Gyrate atrophy of the choroid and retina: Update on diagnosis and treatment

Gyrate atrophy of the choroid and retina (GACR) is a rare autosomal recessive disease characterised by elevated plasma ornithine levels due to deficiency of the enzyme ornithine aminotransferase (OAT). The accumulation of this amino acid in plasma leads to the development of patches of chorioretinal atrophy in the peripheral retina extending into the macular area. Patients usually present with night blindness followed by constriction of the visual field and, finally, decreased central vision and blindness. The disease is diagnosed by the presence of the characteristic clinical picture, the presence of hyperornithinaemia in plasma and the detection of mutations in the OAT enzyme gene. There is currently no effective gene therapy and the most common therapeutic intervention mainly involves dietary modifications with arginine restriction. This article aims to summarise the pathogenesis, clinical and diagnostic findings and treatment options in patients with GACR.

Prolonged diacetylmorphine take-home during the COVID-19 pandemic-Results of a retrospective cohort study

BACKGROUND AND AIMS

Legal regulations for dispensing in Swiss heroin-assisted treatment were relaxed during the COVID-19 pandemic, allowing prolonged take-home of up to 7 days instead of two to reduce patient contact and the risk of infection. Our study aimed to measure the consequences of this new practice.

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective cohort study set in Switzerland's largest outpatient centre for opioid agonist therapy. One hundred and thirty-four (72.4%) of the 185 patients receiving oral diacetylmorphine (DAM) participated in the study.

MEASUREMENTS

Through the utilization of electronic medication prescription and dispensing software, as well as the electronic medical record, the following data were extracted to explore the potential consequences: dose of DAM, the number of antibiotic therapies, emergency hospitalizations and incarcerations. Age, gender, prescriptions for psychotrophic drugs and additional prescription for injectable DAM were tested to assess an increased risk of losing prolonged take-home privileges. Data in the year since prolonged take-home (period 2) were compared with data from the equivalent prior year (period 1).

FINDINGS

DAM take-home was not associated with a change in DAM dose (P = 0.548), the number of emergency hospitalizations (P = 0.186) or the number of incarcerations (P = 0.215); 79.1% of all patients were able to maintain their extended take-home privileges. However, patients who had injectable DAM experienced significant reductions in their prolonged take-home privileges.

CONCLUSION

Allowing patients to take home oral diacetylmorphine for up to 7 days as treatment for opioid use disorder does not appear to pose any demonstrable health risk. It is generally manageable for the large majority of patients. However, careful consideration of prolonged take-home for patients with additional injectable diacetylmorphine is recommended, as these patients are more likely to lose take-home privileges.

What features of drug treatment programs help, or not, with access? a qualitative study of the perspectives of family members and community-based organization staff in Atlantic Canada

BACKGROUND

Withdrawal management and opioid agonist treatment (OAT) programs help to reduce some of the harms experienced by people who use substances (PWUS). There is literature on how features of drug treatment programs (e.g., policies and practices) are helpful, or not helpful, to PWUS when seeking access to, or in, treatment. There is, however, relatively little literature based on the perspectives of family members/family of choice of PWUS and community-based organization staff within the context of Atlantic Canada. This paper explored the perspectives of these two groups on what was helpful, or not, about drug treatment programs in Atlantic Canada in terms of supporting access to, and retention in, treatment.

METHODS

One-on-one qualitative telephone interviews were conducted in 2020 with the two groups. Interviews focused on government-funded withdrawal management and OAT programs. Data were coded using a qualitative data management program (ATLAS.ti) and analyzed inductively for key themes/subthemes using grounded theory techniques.

RESULTS

Fifteen family members/family of choice and 16 community-based organization staff members participated (n = 31). Participants spoke about features of drug treatment programs in various places, and noted features that were perceived as helpful (e.g., quick access), as well as not helpful (e.g., wait times, programs located far from where PWUS live). Some participants provided their perceptions of how PWUS felt when seeking or accessing treatment. A number of participants reported taking various actions to help support access to treatment, including providing transportation to programs. A few participants also provided suggestions for change to help support access and retention such as better alignment of mental health and addiction systems.

CONCLUSIONS

Participants highlighted several helpful and not helpful features of drug treatment programs in terms of supporting treatment access and retention. Previous studies with PWUS and in other places have reported similar features, some of which (e.g., wait times) have been reported for many years. Changes are needed to reduce barriers to access and retention including the changes recommended by study participants. It is critical that the voices of key groups, (including PWUS) are heard to ensure treatment programs in all places support access and retention.

Effect of antioxidants on semen parameters in men with oligo-astheno-teratozoospermia: a network meta-analysis

BACKGROUND

Although antioxidants are largely used in subfertile men with oligo-astheno-teratozoospermia (OAT), the choice among different molecules is challenged by the lack of comparative head-to-head studies. The network meta-analysis (NMA) can overcome limitations of pairwise meta-analyses, since it incorporates direct and indirect evidence into a single model generating an effectiveness hierarchy.

OBJECTIVE

To assess with a NMA the effects of antioxidants in improving seminal parameters in idiopathic OAT.

MATERIALS AND METHODS

PubMed, Scopus, Cinahl, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing any antioxidant treatment to each other or placebo in men with at least one idiopathic seminal abnormality. Data were included in a random-effects NMA, where efficacy of treatments was ranked by surface under the cumulative ranking curve (SUCRA).

RESULTS

29 RCTs provided information on 2045 men (mean age: 33.5 years) with idiopathic OAT and 19 antioxidant preparations. Compared to placebo, l-carnitine, especially in combination with l-acetyl-carnitine (LAC), had the highest SUCRA for sperm concentration, progressive motility, and morphology. Folate was the only other compound effective on sperm concentration. Vitamin E+selenium or zinc had the highest SUCRA for total motility. A contribution on progressive motility was revealed for pentoxifylline and vitamin E+CoQ10.

The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study

STUDY OBJECTIVES

To prospectively validate drug-induced sleep endoscopy with mandibular advancement maneuvers as a prediction tool for treatment success of oral appliance treatment (OAT).

METHODS

Seventy-seven patients diagnosed with moderate obstructive sleep apnea were included and underwent drug-induced sleep endoscopy. The upper airway collapse was assessed using the VOTE classification. Additionally, three mandibular advancement maneuvers were performed to predict treatment success of OAT. If the maneuver was negative, the level and degree and configuration of the persistent collapse was described according to the VOTE classification. All patients were treated with OAT and completed a follow-up sleep study with OAT in situ without regard to their anticipated response to treatment.

RESULTS

Sixty-four patients completed 6-month follow up. A positive jaw thrust maneuver proved to be significantly associated with favorable OAT response, whereas the chin lift maneuver and the vertical chin lift maneuver were not. Additionally, a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver was significantly associated with unfavorable OAT response.

CONCLUSIONS

The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting OAT response. Patients with a positive jaw thrust maneuver should be counseled toward favorable OAT response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of unfavorable OAT response. A negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing drug-induced sleep endoscopy solely for predicting the efficacy of OAT. However, the results of the current study could be influenced by heterogeneity in the assessment of respiratory parameters, variability in the performance of the mandibular advancement maneuvers, and the instability of bolus technique sedation.

CLINICAL TRIAL REGISTRATION

Registry: Netherlands Trial Register; Name: Drug-induced Sleep Endoscopy: a prediction tool for success rate of oral appliance treatment; Identifier: NL8425; URL: https://www.onderzoekmetmensen.nl/en/trial/20741.

CITATION

Veugen CCAFM, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2024;20(3): 353-361.

Impact of the Inhibition of Organic Anion Transporter on Tricyclo-DNA-Mediated Exon Skipping in the mdx Mouse Model

Antisense-mediated exon skipping is one of the most promising therapeutic strategies for Duchenne muscular dystrophy (DMD) and some antisense oligonucleotide (ASO) drugs have already been approved by the U.S. FDA for DMD. The potential of this therapy is still limited by several challenges including the poor distribution of ASOs to target tissues. Indeed, most of them accumulate in the kidney and tend to be rapidly eliminated after systemic delivery. We hypothesized here that preventing renal clearance of ASO using organic anion transporter (OAT) inhibitor could increase the bioavailability of ASOs and thus their distribution to target tissues and ultimately their efficacy in muscles. Mdx mice were, therefore, treated with ASO with or without the OAT inhibitor named probenecid. Our findings indicate that OAT inhibition, or at least using probenecid, does not improve the therapeutic potential of ASO-mediated exon-skipping approaches for the treatment of DMD.

Clinical, biochemical and molecular analysis in a cohort of individuals with gyrate atrophy

BACKGROUND

Gyrate atrophy of the choroid and retina is a rare autosomal recessive metabolic disorder caused by biallelic variants in the OAT gene, encoding the enzyme ornithine δ-aminotransferase. Impaired enzymatic activity leads to systemic hyperornithinaemia, which in turn underlies progressive chorioretinal degeneration. In this study, we describe the clinical and molecular findings in a cohort of individuals with gyrate atrophy.

METHODS

Study participants were recruited through a tertiary UK clinical ophthalmic genetic service. All cases had a biochemical and molecular diagnosis of gyrate atrophy. Retrospective phenotypic and biochemical data were collected using electronic healthcare records.

RESULTS

18 affected individuals from 12 families (8 male, 10 female) met the study inclusion criteria. The median age at diagnosis was 8 years (range 10 months - 33 years) and all cases had hyperornithinaemia (median: 800 micromoles/L; range: 458-1244 micromoles/L). Common features at presentation included high myopia (10/18) and nyctalopia (5/18). Ophthalmic findings were present in all study participants who were above the age of 6 years. One third of patients had co-existing macular oedema and two thirds developed pre-senile cataracts. Compliance with dietary modifications was suboptimal in most cases. A subset of participants had extraocular features including a trend towards reduced fat-free mass and developmental delay.

CONCLUSIONS

Our findings highlight the importance of multidisciplinary care in families with gyrate atrophy. Secondary ophthalmic complications such as macular oedema and cataract formation are common. Management of affected individuals remains challenging due to the highly restrictive nature of the recommended diet and the limited evidence-base for current strategies.

Probenecid, an Old Drug with Potential New Uses for Central Nervous System Disorders and Neuroinflammation

Probenecid is an old uricosuric agent used in clinics to treat gout and reduce the renal excretion of antibiotics. In recent years, probenecid has gained attention due to its ability to interact with membrane proteins such as TRPV2 channels, organic anion transporters, and pannexin 1 hemichannels, which suggests new potential therapeutic utilities in medicine. Some current functions of probenecid include their use as an adjuvant to increase the bioavailability of several drugs in the Central Nervous System (CNS). Numerous studies also suggest that this drug has important neuroprotective, antiepileptic, and anti-inflammatory properties, as evidenced by their effect against neurological and neurodegenerative diseases. In these studies, the use of probenecid as a Panx1 hemichannel blocker to reduce neuroinflammation is highlighted since neuroinflammation is a major trigger for diverse CNS alterations. Although the clinical use of probenecid has declined over the years, advances in its use in preclinical research indicate that it may be useful to improve conventional therapies in the psychiatric field where the drugs used have a low bioavailability, either because of a deficient passage through the blood-brain barrier or a high efflux from the CNS or also a high urinary clearance. This review summarizes the history, pharmacological properties, and recent research uses of probenecid and discusses its future projections as a potential pharmacological strategy to intervene in neurodegeneration as an outcome of neuroinflammation.

Osteochondral Autograft Transplantation for Proximal Pole Scaphoid Nonunions

PURPOSE

Osteochondral autograft transplantation (OAT) is a technique to reconstruct the proximal pole scaphoid nonunion associated with an intact dorsal and volar scapholunate ligament. This study aimed to report the clinical and radiographic outcomes in patients who underwent OAT for this indication.

METHODS

A retrospective review of patients who underwent proximal pole scaphoid nonunion reconstruction with a femoral trochlea OAT was undertaken between 2018 and 2022. Patient demographics, scaphoid nonunion characteristics, surgery details, and clinical and radiographic outcomes were obtained.

RESULTS

Eight patients underwent the procedure at an average of 18.2 months from injury. Four patients failed prior attempts at scaphoid union surgery, one of whom failed two prior surgeries. Four had no prior surgery. The average follow-up was 11.8 months. The postoperative wrist flexion-extension arc of motion was 125° or 87% of the contralateral wrist. Grip strength averaged 30.0 kg or 86% of the contralateral side. Adjusted grip strength for hand dominance was 81% of the contralateral side. All OATs healed. Computed tomography scan confirmed the union in 6 patients between 6 and 10 weeks. Two patients whose radiographs demonstrated OAT incorporation at the time of follow-up did not undergo advanced imaging.

CONCLUSIONS

Osteochondral autograft transplantation is an attractive surgical reconstructive procedure for patients with proximal pole scaphoid nonunions associated with an intact scapholunate ligament. Osteochondral autograft transplantation mitigates the need for vascularized bone grafting, has a rapid time to osseous incorporation, and has a simple postoperative course in which patients can expect early union, near-full range of motion, and grip strength.

LEVEL OF EVIDENCE

Therapeutic V.

Evaluation of the gap in delivery of opioid agonist therapy among individuals with opioid-related health problems: a population-based retrospective cohort study

AIMS

Although opioid-related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid-related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment.

DESIGN

A population-based retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Individuals who sought medical care for opioid-related health problems or died from an opioid-related cause between 2005 and 2019.

MEASUREMENTS

Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e. 'off OAT', 'retained on OAT < 6 months', 'retained on OAT ≥ 6 months').

FINDINGS

Of 122 811 individuals in the cohort, 97 516 (79.4%) received OAT at least once during the study period. There was decreasing 6-month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month [odds ratio (OR) = 1.26, 95% confidence interval (CI) = 1.23-1.28] but lower odds of OAT retention (OR = 0.90, 95% CI = 0.88-0.92), while the reverse was observed for older individuals (monthly: OR = 0.76 per 10-year increase, 95% CI = 0.76-0.77; retention: OR = 1.36 per 10-year increase, 95% CI = 1.34-1.38) and individuals with higher neighbourhood income (e.g. highest income quintile, monthly: OR = 0.79, 95% CI = 0.77-0.82; highest income quintile, retention: OR = 1.15, 95% CI = 1.11-1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR = 0.75, 95% CI = 0.73-0.78; mental health: OR = 0.89, 95% CI = 0.87-0.92) and OAT retention (rural: OR = 0.79, 95% CI = 0.77-0.82; mental health: OR = 0.81, 95% CI = 0.78-0.83), as well as higher risk of starting/stopping OAT [rural, starting OAT: hazard ratio (HR) = 1.07, 95% CI = 1.05-1.10; mental health, starting OAT: HR = 1.20, 95% CI: 1.18-1.23; rural, stopping OAT: HR = 1.24, 95% CI: = 1.22-1.26; mental health, stopping OAT: HR = 1.11, 95% CI = 1.09-1.13]. Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR = 1.49, 95% CI = 1.33-1.66; on OAT death: HR = 1.20, 95% CI = 1.09-1.31).

CONCLUSIONS

Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions.

Availability of timely methadone treatment in the United States and Canada during COVID-19: A census tract-level analysis

OBJECTIVES

We sought to compare timely access to methadone treatment in the United States (US) and Canada during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional study of census tracts and aggregated dissemination areas (used for rural Canada) within 14 US and 3 Canadian jurisdictions in 2020. We excluded census tracts or areas with a population density of less than one person per square km. Data from a 2020 audit of timely medication access was used to determine clinics accepting new patients within 48 h. Unadjusted and adjusted linear regressions were performed to examine the relationship between area population density and sociodemographic covariates and three outcome variables: 1) driving distance to the nearest methadone clinic accepting new patients, 2) driving distance to the nearest methadone clinic accepting new patients for medication initiation within 48 h, and 3) the difference in the driving distance between the first and second outcome.

RESULTS

We included 17,611 census tracts and areas with a population density greater than one person per square kilometer. After adjusting for area covariates, US jurisdictions were a median of 11.6 miles (p value <0.001) further from a methadone clinic accepting new patients and 25.1 miles (p value <0.001) further from a clinic accepting new patients within 48 h than Canadian jurisdictions.

CONCLUSIONS

These results suggest that the more flexible Canadian regulatory approach to methadone treatment is associated with a greater availability of timely methadone treatment and reduced urban-rural disparity in availability, compared to the US.

Characteristics of Stress Sensitivity in Heroin Use Disorder Patients during Their Opioid Agonist Treatment

In the present study, performed on a sample of Heroin Use Disorder (HUD) patients undergoing Opioid Agonist Treatment (OAT), we attempted to explore the relationships between stress sensitivity and heroin addiction-related clinical aspects. HUD patients' stress sensitivity was evaluated with the Heroin/PTSD-Spectrum questionnaire (H/PSTD-S). The Drug Addiction History Questionnaire (DAH-Q), the Symptomatological Check List-90 (SCL-90), and The Behavioural Covariate of Heroin Craving inventory (CRAV-HERO) were all used, as were the Deltito Subjective Wellness Scale (D-SWS), a self-report scale evaluating subjective well-being; the Cocaine Problem Severity Index (CPSI), a questionnaire determining the extent of a cocaine problem; and the Marijuana Craving Questionnaire (MC-Q), an instrument assessing craving for cannabinoids. We checked correlations between stress sensitivity and the extent of HUD clinical features and compared patients with and without problematic stress sensitivity. H/PTSD-S was positively correlated with patients' income, altered mental status, legal problems, the lifetime different treatments index, the current treatment load index, and all SCL-90 indexes and factors. Regarding subjective well-being, stress sensitivity negatively correlated with the contrast best week (last five years) index. Patients with high-stress sensitivity were females with a low income. They exhibited a more severe mental status at treatment entry, greater difficulty in working adaptation, and legal problems during treatment. Additionally, these patients showed a higher level of psychopathology, more impairment in well-being, and more risky behaviours during treatment. Stress sensitivity, as H/PTSD-S, must be considered an outcome of HUD. HUD's addiction history and clinical features are significant risk factors for H/PTSD-S. Therefore, social and behavioural impairment in HUD patients could be considered the clinical expression of the H/PTSD spectrum. In summary, the long-term outcome of HUD is not represented by drug-taking behaviours. Rather, the inability to cope with the contingent environmental conditions is the key feature of such a disorder. H/PTSD-S, therefore, should be seen as a syndrome caused by an acquired inability (increased salience) concerning regular (daily) life events.

The comparison of Y chromosome microdeletion incidence in blood DNA and sperm cell DNA

BACKGROUND

During gamete development and spermatogenesis, certain genes on the Y chromosome (Yq) in the Male-Specific Region (MSR) are responsible for human gametes formation. The long arm Yq is composed of both euchromatin and the genetically inactive heterochromatin regions. This region contains the Azoospermia factors AZFa, AZFb and AZFc. In the case of male infertility, microdeletions on the Yq chromosome appear to be structural chromosomal anomalies linked to sperm abnormality.

METHODS

The present study aimed to look at the incidence, of Asthenospermia (AS), Teratospermia (TS), Oligospermia (OS) and Oligoasthenoteratospermia (OAT) patterns of Y chromosomal microdeletions in Indian infertile men with an (AZF a, b, c). This study was conducted with 75 infertile men as cases and 75 fertile men as a control for AZF locus microdeletion utilizing sequence-tagged sites.

RESULTS

The AZFc region of germ cell DNA (50.6%) was the most deleted section in infertile men when compared to blood DNA (21.3%), followed by deletions in the AZFb region (21.3%) in germ cell DNA whereas blood DNA had no microdeletion in the AZFa region in both germ cell DNA and blood DNA. Infertile men displayed significant Yq microdeletion in both AZFb and also AZFc. Around 33% (25) of 75 infertile men had AZF (a, b, c) region microdeletion in blood DNA, compared to it germ cell DNA had a larger percentage of 72% (54) of Y chromosome microdeletions in the study samples.

CONCLUSION

A high-frequency rate of microdeletions seen in germ cell DNA. PCR-based Y chromosome microdeletion screening using germ cell DNA along with Genomic DNA might help in screening for genetic abnormality in infertile men who endure assisted reproductive technology treatments. This study might be attributable to the interplay of lifestyle and genetic factors, both contributing to the risk of developing these germ-line deletions.

Regulation of Human Endogenous Metabolites by Drug Transporters and Drug Metabolizing Enzymes: An Analysis of Targeted SNP-Metabolite Associations

Drug transporters and drug-metabolizing enzymes are primarily known for their role in the absorption, distribution, metabolism, and excretion (ADME) of small molecule drugs, but they also play a key role in handling endogenous metabolites. Recent cross-tissue co-expression network analyses have revealed a "Remote Sensing and Signaling Network" of multispecific, oligo-specific, and monospecific transporters and enzymes involved in endogenous metabolism. This includes many proteins from families involved in ADME (e.g., SLC22, SLCO, ABCC, CYP, UGT). Focusing on the gut-liver-kidney axis, we identified the endogenous metabolites potentially regulated by this network of ~1000 proteins by associating SNPs in these genes with the circulating levels of thousands of small, polar, bioactive metabolites, including free fatty acids, eicosanoids, bile acids, and other signaling metabolites that act in part via G-protein coupled receptors (GPCRs), nuclear receptors, and kinases. We identified 77 genomic loci associated with 7236 unique metabolites. This included metabolites that were associated with multiple, distinct loci, indicating coordinated regulation between multiple genes (including drug transporters and drug-metabolizing enzymes) of specific metabolites. We analyzed existing pharmacogenomic data and noted SNPs implicated in endogenous metabolite handling (e.g., rs4149056 in SLCO1B1) also affecting drug ADME. The overall results support the existence of close relationships, via interactions with signaling metabolites, between drug transporters and drug-metabolizing enzymes that are part of the Remote Sensing and Signaling Network, and with GPCRs and nuclear receptors. These analyses highlight the potential for drug-metabolite interactions at the interfaces of the Remote Sensing and Signaling Network and the ADME protein network.

Exogenous Proline Improves Salt Tolerance of Alfalfa through Modulation of Antioxidant Capacity, Ion Homeostasis, and Proline Metabolism

Alfalfa (Medicago sativa L.) is an important forage crop, and its productivity is severely affected by salt stress. Although proline is a compatible osmolyte that plays an important role in regulating plant abiotic stress resistance, the basic mechanism of proline requires further clarification regarding the effect of proline in mitigating the harmful effects of salinity. Here, we investigate the protective effects and regulatory mechanisms of proline on salt tolerance of alfalfa. The results show that exogenous proline obviously promotes seed germination and seedling growth of salt-stressed alfalfa. Salt stress results in stunted plant growth, while proline application alleviates this phenomenon by increasing photosynthetic capacity and antioxidant enzyme activities and decreasing cell membrane damage and reactive oxygen species (ROS) accumulation. Plants with proline treatment maintain a better K⁺/Na⁺ ratio by reducing Na⁺ accumulation and increasing K⁺ content under salt stress. Additionally, proline induces the expression of genes related to antioxidant biosynthesis (Cu/Zn-SOD and APX) and ion homeostasis (SOS1, HKT1, and NHX1) under salt stress conditions. Proline metabolism is mainly regulated by ornithine-δ-aminotransferase (OAT) and proline dehydrogenase (ProDH) activities and their transcription levels, with the proline-treated plants displaying an increase in proline content under salt stress. In addition, OAT activity in the ornithine (Orn) pathway rather than Δ¹-pyrroline-5-carboxylate synthetase (P5CS) activity in the glutamate (Glu) pathway is strongly increased under salt stress, made evident by the sharp increase in the expression level of the OAT gene compared to P5CS1 and P5CS2. Our study provides new insight into how exogenous proline improves salt tolerance in plants and that it might be used as a significant practical strategy for cultivating salt-tolerant alfalfa.

Allograft Versus Autograft Osteochondral Transplant for Chondral Defects of the Talus: Systematic Review and Meta-analysis

BACKGROUND

It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent.

PURPOSE

A systematic review of the literature was conducted to compare allografts and autografts in terms of patient-reported outcome measures (PROMs), MRI findings, and complications.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This study was conducted according to the PRISMA guidelines. The literature search was conducted in February 2021. All studies investigating the outcomes of allograft and/or autograft osteochondral transplant as management for osteochondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Data concerning the rates of failure and revision surgery were also collected. Continuous data were analyzed using the mean difference (MD), whereas binary data were evaluated with the odds ratio (OR) effect measure.

RESULTS

Data from 40 studies (1174 procedures) with a mean follow-up of 46.5 ± 25 months were retrieved. There was comparability concerning the length of follow-up, male to female ratio, mean age, body mass index, defect size, VAS score, and AOFAS score (P > .1) between the groups at baseline. At the last follow-up, the MOCART (MD, 10.5; P = .04) and AOFAS (MD, 4.8; P = .04) scores were better in the autograft group. The VAS score was similar between the 2 groups (P = .4). At the last follow-up, autografts demonstrated lower rate of revision surgery (OR, 7.2; P < .0001) and failure (OR, 5.1; P < .0001).

CONCLUSION

Based on the main findings of the present systematic review, talar osteochondral transplant using allografts was associated with higher rates of failure and revision compared with autografts at midterm follow-up.

Ornithine aminotransferase and carbamoyl phosphate synthetase 1 involved in ammonia metabolism serve as novel targets for early stages of gastric cancer

Objective

The sensitivity and specificity of current biomarkers for gastric cancer were insufficient. The aim of the present study was to screen novel biomarkers and determine the diagnostic values of ornithine aminotransferase (OAT) and carbamoyl phosphate synthetase 1 (CPS1) for detecting gastric cancer.

Methods

With stable isotope tags, we labelled an initial discovery group of four paired gastric cancer tissue samples and identified with LC‐ESI‐MS/MS. A validation group of 159 gastric cancer samples and 30 healthy controls were used to validate the candidate targets. GSEA was used to explore the pathways activated in gastric cancer.

Results

Four hundred and thirty one proteins were found differentially expressed in gastric cancer tissues. Of these proteins, OAT and CPS1 were found over‐expressed in gastric cancer patients, with sensitivity of 70.4% (95% CI: 63.3%–77.6%) and specificity of 80.5% (95% CI: 74.3%–86.7%) for ornithine aminotransferase, and with sensitivity of 68.6% (95% CI: 61.3%–75.8%) and specificity of 73% (95% CI: 66%–79.9%) for carbamoyl phosphate synthetase 1. The co‐expression of OAT and CPS1 in gastric cancer tissues has a sensitivity of 81% (95% CI: 73.2%–88.8%) and specificity of 89% (95% CI: 83%–95%). Furthermore, both OAT and CPS1 were overexpressed in patients with local invasion T3 and T4 stages than those in patients with T1 and T2 stages. The co‐expression of OAT and CPS1 was strongly correlated with histological grade I 68% (95% CI: 58.7%–77.3%) and TNM stage I/II 52% (95% CI: 42%–62%). The areas under ROC curves were up to 0.758 for the co‐expression of OAT and CPS1 in gastric cancer. GSEA results showed that two gene sets and 30 gene sets were activated in OAT high‐ and CPS1 high‐expression patients with gastric cancer, respectively.

Conclusions

The present findings indicated a tight correlation between the co‐expression of OAT and CPS1 and the histological grade, local invasion, and TNM stages of gastric cancer. Therefore, OAT and CPS1 might be predictors for gastric cancer invasion and potential targets for anticancer drug design for gastric cancer.

Surgical Management of Focal Chondral Defects of the Talus: A Bayesian Network Meta-analysis

BACKGROUND

No consensus has been reached regarding the optimal surgical treatment for focal chondral defects of the talus.

PURPOSE

A Bayesian network meta-analysis was conducted to compare the clinical scores and complications of mosaicplasty, osteochondral auto- and allograft transplant, microfracture, matrix-assisted autologous chondrocyte transplant, and autologous matrix-induced chondrogenesis (AMIC) for chondral defects of the talus at midterm follow-up.

STUDY DESIGN

Bayesian network meta-analysis; Level of evidence, 4.

METHODS

This Bayesian network meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions. PubMed, Embase, Google Scholar, and Scopus databases were accessed in February 2021. All clinical trials comparing 2 or more surgical interventions for the management of chondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, rate of failure, and rate of revision surgery. The network meta-analysis were performed through the routine for Bayesian hierarchical random-effects model analysis. The log odds ratio (LOR) effect measure was used for dichotomous variables, and the standardized mean difference (SMD) was used for continuous variables.

RESULTS

Data from 13 articles (521 procedures) were retrieved. The median length of the follow-up was 47.8 months (range, 31.7-66.8 months). Analysis of variance revealed no difference between the treatment groups at baseline in terms of age, sex, body mass index, AOFAS score, VAS score, and mean number of defects. AMIC demonstrated the greatest AOFAS score (SMD, 11.27) and lowest VAS score (SMD, -2.26) as well as the lowest rates of failure (LOR, 0.94) and revision (LOR, 0.94). The test for overall inconsistency was not significant.

CONCLUSION

At approximately 4 years of follow-up, the AMIC procedure for management of focal chondral defects of the talus produced the best outcome.

Elucidation of clearance mechanism of TP0463518, a novel hypoxia-inducible factor prolyl hydroxylase inhibitor: does a species difference in excretion routes exist between humans and animals?

1. TP0463518, a novel hypoxia-inducible factor prolyl hydroxylase inhibitor, is reportedly excreted predominantly through urinary excretion in an unchanged form in humans, with partial biliary excretion also possible. However, the clearance mechanisms remain unclear. The aim of this study was to investigate the clearance mechanisms in humans and to assess species differences in the excretion routes.2. TP0463518 was not metabolised in rat, dog, or human hepatocytes. TP0463518 is a substrate for human BCRP, OATP1B1, OATP1B3, and OAT3, suggesting that renal uptake by OAT3 is probably the predominant clearance route, with hepatic uptake by OATP1B1 and OATP1B3 contributing partially to clearance in humans.3. A species difference in excretion routes was observed. The unchanged urinary excretion rates in humans, male rats, female rats, dogs, and monkeys were 80.7%, 0.1%, 40.9%, 15.2%, and 72.6%, respectively. Urinary excretion was predominant in humans and monkeys, while only biliary excretion was observed in male rats. Uptake studies using hepatocytes showed that the hepatic uptake clearance in rats was 13.6-fold higher than that in humans. Therefore, not only reabsorption via renal tubules, but also hepatic uptake seems to be involved in the species differences in excretion routes between rats and humans.

Factors associated with patient perceived suboptimal dosing of in-hospital opioid agonist therapy among people who use illicit drugs in Vancouver, Canada

Optimal dosing of opioid agonist therapy (OAT) is essential for treatment success. However, initiation and maintenance of OAT in hospital settings can be challenging given differing levels of opioid tolerance, withdrawal, and intoxication among patients.

The objective of this study was to characterize the prevalence and factors associated with in-hospital patient perceived suboptimal OAT dosing among people who use illicit drugs (PWUD) in Vancouver, Canada.

Data were derived from three prospective cohorts of PWUD in Vancouver, Canada. Bivariable and multivariable logistic regression models were used to examine factors associated with patient perceived suboptimal in-hospital OAT dose.

273 study participants were prescribed OAT while in hospital: 83 (30.4%) participants perceived their OAT dose to be suboptimal. In a multivariable model, factors positively associated with a perceived suboptimal OAT dose included: homelessness (adjusted odds ratio [AOR] = 2.85; 95% CI: 1.53-5.28), daily stimulant use (AOR = 2.03; 95% CI: 1.14-3.63) and illicit drug use while in hospital (AOR = 2.33; 95% CI: 1.31-4.16).

Almost one third of participants perceived receiving a suboptimal OAT dose while in hospital. These observed correlations indicate that a patient's perception of suboptimal OAT dosing in hospital may be more prevalent for patients who are homeless, report polysubstance use with stimulants and opioids and who obtain illicit drugs while hospitalized. While cautious prescribing of OAT in patients experiencing hospitalization is important, these findings demonstrate a high prevalence of and apparent risk factors for perceived suboptimal OAT dosing.

Differential OAT methylation correlates with cell infiltration in tumor microenvironment and overall survival post-radiotherapy in oral squamous cell carcinoma patient

BACKGROUND

Given that DNA methylation and tumor microenvironment (TME) are susceptible to radiotherapy, we aimed to figure out specific differential DNA methylation to reflect oral squamous cell carcinoma (OSCC) prognosis and associated effect on TME changes post-radiotherapy, performing as an efficient biomarker.

MATERIALS AND METHODS

Differentially methylation analysis was performed using data from TCGA. Curves of Kaplan Meier (K-M) survival, cumulative hazard and events, Cox proportional hazards and Linear regression model were conducted to screen and validate differential methylation genes, while multiple regression equation to analyze if ornithine aminotransferase (OAT) methylation correlates with radiotherapy. For correlation between OAT methylation and immune infiltrates, CIBERSORT and ESTIMATE algorithms were performed, following GSEA and ssGSEA analysis to evaluate biological process.

RESULTS

Compared to normal tissues, only OAT in OSCC was differential significantly by K-M analysis (p = 0.0364). OAT hypermethylation was associated with increased overall survival (HR: 0.65, p = 0.0358). Radiotherapy correlated with OAT methylation (β = -0.01, p = 0.0061); most patients with OAT hypermethylation were radiation-sensitive. Hypomethylated OAT correlated with higher cell infiltrations in TME. Neuroactive ligand-receptor interaction was most significantly related to OAT methylation (p = 9.2e-10). Sulfur metabolism was the most significantly in OAT hypermethylation group (p = 0.0041) and RIG-I-like receptor in OAT hypomethylation group (p = 0.0094).

CONCLUSION

OAT methylation can serve as a predictor of OSCC prognosis post-radiotherapy with potential mechanism by changing cell infiltrations in TME, but further experimental study deserves to carry out confirming the role and mechanism of OAT methylation in OSCC. This article is protected by copyright. All rights reserved.

Inspired by Nature-Functional Analogues of Molybdenum and Tungsten-Dependent Oxidoreductases

Throughout the previous ten years many scientists took inspiration from natural molybdenum and tungsten-dependent oxidoreductases to build functional active site analogues. These studies not only led to an ever more detailed mechanistic understanding of the biological template, but also paved the way to atypical selectivity and activity, such as catalytic hydrogen evolution. This review is aimed at representing the last decade’s progress in the research of and with molybdenum and tungsten functional model compounds. The portrayed systems, organized according to their ability to facilitate typical and artificial enzyme reactions, comprise complexes with non-innocent dithiolene ligands, resembling molybdopterin, as well as entirely non-natural nitrogen, oxygen, and/or sulfur bearing chelating donor ligands. All model compounds receive individual attention, highlighting the specific novelty that each provides for our understanding of the enzymatic mechanisms, such as oxygen atom transfer and proton-coupled electron transfer, or that each presents for exploiting new and useful catalytic capability. Overall, a shift in the application of these model compounds towards uncommon reactions is noted, the latter are comprehensively discussed.

[Opioid agonist therapy and the German Narcotic Drugs Prescription Ordinance from the pharmacist's perspective]

BACKGROUND

Opioid agonist therapy (OAT) has been established to be the most important therapy option for improving health and social burdens of people with opioid dependence. Pharmacies provide drug substitutes to substitution practices or outpatient clinics and administer drugs to substituted patients (medication under visual control) or supply prescriptions for unsupervised, at-home use by patients. Given the gaps in medical care, the relevance of pharmacies for the comprehensive treatment of opioid-dependent patients will become even more important in the future. The 3^rd Revision of the Narcotic Drugs Prescription Ordinance (NDPO) adopted sweeping reforms to the framework of OAT in 2017. This paper examines the impact of this reform from the pharmacist's perspective.

METHODS

Between November 2020 and March 2021, pharmacists in the German federal states of Hamburg, North-Rhine Westphalia, Saxony, and Bavaria were informed by their State Chambers of Pharmacists about participation in this online study. A total of 480 questionnaires were evaluated. The analysis differentiates between pharmacists who are currently involved in the substitution of opioid-dependent patients (54.2%), pharmacists who were involved in the past (21.4%), and those who have never been involved in opioid substitution (24.4%).

RESULTS

Pharmacists involved in OAT have not seen any positive changes resulting from the 3^rd Revision of the NDPO. According to 97.9% of the pharmacists, remuneration for administering medication under visual control should be analogous to remuneration in doctors' practices. Mixed prescriptions (prescription of take-home dose and intermediate medication under visual control) increase the administrative workload and have been rejected by a quarter of the pharmacists. Non-involved pharmacists significantly overestimated the occurrence of critical situations with substituted patients in the pharmacy. While only 2.7% of pharmacists involved in OAT reported drug emergencies, 23.1% of non-involved pharmacists expressed such concerns. 39.3% of the pharmacists felt they could be motivated to participate in OAT if they were approached directly, and 73.9% of the pharmacists who are currently involved in OAT said they could provide substitution medication under visual control to additional opioid-dependent patients.

CONCLUSIONS

The 3^rd Revision of the NDPO has no influence on the situation and willingness of pharmacists to be involved in OAT. However, to ensure that pharmacists continue to be actively involved in OAT and attract new substituting pharmacies, their importance for comprehensive OAT must be upgraded. This includes, and not least, the funding of pharmacists' administration of substitution drugs under visual control. In addition, knowledge about OAT, attitudes toward opioid-dependent patients, and contact anxiety could be addressed by promoting educational awareness and training.

Association among sperm chromatin condensation, sperm DNA fragmentation and 8-OHdG in seminal plasma and semen parameters in infertile men with oligoasthenoteratozoospermia

The present study aimed to investigate the clinical role of standard sperm diagnosis parameters (sperm concentration, motility, morphology) as well as aniline blue staining of histones, 8-OHdG, TUNEL assay were performed on semen samples in infertile men with oligoasthenoteratozoospermia (OAT). Thirty-two infertile and ten proven fertile men were included in the study. Chromatin condensation sperm in infertile men was significantly lower compared to the fertile men (p < 0.0001). Age, sperm concentration, morphology and motility were significantly negatively correlated with chromatin condensation (p < 0.05). However, no significant correlations among the chromatin condensation, SDF and sperm DNA damage were detected in terms of 8-OHdG concentration.

Agonist Treatment for Opioid Dependence Syndrome: The Impact of Current Understanding upon Recommendations for Policy Initiatives

The provision of opioid agonist treatments (OATs), as a standard approach towards opioid dependence syndrome, differs widely between countries. In response to access disparities, in 2014, the Council of Europe’s Pompidou Group first brought together an expert group on framework conditions for the treatment of opioid dependence. The group used a Delphi approach to structure their discussions and develop guiding principles for the modernisation of OAT regulations and legislation. The expert group identified some 60 guiding principles, which were then the subject of wide public consultation. Endorsed by Pompidou Group member states, the final report identified four key recommendations: (1) Prescription and delivery without prior authorisation schemes; (2) Effective removal of financial barriers to access to care; (3) Coordination and follow-up by a national consultative body; and (4) Neutral, precise and respectful terminology. During meetings, the expert group hypothesised that inequalities in OAT access are likely to be linked to underlying rationales which in theory are contradictory, but in practice co-exist within the different political frameworks. The present article considers the perceived influence upon different regulatory frameworks. Discussion is centred around the potential impact of underlying rationales upon the effective implementation of a modernised framework.

Changes in health-related quality of life for HCV-infected people who inject drugs on opioid agonist treatment following sustained virologic response

BACKGROUND

Although efforts to treat hepatitis C virus (HCV) in people who inject drugs (PWID) yield high rates of sustained virologic response (SVR), the relationship between successful HCV treatment and health-related quality of life (HRQOL) among PWID is poorly understood. This study examined HRQOL changes throughout HCV treatment and post-treatment for PWID achieving SVR.

METHODS

Participants included 141 PWID who achieved SVR following HCV treatment onsite at three opioid agonist treatment (OAT) clinics in Bronx, NY. The EQ-5D-3L assesses five health dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), producing an index of HRQOL ranging from 0-1. EQ-5D-3L was measured at baseline, 4-, 8-, and 12-weeks during treatment and 12- and 24-weeks post-treatment. Linear mixed effects regression models were used to assess changes in the mean EQ-5D-3L index over time.

RESULTS

Mean EQ-5D-3L index baseline was 0.66 (SE=0.02). Whereas over half the population reported no baseline problems with self-care (85.1%), usual activities (56.0%), and mobility (52.5%), at least two-thirds reported problems with pain/discomfort (78.0%) and anxiety/depression (66.0%), with 22.0% and 21.3% reporting extreme problems for pain/discomfort and anxiety/depression, respectively. Twenty-four weeks post-treatment, proportions reporting pain/discomfort and anxiety/depression decreased by 25.7% and 24.0%, respectively. The mean EQ-5D-3L index significantly improved during treatment (p<0.0001), and improvement was sustained following treatment completion, with mean EQ-5D-3L index of 0.77 (SE=0.02) 12-weeks post-SVR.

CONCLUSIONS

HCV treatment led to sustained improvement in HRQOL for PWID on OAT who achieved SVR. Future research is necessary to determine whether improvements in HRQOL can be sustained beyond 12-weeks post-SVR.

Concurrent Initiation of Hepatitis C and Opioid Use Disorder Treatment in People Who Inject Drugs

BACKGROUND

People who inject drugs have a high prevalence of hepatitis C virus (HCV) and significant disease associated with drug use; however, HCV treatment often occurs in absence of interventions to address opioid use disorder and drug use-related harms. The impact of concurrent initiation of opioid agonist therapy (OAT) on HCV treatment and drug use outcomes is unknown.

METHODS

In this prospective, open-label, observational trial at a harm reduction organization's drop-in center in Washington, DC, 100 patients with chronic HCV infection, opioid use disorder, and ongoing injection drug use were treated with sofosbuvir-velpatasvir for 12-weeks and offered buprenorphine initiation. The primary end point was sustained virologic response (SVR), and secondary end points included uptake of and retention in OAT, change in risk behavior, and determinants of SVR.

RESULTS

Eighty-two patients (82%) achieved SVR, which was not associated with baseline OAT status (P = .33), on-treatment drug use (P >.99), or imperfect daily adherence (P = .35) but was significantly associated with completing 2 or more 28-pill bottles of sofosbuvir-velpatasvir (P < .001) and receiving OAT at week 24 (P = .01). Of 67 patients not already receiving OAT at baseline, 53 (79%) started OAT. At week 24, 68 (68%) patients were receiving OAT. Receipt of OAT was associated with fewer opiate-positive urine drug screens (P = .003), lower human immunodeficiency virus risk-taking behavior scores (P < .001), and lower rates of opioid overdose (P = .04).

CONCLUSIONS

The Novel Model of Hepatitis C Treatment as an Anchor to Prevent HIV, Initiate Opioid Agonist Therapy, and Reduce Risky Behavior study demonstrates high uptake of buprenorphine collocated with HCV treatment, and it shows that concurrent initiation of OAT with HCV treatment can result in high rates of SVR while reducing risks associated with drug use.

CLINICAL TRIALS REGISTRATION

NCT03221309.

Hepatitis C virus DAA treatment adherence patterns and SVR among people who inject drugs treated in opioid agonist therapy programs

BACKGROUND

Adequate medication adherence is critical for achieving sustained viral response (SVR) of hepatitis C virus (HCV) among people who inject drugs (PWID). However, it is less known which patterns of direct-acting antiviral (DAA) treatment adherence are associated with SVR in this population or what factors are associated with each pattern.

METHODS

The randomized three-arm PREVAIL study utilized electronic blister packs to obtain daily time frame adherence data in opiate agonist therapy program settings. Exact logistic regressions were applied to test the associations between SVR and six types of treatment adherence patterns.

RESULTS

Of the 113 participants treated with combination DAAs, 109 (96.5%) achieved SVR. SVR was significantly associated with all pattern parameters except for number of switches between adherent and missed days: total adherent daily doses (exact AOR=1.12; 95%CI=1.04-1.22), percent total doses (1.09; 1.03-1.16), days on treatment (1.16; 1.05-1.32), maximum consecutive adherent days (1.34; 1.06-2.04), maximum consecutive non-adherent days (.85; .74-.95=.003). SVR was significantly associated with total adherent doses in the first two months of treatment, it was not in the last month. Compared to White participants (30.7±11.8(se)), Black (18.4±7.8) and Hispanic participants (19.2±6.1) had significantly shorter maximum consecutive adherent days. While alcohol intoxication was significantly associated with frequent switches, drug use was not associated with any adherence pattern.

CONCLUSION

Consistent maintenance of adequate total dose adherence over the entire course of HCV treatment is important in achieving SVR among PWID. Additional integrative addiction and medical care may be warranted for treating PWID experiencing alcohol intoxication.

Pre-exposure prophylaxis awareness, acceptability and potential stigma among medical and non-medical clinic staff in methadone treatment settings in northern New Jersey: The key role of non-medical staff in enhancing HIV prevention

BACKGROUND

HIV prevention is needed among people who use drugs (PWUD) due to mixing sex and drugs, selling/trading sex, and/or injecting drugs. Pre-exposure prophylaxis (PrEP) is an extremely effective biomedical HIV prevention strategy, but uptake remains low among communities most in need of HIV prevention, including PWUD. Previous studies have found that providers are less willing to prescribe PrEP to PWUD, yet PWUD express high levels of PrEP acceptance. More research is needed to understand how people who provide substance use treatment services think about PrEP to maximize this biomedical prevention strategy.

METHODS

The study conducted semistructured interviews with 29 staff members in two methadone clinic settings in urban northern New Jersey. Staff members included medical providers, methadone counselors, intake coordinators, front desk staff, lab technicians, security guards, and administrative/leadership personnel.

RESULTS

All staff recognized the need for HIV prevention among their patient populations, but most were either unaware of PrEP or unfamiliar with its purpose and how it works. Medical providers were more likely to have some PrEP knowledge in comparison to counselors and other staff, but the former largely did not have in-depth knowledge. Among those familiar with PrEP, many confused PrEP with HIV medication, as Truvada was the only FDA-approved PrEP at the time of the study. About half of participants expressed clear support for PrEP, while the other half expressed mixed or negative attitudes related to HIV, sexual behavior, and mistrust of the medication. Both the positive and negative perceptions entailed stigmatizing elements.

RECOMMENDATIONS

Due to patients' frequent interactions with non-medical staff (e.g., front desk staff, lab technicians, etc.), all staff, not only medical personnel, should be aware of PrEP and comfortable discussing it to foster well-informed, nonjudgmental conversations about HIV prevention with patients. PrEP education should specifically address HIV and sexual-related stigma, as even positive perceptions of PrEP may entail stigmatizing elements.

High HCV cure rates among people who inject drugs and have suboptimal adherence: A patient-centered approach to HCV models of care

BACKGROUND

Though people who inject drugs (PWID) make up the majority of the hepatitis C virus (HCV) epidemic, concerns about adherence often exclude PWID from receiving direct-acting antiviral (DAA) medication. The most effective models of HCV care to promote sustained virologic response (SVR) and high adherence need to be evaluated.

METHODS

We conducted a prospective cohort study in three opioid treatment programs (OTPs) in the Bronx, NY. Participants, in collaboration with providers, chose one of three models of onsite care: directly observed therapy (mDOT), group treatment (GT), or self-administered individual treatment (SIT).  SVR12, daily adherence, and participant characteristics were compared between groups.

RESULTS

Of 61 participants, the majority were male (62%) and Latino (67%), with a mean age of 53 (SD 9). Participants received DAAs via one of three models of care: mDOT (21%), GT (25%), or SIT (54%). The majority (59%) used illicit drugs during treatment. Overall, SVR12 was 98% with no differences between models of care: mDOT (100%), GT (100%), and SIT (97%) (p = 1.0). Overall, daily adherence was 73% (SD 16); 86% among those who chose mDOT compared to 71% among those who chose GT (p<0.01) and 73% among those who chose SIT (p<0.01).

CONCLUSION

Despite ongoing illicit drug use and suboptimal adherence, SVR12 was high among PWID treated onsite at an OTP using any one of three models of care. Shared decision making in real world settings may be key to choosing the appropriate model of care for PWID.

A Phylogenetic Analysis of Hepatitis C Virus Transmission, Relapse, and Reinfection Among People Who Inject Drugs Receiving Opioid Agonist Therapy

BACKGROUND

Understanding hepatitis C virus (HCV) transmission among people who inject drugs (PWID) is essential for HCV elimination. We aimed to differentiate reinfections from treatment failures and to identify transmission linkages and associated factors in a cohort of PWID receiving opioid agonist therapy (OAT).

METHODS

We analyzed baseline and follow-up specimens from 150 PWID from 3 OAT clinics in the Bronx, New York. Next-generation sequencing data from the hypervariable region 1 of HCV were analyzed using Global Hepatitis Outbreak and Surveillance Technology.

RESULTS

There were 3 transmission linkages between study participants. Sustained virologic response (SVR) was not achieved in 9 participants: 7 had follow-up specimens with similar sequences to baseline, and 2 died. In 4 additional participants, SVR was achieved but the participants were viremic at later follow-up: 2 were reinfected with different strains, 1 had a late treatment failure, and 1 was transiently viremic 17 months after treatment. All transmission linkages were from the same OAT clinic and involved spousal or common-law partnerships.

CONCLUSION

This study highlights the use of next-generation sequencing as an important tool for identifying viral transmission and to help distinguish relapse and reinfection among PWID. Results reinforce the need for harm reduction interventions among couples and those who report ongoing risk factors after SVR.

Principles and Experimental Considerations for In Vitro Transporter Interaction Assays

Drug transporters are universally acknowledged as important determinants of the absorption, distribution, metabolism, and excretion of both endogenous and exogenous compounds. Altered transporter function, whether due to genetic polymorphism, DDIs, disease, or environmental factors such as dietary constituents, can result in changes in drug efficacy and/or toxicity due to changes in circulating or tissue levels of either drugs or endogenous substrates.Prediction of whether and to what extent the biological fate of a drug is influenced by drug transporters, therefore, requires in vitro test systems that can accurately predict the risk and magnitude of clinical DDIs. While these in vitro assessments appear simple in theory, practitioners recognize that there are multiple factors that can influence experimental outcomes. A better understanding of these variables, including test compound characteristics, test systems, assay formats, and experimental design, will enable clear, actionable steps and translatable outcomes that may avoid unnecessary downstream clinical engagement. This chapter will delineate the role of these variables in improving in vitro assay outcomes.

A national model of remote care for assessing and providing opioid agonist treatment during the COVID-19 pandemic: a report

Background

Health services globally are struggling to manage the impact of COVID-19. The existing global disease burden related to opioid use is significant. Particularly challenging groups include older drug users who are more vulnerable to the effects of COVID-19. Increasing access to safe and effective opioid agonist treatment (OAT) and other harm reduction services during this pandemic is critical to reduce risk. In response to COVID-19, healthcare is increasingly being delivered by telephone and video consultation, and this report describes the development of a national model of remote care to eliminate waiting lists and increase access to OAT in Ireland.

Purpose and findings

The purpose of this initiative is to provide easy access to OAT by developing a model of remote assessment and ongoing care and eliminate existing national waiting lists. The Irish College of General Practitioners in conjunction with the National Health Service Executive office for Social Inclusion agreed a set of protocols to enable a system of remote consultation but still delivering OAT locally to people who use drugs.

This model was targeted at OAT services with existing waiting lists due to a shortage of specialist medical staff. The model involves an initial telephone assessment with COVID-risk triage, a single-patient visit to local services to provide a point of care drug screen and complete necessary documentation and remote video assessment and ongoing management by a GP addiction specialist. A secure national electronic health link system allows for the safe and timely delivery of scripts to a designated local community pharmacy.

Conclusion

The development of a remote model of healthcare delivery allows for the reduction in transmission risks associated with COVID-19, increases access to OAT, reduces waiting times and minimises barriers to services. An evaluation of this model is ongoing and will be reported once completed. Fast adaptation of OAT delivery is critical to ensure access to and continuity of service delivery and minimise risk to our staff, patients and community. Innovative models of remote healthcare delivery adapted during the COVID-19 crisis may inform and have important benefits to our health system into the future.

Assessment of seminal YKL-40 in infertile men with varicocele

Several studies attempted to explain the negative impact of varicocele on spermatogenesis and fertilisation processes. YKL-40 is a novel glycoprotein biomarker that had been associated with several diseases. This quasi-interventional study aimed to assess the seminal levels of YKL-40 in infertile men with varicocele before and after varicocelectomy. Overall, 50 men were included in this study divided into 20 healthy fertile men and 30 infertile oligoasthenoteratozoospermic (OAT) men with varicocele that underwent varicocelectomy. All participants were subjected to history taking, clinical examination and scrotal Doppler. Also, semen analysis and seminal YKL-40 assessment were carried out in the start and 6 months after varicocele surgical repair. The results showed a significant increase in the mean seminal YKL-40 level in infertile OAT men with varicocele compared with the healthy fertile men. Six months post-varicocelectomy, the mean seminal KYL-40 level exhibited significant decreases correlated with improved sperm parameters. Overall, seminal levels of YKL-40 showed significant negative correlations with sperm concentration, total sperm motility and sperm normal morphology. It could be concluded that seminal YKL-40 is elevated in infertile OAT men with varicocele where varicocelectomy induces decreased seminal YKL-40 levels correlated with improved semen parameters.

Hepatitis C reinfection after successful antiviral treatment among people who inject drugs: A meta-analysis

BACKGROUND & AIMS

HCV reinfection following successful treatment can compromise treatment outcomes. This systematic review assessed the rate of HCV reinfection following treatment among people with recent drug use and those receiving opioid agonist therapy (OAT).

METHODS

We searched bibliographic databases and conference abstracts for studies assessing post-treatment HCV reinfection rates among people with recent drug use (injecting or non-injecting) or those receiving OAT. Meta-analysis was used to cumulate reinfection rates and meta-regression was used to explore heterogeneity across studies.

RESULTS

Thirty-six studies were included (6,311 person-years of follow-up). The overall rate of HCV reinfection was 5.9/100 person-years (95% CI 4.1-8.5) among people with recent drug use (injecting or non-injecting), 6.2/100 person-years (95% CI 4.3-9.0) among people recently injecting drugs, and 3.8/100 person-years (95% CI 2.5-5.8) among those receiving OAT. Reinfection rates were comparable following interferon-based (5.4/100 person-years; 95% CI 3.1-9.5) and direct-acting antiviral (3.9/100 person-years; 95% CI 2.5-5.9) therapy. In stratified analysis, reinfection rates were 1.4/100 person-years (95% CI 0.8-2.6) among people receiving OAT with no recent drug use, 5.9/100 person-years (95% CI 4.0-8.6) among people receiving OAT with recent drug use, and 6.6/100 person-years (95% CI 3.4-12.7) among people with recent drug use not receiving OAT. In meta-regression analysis, longer follow-up was associated with lower reinfection rate (adjusted rate ratio [aRR] per year increase in mean/median follow-up 0.77; 95% CI 0.69-0.86). Compared with people receiving OAT with no recent drug use, those with recent drug use receiving OAT (aRR 3.50; 95% CI 1.62-7.53), and those with recent drug use not receiving OAT (aRR 3.96; 95% CI 1.82-8.59) had higher reinfection rates.

CONCLUSION

HCV reinfection risk following treatment was higher among people with recent drug use and lower among those receiving OAT. The lower rates of reinfection observed in studies with longer follow-up suggested higher reinfection risk early post-treatment.

LAY SUMMARY

Our findings demonstrate that although reinfection by hepatitis C virus occurs following successful treatment in people with recent drug use, the rate of hepatitis C reinfection is lower than the rates of primary infection reported in the literature for this population - reinfection should not be used as a reason to withhold therapy from people with ongoing injecting drug use. The rate of hepatitis C reinfection was lowest among people receiving opioid agonist therapy with no recent drug use. These data illustrate that harm reduction services are required to reduce the reinfection risk, while regular post-treatment hepatitis C assessment is required for early detection and retreatment.

Clinical outcome after mosaicplasty of knee articular cartilage defects of patellofemoral joint versus tibiofemoral joint

Background

The purpose was to investigate survival of cartilage repair in the knee joint by osteochondral autograft transfer stratified by location of the lesion; patellofemoral joint (N = 26) versus the medial or lateral femoral condyles (N = 58).

Methods

For survival analyses, “failure” was defined as the event of a patient reporting a poor Lysholm score (below 65 points) or undergoing a knee replacement procedure.

Results

The survival distribution was not significantly different between the patellofemoral joint and the tibiofemoral joint groups.

Conclusions

The current study suggest that similar long-term outcome can be expected after OAT procedures for the patellofemoral or tibiofemoral joint.

Level of evidence

Therapeutic study, Level III.

Surgical Technique and Clinical Outcomes of Osteochondral Autograft Transplantation for Large Osteonecrotic Lesions of the Femoral Condyle With Residual Normal Cartilage: The Eyeglass Technique

Background:

Osteochondral autograft transplantation (OAT) is usually performed for a defect that is <400 mm² because of the limitations of autografts.

Purpose:

To present the surgical technique and clinical outcomes of OAT using the eyeglass technique for large osteonecrotic lesions of the femoral condyle (LOFs) (>400 mm²) with residual normal cartilage.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Cases (group 1) included 15 patients (18 knees) who underwent OAT using the eyeglass technique for LOFs with residual normal cartilage, while controls (group 2) included 11 patients (11 knees) who underwent OAT using the standard technique for small osteonecrotic lesions of the femoral condyle (≤400 mm²). Clinical outcomes were evaluated preoperatively and at the final follow-up (group 1, 56 months; group 2, 48 months) according to the International Knee Documentation Committee (IKDC) objective grade, the IKDC subjective score, and the Japanese Orthopaedic Association (JOA) score.

Results:

The mean lesion size was 685 mm² in group 1 and 230 mm² in group 2. Patients in group 1 had postoperative scores equivalent to those in group 2. The postoperative IKDC subjective scores in group 1 (mean, 86.9) and group 2 (mean, 87.0) showed no significant difference at the final follow-up (P = .653). For postoperative IKDC objective grades, 83.3% of group 1 and 81.8% of group 2 were graded as “nearly normal” or better, and no significant intergroup difference was found for the IKDC objective grade (P = .989). Also, no significant intergroup difference was found for the postoperative JOA score (group 1, 93.9; group 2, 81.4; P = .480). Nine second-look arthroscopic procedures were performed in group 1 compared with 4 in group 2, and all patients had plugs that were graded as “nearly normal” or better by the International Cartilage Repair Society classification system.

Conclusion:

The postoperative results of patients who underwent OAT using the eyeglass technique for large osteonecrotic lesions (>400 mm²) were equivalent to the results of patients who underwent OAT using the standard technique for small osteonecrotic lesions (≤400 mm²).

Mapping Metabolic Events in the Cancer Cell Cycle Reveals Arginine Catabolism in the Committed SG2M Phase

Alterations in cell-cycle regulation and cellular metabolism are associated with cancer transformation, and enzymes active in the committed cell-cycle phase may represent vulnerabilities of cancer cells. Here, we map metabolic events in the G1 and SG2M phases by combining cell sorting with mass spectrometry-based isotope tracing, revealing hundreds of cell-cycle-associated metabolites. In particular, arginine uptake and ornithine synthesis are active during SG2M in transformed but not in normal cells, with the mitochondrial arginase 2 (ARG2) enzyme as a potential mechanism. While cancer cells exclusively use ARG2, normal epithelial cells synthesize ornithine via ornithine aminotransferase (OAT). Knockdown of ARG2 markedly reduces cancer cell growth and causes G2M arrest, while not inducing compensation via OAT. In human tumors, ARG2 is highly expressed in specific tumor types, including basal-like breast tumors. This study sheds light on the interplay between metabolism and cell cycle and identifies ARG2 as a potential metabolic target.

Investigating Aspects of Renal Physiology and Pharmacology in Organ and Organoid Culture

Some aspects of renal physiology, in particular transport across tubular epithelia, are highly relevant to pharmacokinetics and to drug toxicity. The use of animals to model human renal physiology is limited, but human-derived renal organoids offer an alternative, relevant system in culture. Here, we explain how the activity of specific transport systems can be assessed in renal organoid and organ culture, using a system illustrated mainly for mouse but that can be extended to human organoids.

Patterns and history of prescription drug use among opioid-related drug overdose cases in British Columbia, Canada, 2015-2016

BACKGROUND

British Columbia is the epicenter of the current fentanyl-related overdose crisis in Canada. Our study characterizes prescribing histories of people who had an opioid-related overdose compared to matched controls.

METHODS

We examined linked administrative data for individuals who overdosed between January 1, 2015 and November 30, 2016. Past prescriptions over five years were assessed for opioids for pain, opioid agonist therapy, benzodiazepines/z-drugs, antidepressants, antipsychotics, gabapentinoids, mood stabilizers and anti-epileptics, muscle relaxants, and other sedating medications. Prescribing history of 9964 cases was compared with that of 49,820 matched controls.

RESULTS

Overdose cases were more likely to be prescribed opioids for pain and to have used prescription opioids on a long-term basis in the previous five years compared to controls. However, at the time of overdose, 92% of men and 86% of women did not have an active opioid for pain prescription, and approximately half had not filled one in the past five years. Those who overdosed tended to have more prescriptions for psychotropic substances than controls. Fewer than 10% of cases had an active prescription for opioid agonist therapy and most were not on treatment in the past.

CONCLUSIONS

Low prevalence of active prescriptions for opioids for pain at the time of overdose suggests that opioid prescribing plays a limited short-term impact in the current fentanyl-related crisis of overdoses. While liberal opioid prescribing practices may have contributed to the development of the current overdose crisis, regulation and enforcement of clinicians' prescribing practices will likely have limited impact in reducing overdoses.

Outcomes of Joint Preservation Procedures for Cartilage Injuries in the Hip: A Systematic Review and Meta-analysis

Background:

The detection and management of chondral injuries of the hip, especially in a younger patient population, may preempt joint degeneration. Although the outcomes of preservation techniques have been well described for other weightbearing joints, such as the knee, evidence for hip joint preservation after procedures such as microfracture and autologous chondrocyte implantation remains in its infancy.

Purpose:

To evaluate outcomes of joint preservation procedures in the hip, including the success rate and patient-reported outcomes (PROs).

Study Design:

Systematic review; Level of evidence, 4.

Methods:

This review was performed using the terms “hip arthroscopy,” “microfracture,” “autologous chondrocyte implantation,” “fibrin glue,” “osteochondral transfer,” and variations thereof in 5 electronic databases, yielding 325 abstracts. After the application of eligibility criteria, 19 articles were included. Weighted means were calculated for PROs, and pooled estimates were calculated for age, follow-up, chondral lesion size, and success of hip preservation procedures with a random-effects proportion meta-analysis.

Results:

A total of 1484 patients (1502 hips) were identified across 19 studies (mean age, 38.0 ± 1.3 years; mean follow-up, 31.8 ± 9.6 months). Hip joint preservation techniques demonstrated a high success rate, ranging from 85.6% to 99.7%. The mean pooled chondral lesion size was 2.5 ± 0.3 cm² (95% CI, 1.9-3.0 cm²). Microfracture was the most frequent technique, utilized by 11 studies, and demonstrated an 89.6% success rate (95% CI, 82.4%-96.7%). The highest pooled success rate was exhibited by autologous membrane-induced chondrogenesis in 3 studies (99.7% [95% CI, 99.0%-100.0%]). All PROs demonstrated a statistically significant increase postoperatively, including the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score–Activities of Daily Living and Hip Outcome Score–Sports-Specific Subscale (all P < .05). The visual analog scale for pain also demonstrated a statistically significant decrease of 37.2% (P < .05).

Conclusion:

Hip preservation procedures demonstrate a high success rate, with microfracture representing the most frequently utilized cartilage preservation technique in the peer-reviewed literature. PROs significantly improved after surgery. Further investigation of hip preservation modalities with long-term follow-up is required to create evidence-based clinical recommendations and treatment algorithms.

Orthopedic Surgical Options for Joint Cartilage Repair and Restoration

The limited natural capacity for articular cartilage to regenerate has led to a continuously broadening array of surgical interventions. Used once patients' symptoms are not relieved by nonoperative management, these share the goals of joint preservation and restoration. Techniques include bone marrow stimulation, whole-tissue transplantation, and cell-based strategies, each with its own variations. Many of these interventions are performed arthroscopically or with extended-portal techniques. Indications, operative techniques, unique benefits, and limitations are presented.

CD4+ AND CD8+ T-CELLS EXPRESSING INTERFERON GAMMA IN ACTIVE PULMONARY TUBERCULOSIS PATIENTS

Background

Tuberculosis (TB) is a global health problem. Immune response through CD4⁺ and CD8⁺ T cells is needed to produce Interferon gamma (IFN-γ), a cytokine eliminate Mycobacterium tuberculosis. We aimed to compare the cellular immune response based on the percentage of CD4⁺ and CD8⁺ T cells expressing interferon gamma in active pulmonary tuberculosis patients before and after 2 months of tuberculosis treatment.

Methods

It is a longitudinal cohort study included 12 patients with new active pulmonary TB of the Pulmonary Hospital, Surabaya. The CD4⁺ and CD8⁺ T cells expressing interferon gamma was measured by flow cytometry method.

Results

The mean CD4⁺ interferon gamma percentage of new active pulmonary TB before treatment was higher than 2 months after tuberculosis treatment (4.48% vs. 1.52%) and there was a significantly decreased (p = 0.025). The mean CD8⁺ interferon gamma percentage of new active pulmonary TB before treatment was higher than 2 months after tuberculosis treatment (3.56% vs. 2.89%) but not significantly decreased (p = 0.186).

Conclusions

The mean CD4⁺ IFN-γ percentage of new active pulmonary TB before treatment was higher than 2 months after treatment, suggesting that CD4⁺ T cells expressing IFN-γ play a role in protection against pulmonary TB infection.

Xenobiotic transporters and kidney injury

Renal proximal tubules are targets for toxicity due in part to the expression of transporters that mediate the secretion and reabsorption of xenobiotics. Alterations in transporter expression and/or function can enhance the accumulation of toxicants and sensitize the kidneys to injury. This can be observed when xenobiotic uptake by carrier proteins is increased or efflux of toxicants and their metabolites is reduced. Nephrotoxic chemicals include environmental contaminants (halogenated hydrocarbon solvents, the herbicide paraquat, the fungal toxin ochratoxin, and heavy metals) as well as pharmaceuticals (certain beta-lactam antibiotics, antiviral drugs, and chemotherapeutic drugs). This review explores the mechanisms by which transporters mediate the entry and exit of toxicants from renal tubule cells and influence the degree of kidney injury. Delineating how transport proteins regulate the renal accumulation of toxicants is critical for understanding the likelihood of nephrotoxicity resulting from competition for excretion or genetic polymorphisms that affect transporter function.

Barriers to access to opioid medicines for patients with opioid dependence: a review of legislation and regulations in eleven central and eastern European countries

BACKGROUND AND AIMS

Barriers linked to drug control systems are considered to contribute to inequitable access to controlled medicines, leaving millions of people in pain and suffering. Most studies focus on access to opioids for the treatment of severe (cancer) pain. This study aims to identify specific access barriers for patients with opioid dependence in legislation and regulations of 11 central and eastern European countries.

METHODS

This study builds on a previous analysis of legislation and regulations as part of the EU 7th Framework Access To Opioid Medication in Europe (ATOME) project. An in-depth analysis was undertaken to determine specific barriers for patients with opioid dependence in need of opioid analgesics or opioid agonist therapy (OAT). For each country, the number and nature of specific potential barriers for these patients were assessed according to eight categories: prescribing; dispensing; manufacturing; usage; trade and distribution; affordability; penalties; and other. An additional keyword search was conducted to minimize the omission of barriers. Barriers in an additional category, language, were recorded qualitatively. Countries included Bulgaria, Cyprus, Estonia, Greece, Hungary, Latvia, Lithuania, Serbia, Slovakia, Slovenia and Turkey.

RESULTS

Ten of the 11 countries (all except Estonia) showed specific potential barriers in their legislation and regulations. The total number of barriers varied from two (Slovenia) to 46 (Lithuania); the number of categories varied from one (Slovenia) to five (Lithuania). Most specific potential barriers were shown in the categories 'prescribing', 'usage' and 'other'. The total number in a single category varied from one to 18 (Lithuania, prescribing). Individual differences between countries in the same specific potential barrier were shown; for example, variation in minimum age criteria for admission to OAT ranging from 15 (Lithuania, in special cases) to 20 years (Greece). All countries had stigmatizing language in their legislation.

CONCLUSIONS

Patients with opioid dependence are likely to experience specific barriers to accessing opioids in addition to those experienced by other non-dependent patients.

Surgical treatments of cartilage defects of the knee: Systematic review of randomised controlled trials

BACKGROUND

The aim of this systematic review was to identify high quality randomised controlled trials (RCTs) and to provide an update on the most appropriate surgical treatments for knee cartilage defects.

METHODS

Two reviewers independently searched three databases for RCTs comparing at least two different treatment techniques for knee cartilage defects. The search strategy used terms mapped to relevant subject headings of MeSH terms. Strict inclusion and exclusion criteria were used to identify studies with patients aged between 18 and 55 years with articular cartilage defects sized between one and 15cm². Risk of bias was performed using a Coleman Methodology Score. Data extracted included patient demographics, defect characteristics, clinical outcomes, and failure rates.

RESULTS

Ten articles were included (861 patients). Eight studies compared microfracture to other treatment; four to autologous chondrocyte implantation (ACI) or matrix-induced ACI (MACI); three to osteochondral autologous transplantation (OAT); and one to BST-Cargel. Two studies reported better results with OAT than with microfracture and one reported similar results. Two studies reported superior results with cartilage regenerative techniques than with microfracture, and two reported similar results. At 10years significantly more failures occurred with microfracture compared to OAT and with OAT compared to ACI. Larger lesions (>4.5cm²) treated with cartilage regenerative techniques (ACI/MACI) had better outcomes than with microfracture.

CONCLUSIONS

Based on the evidence from this systematic review no single treatment can be recommended for the treatment of knee cartilage defects. This highlights the need for further RCTs, preferably patient-blinded, using an appropriate reference treatment or a placebo procedure.

Transport properties of valsartan, sacubitril and its active metabolite (LBQ657) as determinants of disposition

1. The potential for drug-drug interactions of LCZ696 (a novel, crystalline complex comprising sacubitril and valsartan) was investigated in vitro. 2. Sacubitril was shown to be a highly permeable P-glycoprotein (P-gp) substrate and was hydrolyzed to the active anionic metabolite LBQ657 by human carboxylesterase 1 (CES1b and 1c). The multidrug resistance-associated protein 2 (MRP2) was shown to be capable of LBQ657 and valsartan transport that contributes to the elimination of either compound. 3. LBQ657 and valsartan were transported by OAT1, OAT3, OATP1B1 and OATP1B3, whereas no OAT- or OATP-mediated sacubitril transport was observed. 4. The contribution of OATP1B3 to valsartan transport (73%) was appreciably higher than that by OATP1B1 (27%), Alternatively, OATP1B1 contribution to the hepatic uptake of LBQ657 (∼70%) was higher than that by OATP1B3 (∼30%). 5. None of the compounds inhibited OCT1/OCT2, MATE1/MATE2-K, P-gp, or BCRP. Sacubitril and LBQ657 inhibited OAT3 but not OAT1, and valsartan inhibited the activity of both OAT1 and OAT3. Sacubitril and valsartan inhibited OATP1B1 and OATP1B3, whereas LBQ657 weakly inhibited OATP1B1 but not OATP1B3. 6. Drug interactions due to the inhibition of transporters are unlikely due to the redundancy of the available transport pathways (LBQ657: OATP1B1/OAT1/3 and valsartan: OATP1B3/OAT1/3) and the low therapeutic concentration of the LCZ696 analytes.

In vitro assessment of the roles of drug transporters in the disposition and drug-drug interaction potential of olaparib

1. In vitro assessments were conducted to examine interactions between olaparib (a potent oral inhibitor of poly[ADP-ribose] polymerase) and drug transporters. 2. Olaparib showed inhibition of the hepatic drug uptake transporters OATP1B1 (IC₅₀ values of 20.3 μM and 27.1 μM) and OCT1 (IC₅₀ 37.9 μM), but limited inhibition of OATP1B3 (25% at 100 μM); inhibition of the renal uptake transporters OCT2 (IC₅₀ 19.9 μM) and OAT3 (IC₅₀ 18.4 μM), but limited inhibition of OAT1 (13.5% at 100 μM); inhibition of the renal efflux transporters MATE1 and MATE2K (IC₅₀s 5.50 μM and 47.1 μM, respectively); inhibition of the efflux transporter MDR1 (IC₅₀ 76.0 μM), but limited inhibition of BCRP (47% at 100 μM) and no inhibition of MRP2. At clinically relevant exposures, olaparib has the potential to cause pharmacokinetic interactions via inhibition of OCT1, OCT2, OATP1B1, OAT3, MATE1 and MATE2K in the liver and kidney, as well as MDR1 in the liver and GI tract. Olaparib was found to be a substrate of MDR1 but not of several other transporters. 3. Our assessments indicate that olaparib is a substrate of MDR1 and may cause clinically meaningful inhibition of MDR1, OCT1, OCT2, OATP1B1, OAT3, MATE1 and MATE2K.

Oral anticoagulation with vitamin K inhibitors and determinants of successful self-management in primary care

BACKGROUND

Self-management may be an option to monitor oral anticoagulant therapy in health systems, but before recommending it, we need to assess patients' ability to take on this task. The purpose of the study was to describe patients' ability to self-manage and associated factors.

METHODS

This was a 3-year prospective quasi-experimental study with a control group. Overall, 333 patients on anticoagulant therapy from seven primary care health centres of the Basque Health Service were included in the intervention group and followed up for 6 months after the intervention, assessing their ability to self-test and self-manage. The intervention consisted of a patient training programme, providing detailed information on their condition and its treatment, and practical training in how to use a portable blood coagulation monitor and adjust their anticoagulant dose. Comparisons were made with a control group (333 patients receiving OAT under usual care from the same seven health centres). Outcome variables were ability to self-manage, quality of the outcome (in terms of time in therapeutic range), and quality of life in the intervention group, and general patient characteristics (age and sex), clinical variables (reason for OAT, INR range), and quality of the outcome (in terms of percentage of INR measurements in range and complications) in both groups.

RESULTS

Overall, 26.13 % of patients invited to participate in the intervention agreed. Of these, 99 % successfully learned to self-manage their OAT. Just 4.2 % did not complete the follow-up, in all cases for reasons unrelated to self-management, and 4.5 % required additional learning support. Outcomes were better than under usual care in terms of percentage of INR measurements in range (12 %), rate of complications (4 %) and quality of life (9.2 %).

LIMITATIONS

Patients were only followed-up period for 6 months and the study was conducted in a single health organization. Though patients eligible to participate were selected randomly, they were not randomly allocated to the groups. This is a potential source of selection bias. Data needed to calculate in-range time were not collected from controls; rather the results for the self-management group were compared with external data from other studies.

CONCLUSIONS

Almost all participants achieved competency in self-management, with no differences by age, sex, concurrent illnesses, polypharmacy or educational level. The greatest barrier to self-management was the attitude of patients themselves and those around them. Self-management in primary care is a good alternative to usual care, patients having longer times in therapeutic range and fewer complications, and improving their quality of life. Remote management is a good support tool.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01878539.