Barriers and facilitators to use of buprenorphine in state-licensed specialty substance use treatment programs: A survey of program leadership

INTRODUCTION

Medications for opioid use disorder (MOUD), including buprenorphine, reduce overdose risk and improve outcomes for individuals with opioid use disorder (OUD). However, historically, most non-opioid treatment program (non-OTP) specialty substance use treatment programs have not offered buprenorphine. Understanding barriers to offering buprenorphine in specialty substance use treatment settings is critical for expanding access to buprenorphine. This study aims to examine program-level attitudinal, financial, and regulatory factors that influence clients' access to buprenorphine in state-licensed non-OTP specialty substance use treatment programs.

METHODS

We surveyed leadership from state-licensed non-OTP specialty substance use treatment programs in New Jersey about organizational characteristics, including medications provided on- and off-site and percentage of OUD clients receiving any type of MOUD, and perceived attitudinal, financial, and regulatory barriers and facilitators to buprenorphine. The study estimated prevalence of barriers and compared high MOUD reach (n = 36, 35 %) and low MOUD reach (n = 66, 65 %) programs.

RESULTS

Most responding organizations offered at least one type of MOUD either on- or off-site (n = 80, 78 %). However, 71 % of organizations stated that fewer than a quarter of their clients with OUD use any type of MOUD. Endorsement of attitudinal, financial, and institutional barriers to buprenorphine were similar among high and low MOUD reach programs. The most frequently endorsed government actions suggested to increase use of buprenorphine were facilitating access to long-acting buprenorphine (n = 95, 96 %), education and stigma reduction for clients and families (n = 95, 95 %), and financial assistance to clients to pay for medications (n = 90, 90 %).

CONCLUSIONS

Although non-OTP specialty substance use programs often offer clients access to MOUD, including buprenorphine, most OUD clients do not actually receive MOUD. Buprenorphine uptake in these settings may require increased financial support for programs and clients, more robust education and training for providers, and efforts to reduce the stigma associated with medication among clients and their families.

Beliefs and Attitudes about Vermont's Buprenorphine Decriminalization Law among Clinicians Who Prescribe Buprenorphine

BACKGROUND

On June 1, 2021, Vermont repealed all criminal penalties for possessing 224 milligrams or less of buprenorphine. We examined the potential impact of decriminalization with a survey of Vermont clinicians who prescribed buprenorphine within the past year.

METHODS

All 638 Vermont clinicians with a waiver to prescribe buprenorphine were emailed the survey by Vermont Department of Health; 117 responded. We estimated the prevalence of the following four outcomes, for all responding clinicians and stratified by clinician demographics and practice characteristics: awareness of decriminalization, beliefs about the effects of decriminalization, support for decriminalization, and changes in practice resulting from decriminalization.

RESULTS

72 (62%) prescribers correctly stated that Vermont does not have criminal penalties for buprenorphine possession. 107 (91%) support decriminalization. 56 (48%) believe that, because buprenorphine is decriminalized, their patients are more likely to give, sell, or trade the buprenorphine that is prescribed to them to someone else. However, only 5 providers (4%) said they now prescribe to fewer patients.

CONCLUSION

The great majority of Vermont clinicians who prescribe buprenorphine support its decriminalization and have not changed their prescribing practices because of decriminalization.

Attitudes and beliefs about Vermont's 2021 buprenorphine decriminalization law among residents who use illicit opioids

BACKGROUND

In July 2021, Vermont removed all criminal penalties for possessing 224mg or less of buprenorphine.

METHODS

Vermont residents (N=474) who used illicit opioid drugs or received treatment for opioid use disorder in the past 90 days were recruited for a mixed-methods survey on the health and criminal legal effects of decriminalization. Topics assessed included: motivations for using non-prescribed buprenorphine, awareness of and support for decriminalization, and criminal legal system experiences involving buprenorphine. We examined the frequencies of quantitative measures and qualitatively summarized themes from free-response questions.

RESULTS

Three-quarters of respondents (76%) reported lifetime use of non-prescribed buprenorphine. 80% supported decriminalization, but only 28% were aware buprenorphine was decriminalized in Vermont. Respondents described using non-prescribed buprenorphine to alleviate withdrawal symptoms and avoid use of other illicit drugs. 18% had been arrested while in buprenorphine, with non-White respondents significantly more likely to report such arrests (15% v 33%, p<0.001).

CONCLUSION

Decriminalization of buprenorphine may reduce unnecessary criminal legal system involvement, but its health impact was limited by low awareness at the time of our study.

The Limitations of Frailty Assessment Tools in ANCA-Associated Vasculitis

Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) can be associated with a high burden of morbidity and mortality in an ageing population. It is increasingly recognised that individualised management is needed. Few studies have looked specifically at frailty related outcomes in AAV and a gap remains in understanding the application of frailty assessment tools in these patients. We carried out a single centre, cohort study between 2017 to 2022. Forty-one patients who had newly diagnosed or relapsing AAV and aged ≥65 years were included. The Clinical Frailty Scale (CFS) score at presentation was assessed by health care practitioners and interval CFS scores were carried out a minimum of 6 weeks from diagnosis. The aim was to determine if patients living with frailty had worse outcomes or if their perceived frailty improved with immunosuppressive treatment. The median CFS at diagnosis was 4 (vulnerable) and this remained at follow up. There was no significant interval change in CFS (P=0.16) suggesting that the patients did not become frailer and instead there was a tendency towards improved frailty scores at re-assessment. There was no significant difference in end stage kidney disease between those with higher (>5) or lower (≤5) CFS (P=1.0), although crude mortality was higher among those with an initial CFS >5 (P=0.03). Overall, we demonstrated that CFS has limitations in determining patients that may be frail as a result of disease burden with the potential to improve with treatment and clinicians should be mindful of this when making decisions relating to management.

105 EVALUATION OF A NEW PHYSIOTHERAPY-LED VESTIBULAR SERVICE EMBEDDED IN THE FALLS AND SYNCOPE UNIT

Background

Clinical presentations in the falls and syncope unit (FASU) are diverse and require a range of skillsets. Vestibular disorders amount to a significant proportion of presentations. In our FASU, we embedded a 0.5 FTE specialist physiotherapist with expertise in vestibular disorders to work alongside medical and nursing staff. We conducted a service evaluation of the activity of this new service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office. Pseudonymised data was collected corresponding to all new FASU physiotherapy service attendances between August 2021 and May 2022. Descriptive statistics were complemented by a binary logistic regression model to establish independent predictors of more than one physiotherapy session being required over the period.

Results

There were 104 episodes recorded by the new service, corresponding to 101 unique patients. Mean age was 67.7 (SD 19.0, range 17-93), and 73.1% were women. 67% were treated and discharged in 1 session. On average, patients had had a mean of 2 falls prior to the consultation (range 0-25). 28.8% were using a walking aid, and 54.8% self-reported fear of falling. 25% of the referrals to the service were due to suspected vestibular disorders, 62% of which were directly treated by the physiotherapy service. The logistic regression model adjusting by age, sex, use of walking aid, number of falls, and fear of falling showed that only referral for vestibular disorder was an independent predictor of patients needing more than 1 physiotherapy treatment (OR 3.91, 95% CI 1.32-11.58, P=0.014).

Conclusion

Vestibular disorders are common in FASU, and a majority can be treated by a specialist physiotherapy service. Repeated vestibular maneuvers are often needed in such patients. A responsive, embedded physiotherapy service in FASU can directly address this need and further evaluation will focus on the impact of this service on avoidance of ED attendances.

268 AUDIT: GENERIC PRESCRIBING COMPLIANCE IN AN ACUTE HOSPITAL

Background

Generic prescribing is cost-effective, and evidence suggests that clinical outcomes compared with brand name products are largely equivalent. Hospital guidelines recommend that medications should be prescribed using the approved generic name, not the brand name. There are some exceptions to this. Anecdotal evidence suggests that medication reconciliation for patients on admission to hospital are charted by brand name rather than the generic title. To investigate this we conducted a four-day audit of the prescribing of medications on patients admitted to medical wards in an acute hospital.

Methods

This audit took place over a four-day period. The Kardex of each patient admitted to the three medical wards was reviewed. Patients admitted under cardiology, haematology and oncology were excluded. All medications including whether they were prescribed using the generic or brand name were collected. Statistical analysis was carried out using Microsoft Excel.

Results

A total of 33 kardexes were collected. Two hundred and fifty-seven prescribed medications were reviewed. Ninety-five were charted as brand names and 63% (n=162) were prescribed using the generic name. One hundred and eighteen different categories of medications were prescribed. Enoxaparin was prescribed using the brand name ten times and the generic title three times. The antibiotic Piperacillin/tazobactam was prescribed three times using the brand name and one time using the generic title. Of the eight times atorvastatin was prescribed, it was charted using the generic name seven times (88%).

Conclusion

Almost two-thirds of medications for patients admitted to medical wards are prescribed using generic titles. However, there is room for improvement. Of note, commonly prescribed medications such as enoxaparin and certain antimicrobials were prescribed using the brand name. Opportunities e.g., induction, grand rounds and Non-Consultant Hospital Doctor (NCHD) teaching sessions should be utilised to provide education on the importance of generic prescribing to all NCHDs admitting patients.

110 DEVELOPMENT AND DELIVERY OF A MULTI-DISCIPLINARY HYBRID EDUCATION PROGRAM IN SYNCOPE AND RELATED DISORDERS DURING THE COVID-19 PANDEMIC

Background

Syncope and related disorders is an important area for training of all health professionals. During the COVID-19 pandemic, we adapted the delivery of our annual face-to-face certified program to a 9-month hybrid program. Here, we describe the development, delivery, and evaluation of such new program.

Methods

A pre-existing curriculum was modified to incorporate online content, online lecture delivery and interactive group learning, in addition to individual practical placements in a syncope management unit, in line with government and hospital infection control guidance at the time. Monthly content included video consultant case presentations, ECG analysis and interpretation, and instructional videos of diagnostic testing and relevant technologies. A comprehensive online week-long lecture program was developed.

Results

The lecture week included 30 clinical lectures, 10 clinical case presentations and 10 ‘how to’ practical videos for testing/monitoring procedures. Further learning over zoom incorporated learner case presentations in a small group format. At the completion of the course the leaners attended a final online half day of lectures and completed the multi choice question examination.

Conclusion

“Thank you so much for putting together such a fantastic week of training.” “The quality and expertise of the speakers was outstanding.” “I have taken a huge amount away to incorporate into my practice and local unit.”

The above learner feedback is consistent with our aim to deliver a high-quality specialist program for those interested in advancing the management of syncope and related disorders. Over time, this specialist training will aid the development of regional syncope management units across Ireland. The benefits of a hybrid learning model include multiple options to cater for all categories of learners, thus suggesting it is the cornerstone of future learning modalities.

Skin and respiratory ill-health attributed to occupational face mask use

BACKGROUND

Face mask use in the workplace has become widespread since the onset of the Covid-19 pandemic and has been anecdotally linked to adverse health consequences.

AIMS

To examine reports of adverse health consequences of occupational face mask use received by The Health and Occupation Research (THOR) network before and after the pandemic onset.

METHODS

THOR databases were searched to identify all cases of ill-health attributed to 'face mask' or similar suspected causative agent between 1 January 2010 and 30 June 2021.

RESULTS

Thirty two cases were identified in total, 18 reported by occupational physicians and 14 by dermatologists. Seventy-five per cent of cases were reported after the pandemic onset and 91% cases were in the health and social care sector. 25 of the 35 (71%) diagnoses were dermatological, the most frequent diagnoses being contact dermatitis (14 cases) and folliculitis/acne (6 cases). Of the seven respiratory diagnoses, four were exacerbation of pre-existing asthma.

CONCLUSIONS

There is evidence of an abrupt increase in reports of predominantly dermatological ill-health attributed to occupational face mask use since the start of the pandemic. Respiratory presentations have also occurred.

Persisting Symptomatic Severe Secondary Mitral Regurgitation in Heart Failure Patients

Aims We aimed to assess the rate of persisting severe symptomatic secondary mitral regurgitation (MR) in a newly diagnosed heart failure (HF) population following optimisation of guideline directed medical therapy (GDMT), cardiac resynchronisation therapy (CRT) and revascularisation. Methods We assessed all new patients referred to our hospital group’s HF clinics. We retrospectively reviewed these patients at HF clinic enrolment, HF programme completion, as well as most recent follow up. Results Of the 242 new patients referred to our HF clinics, there were 10 patients (4.1%) who had either persisting symptomatic severe secondary MR at HF programme completion, or had undergone mitral valve surgery. There were no percutaneous mitral valve repairs at the time of these patients’ referrals. The rates of ACE/ARB/ARNI, BB and MRA use were 87.8%, 94.1%, and 49.8% in those with mid ranged, or reduced ejection fraction. The rates of ICD and CRT therapy were 15.1% and 4.4% at follow up. Patients with severe MR had higher time adjusted rates of death or hospitalization for heart failure. Conclusion In a well-treated newly diagnosed HF population, repeat assessment at HF programme completion suggests 4.1% of patients have a persisting indication for percutaneous mitral valve repair based on persisting severe symptomatic secondary MR.

204 FRAILTY BUT NOT AGE IS ASSOCIATED WITH IMPAIRED ORTHOSTATIC CEREBRAL OXYGENATION

Background

The effects of age and frailty on cerebrovascular function are poorly understood. Here we investigate the hypotheses that aging, and frailty are accompanied by impaired regulation of cerebral oxygenation during standing in a patient population of older adults.

Methods

We recruited patients from a national Falls and Syncope service. All patients underwent an active stand test (5–10 min lying, 3 min standing) with continuous monitoring of blood pressure (BP) and heart rate. Tissue saturation index (TSI) was concurrently measured using near-infrared spectroscopy and its recovery measured at 30s after standing. Frailty was assessed as a comorbidity count using a 27-item questionnaire. Robust linear regression was used to investigate the association between TSI, age and frailty in a multivariate model with covariate adjustment, including the concurrent BP values. A p-value &lt;0.05 was considered significant.

Results

304 patients (median(IQR): 71(14) years, 57% females) were recruited. Age was not associated with cerebral oxygenation after standing (β: −0.001 (−0.017 0.015), p = 0.899), even after stratification by sex (males: β: −0.010 (−0.045 0.024), p = 0.558, females: β: 0.000 (−0.017 0.018), p = 0.967). Frailty, was associated with a lower TSI at 30s after standing (β: −0.153 (−0.248–0.058), p = 0.002). After sex stratification, no associations with frailty were observed in males (β: −0.052 (−0.226 0.123), p = 0.557), while frailer females demonstrated a lower TSI at 30 seconds after standing (β: −0.179 (−0.294–0.063), p = 0.003) despite BP correction.

Conclusion

Our results suggest alternative mechanisms of cerebral oxygenation regulation independent of blood pressure (and presumably cerebral autoregulation) are involved in frailty related impairments of brain haemodynamics which are also independent of ageing. Such impairments represent novel biomarkers of frailty and represent potentially novel modifiable risk factors (independent of BP management) of hypoperfusion related disorders in clinical ageing.

Frailty is associated with impaired cerebral oxygenation recovery during

 

Frailty is associated with impaired peripheral circulatory responses to standing in older adults. However, little is known about how frailty affects cerebrovascular function during such activities of daily living. Here we investigate the association between frailty and cerebral oxygenation during standing in a large clinical cohort of fallers and fainters.

Participants were recruited from a national Falls and Syncope unit and underwent an active stand test (5–10 minutes lying supine, 3 minutes standing) with concurrent monitoring of continuous blood pressure (BP) and heart rate (HR) and tissue saturation index (TSI) using near-infrared spectroscopy (NIRS). Frailty was measured using a count of deficits (27 morbidities). Robust linear regression was applied to study the association between features of dynamic cerebral oxygenation (changes from baseline at nadir, overshoot, 30s and steady state; and recovery rate) and frailty while correcting for covariates. A p-value &lt;0.05 was considered significant.

Frailty was associated with deficits in TSI at 30s after standing (β: −0.165, CI: (−0.261, −0.069), p=0.005), as well as a lower diastolic BP at 30s (β: −1.346, CI: (−2.287, −0.405), p=0.032) and standing steady-state (β: −1.182, CI: (−2.038, −0.325), p=0.032). When stratified by gender, frailty was associated in women with a lower TSI at overshoot (β: −0.174, CI: (−0.312, −0.037), p=0.043) and 30s (β: −0.216 (−0.344, −0.089), p=0.010), and impaired DBP recovery at overshoot (β: −1.623, CI: (−2.865, −0.391), p=0.045) and attenuated HR response at 30s (β: −0.701, CI: (−1.246, −0.155), p=0.036). No associations were found in men.

Impaired cerebral oxygenation and BP responses to standing are associated with frailty in patients with falls and syncope, with stronger effects in women, suggesting that frailty may increase risk of hypoperfusion and consequent syncope, falls, and brain ageing. Our results demonstrate the clinical utility and feasibility of using NIRS in this context which can be used to further personalise patient management.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Irish Research Council Cerebral oxygenation and frailty

Optical fibre based real-time measurements during an LDR prostate brachytherapy implant simulation: using a 3D printed anthropomorphic phantom

An optical fibre sensor based on radioluminescence, using the scintillation material terbium doped gadolinium oxysulphide (Gd₂O₂S:Tb) is evaluated, using a 3D printed anthropomorphic phantom for applications in low dose-rate (LDR) prostate brachytherapy. The scintillation material is embedded in a 700 µm diameter cavity within a 1 mm plastic optical fibre that is fixed within a brachytherapy needle. The high spatial resolution dosimeter is used to measure the dose contribution from Iodine-125 (I-125) seeds. Initially, the effects of sterilisation on the sensors (1) repeatability, (2) response as a function of angle, and (3) response as a function of distance, are evaluated in a custom polymethyl methacrylate phantom. Results obtained in this study demonstrate that the output response of the sensor, pre- and post-sterilisation are within the acceptable measurement uncertainty ranging from a maximum standard deviation of 4.7% pre and 5.5% post respectively, indicating that the low temperature sterilisation process does not damage the sensor or reduce performance. Subsequently, an LDR brachytherapy plan reconstructed using the VariSeed treatment planning system, in an anthropomorphic 3D printed training phantom, was used to assess the suitability of the sensor for applications in LDR brachytherapy. This phantom was printed based on patient anatomy, with the volume and dimensions of the prostate designed to represent that of the patient. I-125 brachytherapy seeds, with an average activity of 0.410 mCi, were implanted into the prostate phantom under trans-rectal ultrasound guidance; following the same techniques as employed in clinical practice by an experienced radiation oncologist. This work has demonstrated that this sensor is capable of accurately identifying when radioactive I-125 sources are introduced into the prostate via a brachytherapy needle.

A Review of a Tertiary Referral Centre's CT Coronary Angiography Programme

Aims To investigate the implication of outpatient CT coronary angiogram (CTCA) waiting times on patient outcomes and service provision. Methods All outpatient CTCAs requested for stable chest pain during 2017 in our catchment area were included. Rate of major adverse cardiovascular events (MACE), presentations with chest pain to the emergency department (ED), cardiology outpatient attendance, time interval in alteration of Coronary artery disease (CAD) prognostic treatment, rate of angiography and percutaneous coronary intervention (PCI) were noted. Results 172 CTCAs were included. 11 (6.4%) presented to ED with chest pain. 38 (22.1%) attended outpatients prior to scan completion. 17 (9.9%) required alteration of prognostic treatment, taking on average 10.4 (+/-4.5) months to occur. 21 (12.2%) underwent coronary angiography and 7 (4.1%) had PCI, which took on average 9.9 (+/-6.6) months. One non-fatal MI requiring CABG was noted. Conclusion The low rate of MACE and revascularisation likely represents appropriately low risk patient selection for CTCA. Presentation to clinic prior to scan completion highlights a need for better administration support.

A pilot study of a novel, incentivised mHealth technology to monitor the vaccine supply chain in rural Zambia

Introduction

The World Health Organization estimates that up to half of vaccines are wasted, however only a minority of mHealth programs in Africa have been directed at vaccine supply chain optimisation. We piloted a novel mHealth solution dependent only on short message services (SMS) technology that allowed workers in rural health centres in Zambia to report vaccine stock levels directly to an online platform. Small airtime incentives were offered to encourage users to engage with the system, as well as weekly reminder messages asking for stock updates.

Methods

The primary outcome measured was the percentage-of-doses-tracked, calculated over the study period. Each vaccine box was randomly allocated to offer either a standard or double airtime incentive and either weekly or daily reminders, in a 2 x 2 design; ANOVA was used to calculate if any of these factors affected time-to-reply.

Results

Over the study period, the total percentage-of-doses-tracked was 39.9%. Within the subset of users who sent at least one message to the platform, the percentage-of-doses-tracked was 93.8%. There was no significant difference in average time-to-reply between the standard airtime incentive and double airtime incentive groups, nor was there a significant difference between the standard reminder and daily follow-up reminder groups.

Conclusion

This pilot study found that in an active subgroup of health workers, an incentivised mHealth solution was able to collect tracking data for 93.8% of doses. More research is needed to identify methods to encourage healthcare workers to engage in timely stock reporting practices.

A practical guide to active stand testing and analysis using continuous beat-to-beat non-invasive blood pressure monitoring

PURPOSE

The average adult stands approximately 50-60 times per day. Cardiovascular responses evoked during the first 3 min of active standing provide a simple means to clinically assess short-term neural and cardiovascular function across the lifespan. Clinically, this response is used to identify the haemodynamic correlates of patient symptoms and attributable causes of (pre-)syncope, and to detect autonomic dysfunction, variants of orthostatic hypotension, postural orthostatic tachycardia syndrome and orthostatic hypertension.

METHODS

This paper provides a set of experience/expertise-based recommendations detailing current state-of-the-art measurement and analysis approaches for the active stand test, focusing on beat-to-beat BP technologies. This information is targeted at those interested in performing and interpreting the active stand test to current international standards.

RESULTS

This paper presents a practical step-by-step guide on (1) how to perform active stand measurements using beat-to-beat continuous blood pressure measurement technologies, (2) how to conduct an analysis of the active stand response and (3) how to identify the spectrum of abnormal blood pressure and heart rate responses which are of clinical interest.

CONCLUSION

Impairments in neurocardiovascular control are an attributable cause of falls and syncope across the lifespan. The simple active stand test provides the clinician with a powerful tool for assessing individuals at risk of such common disorders. However, its simplicity belies the complexity of its interpretation. Care must therefore be taken in administering and interpreting the test in order to maximise its clinical benefit and minimise its misinterpretation.

Paediatrician's guide to epigenetics

Epigenetic regulation of gene expression is critical for normal development. Dysregulation of the epigenome can lead to the development and progression of a number of diseases relevant to paediatricians, including disorders of genomic imprinting and malignancies. It has long been recognised that early life events have implications for future disease risk, and epigenetic modifications may play a role in this, although further high-quality research is needed to better understand the underlying mechanisms. Research in the field of epigenetics will contribute to a greater understanding of growth, development and disease; however, paediatricians need to be able to interpret such research critically, in order to use the potential advances brought about through epigenetic studies while appreciating their limitations.

Should Artificial Intelligence Augment Medical Decision Making? The Case for an Autonomy Algorithm

A significant proportion of elderly and psychiatric patients do not have the capacity to make health care decisions. We suggest that machine learning technologies could be harnessed to integrate data mined from electronic health records (EHRs) and social media in order to estimate the confidence of the prediction that a patient would consent to a given treatment. We call this process, which takes data about patients as input and derives a confidence estimate for a particular patient's predicted health care-related decision as an output, the autonomy algorithm. We suggest that the proposed algorithm would result in more accurate predictions than existing methods, which are resource intensive and consider only small patient cohorts. This algorithm could become a valuable tool in medical decision-making processes, augmenting the capacity of all people to make health care decisions in difficult situations.

National audit of perinatal HIV infections in the UK, 2006-2013: what lessons can be learnt?

Objectives

The aim of the study was to investigate circumstances surrounding perinatal transmissions of HIV (PHIVs) in the UK.

Methods

The National Study of HIV in Pregnancy and Childhood conducts comprehensive surveillance of all pregnancies in women diagnosed with HIV infection and their infants in the UK; reports of all HIV‐diagnosed children are also sought, regardless of country of birth. Children with PHIV born in 2006–2013 and reported by 2014 were included in an audit, with additional data collection via telephone interviews with clinicians involved in each case. Contributing factors for each transmission were identified, and cases described according to main likely contributing factor, by maternal diagnosis timing.

Results

A total of 108 PHIVs were identified. Of the 41 (38%) infants whose mothers were diagnosed before delivery, it is probable that most were infected in utero, around 20% intrapartum and 20% through breastfeeding. Timing of transmission was unknown for most children of undiagnosed mothers. For infants born to diagnosed women, the most common contributing factors for transmission were difficulties with engagement and/or antiretroviral therapy (ART) adherence in pregnancy (14 of 41) and late antenatal booking (nine of 41); for the 67 children with undiagnosed mothers, these were decline of HIV testing (28 of 67) and seroconversion (23 of 67). Adverse social circumstances around the time of pregnancy were reported for 53% of women, including uncertain immigration status, housing problems and intimate partner violence. Eight children died, all born to undiagnosed mothers.

Conclusions

Priority areas requiring improvement include reducing incident infections, improving ART adherence and facilitating better engagement in care, with attention to addressing the health inequalities and adverse social situations faced by these women.

The Impact of Systematic Point-of-Care Ultrasound on Management of Patients in a Resource-Limited Setting

Although target point-of-care (POC) ultrasonography has been shown to benefit patients in resource-limited settings, it is not clear whether a systematic POC ultrasound assessment in these settings can also lead to similar changes in patient management. A predefined systematic set of POC ultrasound scans were performed on inpatients at a tertiary referral hospital in Tanzania to see if this resulted in changes to patient management. Of the 55 patients scanned, an abnormality was detected in 75% (N = 41), and a change in patient management was recommended or implemented on the basis of POC ultrasound findings in 53% (N = 29). The main impact was earlier initiation of treatment due to more rapid and accurate diagnosis. Further research is warranted to determine whether systematic POC ultrasonography would result in improved patient outcomes in resource-limited settings.

Cerebrospinal fluid total tau concentration predicts clinical phenotype in Huntington's disease

Huntington's disease (HD) is a hereditary neurodegenerative condition with no therapeutic intervention known to alter disease progression, but several trials are ongoing and biomarkers of disease progression are needed. Tau is an axonal protein, often altered in neurodegeneration, and recent studies pointed out its role on HD neuropathology. Our goal was to study whether cerebrospinal fluid (CSF) tau is a biomarker of disease progression in HD. After informed consent, healthy controls, pre-symptomatic and symptomatic gene expansion carriers were recruited from two HD clinics. All participants underwent assessment with the Unified HD Rating Scale '99 (UHDRS). CSF was obtained according to a standardized lumbar puncture protocol. CSF tau was quantified using enzyme-linked immunosorbent assay. Comparisons between two groups were tested using ancova. Pearson's correlation coefficients were calculated for disease progression. Significance level was defined as p < 0.05. Seventy-six participants were included in this cross-sectional multicenter international pilot study. Age-adjusted CSF tau was significantly elevated in gene expansion carriers compared with healthy controls (p = 0.002). UHDRS total functional capacity was significantly correlated with CSF tau (r = -0.29, p = 0.004) after adjustment for age, and UHDRS total motor score was significantly correlated with CSF tau after adjustment for age (r = 0.32, p = 0.002). Several UHDRS cognitive tasks were also significantly correlated with CST total tau after age-adjustment. This study confirms that CSF tau concentrations in HD gene mutation carriers are increased compared with healthy controls and reports for the first time that CSF tau concentration is associated with phenotypic variability in HD. These conclusions strengthen the case for CSF tau as a biomarker in HD. In the era of novel targeted approaches to Huntington's disease, reliable biomarkers are needed. We quantified Tau protein, a marker of neuronal death, in cerebrospinal fluid and found it was increased in patients with Huntington's disease and predicted motor, cognitive, and functional disability in patients. It is therefore likely to be a biomarker of disease progression, and possibly of therapeutic response. Read the Editorial Highlight for this article on page 9.

Presentation for care and antenatal management of HIV in the UK, 2009-2014

Objectives

Despite very low rates of vertical transmission of HIV in the UK overall, rates are higher among women starting antenatal antiretroviral therapy (ART) late. We investigated the timing of key elements of the care of HIV‐positive pregnant women [antenatal care booking, HIV laboratory assessment (CD4 count and HIV viral load) and antenatal ART initiation], to assess whether clinical practice is changing in line with recommendations, and to investigate factors associated with delayed care.

Methods

We used the UK's National Study of HIV in Pregnancy and Childhood for 2009−2014. Data were analysed by fitting logistic regression and Cox proportional hazards models.

Results

A total of 5693 births were reported; 79.5% were in women diagnosed with HIV prior to that pregnancy. Median gestation at antenatal booking was 12.1 weeks [interquartile range (IQR) 10.0–15.6 weeks] and booking was significantly earlier during 2012–2014 vs. 2009–2011 (P < 0.001), although only in previously diagnosed women. Overall, 42.2% of pregnancies were booked late (≥ 13 gestational weeks). Among women not already on treatment, antenatal ART commenced at a median of 21.4 (IQR18.1–24.5) weeks and started significantly earlier in the most recent time period (P < 0.001). Compared with previously diagnosed women, those newly diagnosed during the current pregnancy booked later for antenatal care and started antenatal ART later (both P < 0.001). Multivariable analyses revealed demographic variations in access to or uptake of care, with groups including migrants and parous women initiating care later.

Conclusions

Although women are accessing antenatal and HIV care earlier in pregnancy, some continue to face barriers to timely initiation of antenatal care and ART.

Disease severity of Shiga toxin-producing E. coli O157 and factors influencing the development of typical haemolytic uraemic syndrome: a retrospective cohort study, 2009-2012

OBJECTIVES

Assess the disease severity of Shiga toxin-producing Escherichia coli (STEC) O157 infection and factors influencing the development of typical haemolytic uraemic syndrome (tHUS).

DESIGN

A retrospective cohort study using data collected through routine surveillance questionnaires between 2009 and 2012.

PARTICIPANTS

3323 symptomatic cases of STEC O157.

MAIN OUTCOME MEASURES

Incidence of human STEC O157 and tHUS, proportion of cases reporting bloody diarrhoea, hospitalisation, tHUS and death. Odds of progression to tHUS and predicted percentage chance of developing tHUS based on case demographics, STEC O157 strain characteristics and clinical symptoms.

RESULTS

From 2009 to 2012, 3323 cases of symptomatic STEC O157 with completed questionnaires were reported, of which 172 developed tHUS (5.18%). Being aged 1-4 years (OR 8.65, 95% CI 5.01 to 14.94, p=0.004) or female (OR 1.61, 95% CI 1.12 to 2.30, p=0.009), being infected with phage type (PT) 21/28 (OR 2.07, 95% CI 1.25 to 3.42, p=0.005) or PT 2 (OR 2.18, 95% CI 1.06 to 4.50, p=0.034), receiving β-lactam antibiotics (OR 4.08, 95% CI 1.43 to 11.68, p=0.009) and presenting with vomiting (OR 3.16, 95% CI 2.16 to 4.62, p<0.001) or bloody diarrhoea (OR 2.10, 95% CI 1.38 to 3.20, p=0.001) were found to be significant risk factors for progression to tHUS. The predicted percentage chance of developing tHUS varied from under 1% to 50% if all risk factors were present.

CONCLUSIONS

The data from this study indicate the use of β-lactam antibiotics should be avoided in suspected cases of STEC infection in all age groups, particularly in those under the age of 5.

CNS Myelin Sheath Lengths Are an Intrinsic Property of Oligodendrocytes

Since Río-Hortega's description of oligodendrocyte morphologies nearly a century ago, many studies have observed myelin sheath-length diversity between CNS regions. Myelin sheath length directly impacts axonal conduction velocity by influencing the spacing between nodes of Ranvier. Such differences likely affect neural signal coordination and synchronization. What accounts for regional differences in myelin sheath lengths is unknown; are myelin sheath lengths determined solely by axons or do intrinsic properties of different oligodendrocyte precursor cell populations affect length? The prevailing view is that axons provide molecular cues necessary for oligodendrocyte myelination and appropriate sheath lengths. This view is based upon the observation that axon diameters correlate with myelin sheath length, as well as reports that PNS axonal neuregulin-1 type III regulates the initiation and properties of Schwann cell myelin sheaths. However, in the CNS, no such instructive molecules have been shown to be required, and increasing in vitro evidence supports an oligodendrocyte-driven, neuron-independent ability to differentiate and form initial sheaths. We test this alternative signal-independent hypothesis--that variation in internode lengths reflects regional oligodendrocyte-intrinsic properties. Using microfibers, we find that oligodendrocytes have a remarkable ability to self-regulate the formation of compact, multilamellar myelin and generate sheaths of physiological length. Our results show that oligodendrocytes respond to fiber diameters and that spinal cord oligodendrocytes generate longer sheaths than cortical oligodendrocytes on fibers, co-cultures, and explants, revealing that oligodendrocytes have regional identity and generate different sheath lengths that mirror internodes in vivo.

Duration of ruptured membranes and mother-to-child HIV transmission: a prospective population-based surveillance study

OBJECTIVE

To investigate the association between duration of rupture of membranes (ROM) and mother-to-child HIV transmission (MTCT) rates in the era of combination antiretroviral therapy (cART).

DESIGN

The National Study of HIV in Pregnancy and Childhood (NSHPC) undertakes comprehensive population-based surveillance of HIV in pregnant women and children.

SETTING

UK and Ireland.

POPULATION

A cohort of 2398 singleton pregnancies delivered vaginally, or by emergency caesarean section, in women on cART in pregnancy during the period 2007-2012 with information on duration of ROM; HIV infection status was available for 1898 infants.

METHODS

Descriptive analysis of NSHPC data.

MAIN OUTCOME MEASURES

Rates of MTCT.

RESULTS

In 2116 pregnancies delivered at term, the median duration of ROM was 3 hours 30 minutes (interquartile range, IQR 1-8 hours). The overall MTCT rate for women delivering at term with duration of ROM ≥4 hours was 0.64% compared with 0.34% for ROM <4 hours, with no significant difference between the groups (OR 1.90, 95% CI 0.45-7.97). In women delivering at term with a viral load of <50 copies/ml, there was no evidence of a difference in MTCT rates with duration of ROM ≥4 hours, compared with <4 hours (0.14% for ≥4 hours versus 0.12% for <4 hour; OR 1.14, 95% CI 0.07-18.27). Among infants born preterm with infection status available, there were no transmissions in 163 deliveries where the maternal viral load was <50 copies/ml.

CONCLUSIONS

No association was found between duration of ROM and MTCT in women taking cART.

TWEETABLE ABSTRACT

Rupture of membranes of more than 4 hours is not associated with MTCT of HIV in women on effective ART delivering at term.

Identification of verocytotoxin-producing Escherichia coli O117:H7 in men who have sex with men, England, November 2013 to August 2014

Between November 2013 and August 2014, nine cases of verocytotoxin-producing Escherichia coli O117:H7 VT1 were confirmed in adult men. Further investigation using semi-structured interviews revealed that eight cases were United Kingdom (UK)-born men who have sex with men (MSM) who had sexually acquired infection in the UK. Most were HIV-positive with high numbers of sexual partners. This behavioural profile resembles that associated with the recent rapid increase in other sexually acquired infections in MSM.

Predicting carotid artery disease and plaque instability from cell-derived microparticles

OBJECTIVES

Cell-derived microparticles (MPs) are small plasma membrane-derived vesicles shed from circulating blood cells and may act as novel biomarkers of vascular disease. We investigated the potential of circulating MPs to predict (a) carotid plaque instability and (b) the presence of advanced carotid disease.

METHODS

This pilot study recruited carotid disease patients (aged 69.3 ± 1.2 years [mean ± SD], 69% male, 90% symptomatic) undergoing endarterectomy (n = 42) and age- and sex-matched controls (n = 73). Plaques were classified as stable (n = 25) or unstable (n = 16) post surgery using immunohistochemistry. Blood samples were analysed for MP subsets and molecular biomarkers. Odds ratios (OR) are expressed per standard deviation biomarker increase.

RESULTS

Endothelial MP (EMP) subsets, but not any vascular, inflammatory, or proteolytic molecular biomarker, were higher (p < .05) in the unstable than the stable plaque patients. The area under the receiver operator characteristic curve for CD31(+)41(-) EMP in discriminating an unstable plaque was 0.73 (0.56-0.90, p < .05). CD31(+)41(-) EMP predicted plaque instability (OR = 2.19, 1.08-4.46, p < .05) and remained significant in a multivariable model that included transient ischaemic attack symptom status. Annexin V(+) MP, platelet MP (PMP) subsets, and C-reactive protein were higher (p < .05) in cases than controls. Annexin V(+) MP (OR = 3.15, 1.49-6.68), soluble vascular cell adhesion molecule-1 (OR = 1.64, 1.03-2.59), and previous smoking history (OR = 3.82, 1.38-10.60) independently (p < .05) predicted the presence of carotid disease in a multivariable model.

CONCLUSIONS

EMP may have utility in predicting plaque instability in carotid patients and annexin V(+) MPs may predict the presence of advanced carotid disease in aging populations, independent of established biomarkers.

A multi-country outbreak of Salmonella Newport gastroenteritis in Europe associated with watermelon from Brazil, confirmed by whole genome sequencing: October 2011 to January 2012

In November 2011, the presence of Salmonella Newport in a ready-to-eat watermelon slice was confirmed as part of a local food survey in England. In late December 2011, cases of S. Newport were reported in England, Wales, Northern Ireland, Scotland, Ireland and Germany. During the outbreak, 63 confirmed cases of S. Newport were reported across all six countries with isolates indistinguishable by pulsed-field gel electrophoresis from the watermelon isolate.A subset of outbreak isolates were whole-genome sequenced and were identical to, or one single nucleotide polymorphism different from the watermelon isolate.In total, 46 confirmed cases were interviewed of which 27 reported watermelon consumption. Further investigations confirmed the outbreak was linked to the consumption of watermelon imported from Brazil.Although numerous Salmonella outbreaks associated with melons have been reported in the United States and elsewhere, this is the first of its kind in Europe.Expansion of the melon import market from Brazil represents a potential threat for future outbreaks. Whole genome sequencing is rapidly becoming more accessible and can provide a compelling level of evidence of linkage between human cases and sources of infection,to support public health interventions in global food markets.

Outbreak of Shiga toxin-producing E. coli O157 associated with consumption of watercress, United Kingdom, August to September 2013

An increase in the number of cases of Shiga toxin-producing Escherichia coli O157 PT 2 stx2 infection was reported in the United Kingdom on 9 September 2013. Of the 19 cases, 13 were interviewed, of which 10 reported consuming watercress purchased from one retailer. The retailer recalled pre-packed bagged salads containing watercress on 12 September. The descriptive epidemiology was supported by a case–case study performed after control measures were implemented.

Molecular discrimination of Perna (Mollusca: Bivalvia) species using the polymerase chain reaction and species-specific mitochondrial primers

This work was prompted by the need to be able to identify the invasive mussel species, Perna viridis, in tropical Australian seas using techniques that do not rely solely on morphology. DNA-based molecular methods utilizing a polymerase chain reaction (PCR) approach were developed to distinguish unambiguously between the three species in the genus Perna. Target regions were portions of two mitochondrial genes, cox1 and nad4, and the intergenic spacer between these that occurs in at least two Perna species. Based on interspecific sequence comparisons of the nad4 gene, a conserved primer has been designed that can act as a forward primer in PCRs for any Perna species. Four reverse primers have also been designed, based on nad4 and intergenic spacer sequences, which yield species-specific products of different lengths when paired with the conserved forward primer. A further pair of primers has been designed that will amplify part of the cox1 gene of any Perna species, and possibly other molluscs, as a positive control to demonstrate that the PCR is working.

Phenolic acids protect low density lipoproteins from peroxynitrite-mediated modification in vitro

The role of reactive nitrogen species, such as peroxynitrite, in atherogenesis and the protective effect of dietary phenolic compounds are not yet understood. In this study, we sought firstly to determine whether phenolic acids become nitrated by peroxynitrite and then whether phenolic acid nitration can prevent consumption of gamma-tocopherol and thus enhance the resistance of LDL to oxidation by peroxynitrite. Coumaric acid was found to be readily nitrated by peroxynitrite and it also demonstrated a protective effect on y-tocopherol. Of greater significance was its potent inhibition of lipid peroxidation which was equal to that of caffeic acid.

A pilot study for a randomized controlled trial comparing the efficacy, safety and cost-effectiveness of surgical treatments of the prostate

OBJECTIVE

To assess the numbers of men in outpatients and subsequently undergoing transurethral resection of the prostate (TURP) who were referred during 1993-94 and 1996-97, thereby assessing the feasibility of a subsequent study of treatment efficacy in men with bladder outlet obstruction secondary to benign prostatic hyperplasia, prospectively randomized to the surgical treatment options, i.e. TURP, laser ablation of the prostate, transurethral needle ablation and T3 thermotherapy, to investigate treatment outcome, cost-efficacy and cost-benefit.

PATIENTS AND METHODS

All patients considered and consenting for prostate surgery were reviewed prospectively with a view to inclusion in the proposed trial. The diagnosis was based on two estimates of flow rate from voids of >150 mL and from symptoms assessed using the International Prostate Symptom Score. All patients had TURP explained by a urological surgeon and nursing staff, and subsequently had further consultation with research staff.

RESULTS

Patients seen in clinic as new referrals increased by 11% between the periods assessed, although the numbers undergoing TURP decreased by 19%. Of the 383 patients screened, who were on the waiting list for TURP, only 13 elected to enter the trial. Of the 383 men, 267 (67%) ultimately had prostate surgery, with 39 (10%) electing to continue with watchful waiting and 34 (9%) continuing with pharmacotherapy.

CONCLUSION

Although more men with benign prostatic disease and lower urinary tract symptoms are being seen in clinics, the reduced proportion of patients continuing to surgical intervention will lead to increasing difficulty in carrying out randomized controlled clinical trials assessing surgical options. With ever more therapeutic options available, patients find it difficult to make decisions in both the clinical situation and when asked to enter a trial. Fully informed decisions by both the surgeon and the patient will only be possible when objective data are available from trials that investigate outcome, cost-efficacy and cost-benefit. This study suggests that when presented with more information and counselling, fewer men decide to undergo prostate surgery for symptomatic BPH.

A chromatographic method for the preparative separation of phosphohistidines

The driving force behind this new chromatographic technique was to develop a method for purifying preparative quantities of phosphohistidines in a single step that provided good resolution wit eluants that could be easily removed. The current method can provide milligram quantities of each phosphohistidine; however, the later 1H NMR analysis of the dried, individually purified phosphohistidines showed that histidine was present along with each of the individual phosphohistidines. The stability of each phosphohistidine during storage does not appear to be a problem because the amounts of histidine contamination of freshly freeze-dried samples were compared with those of samples stored at -80 degrees C under nitrogen for 2 weeks and were found to be similar (data not shown). Possibly, the lyophilization and preparation of solutions for NMR analysis resulted in a certain amount of hydrolysis of phosphohistidine, particularly with the less stable 1- and 1,3-forms (5, 6). It was noted that when the lyophilized samples were initially dissolved in D2O for NMR analysis, the pH was between 6 and 7; this may have resulted in some hydrolysis of the phosphohistidines. This hydrolysis can be reduced by the addition of 50 mM potassium hydroxide to the pooled fractions collected from the chromatography, so that the alkalinity of the samples is maintained throughout the subsequent processes. The data obtained for the assignment of individual phosphohistidines by 1H and 31P NMR analysis seem consistent with those obtained by other independent studies (6, 10). The NMR analysis was a powerful tool in assigning the identity of each purified phosphohistidine, although caution should be used when considering free phosphohistidines as references for NMR detection of phosphohistidines in native proteins. Lecroisey et al. (10) showed that there were differences between the chemical shifts observed for free phosphohistidine compared to those for phosphohistidine in dipeptides. However, for the purposes of phosphoamino acid analysis, these purified phosphohistidines are used by this group as references in the detection of phosphohistidine in proteins.

The Irish cystic fibrosis database

We have found records of 1014 Irish cystic fibrosis patients alive by December 1994, belonging to 883 families. Prevalence in the population is 1/3475 and incidence at birth 1/1461, with a gene frequency of 2.6%. Twenty percent of the patients are aged over 20 years, but at present survival rate falls rapidly after that age. We have identified 85% of the mutations on the CFTR gene in a sample of 29% of the families (506 CF chromosomes). Mutation delta F508 is found in 72% of Irish CF chromosomes, G551D in 6.9%, and R117H in 2%. These are the highest frequencies reported for the latter two mutations world wide. Another seven mutations are found in an additional 4% of CF families. We present new microsatellite haplotype data that could be useful for genetic counselling of CF families bearing some of the 15% of CF mutations still unidentified, and comment on possible uses of our database.