Estimating the total utilization of take home naloxone during an unregulated drug toxicity crisis: A Bayesian modeling approach.

BACKGROUND: British Columbia (BC) Canada has a large take-home naloxone (THN) program, implemented as part of the provincial response to the ongoing toxic unregulated drug supply emergency. Ascertaining the rate of use of THN kits is vital to understanding the full impact of the program. However, this is a challenging problem due to under-reporting of kit distribution. This study aims to estimate the total number of THN kits used based on the number of THN kits shipped, the number of THN kits reported as distributed, and the number of THN kits reported as used. METHODS: We used BC THN shipment and distribution records (February 2015 to August 2023) to inform a simple Bayesian model of naloxone kit distribution and use. A logistic regression term by health region and distribution site type was incorporated to account for variable under-reporting, and a convolution term was incorporated to account for kit distribution. RESULTS: We find the number of THN kits reported as used, and the number of total THN kits distributed, are largely under-reported. An estimated 1,500 (95 % CrI: 1,430 - 1,590) THN kits per 10,000 BC population were used, of which 288 per 10,000 had been reported as used. Of all the THN kits shipped, the model estimated that 43 % (95 % CrI: 41-45 %) of kits were used. We also found variation in both distribution and use by distribution site type, with kits distributed from overdose prevention sites having the highest rate of use (56 %; 95 % CrI: 53-59 %). CONCLUSION: Across all sites, kit use is approximately five times higher than has been reported. Our framework can also be applied to other localities where THN programs operate, in order to better estimate the true reach and impact of take home naloxone distribution.

Digitally shaped ethnographic relationships during a global pandemic and beyond.

Social distancing and public safety measures enacted in response to COVID-19 created a surge in methodological "advice" for researchers facing disruption to fieldwork. Resources and publications frequently encouraged changes vis-a-vis digitally enhanced methods or employment of digital ethnography. For ethnographers, the establishment and maintenance of ethnographic relationships in pandemic contexts restricted to virtual interactions has not been thoroughly explored, leaving those trained in recruitment, rapport-building, and field engagement with fewer resources to navigate this integral topic. Here, we provide insights into how ethnographic relationships may be developed when there is limited access to the field and traditional relationship building is not possible. We argue that as ethnographic methods change and adapt, so too must perspectives on ethnographic relationship development. By closely examining ethnographic relationships confined to digital spaces in the context of the Tennessee tornado recovery amid the COVID-19 pandemic, this project sheds light on how to overcome this challenge.

Biochemical Analysis Leads to Improved Orthogonal Bioluminescent Tools.

Engineered luciferase-luciferin pairs have expanded the number of cellular targets that can be visualized in tandem. While light production relies on selective processing of synthetic luciferins by mutant luciferases, little is known about the origin of selectivity. The development of new and improved pairs requires a better understanding of the structure-function relationship of bioluminescent probes. In this work, we report a biochemical approach to assessing and optimizing two popular bioluminescent pairs: Cashew/d-luc and Pecan/4'-BrLuc. Single mutants derived from Cashew and Pecan revealed key residues for selectivity and thermal stability. Stability was further improved through a rational addition of beneficial residues. In addition to providing increased stability, the known stabilizing mutations surprisingly also improved selectivity. The resultant improved pair of luciferases are >100-fold selective for their respective substrates and highly thermally stable. Collectively, this work highlights the importance of mechanistic insight for improving bioluminescent pairs and provides significantly improved Cashew and Pecan enzymes which should be immediately suitable for multicomponent imaging applications.

Impact of Prostate Health Index Results for Prediction of Biopsy Grade Reclassification During Active Surveillance.

PURPOSE: We assessed whether Prostate Health Index results improve prediction of grade reclassification for men on active surveillance. METHODS AND MATERIALS: We identified men in Canary Prostate Active Surveillance Study with Grade Group 1 cancer. Outcome was grade reclassification to Grade Group 2+ cancer. We considered decision rules to maximize specificity with sensitivity set at 95%. We derived rules based on clinical data (R1) vs clinical data+Prostate Health Index (R3). We considered an "or"-logic rule combining clinical score and Prostate Health Index (R4), and a "2-step" rule using clinical data followed by risk stratification based on Prostate Health Index (R2). Rules were applied to a validation set, where values of R2-R4 vs R1 for specificity and sensitivity were evaluated. RESULTS: We included 1,532 biopsies (n = 610 discovery; n = 922 validation) among 1,142 men. Grade reclassification was seen in 27% of biopsies (23% discovery, 29% validation). Among the discovery set, at 95% sensitivity, R2 yielded highest specificity at 27% vs 17% for R1. In the validation set, R3 had best performance vs R1 with Δsensitivity = -4% and Δspecificity = +6%. There was slight improvement for R3 vs R1 for confirmatory biopsy (AUC 0.745 vs R1 0.724, ΔAUC 0.021, 95% CI 0.002-0.041) but not for subsequent biopsies (ΔAUC -0.012, 95% CI -0.031-0.006). R3 did not have better discrimination vs R1 among the biopsy cohort overall (ΔAUC 0.007, 95% CI -0.007-0.020). CONCLUSIONS: Among active surveillance patients, using Prostate Health Index with clinical data modestly improved prediction of grade reclassification on confirmatory biopsy and did not improve prediction on subsequent biopsies.

Factors associated with take-home naloxone kit usage in British Columbia: an analysis of administrative data.

BACKGROUND: The British Columbia (BC) Take-Home Naloxone (THN) program provides naloxone to people at risk of experiencing or witnessing an opioid overdose for use in reversing suspected overdose events. This study seeks to examine trends and correlates of individuals obtaining a THN kit in BC between 2017 and 2020. METHODS: Records of THN kits distributed between 2017 and 2020 were the primary source of data for this analysis. Frequency tables were used to describe characteristics of people obtaining kits from THN sites. Correlates of individuals obtaining a THN kit to replace a previous kit reported as used to reverse an overdose were assessed with multivariate logistic regression. RESULTS: Between January 1, 2017, and December 31, 2020, 240,606 THN kits were reported distributed by registered sites to members of the public, with 90,011 records indicating that a kit was obtained to replace a previous kit that had been used to reverse an overdose. There was a significant trend in increasing kits reported used by year (p < 0.01). The kit recipient's risk of overdose was a significant predictor of having reported using a THN kit, and the strength of the association was dependent on gender (Male: Adjusted odds ratio (AOR) 5.37 [95% confidence interval (CI) 5.08 - 5.67]; Female: AOR 8.35 [95% CI 7.90 - 8.82]; Trans and gender expansive: AOR 3.68 [95% CI 2.82 - 4.79]). CONCLUSIONS: Between 2017 and 2020, THN kits were used to reverse tens of thousands of overdose events in BC, with people at risk of overdose (i.e. people who use drugs [PWUD]) having greater odds of using a kit to reverse an overdose than those not at risk. Thus, PWUD are responsible for reversing the vast majority of overdoses. THN kits are being distributed to the people who use them most. However, additional strategies in conjunction with community-based naloxone distribution programs are needed to address the rising number of illicit drug toxicity deaths.

Knowledge of the Good Samaritan Drug Overdose Act and possession of a naloxone kit among people recently released from prison.

PURPOSE: This study aims to describe knowledge of Canada's Good Samaritan Drug Overdose Act (GSDOA) and take home naloxone (THN) training and kit possession among people being released from provincial correctional facilities in British Columbia. DESIGN/METHODOLOGY/APPROACH: The authors conducted surveys with clients of the Unlocking the Gates Peer Health Mentoring program on their release. The authors compared the characteristics of people who had and had not heard of the GSDOA and who were in possession of a THN kit. FINDINGS: In this study, 71% people had heard of the GSDOA, and 55.6% were in possession of a THN kit. This study found that 99% of people who had heard of the GSDOA indicated that they would call 911 if they saw an overdose. Among people who perceived themselves to be at risk of overdose, 28.3% did not have a THN kit. Only half (52%) of participants had a mobile phone, but 100% of those with a phone said they would call 911 if they witnessed an overdose. ORIGINALITY/VALUE: The authors found that people with knowledge of the GSDOA were likely to report that they would call 911 for help with an overdose. Education about the GSDOA should be a standard component of naloxone training in correctional facilities. More than one in four people at risk of overdose were released without a naloxone kit, highlighting opportunities for training and distribution. Access to a cellphone is important in enabling calls to 911 and should be included in discharge planning.

Adverse events related to bystander naloxone administration in cases of suspected opioid overdose in British Columbia: An observational study.

INTRODUCTION: Take-Home Naloxone programs have been introduced across North America in response to rising opioid overdose deaths. There is currently limited real-world data on bystander naloxone administration, overdose outcomes, and evidence related to adverse events following bystander naloxone administration. METHODS: The research team used descriptive statistics from Take-Home Naloxone administration forms. We explored reported demographic variables and adverse events among people who received by-stander administered naloxone in a suspected opioid overdose event between August 31, 2012 and December 31, 2018 in British Columbia. We examined and contextualized differences across years given policy, program and drug toxicity changes. We used multivariate logistic regression to examine whether an association exists between number of ampoules of naloxone administered and the odds that the recipient will experience withdrawal symptoms. RESULTS: A large majority (98.1%) of individuals who were administered naloxone survived their overdose and 69.2% had no or only mild withdrawal symptoms. Receiving three (Adjusted Odds Ratio (AOR) 1.64 (95% Confidence Interval (CI): 1.08-2.48)) or four or more (AOR 2.19 (95% CI: 1.32-3.62)) ampoules of naloxone was significantly associated with odds of moderate or severe withdrawal compared to receiving one ampoule of naloxone. CONCLUSIONS: This study provides evidence from thousands of bystander reversed opioid overdoses using Take-Home Naloxone kits in British Columbia, and suggests bystander-administered naloxone is safe and effective for opioid overdose reversal. Data suggests an emphasis on titration during bystander naloxone training in situations where the person experiencing overdose can be adequately ventilated may help avoid severe withdrawal symptoms. We identified a decreasing trend in the likelihood of moderate or severe withdrawal over the study period.

A panel of selected serum protein biomarkers for the detection of aggressive prostate cancer.

Background: Current PSA-based tests used to detect prostate cancer (PCa) lack sufficient specificity, leading to significant overdetection and overtreatment. Our previous studies showed that serum fucosylated PSA (Fuc-PSA) and soluble TEK receptor tyrosine kinase (Tie-2) had the ability to predict aggressive (AG) PCa. Additional biomarkers are needed to address this significant clinical problem. Methods: A comprehensive Pubmed search followed by multiplex immunoassays identified candidate biomarkers associated with AG PCa. Subsequently, multiplex and lectin-based immunoassays were applied to a case-control set of sera from subjects with AG PCa, low risk PCa, and non-PCa (biopsy negative). These candidate biomarkers were further evaluated for their ability as panels to complement the prostate health index (phi) in detecting AG PCa. Results: When combined through logistic regression, two panel of biomarkers achieved the best performance: 1) phi, Fuc-PSA, SDC1, and GDF-15 for the detection of AG from low risk PCa and 2) phi, Fuc-PSA, SDC1, and Tie-2 for the detection of AG from low risk PCa and non-PCa, with noticeable improvements in ROC analysis over phi alone (AUCs: 0.942 vs 0.872, and 0.934 vs 0.898, respectively). At a fixed sensitivity of 95%, the panels improved specificity with statistical significance in detecting AG from low risk PCa (76.0% vs 56%, p=0.029), and from low risk PCa and non-PCa (78.2% vs 65.5%, p=0.010). Conclusions: Multivariate panels of serum biomarkers identified in this study demonstrated clinically meaningful improvement over the performance of phi, and warrant further clinical validation, which may contribute to the management of PCa.

The implementation and role of a staff naloxone program for non-profit community-based sites in British Columbia: A descriptive study.

INTRODUCTION: The BC Centre for Disease Control implemented the Facility Overdose Response Box (FORB) program December 1st, 2016 to train and support non-healthcare service providers who may respond to an overdose in the workplace. The program aims to support staff at non-profit community-based organizations by ensuring policy development, training, practice overdose response exercises, and post-overdose debriefing opportunities are established and implemented. MATERIALS AND METHODS: Three data sources were used in this descriptive cross-sectional study: FORB site registration data; naloxone administration forms; and a survey that was distributed to FORB sites in February 2019. FORB program site and naloxone administration data from December 1st, 2016 to December 31st, 2019 were analyzed using descriptive statistics. A Cochran-Armitage test was used to assess trends over time in naloxone administration event characteristics. Site coordinator survey results are reported to supplement findings from administrative data. RESULTS: As of December 31st, 2019, FORB was implemented at 613 sites across BC and 1,758 naloxone administration events were reported. The majority (86.3%, n = 1,517) were indicated as overdose reversals. At registration, 43.6% of sites provided housing services, 26.3% offered harm reduction supplies, and 18.6% provided Take Home Naloxone. Refusal to be transported to hospital following overdose events when emergency services were called showed an increasing trend over time. Most respondents (81.3%) reported feeling confident in their ability to respond to the overdose and 59.6% were offered staff debrief. Based on the 89 site survey responses, supports most commonly made available following an overdose were debrief with a fellow staff member (91.0%), debrief with a supervisor (89.9%), and/or counselling services (84.3%). CONCLUSIONS: The uptake of the FORB program has contributed to hundreds of overdose reversals in community settings in BC. Findings suggest that the FORB program supports developing staff preparedness and confidence in overdose response in community-based settings.

Orthogonal Bioluminescent Probes from Disubstituted Luciferins.

Bioluminescence imaging with luciferase-luciferin pairs is routinely used to monitor cellular functions. Multiple targets can be visualized in tandem using luciferases that process unique substrates, but only a handful of such orthogonal probes are known. Multiplexed studies require additional robust, light-emitting molecules. In this work, we report new luciferins for orthogonal imaging that comprise disubstituted cores. These probes were found to be bright emitters with various engineered luciferases. The unique patterns of light output also provided insight into enzyme-substrate interactions necessary for productive emission. Screening studies identified mutant luciferases that could preferentially process the disubstituted analogues, enabling orthogonal imaging with existing bioluminescent reporters. Further mutational analyses revealed the origins of substrate selectivity. Collectively, this work provides insights into luciferase-luciferin features relevant to bioluminescence and expands the number of probes for multicomponent tracking.

Accessing Take-Home Naloxone in British Columbia and the role of community pharmacies: Results from the analysis of administrative data.

INTRODUCTION: British Columbia's (BC) Take-Home Naloxone (THN) program provides naloxone to bystanders for use in cases of suspected opioid overdose. This study seeks to provide trends and analysis from the provincial BC THN program since inception in 2012 to the end of 2018. MATERIALS AND METHODS: BC THN shipment and distribution records from 2012-2018 were retrieved. Frequency distributions were used to describe characteristics of individuals accessing the program. To evaluate correlates of distribution after the addition of hundreds of pharmacy distribution sites, an analytic sample was limited to records from 2018, and multivariate logistic regression was used to evaluate correlates of collecting naloxone at a pharmacy site. RESULTS: Since program inception to the end of 2018, there were 398,167 naloxone kits shipped to distribution sites, 149,999 kits reported distributed, and 40,903 kits reported used to reverse an overdose in BC. There was a significant increasing trend in the number of naloxone kits used to reverse an overdose over time (p<0.01), and more than 90% of kits that were reported used were distributed to persons at risk of an overdose. Individuals not personally at risk of overdose had higher odds of collecting naloxone at a pharmacy site, compared to other community sites (including harm reduction supply distribution sites, peer led organizations, drop-in centers, and supportive housing sites) (Adjusted Odds Ratio (AOR): 2.69; 95% CI: 2.50-2.90). CONCLUSIONS: This study documents thousands of opioid overdose reversals facilitated through the BC THN program. While those at highest risk of overdose may preferentially access naloxone through community sites, naloxone distribution through pharmacies has allowed the BC THN program to expand dramatically, increasing naloxone availability through longer opening hours on evenings and weekends. and in rural and remote regions. A diversity of naloxone distribution sites and strategies is crucial to prevent rising opioid overdose deaths.

Directing Quinone Methide-Dependent Alkylation and Cross-Linking of Nucleic Acids with Quaternary Amines.

Polyamine and polyammonium ion conjugates are often used to direct reagents to nucleic acids based on their strong electrostatic attraction to the phosphoribose backbone. Such nonspecific interactions do not typically alter the specificity of the attached reagent, but polyammonium ions dramatically redirected the specificity of a series of quinone methide precursors. Replacement of a relatively nonspecific intercalator based on acridine with a series of polyammonium ions resulted in a surprising change of DNA products. Piperidine stable adducts were generated in duplex DNA that lacked the ability to support a dynamic cross-linking observed previously with acridine conjugates. Minor reaction at guanine N7, the site of reversible reaction, was retained by a monofunctional quinone methide-polyammonium ion conjugate, but a bisfunctional analogue designed for tandem quinone methide formation modified guanine N7 in only single-stranded DNA. The resulting intrastrand cross-links were sufficiently dynamic to rearrange to interstrand cross-links. However, no further transfer of adducts was observed in duplex DNA. An alternative design that spatially and temporally decoupled the two quinone methide equivalents neither restored the dynamic reaction nor cross-linked DNA efficiently. While di- and triammonium ion conjugates successfully enhanced the yields of cross-linking by a bisquinone methide relative to a monoammonium equivalent, alternative ligands will be necessary to facilitate the migration of cross-linking and its potential application to disrupt DNA repair.

Lessons learned from ramping up a Canadian Take Home Naloxone programme during a public health emergency: a mixed-methods study.

OBJECTIVES: This study describes the 2016 expansion of the British Columbia Take Home Naloxone (BCTHN) programme quantitatively and explores the challenges, facilitators and successes during the ramp up from the perspectives of programme stakeholders. DESIGN: Mixed-methods study. SETTING: The BCTHN programme was implemented in 2012 to reduce opioid overdose deaths by providing naloxone kits and overdose recognition and response training in BC, Canada. An increase in the number of overdose deaths in 2016 in BC led to the declaration of a public health emergency and a rapid ramp up of naloxone kit production and distribution. BCTHN distributes naloxone to the five regional health authorities of BC. PARTICIPANTS: Focus groups and key informant interviews were conducted with 18 stakeholders, including BC Centre for Disease Control staff, urban and rural site coordinators, and harm reduction coordinators from the five regional health authorities across BC. PRIMARY AND SECONDARY OUTCOME MEASURES: Take Home Naloxone (THN) programme activity, qualitative themes and lessons learnt were identified. RESULTS: In 2016, BCTHN responded to a 20-fold increase in demand of naloxone kits and added over 300 distribution sites. Weekly numbers of overdose events and overdose deaths were correlated with increases in THN kits ordered the following week, during 2013-2017. Challenges elicited include forecasting demand, operational logistics, financial, manpower and policy constraints. Facilitators included outsourcing kit production, implementing standing orders and policy changes in naloxone scheduling, which allowed for easier hiring of staff, reduced paperwork and expanded client access. CONCLUSION: For THN programmes preparing for potential increases in naloxone demand, we recommend creating an online database, implementing standing orders and developing online training resources for standardised knowledge translation to site staff and clients.

Building Biological Flashlights: Orthogonal Luciferases and Luciferins for in Vivo Imaging.

Bioluminescence is widely used for real-time imaging in living organisms. This technology features a light-emitting reaction between enzymes (luciferases) and small molecule substrates (luciferins). Photons produced from luciferase-luciferin reactions can penetrate through heterogeneous tissue, enabling readouts of physiological processes. Dozens of bioluminescent probes are now available and many are routinely used to monitor cell proliferation, migration, and gene expression patterns in vivo. Despite the ubiquity of bioluminescence, traditional applications have been largely limited to imaging one biological feature at a time. Only a handful of luciferase-luciferin pairs can be easily used in tandem, and most are poorly resolved in living animals. Efforts to develop spectrally distinct reporters have been successful, but multispectral imaging in large organisms remains a formidable challenge due to interference from surrounding tissue. Consequently, a lack of well-resolved probes has precluded multicomponent tracking. An expanded collection of bioluminescent probes would provide insight into processes where multiple cell types drive physiological tasks, including immune function and organ development. We aimed to expand the bioluminescent toolkit by developing substrate-resolved imaging agents. The goal was to generate multiple orthogonal (i.e., noncross-reactive) luciferases that are responsive to unique scaffolds and could be used concurrently in living animals. We adopted a parallel engineering approach to genetically modify luciferases to accept chemically modified luciferins. When the mutants and analogs are combined, light is produced only when complementary enzyme-substrate partners interact. Thus, the pairs can be distinguished based on substrate selectivity, regardless of the color of light emitted. Sequential administration of the luciferins enables the unique luciferases to be illuminated (and thus resolved) within complex environments, including whole organisms. This Account describes our efforts to develop orthogonal bioluminescent probes, crafting custom luciferases (or "biological flashlights") that can selectively process luciferin analogs (or "batteries") to produce light. In the first section, we describe synthetic methods that were key to accessing diverse luciferin architectures. The second section focuses on identifying complementary luciferase enzymes via a combination of mutagenesis and screening. To expedite the search for orthogonal enzymes and substrates, we developed a computational algorithm to sift through large data sets. The third section features examples of the parallel engineering approach. We identified orthogonal enzyme-substrate pairs comprising two different classes of luciferins. The probes were vetted both in cells and whole organisms. This expanded collection of imaging agents is applicable to studies of immune function and other multicomponent processes. The final section of the Account highlights ongoing work toward building better bioluminescent tools. As ever-brighter and more selective probes are developed, the frontiers of what we can "see" in vivo will continue to expand.

Characterizing the inpatient care of young adults experiencing early psychosis: A medical record review.

AIM: To characterize the inpatient care received by individuals experiencing early psychotic episodes in an inner city hospital. METHOD: Medical records of patients admitted between April 01, 2013, and March 31, 2015, to a psychiatric ward at an inner city hospital were retrospectively examined. Included in the study are patients who were 25 years of age or younger and were hospitalized for psychotic symptoms. Demographics and health service use were summarized using descriptive statistics. RESULTS: A total of 73 inpatients (mean age = 22; males =78%; Caucasian = 41%) met the study inclusion criteria with a combined total of 102 care episodes and an average length of stay of 32.6 days. Monitoring of vital signs (VS) and mental status examinations (MSE) were performed in most care episodes although these were not performed regularly (daily VS checks-31%; MSE every nursing shift-18.6%). In 49% of the care episodes, patients were discharged on long-acting injectable antipsychotics. Even when indicated, not all care episodes had follow-up appointments (82.8%) in the community. The use of seclusion was higher in the wards (32%) than in the emergency department (21%), whereas the use of restraints was higher in the emergency department (16%) than in the wards (<1%). CONCLUSIONS: There is wide variation in the rate at which various clinical care processes are performed and in the provision of inpatient care to younger adults experiencing episodes of early psychosis. Consistent standards of care are needed to reduce variations and improve treatment outcomes and experiences.

Hemostatic and Absorbent PolyHIPE-Kaolin Composites for 3D Printable Wound Dressing Materials.

A novel hemostatic and absorbent wound dressing material compatible with 3D printing is developed to address deficiencies in current wound dressing protocol. The design involves an open celled, microporous hydrogel foam via a high internal phase emulsion (HIPE) template with biocompatible components and tunable hemostatic character by kaolin loading, the viscosity and cure kinetics of which are tailored for 3D printing applications. The use of nontoxic mineral oil organic phase results in cytocompatability with human dermal fibroblasts. Kaolin distribution is shown by X-ray diffraction and elemental dispersive spectroscopy to be exfoliated and dispersed in the hydrogel dressing. In addition to demonstrating high fluid absorption and noncytotoxicity of relevant cell lines, the high internal phase emulsion polymers (polyHIPEs) also match the hemostatic performance of commercial wound dressing materials. Furthermore, the polyHIPEs display the requisite rheological properties for 3D printing that result in the fabrication of a prototype dressing with hierarchical porosity and a large number of controllable form factors.

Diverted Total Synthesis of Promysalin Analogs Demonstrates That an Iron-Binding Motif Is Responsible for Its Narrow-Spectrum Antibacterial Activity.

Promysalin is a species-specific Pseudomonad metabolite with unique bioactivity. To better understand the mode of action of this natural product, we synthesized 16 analogs utilizing diverted total synthesis (DTS). Our analog studies revealed that the bioactivity of promysalin is sensitive to changes within its hydrogen bond network whereby alteration has drastic biological consequences. The DTS library not only yielded three analogs that retained potency but also provided insights that resulted in the identification of a previously unknown ability of promysalin to bind iron. These findings coupled with previous observations hint at a complex multifaceted role of the natural product within the rhizosphere.