Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study.

BACKGROUND: Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. METHODS: We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. RESULTS: There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. CONCLUSIONS: Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.

COVID-19 Outcomes and Risk Factors Among People Living with HIV.

PURPOSE OF REVIEW: In this review, we examine the intersection of the HIV and COVID-19 epidemics with focus on COVID-19-related health outcomes and risk factors for SARS-CoV-2 among people living with HIV (PLWH). RECENT FINDINGS: Evidence to date do not suggest a higher incidence of SARS-CoV-2 infection among PLWH compared to the general population, although-once exposed-PLWH are at greater risk of severe COVID-19 outcomes. Key risk factors for severe COVID-19 include non-HIV comorbidities known to be associated with severe disease, as well as HIV-specific risk factors such as low CD4 + T-cell count, unsuppressed viral load, and tuberculosis co-infection. The disproportionate impact of the SARS-CoV-2 pandemic among Black, Latinx, and Native American/Alaskan Native PLWH could worsen pre-existing disparities in health outcomes among PLWH. Data on SARS-CoV-2 vaccine protection among PLWH needs additional study, although some studies suggest decreased humoral responses among those with low CD4 + T-cell counts, while there is a signal of increased vaccine breakthrough rates among PLWH in two large observational cohorts. Data on post-acute sequelae of SARS-CoV-2 (PASC) among PLWH is also limited. PLWH do not have a higher susceptibility to SARS-CoV-2, but once exposed, they are at higher risk of severe COVID-19 outcomes. Additional resources will need to be dedicated to the development of interventions to improve health outcomes and address disparities among PLWH impacted by the COVID-19 pandemic.

Dehydration and hyponatremia in professional rugby union players: a cohort study observing english premiership rugby union players during match play, field, and gym training in cool environmental conditions.

Fluid and sodium balance is important for performance and health; however, limited data in rugby union players exist. The purpose of the study was to evaluate body mass (BM) change (dehydration) and blood[Na] change during exercise. Data were collected from 10 premiership rugby union players, over a 4-week period. Observations included match play (23 subject observations), field (45 subject observations), and gym (33 subject observations) training sessions. Arrival urine samples were analyzed for osmolality, and samples during exercise were analyzed for [Na]. Body mass and blood[Na] were determined pre- and postexercise. Sweat[Na] was analyzed from sweat patches worn during exercise, and fluid intake was measured during exercise. Calculations of fluid and Na loss were made. Mean arrival urine osmolality was 423 ± 157 mOsm·kg, suggesting players were adequately hydrated. After match play, field, and gym training, BM loss was 1.0 ± 0.7, 0.3 ± 0.6, and 0.1 ± 0.6%, respectively. Fluid loss was significantly greater during match play (1.404 ± 0.977 kg) than field (1.008 ± 0.447 kg, p = 0.021) and gym training (0.639 ± 0.536 kg, p < 0.001). Fluid intake was 0.955 ± 0.562, 1.224 ± 0.601, and 0.987 ± 0.503 kg during match play, field, and gym training, respectively. On 43% of observations, players were hyponatremic when BM increased, 57% when BM was maintained, and 35% when there was a BM loss of 0.1-0.9%. Blood[Na] was the representative of normonatremia when BM loss was >1.0%. The findings demonstrate that rugby union players are adequately hydrated on arrival, fluid intake is excessive compared with fluid loss, and some players are at risk of developing hyponatremia.

The planetary role of seagrass conservation.

Seagrasses are remarkable plants that have adapted to live in a marine environment. They form extensive meadows found globally that bioengineer their local environments and preserve the coastal seascape. With the increasing realization of the planetary emergency that we face, there is growing interest in using seagrasses as a nature-based solution for greenhouse gas mitigation. However, seagrass sensitivity to stressors is acute, and in many places, the risk of loss and degradation persists. If the ecological state of seagrasses remains compromised, then their ability to contribute to nature-based solutions for the climate emergency and biodiversity crisis remains in doubt. We examine the major ecological role that seagrasses play and how rethinking their conservation is critical to understanding their part in fighting our planetary emergency.

Continuous peripheral nerve block catheter infections in combat-related injuries: a case report of five soldiers from Operation Enduring Freedom/Operation Iraqi Freedom.

DESIGN: Case series. SETTING: Military medical facility providing acute care for soldiers injured while fighting in the war in Iraq and Afghanistan. OBJECTIVE: To report a series of infections related to use of continuous peripheral nerve catheters for postoperative pain control in the military polytraumatic setting. The analysis of the above infections includes similarities and differences in infection patterns and attempts to clarify possible risk factors for such infections to include duration of catheter placement, type of catheter, preprocedural antibiotics, and tunnel vs nontunneled catheters. The goal of this analysis is to assist in the development of protocols that may prevent future catheter infections. METHODS: Clinical data were obtained from five previously healthy male soldiers receiving acute care at Brooke Army Medical Center using continuous peripheral nerve catheters for postoperative pain for multiple and frequent procedures. RESULTS: In a total of six catheter infections, two were noted to have superficial skin infections while four were shown to have deep tissue involvement confirmed by imaging studies. All patients were started on initial or additional antibiotics after catheter removal. Three catheter infections, all with stimulating catheters, required surgical irrigation and debridement in the operating room. CONCLUSIONS: Continuous peripheral nerve catheters are not without complications and risks including infection. Duration of catheter use was the most significant factor with the development of a catheter-related infection in our series. This series also highlights how stimulating and nonstimulating catheter infections may present differently, as stimulating catheters may have a greater tendency to present as deep space infections with minimal superficial findings.

The perverse fisheries consequences of mosquito net malaria prophylaxis in East Africa.

Malaria is a serious global health issue, with around 200 million cases per year. As such, great effort has been put into the mass distribution of bed nets as a means of prophylaxis within Africa. Distributed mosquito nets are intended to be used for malaria protection, yet increasing evidence suggests that fishing is a primary use for these nets, providing fresh concerns for already stressed coastal ecosystems. While research documents the scale of mosquito net fisheries globally, no quantitative analysis of their landings exists. The effects of these fisheries on the wider ecosystem assemblages have not previously been examined. In this study, we present the first detailed analysis of the sustainability of these fisheries by examining the diversity, age class, trophic structure and magnitude of biomass removal. Dragnet landings, one of two gear types in which mosquito nets can be utilised, were recorded across ten sites in northern Mozambique where the use of Mosquito nets for fishing is common. Our results indicate a substantial removal of juveniles from coastal seagrass meadows, many of which are commercially important in the region or play important ecological roles. We conclude that the use of mosquito nets for fishing may contribute to food insecurity, greater poverty and the loss of ecosystem functioning.

State Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and Identities.

Objectives: Adolescents in the United States face crucial sexual health behavior issues, including consequences of sexually transmitted infections and diseases, pregnancy, and sexual violence. Lesbian, gay, bisexual, and transgender youth are disproportionately affected by these issues. State policies about sex education in K-12 schools shape what is taught to students about sexual health. In this study, we analyzed the content of school-based sex education policies of all 50 states and focuses on sexual behaviors, relationships, and identities. Methods: Policies analyzed include state statutes, state board of education policies, and state department of education or public instruction curriculum standards. Data were analyzed using content analysis. Results: Most state policies emphasized abstinence from sexual behavior and did not require education about contraceptive and barrier methods. Few policies required detailed information about contraceptive and barrier methods to prevent pregnancy and sexually transmitted infections. Around half of states addressed relationship issues (ie, healthy relationships, sexual decision-making, and sexual violence); however, few states required content on communication about sexual consent. Eight state policies explicitly stigmatized homosexuality. Conversely, 12 states were inclusive of diverse sexual orientations and 7 states were inclusive of diverse gender identities. Conclusion: Sex education policies should be evidence-based and inclusive of sexual diversity.

Global challenges for seagrass conservation.

Seagrasses, flowering marine plants that form underwater meadows, play a significant global role in supporting food security, mitigating climate change and supporting biodiversity. Although progress is being made to conserve seagrass meadows in select areas, most meadows remain under significant pressure resulting in a decline in meadow condition and loss of function. Effective management strategies need to be implemented to reverse seagrass loss and enhance their fundamental role in coastal ocean habitats. Here we propose that seagrass meadows globally face a series of significant common challenges that must be addressed from a multifaceted and interdisciplinary perspective in order to achieve global conservation of seagrass meadows. The six main global challenges to seagrass conservation are (1) a lack of awareness of what seagrasses are and a limited societal recognition of the importance of seagrasses in coastal systems; (2) the status of many seagrass meadows are unknown, and up-to-date information on status and condition is essential; (3) understanding threatening activities at local scales is required to target management actions accordingly; (4) expanding our understanding of interactions between the socio-economic and ecological elements of seagrass systems is essential to balance the needs of people and the planet; (5) seagrass research should be expanded to generate scientific inquiries that support conservation actions; (6) increased understanding of the linkages between seagrass and climate change is required to adapt conservation accordingly. We also explicitly outline a series of proposed policy actions that will enable the scientific and conservation community to rise to these challenges. We urge the seagrass conservation community to engage stakeholders from local resource users to international policy-makers to address the challenges outlined here, in order to secure the future of the world's seagrass ecosystems and maintain the vital services which they supply.

Seagrass science is growing: A report on the 12th International Seagrass Biology Workshop.

This conference report describes the programme of the 12th International Seagrass Biology Workshop, its highlights, areas of growth for the workshop, and potential future directions for the workshop series. The report is written with an eye toward where it fits within the field of seagrass research.

Tracking Nitrogen Source Using δ15N Reveals Human and Agricultural Drivers of Seagrass Degradation across the British Isles.

Excess nutrients shift the ecological balance of coastal ecosystems, and this eutrophication is an increasing problem across the globe. Nutrient levels may be routinely measured, but monitoring rarely attempts to determine the source of these nutrients, even though bio-indicators are available. Nitrogen stable isotope analysis in biota is one such bio-indicator, but across the British Isles, this is rarely used. In this study, we provide the first quantitative evidence of the anthropogenic drivers of reduced water quality surrounding seagrass meadows throughout the British Isles using the stable nitrogen isotope δ15N. The values of δ15N ranged from 3.15 to 20.16‰ (Mean ± SD = 8.69 ± 3.50‰), and were high within the Thames Basin suggesting a significant influx of urban sewage and livestock effluent into the system. Our study provides a rapid 'snapshot' indicating that many seagrass meadows in the British Isles are under anthropogenic stress given the widespread inefficiencies of current sewage treatment and farming practices. Ten of the 11 seagrass meadows sampled are within European marine protected sites. The 10 sites all contained seagrass contaminated by nutrients of a human and livestock waste origin leading us to question whether generic blanket protection is working for seagrasses in the United Kingdom. Infrastructure changes will be required if we are to develop strategic wastewater management plans that are effective in the long-term at protecting our designated Special Areas of Conservation. Currently, sewage pollution is a concealed issue; little information exists and is not readily accessible to members of the public.

Crowdsourcing conservation: The role of citizen science in securing a future for seagrass.

Seagrass meadows are complex social-ecological systems. Understanding seagrass meadows demands a fresh approach integrating "the human dimension". Citizen science is widely acknowledged for providing significant contributions to science, education, society and policy. Although the take up of citizen science in the marine environment has been slow, the need for such methods to fill vast information gaps is arguably great. Seagrass meadows are easy to access and provide an example of where citizen science is expanding. Technological developments have been pivotal to this, providing new opportunities for citizens to engage with seagrass. The increasing use of online tools has created opportunities to collect and submit as well as help process and analyse data. Citizen science has helped researchers integrate scientific and local knowledge and engage communities to implement conservation measures. Here we use a selection of examples to demonstrate how citizen science can secure a future for seagrass.

Reasons for seagrass optimism: Local ecological knowledge confirms presence of dugongs.

Dugongs (Dugong dugon) depend on seagrass meadows for food. As such seagrass and dugong conservation should go hand in hand. Assessing dugong populations is notoriously challenging. In the most resource dependent communities Local Ecological Knowledge (LEK) is generally high and can provide an alternative to the use of expensive ecological surveys to understand dugong populations and support associated resource management decisions. Residents of the Wakatobi National Park (WNP), SE Sulawesi, Indonesia are highly dependent on marine resources for livelihoods and correspondingly LEK is high. Here LEK documents the presence of D. dugon in the WNP and infers changes in population size. Interviews with local residents in 2012-2013 revealed 99 sightings of dugongs since 1942, 48 of which occurred between 2002 and 2012, with 79.82% of respondents having seen a dugong. Declines in the frequency of sightings within the lifetime of several respondents were reported, respondents speculating that populations are reduced. This information can guide further cooperative research and conservation efforts for the protection of a vulnerable species and the seagrass habitat on which it depends.

Indonesia's globally significant seagrass meadows are under widespread threat.

Indonesia's marine ecosystems form a fundamental part of the world's natural heritage, representing a global maxima of marine biodiversity and supporting the world's second largest production of seafood. Seagrasses are a key part of that support. In the absence of empirical data we present evidence from expert opinions as to the state of Indonesia's seagrass ecosystems, their support for ecosystem services, with a focus on fisheries, and the damaging activities that threaten their existence. We further draw on expert opinion to elicit potential solutions to prevent further loss. Seagrasses and the ecosystem services they support across the Indonesian archipelago are in a critical state of decline. Declining seagrass health is the result of shifting environmental conditions due largely to coastal development, land reclamation, and deforestation, as well as seaweed farming, overfishing and garbage dumping. In particular, we also describe the declining state of the fisheries resources that seagrass meadows support. The perilous state of Indonesia's seagrasses will compromise their resilience to climate change and result in a loss of their high ecosystem service value. Community supported management initiatives provide one mechanism for seagrass protection. Exemplars highlight the need for increased local level autonomy for the management of marine resources, opening up opportunities for incentive type conservation schemes.

Rocking the Boat: Damage to Eelgrass by Swinging Boat Moorings.

Seagrass meadows commonly reside in shallow sheltered embayments typical of the locations that provide an attractive option for mooring boats. Given the potential for boat moorings to result in disturbance to the seabed due to repeated physical impact, these moorings may present a significant threat to seagrass meadows. The seagrass Zostera marina (known as eelgrass) is extensive across the northern hemisphere, forming critical fisheries habitat and creating efficient long-term stores of carbon in sediments. Although boat moorings have been documented to impact seagrasses, studies to date have been conducted on the slow growing Posidonia species' rather than the fast growing and rapidly reproducing Z. marina that may have a higher capacity to resist and recover from repeated disturbance. In the present study we examine swinging chain boat moorings in seagrass meadows across a range of sites in the United Kingdom to determine whether such moorings have a negative impact on the seagrass Zostera marina at the local and meadow scale. We provide conclusive evidence from multiple sites that Z. marina is damaged by swinging chain moorings leading to a loss of at least 6 ha of United Kingdom seagrass. Each swinging chain mooring was found to result in the loss of 122 m2 of seagrass. Loss is restricted to the area surrounding the mooring and the impact does not appear to translate to a meadow scale. This loss of United Kingdom seagrass from boat moorings is small but significant at a local scale. This is because it fragments existing meadows and ultimately reduces their resilience to other stressors. Boat moorings are prevalent in seagrass globally and it is likely this impairs their ecosystem functioning. Given the extensive ecosystem service value of seagrasses in terms of factors such as carbon storage and fish habitat such loss is of cause for concern. This indicates the need for the widespread use of seagrass friendly mooring systems in and around seagrass.

The perilous state of seagrass in the British Isles.

Seagrass ecosystems face widespread threat from reduced water quality, coastal development and poor land use. In recent decades, their distribution has declined rapidly, and in the British Isles, this loss is thought to have been extensive. Given increasing knowledge of how these ecosystems support fisheries production, the understanding of their potential rapid loss, and the difficulty in restoring them, it is vital we develop an understanding of the risks they are under, so that management actions can be developed accordingly. Developing an understanding of their environmental status and condition is therefore critical to their long-term management. This study provided, to our knowledge, the first examination of the environmental health of seagrass meadows around the British Isles. This study used a bioindicator approach and involved collecting data on seagrass density and morphology alongside analysis of leaf biochemistry. Our study provides, to the best of our knowledge, the first strong quantitative evidence that seagrass meadows of the British Isles are mostly in poor condition in comparison with global averages, with tissue nitrogen levels 75% higher than global values. Such poor status places their long-term resilience in doubt. Elemental nutrient concentrations and morphological change suggest conditions of excess nitrogen and probable low light, placing many of the meadows sampled in a perilous state, although others, situated away from human populations were perceived to be healthy. Although some sites were of a high environmental health, all sites were considered at risk from anthropogenic impacts, particularly poor water quality and boating-based disturbances. The findings of this study provide a warning of the need to take action, with respect to water quality and disturbance, to prevent the further loss and degradation of these systems across the British Isles.