process and limit toxic exposure, especially for children, the elderly and the most vulnerable victims," said Robert P. Chilcott, PhD, professor at the University of Hertfordshire (UK) and lead study author. "First responder staffing levels and resources may need to be re-evaluated in order to avoid casualties and ensure safe and effective rapid response."

Hearing and communicating instructions in an emergency can be difficult, according to feedback from first responders and participants that is included in the analysis. Concerns were raised that first responder staffing levels would need to increase, and resources would need to be allocated, so that victims deemed "at-risk" (unable for any reason to comply with verbal instruction) were able to follow the time-sensitive decontamination instructions as directed.

The evaluation supports the introduction of an immediate "disrobe and dry" decontamination stage while victims wait for further treatment. The analysis notes that the most effective decontamination methods start by disrobing then include a triple combination of dry, ladder pipe and technical decontamination. "This should be adopted as the standard approach," Dr. Chilcott said.

The initial "dry decontamination" involves rapidly wiping down the victim with any absorbent material (toilet paper, paper towels, diapers, or materials typically carried on an ambulance, such as wound dressings) and does not rely on specialist resources. Dry decontamination enables first responders to reassure victims, start providing instructions and offer situational information.

Next, "ladder pipe decontamination," involves positioning victims of chemical exposure in a corridor between two parallel fire engines then spraying them with water from a hose strapped to an overhead ladder. This procedure was occasionally performed on fully-clothed individuals. Now, the guidelines have been updated to emphasize the need for disrobing prior to any form of wet decontamination. A third step, "technical decontamination," involves specialist units, privacy, warm water and waste containment.

Adding disrobe and dry procedures before ladder pipe decontamination enables more effective time management, the authors note. While setting up the ladder pipe system, first responders should not miss the critical window of opportunity to remove toxic chemicals from hair or skin.

Disrobing may limit the likelihood of a panicking victim fleeing the scene of the incident and prevents contamination on clothes from spreading to skin, the authors write in "Evaluation of US Federal Guidelines (Primary Response Incident Scene Management: 'PRISM') for Mass Decontamination of Casualties During the Initial Operational Response to a Chemical Incident."

The evaluation looked at the clinical and operational efficacy of the recently revised PRISM (Primary Response Incident Scene Management) response, the United States federal guidance for first responders to mass chemical exposure incidents. The simulation took place in August 2017 and included more than 80 volunteers who were exposed to a chemical warfare agent simulant (methyl salicylate, curcumin and baby oil mixture). Fire department and emergency medical service personnel in Rhode Island participated alongside representatives from the Federal Emergency Management Agency (FEMA).

"If a chemical attack or catastrophic accident occurs on American soil, first responders would be relied on to act as quickly and effectively as possible in order to save lives." Dr. Chilcott said. "The revised PRISM guidance should double first responders' efficiency. And, the introduction of the disrobe and dry decontamination stage should further improve clinical outcomes for victims."

Sept. 5, 2018--A new international guideline has been developed to help physicians diagnosis idiopathic pulmonary fibrosis (IPF), a rare and often fatal lung disease whose cause is unknown.

The 2018 clinical practice guideline was developed by experts representing four major respiratory societies--the American Thoracic Society (ATS), the European Respiratory Society (ERS), Japanese Respiratory Society (JRS) and the Latin American Thoracic Society (ALAT)--and published online and in the American Thoracic Society's Sept. 1 edition of the American Journal of Respiratory and Critical Care Medicine.

IPF is the most common and deadly form of a group of more than 200 conditions known broadly as interstitial lung disease. Most often, IPF is diagnosed in adults over age 60 and more often in men than women. Symptoms include shortness of breath, a dry cough and low oxygen levels. The median survival is three to five years after the diagnosis.

"Diagnosing IPF is challenging because these symptoms are non-specific: they occur with all other interstitial lung diseases and with other respiratory problems," said Ganesh Raghu, MD, chair of the guideline committee and professor of medicine and director of the Center for Interstitial Lung Disease at the University of Washington in Seattle. "Because drugs may slow the progression of IPF, an early and accurate diagnosis is essential for prompt and appropriate treatment for this fatal disease."

The 29-member guideline committee included international clinical and scientific experts and an IPF patient. The committee discussed the findings of all accumulated evidence pertinent to IPF, rated the strength of those findings using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system and made recommendations.

"The approach used to develop the guidelines adhered strictly to the state-of-the-art Institute of Medicine Standards for Trustworthy Guidelines," said Kevin C. Wilson, MD, lead methodologist and project manager, as well as professor of medicine at Boston University School of Medicine. "This should provide the health care community with confidence that the recommendations are as unbiased and evidence-based as possible."

The 2018 guideline is an update of IPF diagnostic guidelines the four respiratory societies produced in 2011.

"The 2011 guideline provided the first evidence-based, formal criteria for diagnosis of IPF and allowed patients with a well-defined diagnosis of IPF to participate in numerous clinical studies and randomized controlled trials that enhanced our understanding of the disease," Dr. Raghu said. "However, it became clear that there were significant challenges in ascertaining the diagnosis per the 2011 criteria, and abundant evidence accumulated since then allowed the committee to refine the diagnostic criteria now."

Chief among the refinements included in the criteria is the use of four diagnostic categories based on high-resolution tomography (HRCT) of the lung: usual interstitial pneumonia (UIP) pattern, probable UIP pattern, indeterminate pattern and alternative diagnosis.

The committee recommended the same terminology for both images produced using HRCT of the lung and microscopic analysis of biopsied tissue. Consistent categorization should facilitate multidisciplinary discussions (MDD) between a pulmonologist (and in some cases, a rheumatologist), radiologist and pathologist of a diagnosis, the committee wrote.

The committee made the following recommendations for diagnosing IPF in all adult patients with newly detected interstitial lung disease (ILD) of unknown cause:

For all patients, a detailed history should be taken of both medication use and environmental exposures and serological testing should be performed to exclude connective tissue disease as a potential cause of the ILD.

For patients with a HRCT pattern of probable UIP, indeterminate, or an alternative diagnosis, conditional recommendations were made for performing bronchoalveolar lavage (BAL) and surgical lung biopsy (SLB); due to lack of evidence, no recommendation was made for or against performing transbronchial lung biopsy (TBBx) or lung cryobiopsy.

Conditional recommendation for MDD to aid in diagnosing IPF, particularly when the HRCT pattern has features of probable UIP pattern, indeterminate or alternative diagnosis.

In contrast, for patients with newly detected ILD who have a HRCT pattern of UIP, strong recommendations were made against performing SLB, TBBx and lung cryobiopsy; a conditional recommendation was made against performing BAL.

Strong recommendation against measurement of serum biomarkers for the sole purpose of distinguishing IPF from other ILDs.

"Our hope is that this new guideline will bridge the gap between the experienced IPF experts and general pulmonologists in making a prompt and accurate diagnosis of IPF for the individual unfortunately confronted with the disease," Dr. Raghu said. "This will allow patients to make well-informed decisions about treatment options and participation in clinical trials."

An intervention designed to facilitate treatment for HIV and substance use was associated with a 50 percent reduction in mortality for people living with HIV who inject illicit drugs, a study has found. In addition, the people who received the intervention were nearly twice as likely to report being in treatment for HIV and substance use after one year as those who received their national standard of care. They also were about twice as likely to have suppressed their HIV to undetectable levels after one year. The intervention consisted of psychosocial counseling along with guidance and support navigating the healthcare system. These findings were reported today in the journal The Lancet.

People who inject drugs often have high rates of HIV infection, poor access to and use of treatment for HIV and substance use, and high mortality in the United States and globally. Needle sharing among people who inject drugs is the main route of HIV transmission in some parts of the world.

"People living with HIV who inject drugs often encounter multiple obstacles to beginning and adhering to treatment for HIV infection and substance use," said Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. "This study demonstrates that providing guidance and counseling can help such individuals overcome barriers to starting and staying in care and treatment, leading to a significantly higher rate of HIV suppression and a much lower rate of death."

NIAID co-funded the study with the National Institute on Drug Abuse (NIDA), also part of NIH. The NIH-funded HIV Prevention Trials Network (HPTN) implemented the trial, called HPTN 074.

"People who inject drugs and are living with HIV have potentially fatal co-occurring conditions, yet they and their at-risk partners often face different and confusing care delivery systems," said NIDA Director Nora D. Volkow, M.D. "This study shows that integrated interventions, including help from systems navigators, can dramatically reduce mortality for both conditions."

None of the few new HIV infections in the trial occurred among the injection partners of people living with HIV who received the study intervention. Scientists could not draw a firm conclusion about the impact of the intervention on HIV transmission through injection drug use, however, because the study was not statistically powered to measure that effect.

HPTN 074 took place in three countries with HIV epidemics driven by injection drug use: Indonesia, Ukraine and Vietnam. The study team enrolled 502 men and women ages 18-60 years who are living with HIV and inject drugs, and 806 HIV-uninfected men and women who inject drugs with them (injection partners). At least one injection partner of every person in the study living with HIV enrolled. The people living with HIV were assigned at random to receive either the national standard of care for HIV infection and substance use or the standard of care plus an integrated and flexible intervention designed to facilitate treatment. The study participants were followed for one to two years.

Study participants assigned to receive the intervention were immediately referred to local health-care providers for anti-HIV therapy to treat their infection, prevent sexual transmission of HIV, and potentially prevent HIV transmission via needle sharing. In addition, each participant who received the study intervention was assigned a systems navigator who helped the participant identify and overcome structural barriers to starting and staying in care and treatment for HIV and substance use. Such barriers could include unfamiliarity with how to enroll in medical care for HIV or difficulty keeping treatment-related appointments. Finally, psychosocial counselors helped each study participant overcome their unique psychological obstacles to starting and staying in treatment, such as lack of interest in therapy, difficulty establishing a medication-taking routine, or stigma.

In addition, all study participants, including the HIV-uninfected injection partners, received their country's standard of care for people who inject drugs. This typically included referral for treatment of substance use; referral to needle/syringe exchange programs, if legal and available; injection risk reduction counseling; sexual risk reduction counseling; HIV counseling and testing; and referral for diagnosis and treatment of sexually transmitted infections, hepatitis B and C viruses, and tuberculosis, as appropriate. Those study participants living with HIV who received only the standard of care also were referred to local health-care providers for anti-HIV therapy according to national guidelines for when to start treatment.

At the end of the study, 15 percent of participants with HIV who had received the standard of care had died, compared to seven percent of participants with HIV who had received the intervention, corresponding to a 53 percent reduction in mortality.

Some 26 percent of deaths among study participants who had HIV were considered clearly HIV-related, and 3 percent were due to drug overdose. Among the 42 percent of deaths with unknown cause, 24 percent occurred among people whose immune systems were in poor health. Non-HIV-related medical events caused 21 percent of deaths overall, and trauma and suicide accounted for the remaining eight percent.

After one year, 41 percent of study participants who received the intervention had undetectable levels of HIV in their blood, compared to 24 percent of participants who received only the standard of care. Also, 72 percent of study participants who received the intervention reported being in treatment for HIV at the end of one year, compared to 43 percent of those who received only the standard of care. Forty-one percent of study participants who received the intervention reported being in treatment for substance use at the end of one year, compared to 25 percent of those who received only the standard of care.

"The intervention in this study had a remarkably positive impact on people living with HIV who inject drugs," said Protocol Chair William C. Miller, M.D., Ph.D. "It was designed to be scalable to other settings, and we hope that it can help this important population worldwide." Dr. Miller is professor and chair of the Division of Epidemiology at The Ohio State University College of Public Health in Columbus.

Previous studies have demonstrated that when a person takes anti-HIV medication that suppresses the amount of virus in the blood to undetectable levels, it both protects the health of the individual and prevents sexual transmission of the virus. Whether viral suppression also prevents HIV transmission through needle sharing with injection partners remains unknown. The HPTN 074 study was not designed to determine whether the intervention would reduce the rate of HIV infection among injection partners of the participants living with HIV, but rather to determine the feasibility of a larger study that could measure this effect. In HPTN 074, seven injection partners of participants living with HIV who received only the standard of care became infected, while no injection partners of participants living with HIV who received the study intervention became infected. This result is promising, according to the investigators, but because the overall HIV incidence among injection partners was so low, a larger clinical trial to test the effect of the study intervention on HIV transmission among injection drug users would not be feasible.

Given the success of the study intervention at reducing mortality and increasing the rates of both participation in treatment and viral suppression, investigators have offered the intervention to all the HPTN 074 study participants living with HIV. In addition, all participants living with HIV are being followed for a second year to determine whether the positive effects of the intervention are maintained.

DURHAM, NC - Investigators from the HIV Prevention Trials Network (HPTN) today announced The Lancet has published key results from HPTN 074. At 52 weeks from enrollment, participants in the intervention arm nearly doubled their antiretroviral therapy usage, viral suppression and medication-assisted treatment usage compared to the standard of care arm. Mortality was also reduced by more than half with the intervention. The HPTN 074 study assessed an integrated intervention combining psychosocial counseling and supported referrals for antiretroviral therapy at any CD4 cell count and substance use treatment for people living with HIV who inject drugs compared to the locally available standard of care. The primary objectives of the study included estimating incidence in the standard of care arm while assessing the uptake of an integrated HIV prevention intervention.

"Facilitating antiretroviral therapy and substance use treatment referrals through systems navigation, combined with flexible counseling, led to enhanced antiretroviral therapy and substance use treatment uptake, viral load suppression, and decreased mortality among people living with HIV who inject drugs," said William C. Miller, MD, PhD, MPH, HPTN 074 protocol chair and professor and chair of the Department of Epidemiology at The Ohio State University College of Public Health in Columbus, Ohio. "Although this vanguard trial was not powered for comparing HIV incidence, the occurrence of no HIV infections among partners of the people who inject drugs in the intervention group offers the potential for prevention benefits."

HPTN 074 was a randomized, controlled trial conducted among people who inject drugs in Ukraine, Indonesia and Vietnam. Overall, 502 people living with HIV and 806 people with whom they injected drugs entered the study over 15 months and were followed for 12 to 24 months after enrollment. The median age was 35 years. Eighty-five percent of participants enrolled were men; most of the women who participated in the study were enrolled in Ukraine. At week 26, intervention arm participants were twice as likely to report antiretroviral therapy use compared to the standard of care arm participants and twice as likely to achieve an undetectable viral load. The effects persisted at week 52. Among intervention arm participants at week 52, self-reported substance use treatment uptake was higher compared to the standard of care arm participants. Mortality was significantly lower among intervention arm participants and their partners compared to the standard of care arm participants and their partners. For partners of intervention arm participants, no new HIV infections were observed, while seven were observed among partners in the standard of care arm.

"Injection drug use is a major factor underlying the HIV epidemic in Eastern Europe and Central and Southeast Asia," said Wafaa El-Sadr MD, MPH, MPA, HPTN co-principal investigator and professor of epidemiology and medicine at Columbia University in New York. "This persistently high incidence of HIV infection among people who inject drugs in many locations with concentrated epidemics necessitates aggressive efforts to prevent HIV transmission."

HPTN 074 study sites have completed a one-year study extension, which ended July 6, 2018. Due to the strength of the preliminary study results, all sites began offering the integrated intervention to participants who had not initiated antiretroviral therapy and substance use therapy in the standard of care arm in late 2017.

"The HPTN 074 study assessed the feasibility of an integrated intervention for people living with HIV who inject drugs to reduce HIV transmission to their HIV-uninfected injection partners," said Myron Cohen, MD, HPTN co-principal investigator and director of the University of North Carolina at Chapel Hill Institute for Global Health and Infectious Diseases in Chapel Hill, NC. "These study findings related to antiretroviral therapy use and HIV prevention are promising, and this and other interventions are needed to get people living with HIV who inject drugs into care for their own health and to stop transmission of the virus."

Washington, D.C., -- A new study appearing online today from the American Journal of Psychiatry finds that ketamine's acute antidepressant effect requires opioid system activation, the first time that a receptor site has been shown in humans to be necessary for any antidepressant's mechanism of action. While opioids have been used historically to treat depression, they are known to carry a high risk of dependence. Alan F. Schatzberg, M.D., who led this research at Stanford, cautions against widespread and repeated use of ketamine for depression treatment until more research can be done on both the mechanism of action and the risk of tolerance, abuse and dependence.

Previous research has found ketamine to have rapid-onset antidepressant effects. While the specific mechanism of action for these effects was unknown, it had been generally thought to be due to NMDA receptor antagonism. Since many efforts to develop NMDA antagonists as antidepressants have been unsuccessful, this new study aimed at determining the role of the opioid system in ketamine's antidepressant and dissociative effects in adults with treatment-resistant depression.

Nolan R. Williams, M.D., and Boris D. Heifets, M.D., Ph.D., from Stanford University, co-first authors of the article, hypothesized that ketamine's antidepressant effects may be related to intrinsic opioid receptor properties of ketamine. The study looked at whether use of naltrexone, an opioid blocker, prior to ketamine treatment would reduce the acute antidepressant effects of the ketamine or its dissociative effects. The researchers conducted a randomized double-blind crossover trial involving individuals with treatment resistant depression. Participants received the opioid blocker or a placebo prior to ketamine infusion treatment. Twelve participants completed both conditions in randomized order.

Use of naltrexone dramatically blocked the antidepressant effects of the ketamine but not the dissociative effects, so the trial was halted at the interim analysis. Participants receiving the ketamine plus naltrexone experienced much less reduction in depression symptoms than participants receiving ketamine plus placebo. There were no differences in ketamine-induced dissociation between those receiving naltrexone or a placebo.

In an accompanying editorial in the American Journal of Psychiatry, Mark S. George, M.D., with the Medical University of South Carolina and the VA Medical Center in Charleston, S.C., notes, "We would hate to treat the depression and suicide epidemics by overusing ketamine, which might perhaps unintentionally grow the third head of opioid dependence." George cautions that "with these new findings, we should be cautious about widespread and repeated use of ketamine before further mechanistic testing has been performed to determine whether ketamine is merely another opioid in a novel form."

George also suggests more attention to other underused treatments for depression and suicidality, including electroconvulsive therapy, transcranial magnetic stimulation and cervical vagus nerve stimulation.

BINGHAMTON, N.Y. - Single-step nasal spray naloxone is the easiest to deliver, according to new research led by faculty at Binghamton University, State University at New York.

Expanded access to naloxone, also known as Narcan®, has been identified as a key intervention for reducing opioid-related deaths. However, there is more than one way to administer it and it is unknown which method is most successful when administered by community members.

William Eggleston, clinical assistant professor at the School of Pharmacy and Pharmaceutical Sciences at Binghamton University, was interested in knowing how successfully community members could administer naloxone after basic video training.

"I'm studying things like which type of naloxone should we give to members of the community, and what is the best way to distribute that naloxone," Eggleston said.

In collaboration with SUNY Upstate Medical University in Syracuse, N.Y., Eggleston conducted a study to estimate and compare the rate of successful administration and the time to successful administration by community members for single-step nasal spray, multi-step atomized nasal spray and intramuscular simulated naloxone.

Over a three-day period at the New York State Fair in Syracuse, 138 adults with no prior naloxone training were asked to watch a two-minute video demonstrating how to administer naloxone via one of the three methods - two nasal sprays and one intramuscular - and then to administer the naloxone to a mannequin using their randomly selected method.

After the video training, participants were able to administer the single-step nasal spray naloxone with a higher rate of success than the intramuscular naloxone, and also to administer the single-step nasal spray naloxone more rapidly than either the multi-step atomized spray or the intramuscular naloxone. This information is important for community naloxone programs across the United States.

"With training, nasal sprays in general had a higher degree of success than the shot," Eggleston said. "Even if it seemed to us it was a no-brainer that we should be using nasal sprays, we had no data before, so now we have some to support that."

The study, "A Randomized Usability Assessment of Simulated Naloxone Administration by Community Members," was published in the journal Addiction in August.