What are the impacts of alcohol supply reduction measures on police-recorded adult domestic and family violence in the Northern Territory of Australia?

BACKGROUND

During 2017-18, the Northern Territory (NT) introduced a Banned Drinker Register (BDR) and Minimum Unit Price (MUP) NT-wide; Police Auxiliary Liquor Inspectors (PALIs) in three regional towns; and restrictions on daily purchases/opening hours (DPOH) in one regional town. The BDR is an individual-level alcohol ban; MUP is a pricing policy; and PALIs enforce bans on restricted areas at takeaway outlets. This study examines the impact of these policies on adult domestic and family violence (DFV).

METHODS

We examined DFV assaults and breaches of violence orders from January 2014 - February 2020 using interrupted time series models for NT, Greater Darwin, Katherine, Tennant Creek, and Alice Springs. To account for increasing numbers of individuals on the BDR we tested two timepoints (Sept 2017, March 2018).

FINDINGS

Following DPOH, assaults (78 %) and alcohol-involved assaults (92 %) decreased in Tennant Creek. After PALIs, assaults (79 %) in Tennant Creek, and breaches (39 %) and alcohol-involved breaches (58 %) in Katherine decreased. After MUP, assaults (11 %), alcohol-involved assaults (21 %) and alcohol-involved breaches (21%) decreased NT wide. After MUP/PALIs in Alice Springs, alcohol-involved assaults (33 %), breaches (42 %), and alcohol-involved breaches (57 %) decreased. BDR (Sept 2017) found increases in assaults (44 %) and alcohol-involved assaults (39 %) in Katherine and assaults (10%) and alcohol-involved assaults NT-wide (17 %). There were increases of 21 %-45 % in breaches NT-wide, in Darwin, Katherine, and Alice Springs. Following March 2018 found increases in assaults (33 %) and alcohol-involved assaults (48 %) in Katherine. There were increases - from 20 % to 56 % - in breaches in NT-wide, Katherine, and Alice Springs.

CONCLUSION

PALIs and DPOH were associated with some reductions in DFV; the BDR was associated with some increases. The upward trend commences prior to the BDR, so it is also plausible that the BDR had no effect on DFV outcomes. Although MUP was associated with reductions in the NT-wide model, there were no changes in sites without cooccurring PALIs.

Performance status at the time of lung retransplant predicts long-term function

BACKGROUND

Lung retransplantation is offered to select patients with chronic allograft dysfunction. Given the increased risk of morbidity and mortality conferred by retransplantation, post-transplant function should be considered in the decision of who and when to list. The aim of this study is to identify predictors of post-operative disability in patients undergoing lung retransplantation.

METHODS

Data were collected from the UNOS national dataset and included all patients who underwent lung retransplant from May 2005-March 2023. Pre- and post-operative function was reported by the Karnofsky Performance Status (KPS) and patients were stratified based on their needs. Cumulative link mixed effects models identified associations between pre-transplant variables and post-transplant function.

RESULTS

A total of 1275 lung retransplant patients were included. After adjusting for between-group differences, pre-operative functional status was predictive of post-transplant function; patients requiring Total Assistance ( n = 740) were 74% more likely than No/Some Assistance patients (n = 535) to require more assistance in follow-up (OR 1.74, 95% CI 1.13-2.68, p = .012). Estimated one year survival of Total Assistance patients is lower than No/Some Assistance Recipients (72% vs. 82%, CI 69%-75%; 79%-86%) but similar to overall re-transplant survival (76%, CI 74%-79%).

CONCLUSION

Both survival and regain of function in patients requiring Total Assistance prior to retransplant may be higher than previously reported. Pre-operative functional status is predictive of post-operative function and should weigh in the selection, timing and post-operative care of patients considered for lung retransplantation.

Cell division machinery drives cell-specific gene activation during differentiation in Bacillus subtilis

When faced with starvation, the bacterium Bacillus subtilis transforms itself into a dormant cell type called a "spore". Sporulation initiates with an asymmetric division event, which requires the relocation of the core divisome components FtsA and FtsZ, after which the sigma factor σF is exclusively activated in the smaller daughter cell. Compartment-specific activation of σF requires the SpoIIE phosphatase, which displays a biased localization on one side of the asymmetric division septum and associates with the structural protein DivIVA, but the mechanism by which this preferential localization is achieved is unclear. Here, we isolated a variant of DivIVA that indiscriminately activates σF in both daughter cells due to promiscuous localization of SpoIIE, which was corrected by overproduction of FtsA and FtsZ. We propose that the core components of the redeployed cell division machinery drive the asymmetric localization of DivIVA and SpoIIE to trigger the initiation of the sporulation program.

Using AI/ML to predict blending performance and process sensitivity for Continuous Direct Compression (CDC)

Utilising three artificial intelligence (AI)/machine learning (ML) tools, this study explores the prediction of fill level in inclined linear blenders at steady state by mapping a wide range of bulk powder characteristics to processing parameters. Predicting fill levels enables the calculation of blade passes (strain), known from existing literature to enhance content uniformity. We present and train three AI/ML models, each demonstrating unique predictive capabilities for fill level. These models collectively identify the following rank order of feature importance: RPM, Mixing Blade Region (MB) size, Wall Friction Angle (WFA), and Feed Rate (FR). Random Forest Regression, a machine learning algorithm that constructs a multitude of decision trees at training time and outputs the mode of the classes (classification) or mean prediction (regression) of the individual trees, develops a series of individually useful decision trees. but also allows the extraction of logic and breakpoints within the data. A novel tool which utilises smart optimisation and symbolic regression to model complex systems into simple, closed-form equations, is used to build an accurate reduced-order model. Finally, an Artificial Neural Network (ANN), though less interrogable emerges as the most accurate fill level predictor, with an r2 value of 0.97. Following training on single-component mixtures, the models are tested with a four-component powdered paracetamol formulation, mimicking an existing commercial drug product. The ANN predicts the fill level of this formulation at three RPMs (250, 350 and 450) with a mean absolute error of 1.4%. Ultimately, the modelling tools showcase a framework to better understand the interaction between process and formulation. The result of this allows for a first-time-right approach for formulation development whilst gaining process understanding from fewer experiments. Resulting in the ability to approach risk during product development whilst gaining a greater holistic understanding of the processing environment of the desired formulation.

Police-recorded adult sexual assault in the Northern Territory, Australia: Alcohol involvement and alcohol policy effects

INTRODUCTION

Between 2017 and 2018 three major alcohol policy changes were introduced in the Northern Territory (NT): the Banned Drinker Register, an individual-level ban enforced via ID scanners at takeaway outlets; a Minimum Unit Price on alcohol; and Police Auxiliary Liquor Inspectors, who monitor takeaway outlets to prevent purchase by people who do not have a legal place to consume alcohol. We aimed to: (i) describe alcohol-involved adult sexual assault in the NT; and (ii) estimate the impacts of these alcohol policies on police-recorded adult sexual assault.

METHODS

We used victim records for sexual assault where victims were aged 15 years and over. We undertook descriptive analyses for the NT from 2014 to 2020 and used interrupted time series analysis to assess policy impacts across the NT and in Greater Darwin.

RESULTS

In 2020, the NT adult victimisation rate was 105 per 100,000. A large minority (40%) of adult sexual assaults involved alcohol. Interrupted time series analyses showed no effect of the Banned Drinker Register or Minimum Unit Price on sexual assault across the NT or in Greater Darwin.

DISCUSSION AND CONCLUSIONS

The rate of adult sexual assaults in the NT is extremely high and many involve alcohol. Neither the Banned Drinker Register or Minimum Unit Price were associated with changes in police-recorded adult sexual assault in Greater Darwin or across the NT. Due to small counts, we were unable to assess policy impacts in three of the four main towns, highlighting the challenges of assessing impacts of policies on sexual assault in small population areas.

Lung transplantation in HIV seropositive recipients: An analysis of the UNOS registry

BACKGROUND

Experience with lung transplantation (LT) in patients with human immunodeficiency virus (HIV) is limited. Many studies have demonstrated the success of kidney and liver transplantation in HIV-seropositive (HIV+) patients. Our objective was to conduct a national registry analysis comparing LT outcomes in HIV+ to HIV-seronegative (HIV-) recipients.

METHODS

The United Network for Organ Sharing database was queried to identify LTs performed in adult HIV+ patients between 2016 and 2023. Patients with unknown HIV status, multiorgan transplants, and redo transplants were excluded. The primary endpoints were mortality and graft rejection. Survival time was analyzed using Kaplan-Meier analysis.

RESULTS

The study included 17 487 patients, 67 of whom were HIV+. HIV+ recipients were younger (59 vs. 62 years, p = .02), had higher pulmonary arterial pressure (28 vs. 25 mm Hg, p = .04), and higher lung allocation scores (47 vs. 41, p = .01) relative to HIV- recipients. There were no differences in graft/recipient survival time between groups. HIV+ recipients had higher rates of post-transplant dialysis (18% vs. 8.4%, p = .01), but otherwise had similar post-transplant outcomes to HIV-recipients.

CONCLUSIONS

This national registry analysis suggests LT outcomes in HIV+ patients are not inferior to outcomes in HIV- patients and that well-selected HIV+ recipients can achieve comparable patient and graft survival rates relative to HIV- recipients.

Impact of age and telomere length on circulating T cells and rejection risk after lung transplantation for idiopathic pulmonary fibrosis

BACKGROUND

Most idiopathic pulmonary fibrosis (IPF) lung transplant recipients (IPF-LTRs) have short telomere (ST) length. Inherited mutations in telomere-related genes are associated with the development of T cell immunodeficiency. Despite this, IPF-LTRs with telomere-related rare variants are not protected from acute cellular rejection (ACR). We set out to determine the impact of both age and telomere length on the circulating T cell compartment and ACR burden of IPF-LTRs.

METHODS

We identified 106 IPF-LTRs who had telomere length testing using flowFISH (57 with short telomeres and 49 with long telomeres) as well as a subset from both cohorts who had cryopreserved PBMC at least 1 time point, 6 months posttransplantation. Circulating T cells from before transplantation and at 6 and 12 months posttransplantation were analyzed using multiparameter flow cytometry to study phenotype and functional capacity, and bulk T cell receptor sequencing was performed to study repertoire diversity. Linear regression was used to study the relationship of age and telomere length on early (within 1 year) and late (between 1 and 2 years) ACR.

RESULTS

IPF-LTRs with ST were found to have premature "aging" of their circulating T cell compartment, with age-agnostic elevations in posttransplant terminal differentiation of CD8+ T cells, increased granzyme B positivity of both CD8+ and CD4+ T cells, upregulation of the exhaustion marker, CD57, and chemotactic protein CCR5, and enhanced T cell receptor clonal expansion. Additionally, we found a significant decline in early ACR burden with increasing age, but only in the ST cohort.

CONCLUSIONS

IPF-LTRs with ST have premature "aging" of their circulating T cell compartment posttransplantation and a clear age-related decline in ACR burden.

Immediate Postoperative COVID-19 Infection after Lung Transplantation: A Systematic Review and Case Series

BACKGROUND

With new variants challenging the effectiveness of preventive measures, we are beginning to recognize the reality that COVID-19 will continue to pose an endemic threat. The manifestations of COVID-19 in lung transplant recipients during index admission are poorly understood with very few cases reported in recent lung transplant recipients. Optimal management of immunosuppression and antiviral therapy in recent transplant recipients is challenging.

METHODS

We performed a retrospective analysis identifying lung transplant recipients at our institution who contracted COVID-19 in the immediate postoperative period (within index admission). In addition, we performed a systematic review from January 2020 to August 2023 identifying all publications on the PUBMED database regarding COVID-19 infection in lung transplant recipients during index admission.

RESULTS

We report four cases of COVID-19 pneumonia in lung transplant recipients in the immediate postoperative period and we describe the clinical course, treatment options, and immunosuppression changes to manage this unique clinical problem. All patients made a full recovery and were eventually discharged home. Within our review of the literature, the most prevalent presenting symptoms were cough, dyspnea, and fatigue. Six (75%) patients decreased or held their antimetabolite. The two most common treatments were monoclonal antibodies (38%) and remdesivir (63%).

CONCLUSION

Although previous literature demonstrates that COVID-19 can be deadly in recent lung transplant recipients, rapid treatment with anti-viral therapy/immunotherapy, deescalating immunosuppression, and treatment of respiratory decompensation with Decadron was effective in our patients.

Postoperative Acute Kidney Injury and Long-Term Outcomes After Lung Transplantation

BACKGROUND

This study sought to characterize perioperative risk factors of acute kidney injury (AKI) and report outcomes associated with its development in the immediate postoperative setting after lung transplantation.

METHODS

Study investigator performed a retrospective analysis of all adult patients undergoing primary lung transplantation at a single institution from January 1, 2011 to December 31, 2021 AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria after lung transplantation and was stratified on the basis of whether patients required renal replacement therapy (RRT; AKI-no RRT vs AKI-RRT).

RESULTS

Of the 754 patients included, 369 (48.9%) any AKI developed in the postoperative period (252 AKI-no RRT vs 117 AKI-RRT). Risk factors for postoperative AKI included higher preoperative creatinine levels (odds ratio [OR], 5.15; P < .001), lower preoperative estimated glomerular filtration rate (OR, 0.99; P < 0.018), delayed chest closure (OR, 2.72; P < .001), and higher volumes of postoperative blood products (OR, 1.09; P < .001) in the multivariable analysis. On univariate analysis, both AKI groups were also associated with higher rates of pneumonia (P < .001), reintubation (P < .001), mortality on index admission (P < 0.001), longer ventilator duration (P < .001), longer intensive care unit length of stay (P < .001), and longer hospital length of stay (P < .001), with the highest rates in the AKI-RRT group. In a multivariable survival analysis, postoperative AKI-no RRT (hazard ratio [HR], 1.50; P = .006) and AKI-RRT (HR, 2.70; P < .001) were associated with significantly worse survival independent of severe grade 3 primary graft dysfunction at 72 hours (HR, 1.45; P = .038).

CONCLUSIONS

The development of postoperative AKI was associated with numerous preoperative and intraoperative factors. Postoperative AKI remained significantly associated with poorer posttransplantation survival. Severe cases of AKI necessitating RRT portended the worst survival after lung transplantation.

Application of Positron Emission Particle Tracking (PEPT) for the evaluation of powder behaviour in an incline linear blender for Continuous Direct Compression (CDC)

Positron Emission Particle Tracking (PEPT) is a non-invasive measurement technique which offers the ability to track the motion of individual particles with high temporal and spatial resolution, and thus build up an understanding of the bulk behaviour of a system from its microscopic (particle level) dynamics. Using this measurement technique, we have developed a series of novel metrics to better understand the behaviours of powders during the steady-state operation of a continuous blender system. Results are presented concerning the response of particle motion to processing parameters (mixing blade configuration and RPM), quantifying the motion in terms of predicted mixing performance. It was found that both increasing rpm and increasing hold-up mass (by selecting fewer transport blades and more mixing blades) provided improved mixing conditions. Interestingly, under specific conditions, there is evidence of convection-like mixing occurring at the interface of the transport and mixing region. This suggests the existence of a potential 'folding region' whereby powder is transported up the barrel (and away from the powder bulk bed) before being reconstituted back into the bulk mass. The results also provide valuable experimental data for the development, calibration and validation of future Discrete Element Method (DEM) simulations.

Osimertinib and Selpercatinib Efficacy, Safety, and Resistance in a Multicenter, Prospectively Treated Cohort of EGFR-Mutant and RET Fusion-Positive Lung Cancers

PURPOSE

Acquired RET fusions have been reported at resistance to treatment with EGFR inhibitors in EGFR-mutant non-small cell lung cancer (NSCLC); however, a multicenter cohort of patients with EGFR-mutant lung cancers treated with osimertinib and selpercatinib for RET fusion-mediated osimertinib resistance has not previously been published.

PATIENTS AND METHODS

Patients who received selpercatinib in combination with osimertinib on a prospective expanded access clinical trial (NCT03906331) and single-patient compassionate use programs across five countries were centrally analyzed. All patients had advanced EGFR-mutant NSCLC with a RET fusion detected from tissue or plasma following osimertinib therapy. Clinicopathologic and outcomes data were collected.

RESULTS

Fourteen patients with EGFR-mutant and RET fusion-positive lung cancers who experienced prior progression on osimertinib received osimertinib and selpercatinib. EGFR exon 19 deletions (±T790M, 86%) and non-KIF5B fusions (CCDC6-RET 50%, NCOA4-RET 36%) predominated. Osimertinib 80 mg daily and selpercatinib 80 mg twice daily were the most commonly administered dosages. The response rate, disease control rate, and median treatment duration were 50% [95% confidence interval (CI), 25%-75%, n = 12], 83% (95% CI, 55%-95%), and 7.9 months (range, 0.8-25+), respectively. Resistance was complex, involving EGFR on-target (EGFR C797S), RET on-target (RET G810S), and off-target (EML4-ALK/STRN-ALK, KRAS G12S, BRAF V600E) mechanisms; RET fusion loss; or polyclonal mechanisms.

CONCLUSIONS

For patients with EGFR-mutant NSCLC with an acquired RET fusion as a mechanism of EGFR inhibitor resistance, the addition of selpercatinib to osimertinib was feasible and safe and offered clinical benefit, supporting the prospective evaluation of this combination. See related commentary by Krebs and Popat, p. 2951.

Cell division machinery drives cell-specific gene activation during bacterial differentiation

When faced with starvation, the bacterium Bacillus subtilis transforms itself into a dormant cell type called a "spore". Sporulation initiates with an asymmetric division event, which requires the relocation of the core divisome components FtsA and FtsZ, after which the sigma factor σF is exclusively activated in the smaller daughter cell. Compartment specific activation of σF requires the SpoIIE phosphatase, which displays a biased localization on one side of the asymmetric division septum and associates with the structural protein DivIVA, but the mechanism by which this preferential localization is achieved is unclear. Here, we isolated a variant of DivIVA that indiscriminately activates σF in both daughter cells due to promiscuous localization of SpoIIE, which was corrected by overproduction of FtsA and FtsZ. We propose that a unique feature of the sporulation septum, defined by the cell division machinery, drives the asymmetric localization of DivIVA and SpoIIE to trigger the initiation of the sporulation program.

Directions of change in intrinsic case severity across successive SARS-CoV-2 variant waves have been inconsistent

OBJECTIVES

To determine how the intrinsic severity of successively dominant SARS-CoV-2 variants changed over the course of the pandemic.

METHODS

A retrospective cohort analysis in the NHS Greater Glasgow and Clyde (NHS GGC) Health Board. All sequenced non-nosocomial adult COVID-19 cases in NHS GGC with relevant SARS-CoV-2 lineages (B.1.177/Alpha, Alpha/Delta, AY.4.2 Delta/non-AY.4.2 Delta, non-AY.4.2 Delta/Omicron, and BA.1 Omicron/BA.2 Omicron) during analysis periods were included. Outcome measures were hospital admission, ICU admission, or death within 28 days of positive COVID-19 test. We report the cumulative odds ratio; the ratio of the odds that an individual experiences a severity event of a given level vs all lower severity levels for the resident and the replacement variant after adjustment.

RESULTS

After adjustment for covariates, the cumulative odds ratio was 1.51 (95% CI: 1.08-2.11) for Alpha versus B.1.177, 2.09 (95% CI: 1.42-3.08) for Delta versus Alpha, 0.99 (95% CI: 0.76-1.27) for AY.4.2 Delta versus non-AY.4.2 Delta, 0.49 (95% CI: 0.22-1.06) for Omicron versus non-AY.4.2 Delta, and 0.86 (95% CI: 0.68-1.09) for BA.2 Omicron versus BA.1 Omicron.

CONCLUSIONS

The direction of change in intrinsic severity between successively emerging SARS-CoV-2 variants was inconsistent, reminding us that the intrinsic severity of future SARS-CoV-2 variants remains uncertain.

The Impact of Minimum Unit Price on Police-Recorded Alcohol-Related Assault Rates in the Northern Territory, Australia

OBJECTIVE

From October 1, 2018, the Northern Territory (NT) of Australia introduced a minimum unit price (MUP) for alcohol of AU$1.30 per standard drink. The MUP was introduced to address the high alcohol consumption rates and harms within the NT. This study aimed to investigate the unique short-term impact of the MUP on alcohol-related assaults across the NT, for the NT overall and separately for four key regions (Darwin and Palmerston, Alice Springs, Katherine, and Tennant Creek); which allowed for the consideration of differences in concurrent alcohol interventions and population (e.g., Alice Springs had Police Auxiliary Liquor Inspectors (PALIs) introduced on October 1, 2018, whereas Darwin and Palmerston only had the MUP introduced in this period). PALIs effectively equate to a police officer being stationed in every off-premise liquor vendor.

METHOD

Using data from January 2013 to September 2019, interrupted time series (ITS) analyses assessed the short-term impact of the MUP on the monthly rate of police-recorded alcohol-related assaults.

RESULTS

A 14% reduction (B = -3.07 [-5.40, -0.74], p < .010) was found for alcohol-related assault offenses per 10,000 in Darwin/Palmerston. Significant reductions were also noted in Alice Springs and the NT overall, although PALIs are likely to have contributed to these reductions in addition to the MUP.

CONCLUSIONS

This short-term impact warrants longer-term follow-up to determine whether the reductions in alcohol-related assaults following the introduction of MUP are maintained, and the extent to which assault rates are influenced by other alcohol-policy interventions in the NT.

The SARS-CoV-2 Alpha variant was associated with increased clinical severity of COVID-19 in Scotland: A genomics-based retrospective cohort analysis

OBJECTIVES

The SARS-CoV-2 Alpha variant was associated with increased transmission relative to other variants present at the time of its emergence and several studies have shown an association between Alpha variant infection and increased hospitalisation and 28-day mortality. However, none have addressed the impact on maximum severity of illness in the general population classified by the level of respiratory support required, or death. We aimed to do this.

METHODS

In this retrospective multi-centre clinical cohort sub-study of the COG-UK consortium, 1475 samples from Scottish hospitalised and community cases collected between 1st November 2020 and 30th January 2021 were sequenced. We matched sequence data to clinical outcomes as the Alpha variant became dominant in Scotland and modelled the association between Alpha variant infection and severe disease using a 4-point scale of maximum severity by 28 days: 1. no respiratory support, 2. supplemental oxygen, 3. ventilation and 4. death.

RESULTS

Our cumulative generalised linear mixed model analyses found evidence (cumulative odds ratio: 1.40, 95% CI: 1.02, 1.93) of a positive association between increased clinical severity and lineage (Alpha variant versus pre-Alpha variants).

CONCLUSIONS

The Alpha variant was associated with more severe clinical disease in the Scottish population than co-circulating lineages.

Incorporating local health education priorities in HealthLAB: Learnings from very remote Australia

ISSUE ADDRESSED

It is well-established that health education and promotion programs work best when they have been tailored to meet local contextual needs. In this brief report we describe a health education program and how it identified and incorporated local priorities into its delivery in two remote Aboriginal communities in the "Top End" of the Northern Territory.

METHODS

During the first visit to each community team members met with local stakeholders and ran an inaugural HealthLAB session. Fieldnotes were taken during or directly after each interaction. At the end of each day team members debriefed regarding their fieldnotes. After both trips had been completed, priority areas were extracted from fieldnotes and synthesised.

RESULTS

Although some health priorities were congruent across all groups, Community Members and Childcare staff tended to identify practical solutions while School and Clinic staff were focused on the clinical outcome. Community Members were particularly focused on the wider social and systemic factors impacting health.

CONCLUSION

In response to the need for practical support, HealthLAB modified their health education packages to upskill mothers and sports coaches to provide brief health education sessions to local children and young people. SO WHAT?: It is recognised that many health promotion programs focus on individual behaviours without creating supportive environments. While it was out of scope for HealthLAB to address physical environmental factors, by building local capacity and knowledge to deliver health education, the program can contribute to a healthier and supportive social environment.

Single-center experience of ex vivo lung perfusion and subsequent lung transplantation

BACKGROUND

The safety of lung transplantation using ex vivo lung perfusion (EVLP) has been confirmed in multiple clinical studies; however, limited evidence is currently available regarding the potential effects of EVLP on posttransplant graft complications and survival with mid- to long-term follow-up. In this study, we reviewed our institutional data to better understand the impact of EVLP.

METHODS

Lungs placed on EVLP from 2014 through 2020 and transplant outcomes were retrospectively analyzed. Data were compared between lungs transplanted and declined after EVLP, between patients with severe primary graft dysfunction (PGD3) and no PGD3 after EVLP, and between matched patients with lungs transplanted with and without EVLP.

RESULTS

In total, 98 EVLP cases were performed. Changes in metabolic indicators during EVLP were correlated with graft quality and transplantability, but not changes in physiological parameters. Among 58 transplanted lungs after EVLP, PGD3 at 72 h occurred in 36.9% and was associated with preservation time, mechanical support prior to transplant, and intraoperative transfusion volume. Compared with patients without EVLP, patients who received lungs screened with EVLP had a higher incidence of PGD3 and longer ICU and hospital stays. Lung grafts placed on EVLP exhibited a significantly higher chance of developing airway anastomotic ischemic injury by 30 days posttransplant. Acute and chronic graft rejection, pulmonary function, and posttransplant survival were not different between patients with lungs screened on EVLP versus lungs with no EVLP.

CONCLUSION

EVLP use is associated with an increase of early posttransplant adverse events, but graft functional outcomes and patient survival are preserved.

YArnhem: Co-designing a model of social and emotional wellbeing stepped care for young people of the north east Arnhem region: A development study protocol

INTRODUCTION

More Aboriginal and Torres Strait Islander young people experience high or very high levels of psychological distress compared to their non-Indigenous counterparts. This may be partly attributed to systemic barriers resulting in lower rates of help-seeking, sub-optimal identification of psychological challenges, and undertreatment. Reducing these barriers within health systems is an important factor in reducing the Social and Emotional Wellbeing (SEWB) health burden on young Aboriginal and Torres Strait Islander people.

OBJECTIVES

In partnership with Miwatj Health Aboriginal Corporation (Miwatj), this project will co-design an integrated youth Social and Emotional Wellbeing (SEWB) and mental health stepped care model for remote Aboriginal communities in the north east Arnhem region of the Northern Territory.

DESIGN

A collaborative research approach using co-design methods will underpin a community-centric stepped care allocation method, to which culturally appropriate SEWB and mental health interventions and treatments are assigned. These components of the project will inform a digital platform which will facilitate access to SEWB care for young people in north east Arnhem land. This concept was co-developed in a partnership between researchers and Miwatj and builds on Miwatj's previous work to map the stepped needs of young people. The co-design of the content and features of these outputs will be facilitated through community participation and overseen by community, health, and cultural governance structures. This will ensure the solutions developed by the project are culturally responsive, fit for purpose, and will enhance self-determination while reducing systemic barriers to care.

Drink and drug driving education in the Northern Territory: a qualitative study illustrating issues of access and inequity

OBJECTIVE

In the Northern Territory, people who commit drink driving offences are required to undertake an approved course or treatment to be eligible for a driver's licence, however, course uptake is low. We investigated barriers to program uptake.

METHODS

We conducted semi-structured interviews with 24 program attendees, course providers and government stakeholders. We used a framework analysis.

RESULTS

Program coverage in remote areas was limited, leading to inequitable access. The course cost affected uptake and exacerbated existing financial hardship. There were mixed views among government stakeholders on the program. While some held a view that offenders should 'pay the price', some also saw the user-pays model and high program cost as a clear barrier to accessibility.

CONCLUSIONS

The data from this study demonstrate how the current delivery model for drink and drug driving education increases inequities for those in regional and remote areas, and Aboriginal and Torres Strait Islander people.

IMPLICATIONS FOR PUBLIC HEALTH

Moving away from the current user-pays model to a subsidised or free model may facilitate greater access. Online delivery may increase accessibility; however, consultation is required to ensure the program is delivered equitably with consideration of language, literacy, cultural factors and access to technology.

Learning from alcohol (policy) reforms in the Northern Territory (LEARNT): protocol for a mixed-methods study examining the impacts of the banned drinker register

INTRODUCTION

The Banned Drinker Register (BDR) was reintroduced in the Northern Territory (NT) in September 2017. The BDR is a supply reduction measure and involves placing people who consume alcohol at harmful levels on a register prohibiting the purchase, possession and consumption of alcohol. The current study aims to evaluate the impacts of the reintroduction of the BDR, in the context of other major alcohol policy initiatives introduced across the NT such as Police Auxiliary Liquor Inspectors and a minimum unit price for alcohol of US$1.30 per standard drink.

METHODS AND ANALYSES

The Learning from Alcohol (policy) Reforms in the Northern Territory project will use a mixed-methods approach and contain four major components: epidemiological analysis of trends over time (outcomes include health, justice and social welfare data); individual-level data linkage including those on the BDR (outcomes include health and justice data); qualitative interviews with key stakeholders in the NT (n≥50); and qualitative interviews among people who are, or were previously, on the BDR, as well as the families and communities connected to those on the BDR (n=150). The impacts of the BDR on epidemiological data will be examined using time series analysis. Linked data will use generalised mixed models to analyse the relationship between outcomes and exposures, utilising appropriate distributions. Qualitative data will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from NT Department of Health and Menzies School of Health Research Human Research Ethics Committee (HREC), Central Australia HREC and Deakin University HREC. In addition to peer-reviewed publications, we will report our findings to key organisational, policy, government and community stakeholders via conferences, briefings and lay summaries.

A historical overview of legislated alcohol policy in the Northern Territory of Australia: 1979-2021

BACKGROUND

The Northern Territory (NT) has the highest levels of alcohol consumption and harms in Australia. Since the creation of the NT Liquor Act 1978, which came into effect in 1979, numerous legislated alcohol policies have been introduced to attempt to address these harms. We present a narrative historical overview of alcohol policies implemented in the NT from 1979 to 2021.

METHODS

Using scoping review methodology, databases were searched from 1979 to 2021. Of 506 articles screened, 34 met inclusion criteria. Reference lists of all included articles were searched, resulting in the inclusion of another 41 articles and reports, totalling 75 final documents. Policies were organised using Babor and colleagues (2010) established framework: 1. pricing/ taxation; 2. regulating physical availability; 3. modifying drinking environments; 4. drink-driving countermeasures; 5. restrictions on marketing; 6. education/persuasion; 7. treatment/early intervention.

RESULTS

Two pricing/taxation policies have been implemented, Living With Alcohol (LWA) and Minimum Unit Price, both demonstrating evidence of positive effects on health and consumption outcomes. Eight policies approaches have focused on regulating physical availability, implemented at both individual and local area levels. Several of these policies have varied by location and been amended over time. There is some evidence demonstrating reduction in harms attributable to Liquor Supply Plans, localised restrictions, and General Restricted Areas, although these have been site specific. Of the three policies which targeted modifying the drinking environment; one was evaluated, finding a relocation of social harms, rather than a reduction. The literature outlines a range of controversies, particularly regarding policies in domain 2-3, including racial discrimination and a lack of policy stability. No policies relating to restricting marketing or education/persuasion programs were found. The only drink-driving legislated policy was considered to have contributed to the success of the LWA program. Three policies relating to treatment were described; two were not evaluated and evidence showed no ongoing benefits of Alcohol Mandatory Treatment.

DISCUSSION

The NT has implemented a large number of alcohol policies, several of which have evidence of positive effects. However, these policies have often existed in a context of clear politicisation of alcohol policy, frequently with an implicit focus on Aboriginal people's consumption.

The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS): Rationale, objectives, and design

BACKGROUND

Influenza viruses pose significant disease burdens through seasonal outbreaks and unpredictable pandemics. Existing surveillance programs rely heavily on reporting of medically attended influenza (MAI). Continuously monitoring cause-specific school absenteeism may identify local acceleration of seasonal influenza activity. The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS; Oregon, WI) implements daily school-based monitoring of influenza-like illness-specific student absenteeism (a-ILI) in kindergarten through Grade 12 schools and assesses this approach for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.

METHODS

Starting in September 2014, ORCHARDS combines automated reporting of daily absenteeism within six schools and home visits to school children with acute respiratory infection (ARI). Demographic, epidemiological, and symptom data are collected along with respiratory specimens. Specimens are tested for influenza and other respiratory viruses. Household members can opt into a supplementary household transmission study. Community comparisons are possible using a pre-existing and highly effective influenza surveillance program, based on MAI at five family medicine clinics in the same geographical area.

RESULTS

Over the first 5 years, a-ILI occurred on 6634 (0.20%) of 3,260,461 student school days. Viral pathogens were detected in 64.5% of 1728 children with ARI who received a home visit. Influenza was the most commonly detected virus, noted in 23.3% of ill students.

CONCLUSION

ORCHARDS uses a community-based design to detect influenza trends over multiple seasons and to evaluate the utility of absenteeism for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.

Phase IB Study of Osimertinib in Combination with Navitoclax in EGFR-mutant NSCLC Following Resistance to Initial EGFR Therapy (ETCTN 9903)

PURPOSE

Osimertinib is an effective therapy in EGFR-mutant non-small cell lung cancer (NSCLC), but resistance invariably develops. Navitoclax is an oral inhibitor of BCL-2/BCL-xL that has exhibited synergy with osimertinib in preclinical models of EGFR-mutant NSCLC. In hematologic malignancies, BCL-2 family inhibitors in combination therapy effectively increase cellular apoptosis and decrease drug resistance.

PATIENTS AND METHODS

This single-arm phase Ib study evaluated safety, tolerability, and feasibility of osimertinib and navitoclax, including dose expansion in T790M-positive patients at the recommended phase II dose (RP2D). Eligible patients had advanced EGFR-mutant NSCLC with prior tyrosine kinase inhibitor exposure. Five dose levels were planned with osimertinib from 40 to 80 mg orally daily and navitoclax from 150 to 325 mg orally daily.

RESULTS

A total of 27 patients were enrolled (18 in the dose-escalation cohort and nine in the dose-expansion cohort): median age 65, 67% female, 48% exon 19 del, and 37% L858R, median one prior line of therapy. The most common adverse events were lymphopenia (37%), fatigue (22%), nausea (22%), and thrombocytopenia (37%). No dose-limiting toxicities were seen in dose-escalation cohort; osimertinib 80 mg, navitoclax 150 mg was chosen as the RP2D. Most patients (78%) received >95% of planned doses through three cycles. In expansion cohort, objective response rate was 100% and median progression-free survival was 16.8 months. A proapoptotic effect from navitoclax was demonstrated by early-onset thrombocytopenia.

CONCLUSIONS

Oral combination therapy with navitoclax and osimertinib was safe and feasible at RP2D with clinical efficacy. Early thrombocytopenia was common, supporting an target engagement by navitoclax. Further study of BCL-2/BCL-xL inhibition to enhance osimertinib activity is warranted.

Expect the unexpected - Implications for next phase of COVID-19 response

A case report of a 66 year old male patient with COVID 19 who presented late in the clinical course and subsequently developed respiratory failure requiring intubation, after initially experiencing diarrhoea.

Increased case-finding and uptake of direct-acting antiviral treatment essential for micro-elimination of hepatitis C among people living with HIV: a national record linkage study

OBJECTIVES

Micro-elimination of hepatitis C virus (HCV) in people living with HIV (PLHIV) and co-infected with HCV has been proposed as a key contribution to the overall goal of HCV elimination. While other studies have examined micro-elimination in HIV-treated cohorts, few have considered HCV micro-elimination among those not treated for HIV or at a national level.

METHODS

Through data linkage of national and sentinel surveillance data, we examined the extent of HCV testing, diagnosis and treatment among a cohort of PLHIV in Scotland identified through the national database of HIV-diagnosed individuals, up to the end of 2017.

RESULTS

Of 5018 PLHIV, an estimated 797 (15%) had never been tested for HCV and 70 (9%) of these had undiagnosed chronic HCV. The odds of never having been tested for HCV were the highest in those not on HIV treatment [adjusted odds ratio (aOR) = 7.21, 95% confidence interval (CI): 5.15-10.10). Overall HCV antibody positivity was 11%, and it was at its highest among people who inject drugs (49%). Most of those with chronic HCV (91%) had attended an HCV treatment clinic but only half had been successfully treated (54% for those on HIV treatment, 12% for those not) by the end of 2017. The odds of never having been treated for HCV were the highest in those not on HIV treatment (aOR = 3.60, 95% CI: 1.59-8.15).

CONCLUSIONS

Our data demonstrate that micro-elimination of HCV in PLHIV is achievable but progress will require increased effort to engage and treat those co-infected, including those not being treated for their HIV.

Industry views about the Banned Drinker Register in the Northern Territory: Early lessons from a qualitative evaluation

Introduction and Aims

The Northern Territory Government has recently planned and implemented an extensive suite of alcohol harm minimisation policies, including the reintroduction of the Banned Drinker Register (BDR). It is an explicit alcohol supply reduction measure that places persons who consume alcohol at harmful levels onto a register, prohibiting the purchase of alcohol from take‐away liquor outlets. This paper explores industry stakeholders' perspectives regarding the extent to which the BDR is meeting its objectives to improve community health and safety by reducing alcohol‐related harms.

Design and Methods

Interviews and one focus group were conducted with 66 alcohol industry stakeholders from urban and remote locations. Focusing on outcomes both central (crime and safety) and peripheral (health and therapeutic support) to the stakeholders' interest, the authors used inductive thematic analysis to examine participants' perceptions about the effectiveness of the BDR.

Results

Analysis revealed mixed views about the effectiveness of the BDR. There is a tension between the objective to address public amenity and decrease crime, as expressed by the participants, compared to the health‐focused approach to therapeutic services and referrals identified in other sources.

Discussion and Conclusions

Drawing on these findings, alongside other relevant sources, the authors argue there is a need for a more effective communication strategy to the public and professional community to enhance the capacity of the BDR to meet its goals. The authors recognise the limitations of alcohol industry stakeholder views and identify the need for a comprehensive evaluation approach that includes multiple stakeholder perspectives.

New frontiers in alcohol and gender: The role of health promotion policy and practice in Australia

Scholarship indicates that gender norms influence drinking behaviours, yet the consequences of this for health professionals and health promotion remains neglected. To address this gap, we discuss the implications of gender and alcohol consumption for Australian health promotion and practice. We convey how a more integrated public health approach, aimed at promoting healthy gender expectations and enhancing gender relations, is warranted. We also discuss how changing gender norms pose new challenges for health professionals. By confronting these contentious issues, this commentary helps the health sector consider innovative measures to combat alcohol-related harms.

Bioring® gastric banding for obesity in a private South African hospital

BACKGROUND

Obesity is a significant health problem in South Africa. Surgery is the most effective means of durable weight loss for the morbidly obese. Of the surgical options, laparoscopic adjustable gastric banding is the most controversial. We aimed to assess a single surgeon's experience with a specific band.

METHODS

A retrospective observational study of a continuous cohort of laparoscopic adjustable gastric Cousin Bioring^® band placements from a single private South African hospital was conducted. Three hundred and fifty bands were placed in 347 patients, 75% were female. Variables analysed were BMI obesity class, comorbidities, weight loss, diabetes resolution, adherence to aftercare, patient satisfaction, complications and death.

RESULTS

Outcomes were assessed in 343 patients (4 patients lost to follow-up). The mean follow-up was 39 months (IQR 29-66 months). The mean preoperative BMI was 43.3 kg/m² (IQR 37.4-47.6 kg/m²). Most weight loss occurred in the first year, and 66% achieved > 40% excess weight loss. Resolution of type 2 diabetes and prediabetes occurred in 56.4% and 89.8% of patients respectively. Increasing age (p = 0.002), class 3 obesity (p < 0.001) and suboptimal aftercare (p < 0.001) were associated with failure. One patient developed band erosion and 40 developed band slippage, 34 of whom underwent secondary surgery (32 removals, 2 revisions). All complications were grade I-III. There was no high grade complication, and no death.

CONCLUSIONS

Bioring^® gastric banding achieved moderately good weight loss and resolution of type 2 diabetes with a low complication rate. BMI > 60 and suboptimal aftercare predicted poor outcome.

The index case of SARS-CoV-2 in Scotland

Since its identification in December 2019, SARS-CoV-2 has infected 125,048 persons globally with cases identified in 118 countries across all continents. We report on the Scottish index case of SARS-CoV-2 infection, the virus causing COVID-19.

How the EMERGE guideline on medication adherence can improve the quality of clinical trials

Medication adherence in drug trials is suboptimal, affecting the quality of these studies and adding significant costs. Nonadherence in this setting can lead to null findings, unduly large sample sizes and the need for dose modification after a drug has been approved. Despite these drawbacks, adherence behaviours are not consistently measured, analysed or reported appropriately in trial settings. The ESPACOMP Medication Adherence Reporting Guideline (EMERGE) offers a solution by facilitating a sound protocol design that takes this crucial factor into account. This article summarises key evidence on traditional and newer measurements of adherence, discusses implementation in clinical trial settings and makes recommendations about the analysis and interpretation of adherence data. Given the potential benefits of this approach, the authors call on regulators and the pharmaceutical industry to endorse the EMERGE guideline.

Concepts and Instruments for Patient-Reported Outcome Assessment in Celiac Disease: Literature Review and Experts' Perspectives

BACKGROUND

In diseases where there is a large subjective component, such as celiac disease (CD), patient reported-outcomes (PRO) endpoints are highly relevant. However, there is a gap in knowledge about which PRO endpoints and instruments should be used for clinical trials for treatment of celiac disease.

OBJECTIVES

To identify patient-centered symptom, impact, and health-related quality of life (HRQoL) concepts in CD and relevant PRO instruments, and to gather expert input on concepts and instruments to inform selection of PRO endpoints for use in clinical trials of new CD treatments.

METHODS

A targeted literature review was conducted to identify symptom, impact, and HRQoL concepts, including those captured in PROs further reviewed against U.S. Food and Drug Administration standards for development and validation as endpoints. US and European clinicians, payers, and a patient advocate (n = 21) were interviewed to assess the identified concepts' relative importance in measuring treatment benefit and to gauge the value of potential PROs as endpoints for market access/reimbursement.

RESULTS

Thirty-four published studies were identified: 27 elucidated patient-centered concepts and 7 detailed the development or validation of PRO instruments. The Celiac Disease Symptom Diary and Celiac Disease Patient Reported Outcome instrument were deemed most appropriate for use as endpoints; however, each had limitations related to conceptual coverage, evidence for measurement properties, and feasibility for use in clinical trials. Experts reported gastrointestinal symptoms as most important to treat, with extra-intestinal symptoms burdensome from the patient perspective as well. Payers emphasized measuring both frequency and severity of symptoms and targeting patients nonresponsive to the gluten-free diet for treatment.

CONCLUSIONS

With emerging treatment options for CD, further work is needed to operationalize PRO symptom endpoints that are meaningful to patients, valued by payers, and acceptable to regulators in demonstrating efficacy.

Governing for Health: Advancing Health and Equity through Policy and Advocacy

In an age of wellness peddled to the predominantly white middle-class by the overwhelmingly white upper-class, Baum's book is a firm reminder of the systemic and structural issues which detrimentally impact an individual's health. As Gwyneth Paltrow charges approximately $8000 a ticket for entry to her 'In Goop Health summit' (Bryant, 2019), and lifestyle influencers brand their perfectly styled, plastic free, free range, organic, sustainable lifestyles as authentic and achievable (Chocano, 2019), Baum's distaste for the neoliberal naval gazing (and subsequent individual blaming) is a refreshing addition to the conversation.

Activity-based analysis of potentiometric pH titrations

The discrepancy between concentrations and activities is a predicament well known to the analytical chemist. Because of the difficulty of determining activity coefficients, the standard technique for quantitative equilibrium studies is to work under a particular 'constant ionic strength' by adding an excess of an inert salt. Under such conditions, activity coefficients are approximately constant and can be taken into the equilibrium constants which are defined for the chosen ionic strength (I). Here we propose a fundamentally different approach. Throughout the numerical analysis of the titration data, activity coefficients for all individual species are approximated by well-known equations based on the work of Debye-Hückel. The computational analysis of the measurements strictly obeys the law of mass conservation and obeys the law of mass action only approximately. The main novelty is that now the addition of inert salts is no longer required and measurements are done at minimal I. Consequently, the thermodynamic equilibrium constants are now determined much more robustly based on experiments taken at low I. The approach has been tested and validated with the two very well investigated 3-protic phosphoric and citric acids. In summary: the technique of artificially keeping ionic strength constant has been replaced by improved computational analysis.

Necroptosis inhibition as a therapy for Niemann-Pick disease, type C1: Inhibition of RIP kinases and combination therapy with 2-hydroxypropyl-β-cyclodextrin

Niemann-Pick disease, type C1 (NPC1) is an inborn error of metabolism that results in endolysosomal accumulation of unesterified cholesterol. Clinically, NPC1 manifests as cholestatic liver disease in the newborn or as a progressive neurogenerative condition characterized by cerebellar ataxia and cognitive decline. Currently there are no FDA approved therapies for NPC1. Thus, understanding the pathological processes that contribute to neurodegeneration will be important in both developing and testing potential therapeutic interventions. Neuroinflammation and necroptosis contribute to the NPC1 pathological cascade. Receptor Interacting Protein Kinase 1 and 3 (RIPK1 and RIPK3), are protein kinases that play a central role in mediating neuronal necroptosis. Our prior work suggested that pharmacological inhibition of RIPK1 had a significant but modest beneficial effect; however, the inhibitors used in that study had suboptimal pharmacokinetic properties. In this work we evaluated both pharmacological and genetic inhibition of RIPK1 kinase activity. Lifespan in both Npc1^-/- mice treated with GSK'547, a RIPK1 inhibitor with better pharmacokinetic properties, and Npc1^-/-:Ripk1^kd/kd double mutant mice was significantly increased. In both cases the increase in lifespan was modest, suggesting that the therapeutic potential of RIPK1 inhibition, as a monotherapy, is limited. We thus investigated the potential of combining RIPK1 inhibition with 2-hydroxypropyl-β-cyclodextrin (HPβCD) therapy HPβCD has been shown to slow neurological disease progression in NPC1 mice, cats and patients. HPβCD appeared to have an additive positive effect on the pathology and survival of Npc1^-/-:Ripk1^kd/kd mice. RIPK1 and RIPK3 are both critical components of the necrosome, thus we were surprised to observe no increase survival in Npc1^-/-;Ripk3^-/- mice compared to Npc1^-/- mice. These data suggest that although necroptosis is occurring in NPC1, the observed effects of RIPK1 inhibition may be related to its RIPK3-independent role in neuroinflammation and cytokine production.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Global Burden of Atherosclerotic Cardiovascular Disease in People Living With HIV: Systematic Review and Meta-Analysis

BACKGROUND

With advances in antiretroviral therapy, most deaths in people with HIV are now attributable to noncommunicable illnesses, especially cardiovascular disease. We determine the association between HIV and cardiovascular disease, and estimate the national, regional, and global burden of cardiovascular disease attributable to HIV.

METHODS

We conducted a systematic review across 5 databases from inception to August 2016 for longitudinal studies of cardiovascular disease in HIV infection. A random-effects meta-analysis across 80 studies was used to derive the pooled rate and risk of cardiovascular disease in people living with HIV. We then estimated the temporal changes in the population-attributable fraction and disability-adjusted life-years (DALYs) from HIV-associated cardiovascular disease from 1990 to 2015 at a regional and global level. National cardiovascular DALYs associated with HIV for 2015 were derived for 154 of the 193 United Nations member states. The main outcome measure was the pooled estimate of the rate and risk of cardiovascular disease in people living with HIV and the national, regional, and global estimates of DALYs from cardiovascular disease associated with HIV.

RESULTS

In 793 635 people living with HIV and a total follow-up of 3.5 million person-years, the crude rate of cardiovascular disease was 61.8 (95% CI, 45.8-83.4) per 10 000 person-years. In comparison with individuals without HIV, the risk ratio for cardiovascular disease was 2.16 (95% CI, 1.68-2.77). Over the past 26 years, the global population-attributable fraction from cardiovascular disease attributable to HIV increased from 0.36% (95% CI, 0.21%-0.56%) to 0.92% (95% CI, 0.55%-1.41%), and DALYs increased from 0.74 (95% CI, 0.44-1.16) to 2.57 (95% CI, 1.53-3.92) million. There was marked regional variation with most DALYs lost in sub-Saharan Africa (0.87 million, 95% CI, 0.43-1.70) and the Asia Pacific (0.39 million, 95% CI, 0.23-0.62) regions. The highest population-attributable fraction and burden were observed in Swaziland, Botswana, and Lesotho.

CONCLUSIONS

People living with HIV are twice as likely to develop cardiovascular disease. The global burden of HIV-associated cardiovascular disease has tripled over the past 2 decades and is now responsible for 2.6 million DALYs per annum with the greatest impact in sub-Saharan Africa and the Asia Pacific regions.

CLINICAL TRIAL REGISTRATION

URL: https://www.crd.york.ac.uk/prospero . Unique identifier: CRD42016048257.

Emergence of Nonfalciparum Plasmodium Infection Despite Regular Artemisinin Combination Therapy in an 18-Month Longitudinal Study of Ugandan Children and Their Mothers

As part of a longitudinal cohort investigation of intestinal schistosomiasis and malaria in Ugandan children and their mothers on the shorelines of Lakes Victoria and Albert, we documented risk factors and morbidity associated with nonfalciparum Plasmodium infections and the longitudinal dynamics of Plasmodium species in children. Host age, household location, and Plasmodium falciparum infection were strongly associated with nonfalciparum Plasmodium infections, and Plasmodium malariae infection was associated with splenomegaly. Despite regular artemisinin combination therapy treatment, there was a 3-fold rise in P. malariae prevalence, which was not accountable for by increasing age of the child. Worryingly, our findings reveal the consistent emergence of nonfalciparum infections in children, highlighting the complex dynamics underlying multispecies infections here. Given the growing body of evidence that nonfalciparum malaria infections cause significant morbidity, we encourage better surveillance for nonfalciparum Plasmodium infections, particularly in children, with more sensitive DNA detection methods and improved field-based diagnostics.

Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review

PURPOSE

Proper adherence and persistence to medications are crucial for better quality of life and improved outcomes in rheumatoid arthritis (RA), psoriasis (PsO), and psoriatic arthritis (PsA). We systematically describe current adherence and persistence patterns for RA, PsO, and PsA, with a focus on biologics and identifying factors associated with adherence and persistence.

PATIENTS AND METHODS

Using various databases, a systematic literature review of US-based studies published from 2000 to 2015 on medication adherence and persistence to biologics and associated factors was conducted among patients with RA, PsO, and PsA.

RESULTS

Using the medication possession ratio or the percentage of days covered >80%, RA and PsO adherence rates for etanercept, adalimumab, and infliximab ranged from 16% to 73%, 21% to 70%, and 38% to 81%, respectively. Using the criteria of a ≥45-day gap, RA persistence rates for etanercept, adalimumab, and infliximab ranged from 46% to 89%, 42% to 94%, and 41% to 76%, respectively. In PsO, persistence rates for etanercept and adalimumab ranged from 34% to 50% and 50% to 62%, respectively. Similar persistence rates were observed in PsA. Experienced biologics users showed better adherence and persistence. Younger age, female gender, higher out-of-pocket costs, greater disease severity, and more comorbidities were associated with lower adherence and persistence rates. Qualitative surveys revealed that nonpersistence was partly due to perceived ineffectiveness and safety/tolerability concerns.

CONCLUSION

Biologic adherence and persistence rates in RA, PsO, and PsA in the United States were low, with significant opportunity for improvement. Various factors - including decrease in disease severity; reduction of comorbidities; lower out-of-pocket costs; refilling at specialty pharmacies; and awareness of drug effectiveness, safety, and tolerability - can inform targeted approaches to improve these rates.

Patient-Reported Outcome Assessments as Endpoints in Studies in Infectious Diseases

The goal of administering medical interventions is to help patients live longer or live better. In keeping with this goal, there has been increasing interest in taking the "voice" of the patient into account during the development process, specifically in the evaluation of treatment benefits of medical interventions, and use of patient-centered outcome data to justify reimbursement. Patient-reported outcomes (PROs) are outcome assessments (OAs) used to define endpoints that can provide direct evidence of treatment benefit on how patients feel or function. When PROs are appropriately developed, they can increase the efficiency and clinical relevance of clinical trials. Several PROs have been developed for OA in specific infectious diseases indications, and more are under development. PROs also hold promise for use in evaluating adherence, adverse effects, satisfaction with care, and routine clinical practice.

Airborne particles in indoor environment of homes, schools, offices and aged care facilities: The main routes of exposure

It has been shown that the exposure to airborne particulate matter is one of the most significant environmental risks people face. Since indoor environment is where people spend the majority of time, in order to protect against this risk, the origin of the particles needs to be understood: do they come from indoor, outdoor sources or both? Further, this question needs to be answered separately for each of the PM mass/number size fractions, as they originate from different sources. Numerous studies have been conducted for specific indoor environments or under specific setting. Here our aim was to go beyond the specifics of individual studies, and to explore, based on pooled data from the literature, whether there are generalizable trends in routes of exposure at homes, schools and day cares, offices and aged care facilities. To do this, we quantified the overall 24h and occupancy weighted means of PM₁₀, PM_2.5 and PN - particle number concentration. Based on this, we developed a summary of the indoor versus outdoor origin of indoor particles and compared the means to the WHO guidelines (for PM₁₀ and PM_2.5) and to the typical levels reported for urban environments (PN). We showed that the main origins of particle metrics differ from one type of indoor environment to another. For homes, outdoor air is the main origin of PM₁₀ and PM_2.5 but PN originate from indoor sources; for schools and day cares, outdoor air is the source of PN while PM₁₀ and PM_2.5 have indoor sources; and for offices, outdoor air is the source of all three particle size fractions. While each individual building is different, leading to differences in exposure and ideally necessitating its own assessment (which is very rarely done), our findings point to the existence of generalizable trends for the main types of indoor environments where people spend time, and therefore to the type of prevention measures which need to be considered in general for these environments.

Effectiveness of regular weighing, weight target setting and feedback by community midwives within routine antenatal care in preventing excessive gestational weight gain: randomised controlled trial

Background

Many pregnant women gain excess weight during pregnancy which increases the health risks to the mother and her baby. Interventions to prevent excess weight gain need to be given to the whole population to prevent excess weight gain. The aim of this study was to assess the effectiveness of a simple and brief intervention embedded withinroutine antenatal care to prevent excessive gestation weight gain.

Methods

Six hundred and ten pregnant women (between 10-14 weeks gestation), aged ≥18 years with a body mass index (BMI) ≥18.5 kg/m2, planned to receive community midwife led care or shared care at the time of recruitment are eligible to take part in the study. Women will be recruited from four maternity centres in England. Community midwives complete a short training module before delivering the intervention. In the intervention, midwives weigh women, set maximum weight limits for weight gain at each antenatal appointment and ask women to monitor their weight at home. Themaximum weight limit is adjusted by the midwife at each antenatal appointment if women have exceeded their maximum weight gain limit set at their previous appointment. The intervention will be compared with usual antenatal care. The primary outcome is the proportion of women per group who exceed the Institute of Medicine guidelines for gestational weight gain at 38 weeks of pregnancy according to their early pregnancy BMI category.

Discussion

The proposed trial will test a brief intervention comprising regular weighing, target setting and monitoring ofweight during pregnancy that can be delivered at scale as part of routine antenatal care. Using the professional expertise of community midwives, but without specialist training in weight management, the intervention will incur minimal additionalhealthcare costs, and if effective at reducing excess weight gain, is likely to be very cost effective.

Trial registration

Current controlled trials ISRCTN67427351. Date assigned 29/10/2014.