Mortality, morbidity, and cardiac surgery in Injection Drug Use (IDU)-associated versus non-IDU infective endocarditis: The need to expand substance use disorder treatment and harm reduction services.

BACKGROUND: The addiction crisis is widespread, and unsafe injection practices among people who inject drugs (PWID) can lead to infective endocarditis. METHODS: A retrospective analysis of adult patients with definite or possible infective endocarditis admitted to a tertiary care center in Portland, Maine was performed over three-year period. Our primary objective was to examine differences in demographics, health characteristics, and health service utilization between injection drug use (IDU)-associated infective endocarditis and non-IDU infective endocarditis. The association between IDU and mortality, morbidity (defined as emergency department visits within 3 months of discharge), and cardiac surgery was examined. Bivariate and multivariate analyses were performed. A subgroup descriptive analysis of PWID was also performed to better examine substance use disorder (SUD) characteristics, treatment with medication for opioid use disorder (MOUD) and health service utilization. RESULTS: One-hundred and seven patients were included in the study, of which 39.2% (n = 42) had IDU-associated infective endocarditis. PWID were more likely to be homeless, uninsured, and lack a primary care provider. PWID were notably younger and had less documented comorbidities, however had similar in-hospital mortality rates (10% vs. 14%, p = 0.30), ED visits (50% vs. 54%, p = 0.70) and cardiac surgery (33% vs. 26%, p = 0.42) compared to those with non-IDU infective endocarditis. Ninety-day mortality was less among PWID (19.0% vs. 36.9%, p = 0.05). IDU was not associated with morbidity (adjusted odds ratio (AOR) 0.73, 95% CI 0.18-3.36), 90-day mortality (AOR 0.72, 95% CI 0.17-3.01), or cardiac surgery (AOR 0.15, 95% CI 0.03-0.69). Ninety-day mortality among PWID who received MOUD was lower (3% vs 15%, p = 0.45), as were ED visits (10% vs. 41%, p = 0.42) compared to those who did not receive MOUD. CONCLUSIONS: Our results highlight existing differences in health characteristics and social determinants of health in people with IDU-associated versus non-IDU infective endocarditis. PWID had less comorbidities and were significantly younger than those with non-IDU infective endocarditis and yet still had similar rates of cardiac surgery, ED visits, and in-hospital mortality. These findings emphasize the need to deliver comprehensive health services, particularly MOUD and other harm reduction services, to this marginalized population.

Differentiating trauma from taphonomic alterations.

Differentiating traumatic injuries in bone from taphonomic damage in the postmortem period is a complex process requiring a systematic approach. Trauma by definition occurs while the individual is still living, but bone characteristics usually do not allow delineation of the moment of death. Thus, the anthropologist seeks characteristics that will associate a skeletal defect with the perimortem period, at or about the time of death. However, the anthropological designation of perimortem time period does not have precise boundaries. It refers to remains that lack any sign of remodeling or healing on the one hand, and which have not lost biomechanical elasticity and plasticity on the other hand, i.e., it refers to the condition of skeletal remains when they sustained the suspected injury. Fracture patterns that reflect biomechanical plasticity are lost gradually as the time since death increases, and this pace will depend on the environmental context. There are additional clues to identify postmortem status, including when the damaged feature fits a taphonomic pattern of scavenger modification or weathering, or physically overlies obvious postmortem modifications, or when the feature fits a known pattern of sharp force instruments or weapons. Damage due to recovery or the examination process must be ruled out. The timing of occurrence of a suspected perimortem injury can therefore extend for days or weeks into the time before the actual death, and it can extend for days to months after death. The anthropologist responds to the challenge of differentiating trauma and taphonomic modification by knowing the characteristics of healing bone, the features of biomechanical plasticity reflected in fracture morphology, the taphonomic patterns of scavenging and weathering, the environmental context of discovery and recovery, and the characteristics of the relevant regional taphonomy.

Determining spatial access to opioid use disorder treatment and emergency medical services in New Hampshire.

This research presents an analysis of spatial access to both opioid use disorder treatment facilities and emergency medical services in New Hampshire during 2015-2016, a period during which there was a steep increase in unintentional overdoses involving fentanyl. For this research, spatial access was computed using the enhanced two-step floating catchment area model combined with the Huff model to assess access across New Hampshire and gives attention to supply-side parameters that can impact spatial access. The model is designed to measure access to healthcare services for opioid use disorder patients offered at treatment centers or from buprenorphine treatment practitioners, as well as from emergency medical services across New Hampshire. A composite index of accessibility is proposed to represent overall access to these different treatment services for opioid use disorder patients. Geospatial determinants of spatial access included street network distances, driving times and distance decay relationships, while other key factors were services availability and population demand. Among the towns with the highest composite access scores, approximately 40% were metropolitan locations while 16% were rural towns. The insights from this research showed that for this period, while the opioid crisis was impacting many towns in New Hampshire, high levels of access to treatment services were not uniform across the state. When comparing the access results with data on the towns of residence for individuals who died from unintentional overdoses involving fentanyl during 2015 and 2016, estimates found that approximately 40% of the towns were not estimated to be in the highest class of access to treatment services at the time. This research provides information for local public health officials to support planning strategies to address opioid use disorder treatment access in high-risk regions.

Additive Effects of Cointoxicants in Single-Opioid Induced Deaths.

A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.

Adult scurvy in New France: Samuel de Champlain's "Mal de la terre" at Saint Croix Island, 1604-1605.

Diagnosing scurvy (vitamin C deficiency) in adult skeletal remains is difficult despite documentary evidence of its past prevalence. Analysis of 20 European colonists buried at Saint Croix Island in New France during the winter of 1604-1605, accompanied by their leader Samuel de Champlain's eyewitness account of their symptoms, provided the opportunity to document lesions of adult scurvy within a tightly dated historical context. Previous diagnoses of adult scurvy have relied predominantly on the presence of periosteal lesions of the lower limbs and excessive antemortem tooth loss. Our analysis suggests that, when observed together, reactive lesions of the oral cavity associated with palatal inflammation and bilateral lesions at the mastication muscle attachment sites support the differential diagnosis of adult scurvy. Antemortem loss of the anterior teeth, however, is not a reliable diagnostic indicator. Employing a biocultural interpretive approach, analysis of these early colonists' skeletal remains enhances current understanding of the methods that medical practitioners used to treat the disorder during the Age of Discovery, performing rudimentary oral surgery and autopsies. Although limited by a small sample and taphonomic effects, this analysis strongly supports the use of weighted paleopathological criteria to diagnose adult scurvy based on the co-occurrence of specific porotic lesions.

Fingering a murderer: a successful anthropological and radiological collaboration.

We illustrate an interdisciplinary approach to identify a victim in a case with complex taphonomic and procedural issues. Burning, fragmentation, species commingling, and examination by multiple experts required anthropological preparation and analysis combined with radiographic adaptations to image and match trabecular patterns in unusually small, burned specimens. A missing person was last seen in the company of a reclusive female on a remote rural property. A warranted search found several burn sites containing human and animal bones. Fragment preparation, analysis, and development of a biological profile by anthropologists enabled examination by the odontologist, molecular biologist, and radiologist, and justified use of antemortem radiographs from one potential victim. Visual and radiological comparison resulted in a positive (later confirmed) identification of the victim by radiological matches of three carpal phalanges. Although some dimensional changes are expected with burning, morphological details were preserved, aided by selection of relatively intact, small bones for comparison.