Introduction Chronic elemental mercury (Hg0) toxicity from subcutaneous or intravenous deposits is a rare phenomenon. We report a case of mercury toxicity following injection in the leg, resulting in elevated mercury concentrations that we monitored over two years in an outpatient toxicology clinic.Case A 57-year-old male presented with neurologic symptoms after elemental mercury injection. Initial urine and blood mercury were 245 mcg/L and 560 mcg/L, respectively. After surgical debridement and chelation, he was discharged with persistent neuropathy. He completed four courses of succimer over six months for ongoing neurologic symptoms. After 16 months without follow-up, he returned with progressive nausea and vomiting. After a fifth course of succimer, his urine mercury concentration was 128 mcg/L with little improvement in his symptoms.Discussion Toxicity from subcutaneous and intravascular elemental mercury can be prolonged. This case describes a patient with a large mercury body burden who received intermittent chelation with uncertain effectiveness and minimal clinical symptoms. Our findings suggest that chronic parenteral mercury exposure may only result in mild symptoms. They may also suggest that chelation therapy has limited long-term effectiveness for managing mercury toxicity from retained deposits.

Hospitalization provides an opportunity to improve the Hepatitis C Virus (HCV) cascade of care among people who inject drugs. Little is known about whether this potential opportunity is utilized. We conducted a retrospective chart review at four U.S. academic medical centers among patients hospitalized between 1/1/2018-3/ 31/2022 with ICD-10 diagnosis codes for both opioid use disorder and acute bacterial or fungal infection. Electronic medical records were reviewed manually to confirm injection drug use-related infection for inclusion in the study. Data abstracted from medical records included baseline HCV status at the time of admission; whether HCV antibody screening and confirmatory viral load testing were performed during hospitalization, and their results; follow up for HCV treatment within the same medical system after discharge; and response to treatment. A total of 1651 patients were included. Seventy-five percent of patients with unknown HCV status at the time of admission were screened for HCV during hospitalization, of whom 66% screened positive. Of those with a confirmatory ribonucleic acid (RNA) test, 62% had a detectable viral load (VL). Seventeen percent of those with detectable VL attended a follow up appointment within 12 months. Fifty-five percent of patients with known prior HCV infection were RNA tested, and 65% of those tested had detectable virus. Results revealed sizeable attrition along the entire HCV cascade of care and missed opportunities to engage people who inject drugs in follow up during hospitalization for other infections. Hospitalized individuals who inject drugs need targeted interventions to improve HCV screening, diagnosis, and care linkage.

Objectives Efforts to improve substance use disorder (SUD) care in the emergency department (ED) include deploying peer recovery coaches (PRCs). PRCs operate through a window of lived experience, providing motivational interviewing and linkage to recovery resources. This may include placement into residential treatment, which can be difficult from the ED given time constraints. We describe a novel clinical decision unit (CDU) pathway wherein PRCs facilitated discharge to residential SUD treatment. Methods We performed a retrospective analysis of patients presenting to a single hospital between June 2023 and May 2024. The sample was drawn from the consult list of PRCs. Data were obtained through direct export and manual extraction from the medical record. We performed χ2 analyses to evaluate the effect of patient factors on pathway success. Results In total, 75 encounters were included: 49 men (65.3%), 26 women (34.7%); age range, 18 to 69 years (median, 45 years). Forty-nine (65.3%) encounters were identified as Black, 19 (25.3%) as White, and 7 (9.3%) as other; 24 (32%) had a primary ED diagnosis related to substance use, and 38 (50.6%) had a primary psychiatric diagnosis (eg, suicidal ideation). PRCs placed 53 patients (70.6%) in residential treatment. Three patients had a change in clinical status and were admitted to the hospital. Median CDU length of stay was 27 hours (IQR, 21-44 hours). Forty-five (85%) of those placed were insured. Of the 15 uninsured patients, 8 (53%) were placed. No differences in pathway success were observed based on race, insurance status, or primary substance used. The pathway was more successful for men than for women (difference between groups, 34%; 95% CI, 10%-56%). The most common reason for pathway failure was patient-directed discharge (10 [45.5%] pathway failures). Conclusion In this CDU pathway, PRCs were able to place the majority of patients into residential SUD treatment. Further study is required to examine long-term patient outcomes.

Octreotide is used to treat sulfonylurea induced hypoglycemia, but the effectiveness of intravenous bolus, intravenous infusion, and subcutaneous routes of octreotide administration has not been compared. This is a multi-center, retrospective chart review of patients with suspected sulfonylurea induced hypoglycemia who received octreotide, comparing intravenous bolus, intravenous infusion, and/or subcutaneous routes of octreotide administration. The primary outcome was number of hypoglycemic events after octreotide initiation. Secondary outcomes included total octreotide dose, dextrose administered before and after first octreotide dose, and hospital length of stay. Of 29 included cases, the intravenous bolus group had 10 patients, intravenous infusion group had four patients, and the subcutaneous group had 15 patients. Median post-octreotide hypoglycemic events were zero, 1.5, and zero for bolus, infusion, and subcutaneous groups, respectively. Median total octreotide dose was 50 mcg [IQR: 49 - 100 mcg], 693 mcg [IQR: 402 – 939 mcg], and 100 mcg [IQR: 50 – 150 mcg] for bolus, infusion, and subcutaneous groups, respectively. The bolus (115 grams [41 – 152 grams]) and subcutaneous groups (80 grams [53 – 189 grams]) received less post-octreotide dextrose than the infusion group (256 grams [86 – 560 grams]). Median length was 40, 60, and 62 hours between the bolus, infusion, and subcutaneous groups, respectively. The infusion group had a higher incidence of hypoglycemia and received more post-octreotide dextrose than intravenous bolus or subcutaneous groups, despite a larger total octreotide dose. These findings suggest octreotide infusions may be inferior, but further studies are needed to determine the optimal octreotide administration route for sulfonylurea induced hypoglycemia.

Clandestine fentanyl manufacturing oftentimes introduces adulterants and contaminants. This article aims to evaluate trends in adulterants from a cohort of patients presenting to the emergency department (ED) with illicit opioid overdose across the United States. The Fentalog Study group is a multicenter toxicology study group which evaluated ED patients with suspected opioid overdose at 10 medical centers across the United States between 21 September 2020 through 5 February 2024. Comprehensive qualitative toxicology testing was performed on residual serum specimens. Study sites were divided into three geographic regions: West (California, Oregon, Colorado), Midwest (Missouri, Michigan), and East (New York, New Jersey, Pennsylvania, Georgia). Illicit opioids were defined as fentanyl and fentanyl analogs, heroin or its metabolites, and/or novel potent opioids such as nitazenes. 1295 patients with confirmed illicit opioid overdose were included. Males accounted for the majority (73.7%) of patients. The median age was 39 (IQR: 31-54) years. Adulterants were detected in 745 (57.5%) patients. Quinine was the most abundantly encountered adulterant (433; 33.4%). Antihistamines were the most frequently detected class of adulterants (19.6%). There were significant differences in adulterants detected across the three time periods, with notable decreases in adulterants from time-period 1 (79.5%) to time-period 3 (41.7%; P < .001). Adulterants were found in 84 (27.0%) of patients that presented to a hospital in the Western United States, compared with 181 (24.3%) in the Midwest, and 480 (64.4%) of patients in the East (P < .001). Patients with concurrent cocaine were more likely having an adulterant present than those without cocaine present (OR 1.23; 95% CI 1.15-1.31). In contrast, patients with illicit opioids and concurrent methamphetamine were less likely to have adulterants present (OR 0.89; 95% CI 0.84-0.95). Adulteration of illicit opioids was more likely in the Eastern United States and for those with concurrent cocaine and opioid exposures.

OBJECTIVES:People who inject drugs (PWID) face elevated risks of hospitalizations and readmissions due to serious injection-related infections, yet few evidence-based interventions exist to prevent readmissions. This study aimed to explore factors contributing to rehospitalization among PWID, potential strategies, and assess the acceptability of 2 proposed interventions and implementation considerations. METHODS:We conducted 22 semistructured interviews with 36 health care providers and staff across 4 study sites in Georgia, Maryland, the District of Columbia, and West Virginia from June 2023 to September 2023. Participants were purposively sampled to represent diverse roles in providing or overseeing care to PWID. Interviews explored barriers to care, challenges contributing to rehospitalization, and perceptions of 2 proposed interventions: (1) integrated care for addiction and infectious diseases, and (2) patient navigation to support linkage to care postdischarge. Data were analyzed using rapid qualitative analysis informed by framework and thematic approaches. RESULTS:Three main themes emerged regarding rehospitalization factors (unaddressed structural, health system, and social determinants; gaps in addiction care training; and continuity of care). Participants expressed high acceptability toward the proposed interventions. Three main themes emerged as recommendations for the implementation of the proposed interventions (organizational needs and capacity; leveraging existing resources; patient engagement and retention). CONCLUSIONS:Reducing readmissions among PWID requires addressing provider training gaps, care fragmentation, and structural barriers. Both proposed interventions were deemed acceptable by health care team members. Key implementation factors include strengthening organizational capacity, leveraging existing resources effectively, and using person-centered approaches to build trust and maintain patient engagement and retention.

BACKGROUND:Simultaneous exposure to both benzodiazepines and opioids can lead to synergistic respiratory depression, complicating overdose management. Our objective was to report on the detection of prescription and novel benzodiazepine co-exposures among patients treated in emergency departments (EDs) with suspected opioid overdoses. We aimed to describe novel benzodiazepine exposures in this population and to compare the clinical severity of co-exposure to benzodiazepines and opioids versus opioids alone. METHODS:This study utilized data from the Toxicology Investigators Consortium (ToxIC) Fentalog Study, an observational study at 10 ED sites (Sept 2020-Dec 2023). Waste serum samples were analyzed using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) for the presence of over 1200 novel psychoactive substances (NPS), drugs, therapeutics, and metabolites. Analyses included demographics, clinical severity, and outcomes among those with prescription benzodiazepines, novel benzodiazepines, or no benzodiazepines. RESULTS:Among the patients with opioids present (n = 1427), 29.0% of patients had detectable benzodiazepines. 20.5% of patients had detectable prescription benzodiazepines, and 8.5% of patients had detectable novel benzodiazepines. The most commonly detected prescription benzodiazepine was alprazolam (39.3%); the most common novel benzodiazepine was bromazolam (46.3% of novel benzodiazepines). The median age of those with novel benzodiazepines was 34, which was younger than those without benzodiazepines (40) and those with prescription benzodiazepines (41; p = 0.001). Patients without benzodiazepines received naloxone more frequently (p = 0.02), while novel benzodiazepine co-exposure was associated with higher naloxone nonresponse rates (p = 0.03). Patients with novel benzodiazepines (compared to the opioid-only group) had increased odds of requiring mechanical ventilation (aOR: 2.14; 95% CI: 1.07, 4.05) after adjusting for age, gender, race and ethnicity, and the presence of prescription benzodiazepines and/or fentanyl. CONCLUSIONS:Nearly a third of patients with confirmed opioid overdose presenting to the ED also had concomitant benzodiazepine exposures. Those with novel benzodiazepines had significantly higher odds of intubation, suggesting greater severity of overdose.

Abstract Background Injection-related skin ulcers (IRSU) are a cause of acute bacterial infection among people who inject drugs (PWID). We aimed to measure the prevalence, characteristics, and risk factors for IRSU, and the risk of readmission, among a cohort of PWID hospitalized for infections. Table 1 SD, standard deviation. Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized at four healthcare systems with infections due to injection opioid use between 1/1/2018 and 3/31/2022. Data were collected by abstraction of the electronic medical record and were analyzed by chi-square, multivariable logistic regression, and unpaired t-test. Factors statistically significant for IRSU in bivariate analysis were examined by multivariate logistic regression. Detailed data on IRSU were recorded from the Baltimore site. Table 2 GWU, George Washington University; MOUD, medication for opioid use disorder; UMB, University of Maryland Baltimore; WVU, West Virginia University. Results Of 1652 included patients, 221 (13%) had a documented IRSU. Key demographics were similar between those with and without IRSU (Table 1). The odds of IRSU were higher among those who were positive for fentanyl and older age (Table 2). Baseline IRSU was associated with increased odds of readmission (aOR 1.4, p = 0.02) and a greater number of readmissions within 1 year (1.2 v. 0.9, p = 0.01, Figure 1). Among 116 patients from Baltimore with documented IRSU and detailed data, IRSU was the primary reason for admission in 66%. Xylazine use was not noted in any records. Most patients had < 4 ulcers and ulcers < 10 cm. 13% of patients received sharp debridement and 6% were treated with limb amputation. IRSU was more frequently addressed in the discharge note if IRSU was the primary reason for admission (71% v 50%, p < 0.05). Only 16 (14%) patients were advised or scheduled to attend an outpatient wound care appointment; only 3 (3%) did so within 30 days of discharge (Figure 2). Figure 1 **, p=0.01. Conclusion Among PWID hospitalized for infection, IRSU were common, especially among older patients and those testing positive for fentanyl. Xylazine exposure was likely under-assessed. Importantly, IRSU was associated with an increased risk of hospital readmission, but outpatient planning and follow up were rare. Clinicians caring for PWID must address IRSU alongside other infectious diseases, addiction, and harm reduction interventions. Figure 2 Discharge planning and outpatient care within 30 days of discharge. DC, discharge; *, p=0.048) Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Abstract Background People who inject drugs have high rates of patient directed discharge (PDD). In a cohort of patients hospitalized for serious injection related infections (SIRI), we aimed to assess the factors leading to PDD and the influence of PDD on rehospitalization. Characteristics of study participants Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized at four healthcare systems with SIRI due to injection opioid use between 1/1/2018 and 3/31/2022. Data were collected by abstraction of the electronic medical record and were analyzed by chi-square and multivariable logistic and linear regression. Factors associated with patient directed discharge Results Of 1645 patients, 1180 (72%) had a planned discharge and 465 (28%) had a PDD. PDD was associated with younger age (p< 0.001), white race (p=0.018), and documented opioid withdrawal (p< 0.001). PDD was less likely in patients on medication for opioid use disorder (MOUD) during hospitalization (p< 0.001) or who received consultations by infectious diseases (p< 0.001), social work (p=0.04), or addiction medicine (p=0.003). Compared to those with planned discharge, patients with PDD were less likely to have completed antibiotics at the time of discharge (7% vs 60%; p< 0.001), and 64% left without a plan for antibiotic completion. Patients with PDD were more likely to be readmitted within a year (57% vs 52%; p=0.015), and more likely to have a first readmission due to an infection (81% vs 56%; p< 0.001). Time to readmission was significantly shorter among patients with PDD (15 vs 65d; -41.5 days, p< 0.001). Post-Hospitalization Antibiotic Plan by Discharge Status Conclusion Among people hospitalized with SIRI, we found high rates of PDD associated with insufficient treatment of OUD, evidenced by withdrawal, lack of MOUD, and not receiving an addiction consultation. PDD was consequently associated with higher rates of readmission due to infection and shorter time to readmission, possibly due to discharge without a plan to complete antibiotics. To improve outcomes and reduce readmissions among people with SIRI, efforts to address OUD during hospitalization are crucial, and could reduce PDD. Regardless, given high rates of PDD in this population, strategies to facilitate continuity of antibiotics - including contingency plans for oral or long-acting regimens - may be critical to ensuring resolution of SIRI and improving long-term outcomes. Risk of Readmission within 1-Year Based on Discharge Status Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Abstract Background Harm reduction for persons who inject drugs (PWID) has many components, including HIV testing and Pre-exposure Prophylaxis (PrEP). However, despite the increasing evidence of effectiveness, PrEP remains highly underutilized in these patients at high-risk for infection and subsequent transmission risk to others. Our aim is to identify the gaps in HIV prevention care among a hospitalized PWID population.Table 1:Demographics and Clinical Characteristics Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized with infectious complications of active injection opioid use between 1/1/2018 and 3/31/2022 at four US medical centers. Data were collected by abstraction of the electronic medical record and analyzed by chi-square and multivariate logistic regression.Table 2:Multivariate Analysis of Factors Associated with HIV Screening Results 1168 (74%) adults with unknown HIV status underwent HIV screening during sentinel admission. For risk comparison, 48% of this cohort had active HCV infection. HIV screening was less likely to occur in PWID who were male (69% vs 78% females), Black (51% vs 78% White), hospitalized < 3 days (56%), on non-medical services (62% vs 75%), and without ID consult (56% vs 79%). Only 3 participants were referred for PrEP, and only 4 initiated PrEP within 1 year of discharge. Additionally, nearly half (49%) of this HIV (-) cohort did not have follow up HIV screening. There were 79 HIV (+) individuals: 66 known HIV (+) and 13 new diagnoses. Forty-five (57%) were on anti-retroviral therapy during hospitalization, 28 (35%) had CD4 < 200, 47 (59%) had detectable viral load, and 49 (62%) were referred for HIV care. However, only 37% were confirmed linked to care. Of those in care, 59% were virally suppressed within 12 months.Table 3:HIV Prevention Outcomes among HIV negative group within 12 months Conclusion In a cohort of high-risk PWID hospitalized with infectious complications of substance use, there were low rates of HIV screening, PrEP initiation, and referrals for treatment in HIV (-) individuals. The lack of PrEP initiation in this study is unsurprising; however, the absence of referring patients suggests a lack of awareness of increased PrEP availability. More concerning are the gaps in HIV screening among this high-risk cohort. Clinicians must capitalize on opportunities to provide this population with tools to reduce their risks, which includes HIV screening and PrEP.Figure 1:HIV Care Cascade Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Importance:There is a disproportionately high rate of overdose deaths immediately following an emergency department (ED) visit for opioid overdose. Thus, an improved understanding of disparities in ED treatment and referral is vital. Racial and ethnic disparities in access to naloxone and buprenorphine have been described in the outpatient setting but prevalence in the ED setting remains understudied. Objective:To examine racial and ethnic disparities in treatment referral rates in ED patients with opioid overdose. Design, Setting, and Participants:This is a secondary analysis of a prospective consecutive cohort from the Toxicology Investigators Consortium (TOXIC) Fentalog Study from September 21, 2020, to November 11, 2023. Ten hospital sites were a part of the TOXIC network and participants included ED patients in aged 18 years or older with opioid overdose. Data were analyzed from December 2022 to March 2025. Exposures:Patient race, ethnicity, sex, and other demographic and clinical factors of interest. Main Outcomes and Measures:Study outcomes included the proportion of patients receiving a referral to outpatient addiction care and the proportion receiving a naloxone kit or prescription or buprenorphine prescription at discharge. Descriptive statistics were tabulated, and χ2 and multivariable logistic regression analyses were used to evaluate for differences by race, ethnicity, sex, and other demographic and clinical variables. Results:In this study, 1683 patients met all inclusion criteria (mean [SD] age, 42.5 [14.5] years; 1221 males [72.6%]; 461 females [27.4%]; 447 Black patients [26.6%]; 63 Hispanic patients [4.3%]; 867 White patients [51.5%]). Of the 1683 included patients, 299 (17.8%) received a referral for outpatient treatment, 713 (42.4%) received a naloxone kit or prescription, and 141 (8.4%) received a buprenorphine prescription. Compared with White patients, Black patients had a decreased adjusted odds ratio (aOR) of outpatient treatment referral (aOR, 0.67; 95% CI, 0.47-0.97). Hospital admission was also associated with increased adjusted odds of outpatient treatment referral (aOR, 3.13; 95% CI, 2.34-4.20). Geographic variation was associated with all primary and secondary outcomes. Conclusions and Relevance:In this study, Black patients were less likely to receive outpatient referrals for OUD. These findings underscore the need for targeted interventions to address racial disparities in ED care for OUD, particularly in enhancing referral processes.

Abstract Background Oral (PO) antibiotics are a convenient alternative to parenteral antibiotics and decrease the need for inpatient care. Increasing evidence shows PO antibiotics are effective even in severe infections. We aim to assess PO antibiotic use among hospitalized people who inject drugs (PWID). Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized at four healthcare systems with infections resulting from injection opioid use between 1/1/2018 and 3/31/2022. Data were collected by abstraction of the electronic medical record. Patients were categorized by intended route of the antibiotic course. Data were analyzed by the chi-square test, Fisher’s exact test, and multivariate logistic regression. PO, oral; SSTI, skin and soft tissue infection. Results 1631 patients had an intended treatment plan with either PO (17%) or parenteral (83%) (intravenous, long-acting infusion, or other) antibiotics (Table 1). There was no difference in PO antibiotic use based on gender or unstable housing. PO antibiotics were more likely to be used when planned antibiotic duration was ≤2 weeks (p< 0.0001) and when only skin and soft tissue infection (SSTI) was present (p< 0.0001, Table 2). Alternatively, infectious disease consultation was associated with lower use of PO antibiotics (p< 0.0001). From 2018 to 2022, PO antibiotic use decreased (p< 0.0001, chi-square for trend, Figure 1). Those treated with PO antibiotics were less likely to have ID follow-up scheduled (p=0.0002) and less likely to attend ID follow up (p=0.0024, Figure 2). PO, oral. Conclusion PO antibiotics were rarely used in this large multisite cohort of PWID, especially for infections other than SSTI. Surprisingly, use decreased over the study period, despite emerging evidence for PO antibiotics in complex infections for people who do not inject drugs. PWID with complex infections require long courses of antibiotics, but face barriers to prolonged hospitalization and outpatient infusions due to underinsurance, unstable housing, and untreated addiction. PO antibiotics may facilitate antibiotic completion while reducing patient-directed discharge, and therefore are likely underutilized for PWID. PO, oral. Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Prepulse inhibition (PPI) is a measure of sensorimotor filtering thought to shield the processing of initial weaker auditory stimuli from interruption by a later startle response. Previous studies have shown smoking withdrawal to have a negative impact on sensorimotor filtering, particularly in individuals with psychopathology. Because tobacco use may alleviate sensory and sensorimotor filtering deficits, we examined whether smoking withdrawal-induced changes in PPI were associated with maintenance of smoking abstinence in trauma-exposed individuals with and without PTSD who were attempting to quit smoking. Thirty-eight individuals (n = 24 with current or past PTSD; 14 trauma-exposed healthy controls) made an acute biochemically-verified smoking cessation attempt supported by 8 days of contingency management (CM) and cognitive behavioral therapy (CBT) for smoking. Participants completed a PPI task at the pre-quit baseline, 2 days post-quit, and 5 days post-quit. Post-quit changes in PPI were compared between those who remained abstinent for the first 8-days of the quit attempt and those who lapsed back to smoking. PPI changes induced by biochemically-verified smoking abstinence were associated with maintenance of abstinence across the 8-day CM/CBT-supported quit attempt. As compared to those who maintained tobacco abstinence, participants who lapsed to smoking had significantly lower PPI at 2 and 5 days post-quit relative to baseline. Thus, among trauma-exposed individuals, decreases in PPI during acute smoking cessation supported by CM/CBT are associated with lapse back to smoking. Interventions that improve PPI during early smoking abstinence may facilitate smoking cessation among such individuals who are at high risk for chronic, refractory tobacco use.

Although negative autobiographical memories play a defined etiological role for trauma-related disorders, it is less clear what role they play in other anxiety-related disorders. Understanding the prevalence of negative autobiographical memories that are conceptually related to a patient’s symptoms (i.e., symptom-relevant negative autobiographical memories; SNAMs) in anxiety-related disorders may help inform the development of novel memory-based interventions. The current scoping review examined the prevalence of SNAMs in anxiety disorders and obsessive-compulsive disorder, including SNAMs that were reported to have occurred around symptom onset (i.e., Symptom Onset SNAMs) and SNAMs that were reported to have occurred at any time (i.e., Lifetime SNAMs). Lifetime SNAMs also included a subcategory of SNAMs associated with intrusive imagery. The relationship of the presence of SNAMs to symptom onset, disorder status, and symptom severity was also examined. A systematic search identified 39 relevant articles. The prevalence of Symptom Onset SNAMs assessed by the Phobic Origins Questionnaire, interviews, and the Origins Questionnaire ranged from 30-89% (IQR = 50-68.5%; samples = 23), 23-61% (IQR = 30-49%; samples = 11), and 17-37% (samples = 6), respectively. The prevalence of Lifetime SNAMs ranged from 89-100% (samples = 6) and Intrusive Imagery-Related Lifetime SNAMs ranged from 38-100% (IQR = 60.5-79%; samples = 12). Five of 14 studies observed a significantly higher rate of SNAMs in patient relative to control samples. Findings are discussed with regard to limitations of the current evidence and future research that can inform the value of targeting SNAMs in treatment.

Identifying biomarkers and candidate mechanisms underlying psychological disorders represents an intriguing path toward improving treatments. The promise of this line of research is twofold. First, it can facilitate a more targeted approach to treatment by enabling interventions to specifically target the mechanisms responsible for changes in psychological dysfunction, thereby leading to more potent and personalized interventions. Second, the presence or absence of change in a biomarker or mechanism during treatment may serve as a prognostic indicator of treatment response or maintenance of gains, with the potential to be a more sensitive indicator of clinical change than alternative measures and to inform clinical decision making (e.g., whether to continue or alter treatment approach). Importantly, the evidence that must be accumulated to establish a potential biomarker as a prognostic indicator or targetable mechanism of change is substantial, and the successful translation of biological and other basic research into improved interventions has been somewhat limited ( 1 Ehring T. Limburg K. Kunze A.E. Wittekind C.E. Werner G.G. Wolkenstein L. et al. (When and how) does basic research in clinical psychology lead to more effective psychological treatment for mental disorders?. Clin Psychol Rev. 2022; 95102163 Crossref Scopus (5) Google Scholar ). Nonetheless, the research by Hoge et al. ( 2 Hoge E.A. Armstrong C.H. Mete M. Oliva I. Lazar S.W. Lago T.R. Grillon C. Attenuation of anxiety-potentiated startle after treatment with escitalopram or mindfulness meditation in anxiety disorders. Biol Psychiatry. 2024; 95: 85-92 Abstract Full Text Full Text PDF Google Scholar ) in the current issue of Biological Psychiatry investigates many of the initial questions required for evaluating a candidate mechanism of change (Figure 1), specifically regarding anxiety-potentiated startle (APS) and fear-potentiated startle (FPS). The results raise critical questions that must be addressed to move this line of research forward, particularly related to linking biological constructs and clinical outcomes. SEE CORRESPONDING ARTICLE ON PAGE 85 SEE CORRESPONDING ARTICLE ON PAGE 85 Attenuation of Anxiety-Potentiated Startle After Treatment With Escitalopram or Mindfulness Meditation in Anxiety DisordersBiological PsychiatryVol. 95Issue 1PreviewBiological markers for anxiety disorders may further understanding of disorder pathophysiology and suggest potential targeted treatments. The fear-potentiated startle (FPS) (a measure of startle to predictable threat) and anxiety-potentiated startle (APS) (startle to unpredictable threat) laboratory paradigm has been used to detect physiological differences in individuals with anxiety disorders compared with nonanxious control individuals, and in pharmacological challenge studies in healthy adults. Full-Text PDF