Designing, implementing and evaluating the overdose response with take-home naloxone model of care: An evaluation of client outcomes and perspectives

INTRODUCTION AND DESIGNS

Take-home naloxone (THN) interventions are an effective response to preventing overdose deaths, however uptake across Australia remains limited. This project designed, implemented and evaluated a model of care targeting opioid users attending alcohol and other drug (AOD) treatment, needle and syringe programs (NSP) and related health services targeting people who inject drugs.

DESIGN AND METHODS

Service providers, consumers and regulators collaboratively designed a THN brief intervention (ORTHN, Overdose Response with Take-Home Naloxone) involving client education and supply of naloxone in pre-filled syringes, delivered by nursing, allied health and NSP workers. ORTHN interventions were implemented in over 15 services across New South Wales, Australia. The evaluation included client knowledge, attitudes, substance use and overdose experiences immediately before and 3 months after ORTHN intervention in a subsample of participants.

RESULTS

Six hundred and sixteen interventions were delivered, with 145 participants recruited to the research subsample, of whom 95 completed the three-month follow up. Overdose-related attitudes amongst participants improved following ORTHN, with no evidence of increased substance use or failure to implement other 'first responses' (e.g. calling an ambulance). Nine participants (10%) reversed an overdose using THN in the follow-up period. Participants identified a willingness to access THN from a range of services. While a minority (16%) indicated they were unwilling to pay for THN, the median price that participants were willing to pay was $AUD20 (IQR $10.40).

DISCUSSION AND CONCLUSIONS

The ORTHN model of care for THN appears an effective way to disseminate THN to people who use opioids attending AOD, NSP and related health-care settings.

Adherence to Once-daily and Twice-daily Direct-acting Antiviral Therapy for Hepatitis C Infection Among People With Recent Injection Drug Use or Current Opioid Agonist Therapy

Background

This study investigated adherence and associated factors among people with recent injection drug use (IDU) or current opioid agonist therapy (OAT) and compared once-daily to twice-daily hepatitis C virus (HCV) direct-acting antiviral (DAA) therapy.

Methods

SIMPLIFY and D3FEAT are international, multicenter studies that recruited participants with recent IDU (previous 6 months; SIMPLIFY, D3FEAT) or current OAT (D3FEAT) between March 2016 and February 2017 in 8 countries. Participants received sofosbuvir/velpatasvir (once daily; SIMPLIFY) or paritaprevir/ritonavir/ombitasvir, dasabuvir (twice daily) ± ribavirin (D3FEAT) for 12 weeks administered in electronic blister packs. We evaluated overall adherence (proportion of prescribed doses taken) and nonadherence (<90% adherent) between dosing patterns.

Results

Of 190 participants, 184 (97%) completed treatment. Median adherence was 92%, with higher adherence among those receiving once-daily vs twice-daily therapy (94% vs 87%, P = .005). Overall, 40% of participants (n = 76) were nonadherent (<90% adherent). Recent stimulant injecting (odds ratio [OR], 2.48 [95% confidence interval {CI}, 1.28–4.82]), unstable housing (OR, 2.18 [95% CI, 1.01–4.70]), and twice-daily dosing (OR, 2.81 [95% CI, 1.47–5.36]) were associated with nonadherence. Adherence decreased during therapy. Sustained virologic response was high in nonadherent (89%) and adherent populations (95%, P = .174), with no difference in SVR between those who did and did not miss 7 consecutive doses (92% vs 93%, P = .897).

Conclusions

This study demonstrated high adherence to once- and twice-daily DAA therapy among people with recent IDU or currently receiving OAT. Nonadherence described did not impact treatment outcomes, suggesting forgiveness to nonadherence.

Assessment and delivery of treatment for hepatitis C virus infection in an opioid substitution treatment clinic with integrated peer-based support in Newcastle, Australia

BACKGROUND

Among people who inject drugs (PWID), the prevalence of hepatitis C virus (HCV) infection is high; however HCV treatment uptake remains low. New models of care are needed to address the growing burden of HCV-related disease in PWID and to understand the barriers to assessment and treatment of HCV. This study evaluated assessment and treatment for HCV infection among PWID attending an opioid substitution treatment (OST) clinic with an integrated peer support worker model.

METHODS

Clients with a history of IDU and chronic HCV infection, attending the Newcastle Pharmacotherapy Service, Newcastle Australia, were recruited as part of a multisite prospective observational study (the ETHOS Cohort). Additional chart review was conducted for clients not enrolled in the ETHOS Cohort. A peer support worker was introduced to complement and extend services offered by the clinical team. Client contacts and assessments with a nurse and/or peer worker were evaluated, including those who commenced HCV treatment.

RESULTS

A total of 1447 clients attended the OST service during February 2009 and June 2014. Of these, 378 (26%) were assessed by a nurse and 242 (17%) by a clinician. HCV treatment was commenced by 20 (5%) participants and 15 (75%) achieved a sustained virological response (SVR). During May 2009 and July 2011, 332 nurse contacts and 726 peer worker contacts were evaluated. The nurse-led contacts were related to HCV treatment (50%) and review of pathology tests (34%), whereas peer worker contacts included discussion about HCV treatment (75%), education, counselling and/or support (53%) and general discussion about HCV infection (59%).

CONCLUSION

These data demonstrate that peer support workers facilitate broader discussion about HCV treatment, education and/or support, allowing nurses to focus on HCV-related assessment and treatment. HCV treatment uptake was very low in this cohort, but SVR was high. The integration of peer support workers in treatment programs within OST clinics may address barriers to HCV care, but further studies are needed to assess their impact on assessment and treatment outcomes.

Effect of the apoptosis signal ceramide (C6) on antitumor activity of chemotherapeutic agents in SCID mice

e14642

Introduction: The ceramides are a major signaling pathway for apoptosis in cells undergoing stress or exposure to chemotherapy. We have demonstrated synergistic anti-tumor effects of combining C6 ceramide with paclitaxel, doxorubicin and cisplatin and are currently addressing the question; does C6 augment activity of all the major classes of drugs? Backround: Currently the in vivo anti-tumor effects of C6 with oxaliplatin and Gemcitabine. Methods: Invivo experiments SCID/Beige/Taconic male mice inoculated S.C. with 2X106 L3.6 pancreatic cells were treated 4 days post tumor implant with trice weekly (3x/wk) intraperitoneal (IP) injections of paclitaxel (P) 3.0 m/kg, oxaliplatin (OX) 2.5 mg/kg, cisplatin (CP) 2.5 mg/kg, Gemcitabine (Gem) 10 mg/kg with/without ceramide 10 mg/kg. Mice were observed for 6 weeks and were autopsied when near death. (All controls died by 3rd week). Maximum tumor volume, tumor weight; body weight and survival were recorded. Results: Combination with C6 ceramide augmented the tumor reduction obtained by chemotherapy alone by 57% (while preserving body weight), and increased 6 week survival from 0% (Chemotherapy alone) to 60% with combined therapy. Mean survival was increased from 25 to 37 days. Although short term immunohistochemical studies suggested enhanced apoptosis and increased caspase 3 production by ceramide combinations it may actually be independent of capase activation and mitochondrial activation. Conclusions: Combination therapy with the apoptotic signal C6 ceramide significantly enhanced the anti-tumor effects of the anti microtubule, alkylating Paclitaxel a DNA interculating antibiotic (doxorubicin) the alkylating/DNA adducting agents (cisplatin, oxaliplatin) and an anti metabolite (gemcitabine) suggesting generation of broad based apoptotic signals which interact with major cancer drug classes (tested).

No significant financial relationships to disclose.

Molecular characterization of the protein encoded by the Hermansky-Pudlak syndrome type 1 gene

Hermansky-Pudlak syndrome (HPS) comprises a group of genetic disorders characterized by defective lysosome-related organelles. The most common form of HPS (HPS type 1) is caused by mutations in a gene encoding a protein with no homology to any other known protein. Here we report the identification and biochemical characterization of this gene product, termed HPS1p. Endogenous HPS1p was detected in a wide variety of human cell lines and exhibited an electrophoretic mobility corresponding to a protein of approximately 80 kDa. In contrast to previous theoretical analysis predicting that HPS1p is an integral membrane protein, we found that this protein was predominantly cytosolic, with a small amount being peripherally associated with membranes. The sedimentation coefficient of the soluble form of HPS1p was approximately 6 S as inferred from ultracentrifugation on sucrose gradients. HPS1p-deficient cells derived from patients with HPS type 1 displayed normal distribution and trafficking of the lysosomal membrane proteins, CD63 and Lamp-1. This was in contrast to cells from HPS type 2 patients, having mutations in the beta3A subunit of the AP-3 adaptor complex, which exhibited increased routing of these lysosomal proteins through the plasma membrane. Similar analyses performed on fibroblasts from 10 different mouse models of HPS revealed that only the AP-3 mutants pearl and mocha display increased trafficking of Lamp-1 through the plasma membrane. Taken together, these observations suggest that the product of the HPS1 gene is a cytosolic protein capable of associating with membranes and involved in the biogenesis and/or function of lysosome-related organelles by a mechanism distinct from that dependent on the AP-3 complex.

Three new mutations in a gene causing Hermansky-Pudlak syndrome: clinical correlations

Hermansky-Pudlak syndrome (HPS) consists of oculocutaneous albinism, a platelet storage pool deficiency, and ceroid lipofuscinosis. HPS is common in northwest Puerto Rico, where affected individuals are homozygous for a 16-bp duplication in the gene HPS. Two other homozygous frameshift mutations in HPS were previously identified among non-Puerto Rican patients. Eighteen non-Puerto Rican HPS families were studied and HPS mutations in three of them identified. One mutation, T322insC, has been previously described. However, three additional mutations, E133X, T322delC, and S396delC, have not been reported. Two families exhibited compound heterozygosity for these mutations, although most previously reported HPS patients have been homozygous for a particular mutation. All the newly described mutations were associated with decreased or undetectable levels of HPS RNA by Northern blot analysis of fibroblasts, and all had significant pigment dilution. To date, all mutations in HPS result in a truncated protein, suggesting that the C-terminal portion of the HPS protein is functionally important.

Genetic defects and clinical characteristics of patients with a form of oculocutaneous albinism (Hermansky-Pudlak syndrome)

BACKGROUND

Hermansky-Pudlak syndrome is characterized by oculocutaneous albinism, a storage-pool deficiency, and lysosomal accumulation of ceroid lipofuscin, which causes pulmonary fibrosis and granulomatous colitis in some cases. All identified affected patients in northwest Puerto Rico are homozygous for a 16-bp duplication in exon 15 of a recently cloned gene, HPS. We compared the clinical and laboratory characteristics of these patients with those of patients without the 16-bp duplication.

METHODS

Forty-nine patients -- 27 Puerto Ricans and 22 patients from the mainland United States who were not of Puerto Rican descent -- were given a diagnosis on the basis of albinism and the absence of platelet dense bodies. We used the polymerase chain reaction to determine which patients carried the 16-bp duplication.

RESULTS

Twenty-five of the Puerto Rican patients were homozygous for the 16-bp duplication, whereas none of the non-Puerto Rican patients carried this mutation. Like the patients without the duplication, the patients with the 16-bp duplication had a broad variation in pigmentation. Nine of 16 adults with the duplication, but none of the 10 without it, had a diffusing capacity for carbon monoxide that was less than 80 percent of the predicted value. High-resolution computed tomography in 12 patients with the 16-bp duplication revealed minimal fibrosis in 8, moderate fibrosis in 1, severe fibrosis in 1, and no fibrosis in 2. Computed tomography in eight patients without the duplication revealed minimal fibrosis in three and no fibrosis in the rest. Inflammatory bowel disease developed in eight patients (four in each group) between 3 and 25 years of age.

CONCLUSIONS

The 16-bp duplication in exon 15 of HPS, which we found only in Puerto Rican patients, is associated with a broad range of pigmentation and an increased risk of restrictive lung disease in adults.

Normal brain myelination in a patient homozygous for a mutation that encodes a severely truncated methionine adenosyltransferase I/III

Two isozymes of mammalian methionine adenosyltransferase, MAT I and MAT III, are expressed solely in adult liver. They are, respectively, tetramers and dimers of a single subunit encoded by the gene MAT1A. A third isozyme, MAT II, contains a catalytic subunit encoded by a separate gene, MAT2A, and is expressed in a variety of tissues, including (to a slight extent) adult liver. Based on a recent finding that 2 children with isolated hypermethioninemia and brain demyelination were homozygous for MAT1A mutations predicted to produce severely truncated proteins, and devoid of activity when expressed, it was concluded that complete lack of MAT I/III activity may be associated with neurological symptoms and demyelination. We now report that a 43-year-old man with persistent isolated hypermethioninemia, previously demonstrated to have deficient MAT activity in his liver, has normal brain myelination on MRI and normal neurological function, despite being homozygous for a 539 TG insertion in exon V of MAT1A, so that the gene is predicted to encode a protein of only 184 rather than the normal 395 amino acids. This patient's exon V mutation was demonstrated by SSCP analysis and verified by sequencing. Both parents are heterozygous for the same insertion. This suggests that MAT1A mutations producing severely truncated proteins do not necessarily produce brain demyelination. This finding has relevance to a previously reported 4-year-old girl who was also homozygous for the 539insTG mutation. Finally, our patient's 7% residual hepatic MAT activity, measured at 1 mM methionine, may reflect the hepatic activity of the more ubiquitous enzyme form, MAT II.

Evidence for locus heterogeneity in Puerto Ricans with Hermansky-Pudlak syndrome

Hermansky-Pudlak syndrome (HPS) consists of ocu-locutaneous albinism, a platelet storage-pool deficiency, and ceroid lipofuscinosis. In a recent report on the cloning of an HPS gene, all 22 Puerto Rican HPS patients were homozygous for a 16-bp duplication in exon 15. This presumably reflected a founder effect for the HPS mutation in Puerto Rico. Nevertheless, we ascertained two individuals from central Puerto Rico who lacked the 16-bp duplication, exhibited significant amounts of normal-size HPS mRNA by northern blot analysis, and had haplotypes in the HPS region that were different from the haplotype of every 16-bp-duplication patient. Moreover, these two individuals displayed no mutations in their cDNA sequences, throughout the entire HPS gene. Both patients exhibited pigment dilution, impaired visual acuity, nystagmus, a bleeding diathesis, and absent platelet dense bodies, confirming the diagnosis of HPS. These findings indicate that analysis of Puerto Rican patients for the 16-bp duplication in HPS cannot exclude the diagnosis of HPS. In addition, HPS most likely displays locus heterogeneity, consistent with the existence of several mouse strains manifesting both pigment dilution and a platelet storage-pool deficiency.

Maternal behavior in male rats: effects of medial preoptic area lesions and presence of maternal aggression

Male rats exhibit maternal behavior prepuberally and in adulthood, but the neural mechanisms and the ability of males to respond to hormones that stimulate maternal aggression (following arousal of maternal behavior) in females have not been studies. In Experiment 1, males were exposed to pups to stimulate maternal behavior (sensitization) after either radiofrequency lesions of the MPOA or sham lesions with nonactivated electrodes that penetrated the MPOA. Nonsurgical males served as a CONTROL group. The LESION male group showed severe deficits in all components of maternal behavior compared to the latter two groups that showed no behavioral deficits. Females in the LESION group and those given SHAM 1 lesions (produced by electrodes without current introduced into the MPOA) also showed severe deficits in maternal behavior compared to SHAM 2 females (electrode lowered to above the MPOA without current) and nonsurgical CONTROL females. In Experiment 2, prolonged estradiol (E2), progesterone (P) treatment followed by an injection of either 20 micrograms or 100 micrograms/ kg estradiol benzoate (EB) or oil in castrated males was effective in stimulating short-latency maternal behavior, mainly in the 100 micrograms/kg EB group. Males of this group also showed a high level of maternal aggression that was inversely correlated with their latencies for maternal behavior. All groups showed maternal aggression when maternal behavior was established. The results indicate the MPOA mediates maternal behavior in males as it does in females; maternal aggression in males accompanies the stimulation of maternal behavior and may be stimulated by the same hormones.

Fine mapping of the cystinosis gene using an integrated genetic and physical map of a region within human chromosome band 17p13

The cystinosis gene has been reported to reside in a 3.1 cM region of chromosome 17p13 flanked by markers D17S1828 and D17S1798. We created a yeast artificial chromosome (YAC) contig between these markers and report here an integrated genetic and physical map which will aid in the identification of other genes in this area. Using one pertinent YAC clone, 898A10, we identified new polymorphic markers in the cystinosis gene region. One such marker, D17S2167, was localized by radiation hybrid analysis to within 10.2 cR8000 of D17S1828. Haplotype analysis in two separate informative families revealed recombination events which placed the cystinosis gene between markers D17S1828 and D17S2167, an area estimated to be 187-510 kb in size. This dramatic narrowing of the cystinosis gene region permits the creation of a P1 or cosmid contig across the area of interest. The ultimate cloning of the cystinosis gene should eventually reveal how a functional lysosomal transport protein is synthesized, targetted, processed, and integrated into the lysosomal membrane.

AI/LEARN/Rheumatology. A comparative study of computer-assisted instruction for rheumatology

OBJECTIVE

To assess the effectiveness of AI/LEARN/Rheumatology, a computer-controlled interactive videodisc system for teaching.

METHODS

We assessed improvement in knowledge about rheumatic diseases, using a pretest and posttest in a control year and a treatment year. The subjects were medical students and postgraduate trainees taking the rheumatology elective. The control year used traditional lectures and the standard rheumatology curriculum. The treatment year used AI/LEARN/Rheumatology in place of lectures on rheumatoid arthritis, ankylosing spondylitis, and osteoarthritis.

RESULTS

The trainees showed significant improvement in knowledge in both the control year and the treatment year (P < 0.0001 for both). The average time spent using AI/LEARN/Rheumatology was similar to the time spent in lectures (3 hours). The number of patient consultations in which trainees participated was lower in the treatment year than in the control year; however, the adjusted posttest scores using the pretest as a covariate tended to be higher in the treatment year (P = 0.10). Analysis of covariance of the adjusted posttest scores for the treatment year only showed that the trainees who spent more time using AI/LEARN/Rheumatology learned more (r = 0.57). Trainees felt that AI/LEARN/Rheumatology was the most helpful educational experience of the elective.

CONCLUSION

AI/LEARN/Rheumatology is an effective means of teaching about the rheumatic diseases. It has many advantages: availability for independent study, effective use of trainee's time, and liberation of faculty time from lectures. Trainees enjoyed using AI/LEARN/Rheumatology.

Model predictions for anthelmintic resistance amongst Haemonchus contortus populations in southern Brazil

A computer model developed to study Ostertagia circumcincta resistance to anthelmintics in UK sheep flocks has been adapted for use with Haemonchus contortus under southern Brazilian conditions. The model simulates the effect of different anthelmintic control regimens on the year-to-year pattern of resistance in breeding ewes. The nematode control regimen most used by Brazilian sheep farmers was found to increase the frequency of genes which confer resistance from approximately 3% to 14% in an H. contortus population over a 20 year period. The effect of early versus late season anthelmintic treatment was investigated. This indicated that early season treatment would select for resistance rapidly, whereas late season treatments would not, owing to large numbers of untreated parasites accumulating at the beginning of the season. A model which can predict the development of anthelmintic resistance in parasites of ewes is a valuable tool in the understanding of the effect of different strategies on nematode control programmes and merits further consideration.

AI/Learn/Rheumatology. A computer-assisted educational system for teaching about rheumatic diseases

Education of health professionals about the rheumatic diseases is in need of improvement. The computer is an instrument that can be used efficiently to educate large numbers of users. With specific educational principles in mind, we developed AI/Learn/Rheumatology, a computer-assisted interactive videodisc system for teaching the rheumatic diseases. While interacting with the user, it conveys knowledge using visual and problem-solving techniques. The system is efficient, enjoyable to use, and useful for small groups and independent study. It is applicable for teaching medical and allied health professional students, postgraduate trainees, and primary care physicians.

Preliminary evaluation of learning via the AI/LEARN/Rheumatology interactive videodisc system

AI/LEARN/Rheumatology is a level three videodisc system to teach clinical observational skills in three important diseases: rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. The AI/LEARN software was developed on an independent authoring system called GALE designed for MS-DOS based computers. The purpose of this paper is to present preliminary data about the efficacy of teaching by the use of an interactive videodisc system as evaluated by examinations centered upon disease-oriented learning objectives and by attitude questionnaires. We tested the efficacy of the AI/LEARN/Rheumatology system using both medical students and residents taking the rheumatology elective. Data collected were on learning, attitudes, and ranking of curricular elements of the rotation. We kept records on the student time and search path through the interactive videodisc system. Control data were collected during 1990, before the AI/LEARN/Rheumatology program was available. Data for the treatment groups were collected during 1991 and 1992, while the trainees used the AI/LEARN/Rheumatology system. The basic difference between the control year and the treatment year curricula was the substitution of AI/LEARN/Rheumatology for three hours of lecture covering the three target diseases. AI/LEARN/Rheumatology was as effective as traditional methods of instruction as measured by scores on a multiple choice test. Student and resident learning was related to the time spent on the system. Students and residents ranked the AI/LEARN/Rheumatology system as the single most helpful learning tool in their 8 week rheumatology block, ranking it above the examination of patients.

AI/LEARN: an interactive videodisk system for teaching medical concepts and reasoning

This paper describes AI/LEARN, an educational videodisk system designed to teach clinical observational skills and reasoning in medicine. The AI/LEARN system uses a learning conditions approach to teaching. To teach visual concepts, we use the principle of exemplar/nonexemplar pairs and immediate feedback. To teach If-Then problem solving we use the format of minicases with delayed feedback. The software to operate the system has been custom developed and is domain independent. The result is a prototype of a new authoring package for videodisk teaching which operates on IBM compatible microcomputers. The medical domain selected for this prototype system was rheumatic diseases; the knowledge used to teach reasoning skills is derived from the knowledge base of an expert system: AI/RHEUM.