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3,4-Methylenedioxymethamphetamine (MDMA) is frequently consumed in association with alcohol. The effect of this combination in humans has not been previously investigated. Nine male healthy volunteers received single oral doses of 100 mg of MDMA plus 0.8 g/kg ethanol, 100 mg of MDMA, 0.8 g/kg of ethanol, and placebo in a double blind, double dummy, randomized crossover trial. Measurements included psychomotor performance, subjective effects, and pharmacokinetics. Plasma concentrations of MDMA showed a 13% increase after the use of alcohol, whereas plasma concentrations of alcohol showed a 9 to 15% decrease after MDMA administration. The MDMA-alcohol combination induced longer lasting euphoria and well being than MDMA or alcohol alone. MDMA reversed the subjective sedation induced by alcohol but did not reduce drunkenness feelings. MDMA did not reverse the actions of alcohol on psychomotor abilities. Combined use of MDMA and alcohol causes dissociation between subjective and objective sedation. Subjects may feel euphoric and less sedated and might have the feeling of doing better, but actual performance ability continues to be impaired by the effect of alcohol. Confirmation of these findings in further studies will be highly relevant in terms of road safety.

Computerized physician order entry (CPOE) applications are widely used to prevent medical errors. In our center, a CPOE system has been in use since 2009 on both the inpatient and outpatient levels. A new and simple alert was introduced in the CPOE system to notify healthcare providers of the potential risk of viral reactivation when prescribing biological therapies, thereby facilitating the request for a serological profile (hepatitis B surface antigen [HBsAg], anti-HBc, and anti-HBs) in patients who have not had these tests. Between May 2012 and May 2013, a total of 1,076 patients undergoing biological treatment were included in the implementation of the CPOE in our hospital, resulting in the identification of 4 HBsAg-positive and 69 anti-HBc-positive/HBsAg-negative patients, two of them with positive viral loads. Since the implementation of this alert system, over 90% of patients who were prescribed a biological drug (BD) have undergone serological screening to detect hepatitis B virus (HBV) infection. The use of the alert system has increased the screening rate from less than 50% to 94% for HBsAg and from less than 30% to 85% for anti-HBc in patients for whom a BD is prescribed. Six patients received prophylactic antiviral therapy. No patient had HBV reactivation. Conclusion: This study demonstrates the feasibility of implementing a CPOE system that has allowed our hospital to increase the rate of HBV screening. Its use has facilitated the identification of patients at high risk for HBV reactivation and permitted physicians to prescribe prophylactic measures according to current guidelines. (Hepatology 2014;106–113)

TO THE EDITOR: In the clinical opinion update by Hwang et al, the authors reviewed the most important issues related to hepatitis B virus (HBV) screening in patients who are about to receive cytotoxic chemotherapy for the treatment of malignant diseases. This update notes the importance of screening all patients who are going to be treated with anti-CD20 therapy. The authors also point out that this screening should be extended to patients with high risk factors for HBV infection. Then, when a patient who is hepatitis B surface antigen (HBsAg) positive/hepatitis B core antibody (anti-HBc) positive is identified, antiviral treatment should be started just before or at the same time as chemotherapy. In contrast, patients who are HBsAg negative/anti-HBc positive could be carefully observed with ALT and HBV-DNA levels. In the article by Hwang et al, Spain is included as a country with HBV prevalence greater than 2%. We believe this statement is currently obsolete and should be corrected. Because of the universal vaccination program started circa 1992, the HBV prevalence in Spain is now approximately 0.7% (HBsAg positive). However, this 0.7% prevalence in HBsAg does not disqualify, in our opinion, a universal HBsAg screening for all patients scheduled to receive systemic cancer therapy. As Hwang et al succinctly mentioned, previous studies have shown that universal screening for HBsAg is not only cost effective but actually cost saving when compared with no screening or screening only high-risk individuals before starting chemotherapy, particularly when the prevalence of HBsAg in the low-risk population is greater than 0.20%. Finally, one aspect that we miss in this special article is the mention of currently available innovative strategies to facilitate this HBV screening in the hospital setting, where the majority of immunosuppressive therapies are prescribed. We are referring specifically to the use of the computerized physician order entry–based (CPOE) systems that apply to this subject. As we previously have demonstrated, the use of this CPOE system in our hospital increased theHBV screening rate from less than 50% to 94% forHBsAg and from less than 30% to 85% for anti-HBc in patients for whom a biologic drug was prescribed. In conclusion, we consider it reasonable to recommend universal HBsAg (and anti-HBc) screening for all patients scheduled to receive systemic cancer therapies or other immunosuppressive therapies, adding when available or feasible the potential benefits of new tools such as CPOE systems together with educational efforts to improve the HBV screening rates.