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Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done

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theconversation.com – Kory London, Associate Professor of Emergency Medicine, Thomas Jefferson University – 2024-10-16 07:28:00

Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done

Patients suffering withdrawal from fentanyl and xylazine can require intensive care.

SDI Productions/E+ Collection via Getty Images

Kory London, Thomas Jefferson University

Unimaginable pain and restlessness. Vomiting so frequent and forceful that it can perforate the esophagus. Blood pressure and heart rate so high that they damage the heart. Sweating that drenches clothing and sheets. Nerve sensitivity that makes even the softest touch agonizing. A prolonged panic attack that is provoked and worsened by even mundane activities and conversations.

The withdrawal symptoms from “tranq dope” – the combination of the synthetic opioid fentanyl and the animal tranquilizer xylazine that dominates Philadelphia’s street opioids supply – tend to be far worse than those experienced by even the most severe heroin users of the past.

So it’s no surprise that people will do whatever they can to forestall them. That includes walking out of the hospital before their care is complete.

I’m an associate professor of emergency medicine who has spent a decade as an emergency physician working in Center City and South Philadelphia. I’ve spent most of that time directing projects to improve care for people who use drugs.

Beginning in 2022, our team – a group of emergency and addiction physicians – began experimenting with new approaches to treating tranq dope withdrawal.

We were able to reduce the likelihood of these patients leaving the hospital before treatment was complete by more than half – from 10% to just under 4%.

We also reduced the severity of their suffering, lowering their withdrawal scores – or how they rate their pain and other symptoms – by more than half.

Traditional treatments don’t work

Before tranq dope, treating opioid withdrawal in the emergency department was relatively straightforward, with well-studied, conventional protocols.

For patients without chronic pain, health care providers started buprenorphine, known by its brand name Suboxone, when patients showed signs of withdrawal.

Buprenorphine works by partially, rather than fully, stimulating opioid receptors in the body. This subtle difference relieves symptoms of withdrawal but reduces the risk of overdose if patients continue to use other opioids. It quite literally saves lives.

Tranq dope, however, created a much larger set of challenges.

Fentanyl and other synthetic opioids are dozens to hundreds of times more powerful than heroin. Xylazine, meanwhile, adds symptoms of sedative withdrawal to the mix: restlessness, adrenaline activation and agitation.

As synthetic opioids became pervasive in Philadelphia’s drug supply over the past decade, overdose deaths in the city tripled. Those numbers are beginning to decline, for reasons that remain unclear.

Torso of person wearing black tank top and dirty bandage from bicep to wrist

Fear of withdrawal can even prevent people with serious medical conditions from going to the hospital.

Jeff Fusco/The Conversation US, CC BY-ND

Meanwhile, tranq users started to share buprenorphine horror stories. They refused the medication due to a phenomenon called “precipitated withdrawal.” Precipitated withdrawal is a condition in which taking buprenorphine paradoxically makes withdrawal symptoms worse, rather than improving them. Due to the severity of their symptoms, some patients who precipitate severely even require treatment in the intensive care unit.

Furthermore, when patients did accept buprenorphine, their withdrawal symptoms were no longer being effectively controlled, even with very high doses. We were adrift.

Patients demand discharge

When people with severe substance use disorders are hospitalized, even compassionate staff members sometimes lose patience.

Being confined to a stretcher in a loud, chaotic environment, in withdrawal, with prior traumatic health care experiences, can lead patients to act out. They might repeatedly hit call bells, use inappropriate language, make impulsive decisions or sneak drugs into the hospital.

This creates a lot of stress for nurses and staff, and distracts from the care of others.

So when patients demand to leave before treatments are complete, exhausted care teams often quickly acquiesce. Traditionally, this was termed leaving “against medical advice,” but is now called “patient-directed discharge.”

Patient-directed discharge is associated with higher rates of mortality, permanent disability and rehospitalization.

Rates of patient-directed discharge can be 10 to 50 times higher in people with an opioid use disorder compared with the general public.

A cycle of mistrust can also form, where the expectation that a patient may leave again leads to a less engaged care team, which in turn can make patients more likely to leave.

At staff meetings, some compared the challenges of caring for these individuals to those experienced in the hardest parts of the COVID-19 pandemic.

New approach needed

Many physicians have been reticent to consider other options for treating opioid withdrawal. I believe there are two key reasons for this. One is the lack of Food and Drug Administration approval for alternative treatments. The other is that federal regulations consider addiction a behavioral rather than medical condition, effectively separating most doctors from the addiction care of these individuals.

As fentanyl and xylazine became ubiquitous in Philadelphia’s street dope, local hospitals reported astronomical rates of patient-directed discharge among these patients. This was happening despite the best efforts of hospital staffs that are deeply experienced in conventional opioid withdrawal treatment.

In 2021, an editorial in the Annals of Internal Medicine journal advocated for the use of short-acting opioids for some patients’ opioid withdrawal – which is already common practice in Canada. Short-acting opioids are medications doctors traditionally use to treat acute pain.

Philadelphia hospitals started experimenting with using these previously verboten medications. That included our team at Jefferson Health.

Under a bridge, a person crouches under a blanket in the foreground and two people talk in background

Overdose deaths in Philadelphia spiked as fentanyl and xylazine became more prevalent.

Jeff Fusco/The Conversation US, CC BY-ND

Oxycodone, hydromorphone and ketamine

By using short-acting opioids such as oxycodone or hydromorphone, combined with a low-dose version of buprenorphine, we prevented precipitated withdrawal and treated opioid withdrawal and pain in our patients.

The low-dose bupenorphine can be increased over time to steady doses. This shows patients that the medication is safe and provides them a bridge to long-term treatment.

The short-acting opioids replace the opioids that their bodies are frantically searching for. They reduce their pain and misery, and are decreased when their symptoms are controlled.

Patients with opioid use disorder will often do whatever they can to stay out of the hospital due to fear of withdrawal. Asking how withdrawal symptoms are managed, therefore, is often their first priority when hospitalized. We see this even when they have conditions that require complicated and time-sensitive treatments.

Owing to the vast amounts of opioids many of our patients use, we also give them additional strong medications, or “adjunctive therapies,” to supplement the effects of the short-acting opioids and low-dose buprenorphine. One is ketamine, an anesthetic that affects nerve impulses and is increasingly being used to treat depression, post-traumatic stress discorder and substance use disorders.

Ketamine is also an effective pain medication that can extend the effects of opioids and reduce the number of doses needed.

We additionally add muscle relaxants – which work similarly to xylazine – along with nausea medications and IV fluids, to help give patients a chance at healing.

Side effects and future problems

In patients who received our medications, the risks of serious side effects were minimal. The few patients who suffered serious adverse effects had other acute medical problems that could have contributed to the side effects. Almost all the side effects we saw were mild and resolved on their own.

As powerful synthetic opioids and other contaminants become pervasive in more U.S. cities, more emergency departments will need to figure out how to care for patients in withdrawal so that they don’t leave treatment.

It is our hope that this work will inspire others to do a better job of providing relief to patients suffering from this complicated and severe condition.The Conversation

Kory London, Associate Professor of Emergency Medicine, Thomas Jefferson University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Out-of-balance bacteria is linked to multiple sclerosis − the ratio can predict severity of disease

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theconversation.com – Ashutosh Mangalam, Associate Professor of Pathology, University of Iowa – 2025-03-03 14:03:00

Out-of-balance bacteria is linked to multiple sclerosis − the ratio can predict severity of disease

The myelin sheaths insulating neurons are damaged in multiple sclerosis.
Steve Gschmeissner/Science Photo Library/Brand X Pictures via Getty Images

Ashutosh Mangalam, University of Iowa

Multiple sclerosis is a disease that results when the immune system mistakenly attacks the brain and spinal cord. It affects nearly one million people in the U.S. and over 2.8 million worldwide. While genetics play a role in the risk of developing multiple sclerosis, environmental factors such as diet, infectious disease and gut health are major contributors.

The environment plays a key role in determining who develops multiple sclerosis, and this is evident from twin studies. Among identical twins who share 100% of their genes, one twin has a roughly 25% chance of developing MS if the other twin has the disease. For fraternal twins who share 50% of their genes, this rate drops to around 2%.

Scientists have long suspected that gut bacteria may influence a person’s risk of developing multiple sclerosis. But studies so far have had inconsistent findings.

To address these inconsistencies, my colleagues and I used what researchers call a bedside-to-bench-to-bedside approach: starting with samples from patients with multiple sclerosis, conducting lab experiments on these samples, then confirming our findings in patients.

In our newly published research, we found that the ratio of two bacteria in the gut can predict multiple sclerosis severity in patients, highlighting the importance of the microbiome and gut health in this disease.

Microscopy image of large clump of rod-like bacteria
Akkermansia is commonly found in the human gut microbiome.
Zhang et al/Microbial Biotechnology, CC BY-SA

Bedside to bench

First, we analyzed the chemical and bacterial gut composition of patients with multiple sclerosis, confirming that they had gut inflammation and different types of gut bacteria compared with people without multiple sclerosis.

Specifically, we showed that a group of bacteria called Blautia was more common in multiple sclerosis patients, while Prevotella, a bacterial species consistently linked to a healthy gut, was found in lower amounts.

In a separate experiment in mice, we observed that the balance between two gut bacteria, Bifidobacterium and Akkermansia, was critical in distinguishing mice with or without multiple sclerosis-like disease. Mice with multiple sclerosis-like symptoms had increased levels of Akkermansia and decreased levels of Bifidobacterium in their stool or gut lining.

Bench to bedside

To explore this further, we treated mice with antibiotics to remove all their gut bacteria. Then, we gave either Blautia, which was higher in multiple sclerosis patients; Prevotella, which was more common in healthy patients; or a control bacteria, Phocaeicola, which is found in patients with and without multiple sclerosis. We found that mice with Blautia developed more gut inflammation and worse multiple sclerosis-like symptoms.

Even before symptoms appeared, these mice had low levels of Bifidobacterium and high levels of Akkermansia. This suggested that an imbalance between these two bacteria might not just be a sign of disease, but could actually predict how severe it will be.

We then examined whether this same imbalance appeared in people. We measured the ratio of Bifidobacterium adolescentis and Akkermansia muciniphila in samples from multiple sclerosis patients in Iowa and participants in a study spanning the U.S., Latin America and Europe.

Our findings were consistent: Patients with multiple sclerosis had a lower ratio of Bifidobacterium to Akkermansia. This imbalance was not only linked to having multiple sclerosis but also with worse disability, making it a stronger predictor of disease severity than any single type of bacteria alone.

Microscopy image of clusters of rod bacteria
Bifidobacterium both produces and consumes mucin, a glycoprotein that protects the gut lining.
Paola Mattarelli and Monica Modesto/Katz Lab via Flickr, CC BY-NC

How ‘good’ bacteria can become harmful

One of the most interesting findings from our study was that normally beneficial bacteria can turn harmful in multiple sclerosis. Akkermansia is usually considered a helpful bacterium, but it became problematic in patients with multiple sclerosis.

A previous study in mice showed a similar pattern: Mice with severe disease had a lower Bifidobacterium-to-Akkermansia ratio. In that study, mice fed a diet rich in phytoestrogens – chemicals structurally similar to human estrogen that need to be broken down by bacteria for beneficial health effects – developed milder disease than those on a diet without phytoestrogens. Previously we have shown that people with multiple sclerosis lack gut bacteria that can metabolize phytoestrogen.

Although the precise mechanisms behind the link between the Bifidobacterium-to- Akkermansia ratio and multiple sclerosis is unknown, researchers have a theory. Both types of bacteria consume mucin, a substance that protects the gut lining. However, Bifidobacterium both eats and produces mucin, while Akkermansia only consumes it. When Bifidobacterium levels drop, such as during inflammation, Akkermansia overconsumes mucin and weakens the gut lining. This process can trigger more inflammation and potentially contribute to the progression of multiple sclerosis.

Our finding that the Bifidobacterium-to-Akkermansia ratio may be a key marker for multiple sclerosis severity could help improve diagnosis and treatment. It also highlights how losing beneficial gut bacteria can allow other gut bacteria to become harmful, though it is unclear whether changing levels of certain microbes can affect multiple sclerosis.

While more research can help clarify the link between the gut microbiome and multiple sclerosis, these findings offer a promising new direction for understanding and treating this disease.The Conversation

Ashutosh Mangalam, Associate Professor of Pathology, University of Iowa

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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How are clouds’ shapes made? A scientist explains the different cloud types and how they help forecast weather

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theconversation.com – Ross Lazear, Instructor in Atmospheric and Environmental Sciences, University at Albany, State University of New York – 2025-03-03 07:18:00

Lenticular clouds, like this one over a mountain in Chile, can look like flying saucers.
Bilderbuch/Design Pics Editorial/Universal Images Group via Getty Images

Ross Lazear, University at Albany, State University of New York

Curious Kids is a series for children of all ages. If you have a question you’d like an expert to answer, send it to curiouskidsus@theconversation.com.


How are clouds’ shapes made? – Amanda, age 5, Chile


I’m a meteorologist, and I’ve been fascinated by weather since I was 8 years old. I grew up in Minnesota, where the weather changes from wind-whipping blizzards in winter to severe thunderstorms – sometimes with tornadoes – in the summer. So, it’s not all that surprising that I’ve spent most of my life looking at clouds.

All clouds form as a result of saturation – that’s when the air contains so much water vapor that it begins producing liquid or ice.

Once you understand how certain clouds develop their shapes, you can learn to forecast the weather.

A view showing typical cloud heights shows tall cumulonimbus clouds, low level cumulus and high-level cirrus.
Cloud types show their general heights.
Australian Bureau of Meteorology

Cotton ball cumulus clouds

Clouds that look like cartoon cotton balls or cauliflower are made up of tiny liquid water droplets and are called cumulus clouds.

Often, these are fair-weather clouds that form when the Sun warms the ground and the warm air rises. You’ll often see them on humid summer days.

A horse or donkey next to river bank with puffy clouds in the sky.
Cumulus clouds over Lander, Wyo.
Ross Lazear, CC BY-ND

However, if the air is particularly warm and humid, and the atmosphere above is much colder, cumulus clouds can rapidly grow vertically into cumulonimbus. When the edges of these clouds look especially crisp, it’s a sign that heavy rain or snow may be imminent.

Wispy cirrus are ice clouds

When cumulonimbus clouds grow high enough into the atmosphere, the temperature becomes cold enough for ice clouds, or cirrus, to form.

Clouds made up entirely of ice are usually more transparent. In some cases, you can see the Sun or Moon through them.

Streaks of high white clouds look like paintbrush strokes
Cirrus clouds over the roof of Bard College in Annandale-on-Hudson, N.Y.
Ross Lazear, CC BY-ND

Cirrus clouds that forms atop a thunderstorm spread outward and can form anvil clouds. These clouds flatten on top as they reach the stratosphere, where the atmosphere begins to warm with height.

However, most cirrus clouds aren’t associated with storms at all. There are many ice clouds associated with tranquil weather that are simply regions of the atmosphere with more moisture but not precipitation.

Fog and stratus clouds

Clouds are a result of saturation, but saturated air can also exist at ground level. When this occurs, we call it fog.

In temperatures below freezing, fog can actually deposit ice onto objects at or near the ground, called rime ice.

YouTube video
Reading clouds, with the National Oceanic and Atmospheric Administration.

When clouds form thick layers, we add the word “stratus,” or “layer,” to the name. Stratus can occur just above the ground, or a bit higher up – we call it altostratus then. It can occur even higher and become cirrostratus, or a layer or ice clouds.

If there’s enough moisture and lift, stratus clouds can create rain or snow. These are nimbostratus.

How mountains can create their own clouds

There are a number of other unique and beautiful cloud types that can form as air rises over mountain slopes and other topography.

Lenticular clouds, for example, can look like flying saucers hovering just above, or near, mountaintops. Lenticular clouds can actually form far from mountains, as wind over a mountain range creates an effect like ripples in a pond.

A cloud appears to stream off the side of a tall mountain peak.
A banner cloud appears to stream out from the Matterhorn, in the Alps on the border between Italy and Switzerland.
Zacharie Grossen via Wikimedia, CC BY

Rarer are banner clouds, which form from horizontally spinning air on one side of a mountain.

Wind plays a big role

You might have looked up at the sky and noticed one layer of clouds moving in a different direction from another. Clouds move along with the wind, so what you’re seeing is the wind changing direction with height.

Cirrus clouds at the level of the jet stream – often about 6 miles (10 kilometers), above the ground – can sometimes move at over 200 miles per hour (320 kilometers per hour). But because they are so high up, it’s often hard to tell how fast they are moving.


Hello, curious kids! Do you have a question you’d like an expert to answer? Ask an adult to send your question to CuriousKidsUS@theconversation.com. Please tell us your name, age and the city where you live.

And since curiosity has no age limit – adults, let us know what you’re wondering, too. We won’t be able to answer every question, but we will do our best.The Conversation

Ross Lazear, Instructor in Atmospheric and Environmental Sciences, University at Albany, State University of New York

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Who’s who at the Vatican?

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theconversation.com – Daniel Speed Thompson, Associate Professor of Religious Studies, University of Dayton – 2025-03-03 07:18:00

Who’s who at the Vatican?

Deacons take part in a mass in St. Peter’s Basilica that was supposed to be presided over by Pope Francis.
AP Photo/Alessandra Tarantino

Daniel Speed Thompson, University of Dayton

For more than two weeks, eyes have been on the Vatican, awaiting news about Pope Francis’ health. The pope has been at Rome’s Gemelli Hospital since Feb. 14, 2025, being treated for double pneumonia and other complications.

When a pope is ill, resigns or passes away, who steps in? And who else helps lead the Holy See? The Conversation U.S. asked Daniel Speed Thompson, a theologian at the University of Dayton, for some insight into Vatican City.

Who are the most powerful people at the Vatican, besides the pope?

The Vatican houses the central government of the Catholic Church and is also an independent city-state. The pope is both the head of the Catholic Church and head of state.

In order to govern both, he has the Roman Curia, meaning “court.” In modern terms, the Curia is the papal bureaucracy. It is an extension of the pope’s authority.

In Catholic doctrine, the pope has the highest authority in the church. He can exercise it alone or with the College of Bishops, made up of all the bishops in the world. Bishops named by the pope to the office of “cardinal” can, if under 80 years old, vote to elect a new pope. Some cardinals, but by no means all, serve in the papal Curia in Rome.

Besides the pope, curial officials who oversee important aspects of the church’s political and religious life are often powerful figures. For example, the secretariat of state, headed by Cardinal Pietro Parolin, oversees relations with other countries and international organizations. It also oversees the Vatican’s diplomatic corps.

Two men in black robes with red skullcaps and red sashes walk on a paved road, flanking a man in white robes.
Pope Francis smiles as he walks alongside Vatican Secretary of State Pietro Parolin, left, and Cardinal Giuseppe Versaldi at the Vatican in 2014.
AP Photo/Gregorio Borgia

The Dicastery – “department” – for the Doctrine of the Faith, led by Cardinal Víctor Manuel Fernández, addresses questions about correct Catholic teaching on faith and morals. The Dicastery of Bishops, headed by Cardinal Robert Prevost, coordinates the nominations of new bishops around the world.

All these officials work under the authority of the pope, advocating for and implementing his agenda. For example, Prevost has suggested that all Catholics should be involved in the selection of bishops. This idea is linked with Francis’ call for a more “synodal” church: one that is less hierarchical and shaped by lay Catholics’ concerns and challenges.

If a pope can’t fulfill his duties, who steps in?

When a pope dies – or resigns, like Benedict XVI did in 2013 – the governance of the Catholic Church formally falls to the College of Cardinals. However, the authority of the college is very limited. On their own, cardinals cannot make any significant decisions concerning faith, morals and worship. Nor can they undo previous papal decisions or change church laws about electing a new pope.

All the heads of the dicasteries lose their office upon the death or resignation of a pope. The College of Cardinals serves as a caretaker government whose primary purpose is to prepare for the election of the new pope and oversee day-to-day workings of the Vatican.

One cardinal, known as the “camerlengo,” is responsible for confirming the pope’s death or resignation. He then assumes control over the pope’s residence and coordinates the funeral, if needed. The camerlengo also takes custody of the Vatican’s property in Rome and supervises details for the upcoming conclave.

A man wearing a priest's collar gestures as he speaks, sitting in front of a framed portrait of Pope Francis.
Cardinal Camerlengo Kevin Farrell talks with The Associated Press in his office in Rome in 2018.
AP Photo/Paolo Santalucia

The day-to-day business of the Catholic Church continues, but no big decisions can be made in the absence of a pope. The church cannot appoint new bishops, and the Vatican cannot start new diplomatic efforts.

Are officials at the Vatican often nominated to be pope?

Sometimes. Francis was a cardinal from Argentina before his election as pope and had not served in the Roman Curia. However, Benedict XVI, Francis’ predecessor, did serve as the prefect of the Congregation – now called Dicastery – for the Doctrine of the Faith. Some recent popes served in the Curia earlier in their career but not immediately before their election.

What do you wish more people understood about the Vatican?

Three things. First, the Vatican is unlike any organization in the world. Its religious mission and political status rest on nearly 2,000 years of history. This complicated story provides a unique tradition that anchors the institution of the Catholic Church, but can also block the church from critical self-examination and renewal.

Second, the Vatican is like every organization in the world. Vatican officials can be faithful to the highest standards of their religion, truly wishing to serve the church and the common good of humanity. But they can also be flagrantly immoral, even criminals, and careerist seekers of status or luxury. Francis has consistently called out priests and bishops who see themselves as somehow superior by virtue of their office or their ordination.

Finally, compared with the massive bureaucracies of modern governments and corporations, the Vatican is relatively small and not as wealthy as it is often portrayed.

Although the Curia manages a vast international organization, its resources are far closer to my own midsize Catholic university than to the U.S. government or Apple. Vatican City and the Holy See employ about 2,000 people, with an operating budget of about US$835 million.

Yes, the Catholic Church has wealth – and the ongoing problem of deficits and financial corruption. But the Vatican’s resources pale in comparison with what a modern state or large company can muster.The Conversation

Daniel Speed Thompson, Associate Professor of Religious Studies, University of Dayton

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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