Did drug use increase following COVID-19 relaxation of methadone take-out regulations? 2020 was a complicated year.

BACKGROUND: Relaxation of federal regulations for methadone take-out dosing during the COVID-19 pandemic is unprecedented. The impact of this change on drug use is unknown. This study explores the impact of the federal take-out variance on drug use in one urban opioid treatment program as measured by drug testing. METHODS: This study collected drug test results from 613 patients receiving methadone from July 2020, following COVID-19-related take-out dose adjustments, and July 2019 for comparison. Using a generalized linear mixed model, we computed the average estimated probability of a positive drug test for each year for each take-out phase. To isolate the effect of changing take-out, we removed the main effect of year, while retaining the main effect of take-out phase and the interaction between year and phase. RESULTS: The percent of drug tests positive for opiates, benzodiazepines, and methamphetamine was greater in July 2020 than in July 2019 (p < 0.001 for each), while the percent of tests negative for methadone increased (p < 0.001). Oxycodone, barbiturate, and cocaine positive tests remained stable. In a separate analysis of opioid and non-opioid test results, take-out phase was associated with both opioid and non-opioid positive results (p < 0.001, each outcome). The association of take-out phase with opioid and non-opioid positive results differed in the two years (year-by-phase interaction p < 0.025, each outcome). After removing the year main effect, the rate of positive tests was lower in 2020 for the smallest number of take-out doses, higher for a moderate number of take-out doses, and about the same for the highest number of take-out doses. CONCLUSIONS: Positive opioid and non-opioid drug tests increased following the federal variance allowing more methadone take-out doses, but these findings cannot fully be attributed to alterations in the take-out schedule.

IgA Plasma Cells Are Long-Lived Residents of Gut and Bone Marrow That Express Isotype- and Tissue-Specific Gene Expression Patterns.

Antibody secreting plasma cells are made in response to a variety of pathogenic and commensal microbes. While all plasma cells express a core gene transcription program that allows them to secrete large quantities of immunoglobulin, unique transcriptional profiles are linked to plasma cells expressing different antibody isotypes. IgA expressing plasma cells are generally thought of as short-lived in mucosal tissues and they have been understudied in systemic sites like the bone marrow. We find that IgA+ plasma cells in both the small intestine lamina propria and the bone marrow are long-lived and transcriptionally related compared to IgG and IgM expressing bone marrow plasma cells. IgA+ plasma cells show signs of shared clonality between the gut and bone marrow, but they do not recirculate at a significant rate and are found within bone marrow plasma cells niches. These data suggest that systemic and mucosal IgA+ plasma cells are from a common source, but they do not migrate between tissues. However, comparison of the plasma cells from the small intestine lamina propria to the bone marrow demonstrate a tissue specific gene transcription program. Understanding how these tissue specific gene networks are regulated in plasma cells could lead to increased understanding of the induction of mucosal versus systemic antibody responses and improve vaccine design.

Real-time monitoring of single ZTP riboswitches reveals a complex and kinetically controlled decision landscape.

RNAs begin to fold and function during transcription. Riboswitches undergo cotranscriptional switching in the context of transcription elongation, RNA folding, and ligand binding. To investigate how these processes jointly modulate the function of the folate stress-sensing Fusobacterium ulcerans ZTP riboswitch, we apply a single-molecule vectorial folding (VF) assay in which an engineered superhelicase Rep-X sequentially releases fluorescently labeled riboswitch RNA from a heteroduplex in a 5'-to-3' direction, at ~60 nt s-1 [comparable to the speed of bacterial RNA polymerase (RNAP)]. We demonstrate that the ZTP riboswitch is kinetically controlled and that its activation is favored by slower unwinding, strategic pausing between but not before key folding elements, or a weakened transcription terminator. Real-time single-molecule monitoring captures folding riboswitches in multiple states, including an intermediate responsible for delayed terminator formation. These results show how individual nascent RNAs occupy distinct channels within the folding landscape that controls the fate of the riboswitch.

The Transcription Factor T-bet Resolves Memory B Cell Subsets with Distinct Tissue Distributions and Antibody Specificities in Mice and Humans.

B cell subsets expressing the transcription factor T-bet are associated with humoral immune responses and autoimmunity. Here, we examined the anatomic distribution, clonal relationships, and functional properties of T-bet+ and T-bet- memory B cells (MBCs) in the context of the influenza-specific immune response. In mice, both T-bet- and T-bet+ hemagglutinin (HA)-specific B cells arose in germinal centers, acquired memory B cell markers, and persisted indefinitely. Lineage tracing and IgH repertoire analyses revealed minimal interconversion between T-bet- and T-bet+ MBCs, and parabionts showed differential tissue residency and recirculation properties. T-bet+ MBCs could be subdivided into recirculating T-betlo MBCs and spleen-resident T-bethi MBCs. Human MBCs displayed similar features. Conditional gene deletion studies revealed that T-bet expression in B cells was required for nearly all HA stalk-specific IgG2c antibodies and for durable neutralizing titers to influenza. Thus, T-bet expression distinguishes MBC subsets that have profoundly different homing, residency, and functional properties, and mediate distinct aspects of humoral immune memory.

Transcriptional regulation of germinal center B and plasma cell fates by dynamical control of IRF4.

The transcription factor IRF4 regulates immunoglobulin class switch recombination and plasma cell differentiation. Its differing concentrations appear to regulate mutually antagonistic programs of B and plasma cell gene expression. We show IRF4 to be also required for generation of germinal center (GC) B cells. Its transient expression in vivo induced the expression of key GC genes including Bcl6 and Aicda. In contrast, sustained and higher concentrations of IRF4 promoted the generation of plasma cells while antagonizing the GC fate. IRF4 cobound with the transcription factors PU.1 or BATF to Ets or AP-1 composite motifs, associated with genes involved in B cell activation and the GC response. At higher concentrations, IRF4 binding shifted to interferon sequence response motifs; these enriched for genes involved in plasma cell differentiation. Our results support a model of "kinetic control" in which signaling-induced dynamics of IRF4 in activated B cells control their cell-fate outcomes.

The gross motor function classification system for cerebral palsy and single-event multilevel surgery: is there a relationship between level of function and intervention over time?

BACKGROUND: The purpose of this study was to determine what effect, if any, an intervention such as Single-event multilevel orthopaedic surgery (SEMLS) might have on the relative stability of the gross motor function classification system (GMFCS) for cerebral palsy over a 5-year time period. METHODS: Eighty-four children with spastic cerebral palsy who underwent SEMLS were included. The patients had an average of 5.45 procedures during surgery. Mean age at the time of surgery was 6 years. Two blinded physical therapists applied the GMFCS to functional descriptions extracted from outpatient clinical records. The patients were rated preoperatively, 1, 2, and 5 years postoperatively. RESULTS: Interrater reliability was high, Kw=0.90. Friedman's nonparametric repeated measures analysis of variance was conducted comparing the GMFCS classification levels of the patients preoperatively and 1, 2, and 5 years after SEMLS. The patients as a group showed a significant change to a lower GMFCS classification postsurgery (P<0.001). Children classified at levels I and V of the GMFCS preoperatively showed lesser likelihood of changing functional levels postsurgery. CONCLUSIONS: The results of this investigation support the concept that interventions, especifically SEMLS, can affect the stability of the GMFCS classification. The majority of children in this study showed changes in gross motor function classification as reflected by lower GMFCS scores after SEMLS intervention. We also found that changes were maintained over a period of 5 years. The results of this study suggest that certain interventions, such as SEMLS, might have an effect on the stability of the GMFCS and that effect may be level-dependent. LEVEL OF EVIDENCE: Retrospective Study by Review of Medical Records. Level III in the Therapeutic Study investigating results of treatment category.