Real-world use of long-acting cabotegravir and rilpivirine: 12-month results of the inJectable Antiretroviral therapy feasiBility Study (JABS)

OBJECTIVES

The inJectable Antiretroviral feasiBility Study (JABS) aimed to evaluate the implementation of long-acting regimens in a 'real world' Australian setting, with inclusion of participants with complex medical needs, social vulnerability and/or historical non-adherence.

METHODS

JABS was a 12-month, single-centre, single-arm, open-label phase IV study of long-acting cabotegravir 600 mg plus rilpivirine 900 mg administered intramuscularly every 2 months to adults with treated HIV-1 infection. The primary endpoint was the proportion of attendances and administration of injections within a 14-day dosing window over 12 months, out of the total prescribed doses. Secondary endpoints included proportions of missed appointments, use of oral bridging, discontinuations, virological failures, adverse events and participant-reported outcomes. A multidisciplinary adherence programme embedded in the clinical service known as REACH provided support to JABS participants.

RESULTS

Of 60 participants enrolled by May 2022, 60% had one or more complexity or vulnerability factors identified, including absence of social supports (50%), mental health issues, alcohol or drug use (30%) and financial hardship or instability (13%), among others. Twenty-seven per cent of participants had historical non-adherence to antiretroviral therapy. Out of 395 prescribed doses, 97.2% of injections were administered within correct dosing windows at clinic visits. Two courses of short-term oral bridging were required. The rate of injection site reactions was 29%, the majority being grade 1-2. There were no virological failures, no serious adverse events and only one injection-related study discontinuation. High baseline treatment satisfaction and acceptability of injections increased by month 12. Those with vulnerability factors had similar adherence to injections as those without such factors. Ninety-eight per cent of the participants who completed 12 months on the study have maintained long-acting therapy, virological suppression and retention in care.

CONCLUSIONS

Long-acting cabotegravir plus rilpivirine was associated with very high adherence, maintenance of virological suppression, safety and treatment satisfaction in a diverse Australian clinic population, comparable to results of phase III randomized clinical trials. Individuals with vulnerability factors can achieve adherence to injections with individualized support. Long-acting therapies in this group can increase the subsequent engagement in clinical care.

ATP1A3 related disease manifesting as rapid onset dystonia-parkinsonism with prominent myoclonus and exaggerated startle

We report ATP1A3-associated rapid-onset dystonia-parkinsonism with an atypical presentation including myoclonus and exaggerated startle in four patients. Their prominence over parkinsonism prompted consideration of a syndromic diagnosis of myoclonus dystonia. ATP1α3 dysfunction in GABAergic neurons could explain these examination findings. The spectrum of ATP1A3-associated movement disorders includes myoclonus-dystonia.

Defence context for the UK's Defence Engagement (Health)

Defence Engagement (DE) has been a core UK Defence task since 2015. DE (Health) is the use of military medical capabilities to achieve DE effects within the health sector to achieve security and defence objectives. DE (Health) practitioners must understand the underlying defence context that shapes these objectives. The strategic context is becoming more uncertain with the return of great power competition layered on enduring threats from non-state actors and transnational challenges. The UK response has been to develop the Integrated Review, outlining four national security and international policy objectives. UK Defence has responded by developing the integrated operating concept, differentiating military activity between operating and warfighting. Engage is one of the three functions of operate activity, which is complementary to the other operate functions of protect and constrain. DE (Health) can play a unique role in engagement, given its ability to develop new partnerships through health-related activity. DE (Health) may be an enabler for other engagements or to enable the protect and constrain functions. This will be dependent on delivering improvement in health outcomes. Therefore, the DE (Health) practitioner must be conversant with both the contemporary defence and global health contexts to deliver effective DE (Health) activities. This is an article commissioned for the DE special issue of BMJ Military Health.

Female squirrel monkeys' (Saimiri boliviensis) responses to inequity in a group context; testing a link between cooperation and inequity responses

Primates of several species respond negatively to receiving less preferred rewards than a partner for completing the same task (inequity responses), either rejecting rewards or refusing to participate in the task when disadvantaged. This has been linked to cooperation, with species that cooperate frequently refusing to participate in inequity tasks (the 'cooperation hypothesis'). However, inequity is a social response, and previous research has involved dyads, precluding studying the effects of additional social partners. While dyads allow for tighter control in experimental settings, dyadic interactions in nature do not take place in a social vacuum, so understanding the role of the social context is needed to verify that the pattern of results supports the cooperation hypothesis. Here we focus on Bolivian squirrel monkeys, Saimiri boliviensis, a highly social species that does not generally cooperate and has not responded to inequity in previous dyadic research, although they do respond to receiving a lower reward than they expected. In the current study, we provide a more nuanced test by studying female Bolivian squirrel monkeys, the demographic most likely to cooperate in both field and laboratory contexts, in a more socially relevant group setting. For some reward values, females responded in both the inequity condition, rejecting less preferred rewards when they were disadvantaged relative to their social group, and a contrast condition, wherein all animals received a lower reward than they expected, making it difficult to disentangle contrast from inequity. As in capuchin monkeys, refusals increased when monkeys were to receive low-value rewards compared to medium-value rewards. These results suggest that the relationship between cooperation and inequity responses may be more nuanced than previously suggested, with demographic, social context and reward value potentially influencing outcomes even within species.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Sociodemographic predictors of attendance at a Scottish pain management programme

We examined relationships between various sociodemographic factors and attendance at the Glasgow Pain Management Programme (n = 2899 from 2011 to 2019). We tested for associations between gender, age and socioeconomic deprivation of patients who were invited to attend, and uptake to a programme when invited, attendance at screening assessment, eligibility, adherence and attendance at 3- and 6-month reviews. Uptake was significantly higher for patients from more affluent areas (95% confidence interval (CI) = 0.93–0.99, p = 0.002) and for older patients (95% CI = 0.98–0.99, p = 0.006), although effect sizes were very small. Patients were significantly more likely to be assessed as suitable if they were younger (95% CI = 0.98–0.99, p = 0.013) or female (95% CI = 0.55–0.84, p < 0.001). Attendance at sessions and at 3- and 6-month reviews was higher for patients from more affluent areas (95% CI = 1–1.09, p = 0.001, and 95% CI = 1–1.1, p = 0.044 respectively). We argue that there are multiple potential explanations for these findings and that future work should attempt to determine whether these patterns replicate in other populations and to determine any modifiable causes.

Race matters: cardiovascular disease risk in male US prisoners

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH/National Institute of Nursing Research, 1RC2NR011948

Introduction

Approximately 10% of the 2.2 million prisoners in the US have a diagnosis of cardiovascular disease (CVD) and in 2016, 28% of all deaths in custody were attributable to CVD. Black race, inadequate health literacy, and poor perceived control are predictors of increased cardiovascular disease (CVD) risk, which are prevalent in prisoners. However, little is known about the relationships among race, health literacy, and perceived control in CVD risk for male prisoners.

Objective

The purpose of this study was to explore the relationships among race, health literacy, perceived control, and CVD risk while controlling for well-known risk factors (education, partner status, and body mass index) in male prisoners.

Methods

We used baseline data from 349 male prisoners in a biobehavioral CVD risk reduction intervention. Health literacy was measured using the Newest Vital Sign and perceived control by the Control Attitudes Scale- Revised. CVD risk was quantified with the Framingham Risk Score (FRS). Three indirect effects of race on CVD risk were examined using serial mediation model with two sequential mediators (i.e., health literacy and perceived control) and 95% confidence intervals from 5000 bootstrap samples.

Results

Of the participants (mean age = 36 + 10 years), 64.2% were white and 35.8% were black. Mean education level was 12 years and most (85.8%) were not married or partnered. Mean BMI was 28.3 + 5.0. Mean FRS was 6.63 + 4.90, indicating risk percentages of 2.3 to 13.3% over the next ten years. Black prisoners were younger (35 + 9 versus 37 + 10, p = .047) and had lower levels of health literacy (3.84 + 1.90 versus 4.69 + 1.63, p &lt; .001) than white prisoners. No statistically significant differences in perceived control, education, partner status, or body mass index were noted between races. All three indirect effects of race on CVD were significant while the direct effect of race was not. Compared to white prisoners, black prisoners had higher levels of CVD risk through health literacy (a1b1 = .3571, 95% CI [.0948, .7162]) and lower levels of CVD risk through perceived control (a2b2 = -.1855, 95% CI [-.4388, -.0077]). Black prisoners had higher levels of CVD risk through health literacy influenced by perceived control (a1b2d21 = .0627, 95% CI [.0028, .1409]) indicating that despite the protective effect of higher levels of perceived control in black prisoners, CVD risk remained higher compared to their white counterparts.

Conclusion

Future CVD risk reduction interventions in prisoners of all races, but specifically black male prisoners, should include goals of improving health literacy and perceived control in addition to the traditional modifiable risk factors often included in biobehavioral interventions.

Hand Washing Observations in Fast-Food and Full-Service Restaurants: Results from the 2014 U.S. Food and Drug Administration Retail Food Risk Factors Study

ABSTRACT

Properly executed hand washing by food service employees can greatly minimize the risk of transmitting foodborne pathogens to food and food contact surfaces in restaurants. However, food service employee hand washing is often not done correctly or does not occur as often as it should. The purpose of this study was to assess the relative impact of (i) the convenience and accessibility of hand washing facilities; (ii) the maintenance of hand washing supplies, (iii) multiunit status, (iv) having a certified food protection manager, and (v) having a food safety management system for compliance with proper hand washing. Results revealed marked differences in hand washing behaviors between fast-food and full-service restaurants; 45% of 425 fast-food restaurants and 57% of 396 full-service restaurants were out of compliance for washing hands correctly, and 57% of fast-food restaurants and 78% of full-service restaurants were out of compliance for employee hands being washed when required. Logistic regression results indicated the benefits of accessibility and maintenance of the hand washing sink and of a food safety management system for increasing the likelihood of employees washing hands when they are supposed to and washing them correctly when they do.

HIGHLIGHTS

Response to "isolated head tremor: A DAT SPECT and somatosensory temporal discrimination study."

In response to Ferrazano and colleagues' observation of normal DAT binding in patients with isolated head tremor but with abnormal STDT, we report normal 123-IBZM SPECT in a cohort of patients with adult-onset idiopathic focal dystonia with cervical dystonia and their unaffected first-degree relatives both with normal and abnormal TDTs. We discuss molecular imaging findings in dystonia.

Membrane distillation for concentrated blackwater: Influence of configuration (air gap, direct contact, vacuum) on selectivity and water productivity

Water recovery from concentrated blackwater has been studied using air gap (AGMD), direct contact (DCMD) and vacuum membrane distillation (VMD) to deliver decentralised sanitation. Whilst good water quality was achieved with each configuration, differences in the rejection of volatile compounds was observed. VMD exhibited the highest rejection of volatiles, specifically ammoniacal nitrogen, of all the configurations but fouling inhibited total flux. DCMD exhibited a temperature dependent volatile rejection which resulted in poor rejection at lower feed temperatures (≤40 °C). AGMD was identified as the most promising configuration for application within decentralised sanitation, since the rejection of volatiles was consistent over a range of operating temperatures with ammonia rejection directly related to solution pH. An increase in organic colloids and particles due to faecal contamination reduced COD removal due to the induction of wetting, but was shown to be offset by adoption of a smaller pore size (0.1 μm), and when complemented with upstream solid-liquid separation within a fully integrated system, will provide a robust sanitation solution. Importantly, this work has shown that AGMD can recover water from concentrated blackwater close to international discharge and reuse regulations in a single stage process; this is significant as blackwater consists of only urine and faeces, and is thus 40 times more concentrated than municipal sewage. It is proposed that the water quality produced reflects a step change to delivering safe sanitation, and is complemented by a simple method for heat recovery integration this is similarly advantageous for resource constrained environments common to decentralised sanitation solutions.

Australian experience with total pancreatectomy with islet autotransplantation to treat chronic pancreatitis

BACKGROUND

This study aimed to describe the clinical outcomes of total pancreatectomy with islet autotransplantation (TP-IAT) in Australia.

METHODS

Individuals selected for TP-IAT surgery according to the Minnesota Criteria (Appendix) without evidence of diabetes were evaluated including time to transplantation from pancreatectomy, islet numbers infused and post-transplantation HbA1c, C-peptide, total daily insulin and analgesic requirement.

RESULTS

Sixteen individuals underwent TP-IAT from Australia and New Zealand between 2010 and 2020. Two recipients are deceased. The median islet equivalents/kg infused was 4244 (interquartile range (IQR) 2290-7300). The median C-peptide 1 month post-TP-IAT was 384 (IQR 210-579) pmol/L and at median 29.5 (IQR 14.5-46.5) months from transplant was 395 (IQR 139-862) pmol/L. Insulin independence was achieved in eight of 15 (53.3%) surviving recipients. A higher islet equivalents transplanted was most strongly associated with the likelihood of insulin independence (P < 0.05). Of the 15 surviving recipients, 14 demonstrated substantial reduction in analgesic requirement.

CONCLUSION

The TP-IAT programme in Australia has been a successful new therapy for the management of individuals with chronic pancreatitis including hereditary forms refractory to medical treatment to improve pain management with 50% insulin independence rates.

816 The Effect Of COVID-19 And Service Delivery Changes On 30-Day Mortality in Fractured Neck of Femur Patients: A Case-Control Study

Introduction

The majority of neck of femur (NOF) fractures occur within the home, therefore admissions were not expected to change during the COVID-19 pandemic₍₁₎ . This study investigates the effect of coronavirus and our department’s response on 30-day mortality for patients admitted with NOF fractures.

Method

Data from 65 fractured NOF admissions (22^nd March - 24^th May 2020) was compared with 62 patients from the same period in 2019. Binary logistic regression was used to explore 30-day mortality; accounting for differences in ASA, anaesthetic type, anticoagulation status, surgery type, age, time to surgery and year of admission.

Results

The odds of 30-day mortality was statistically significantly higher in patients who were suspected/confirmed COVID-19 positive (n = 10),(OR 2.39, 95%CI (1.60-74.13)). In COVID-19 negative patients (n = 55), the odds of 30-day mortality was lower in 2020, and approached statistical significance (0.232, 95%CI (0.053-1.02)), compared to the same period in 2019. Median length of stay (LOS) in patients who survived was 11 days in 2020 and 15.5 days in 2019 (p = 0.003).

Conclusions

The results suggest that a COVID-19 diagnosis significantly increases the 30-day mortality in patients with a fractured NOF. The changes implemented in service delivery have shortened LOS and appeared to improve 30-day mortality for those without COVID-19.

Dichloroacetate as a possible treatment for endometriosis-associated pain: a single-arm open-label exploratory clinical trial (EPiC)

Background

Endometriosis (where endometrial-like tissue is found outside the uterus) affects ~ 176 million women worldwide and can lead to debilitating pelvic pain. There is an unmet need for new medical treatment options for endometriosis. Pelvic peritoneal mesothelial cells of women with endometriosis exhibit detrimental metabolic reprogramming that creates an environment favouring the formation and survival of endometriosis lesions. We have generated powerful preclinical proof-of-concept data to show that it is possible to correct this metabolic phenotype using dichloroacetate (DCA), a non-hormonal compound previously used to treat rare metabolic disorders in children. We plan a single-arm, open-label, single site exploratory clinical trial to inform the design of a future randomised controlled trial (RCT) to determine the efficacy of DCA for the treatment of endometriosis-associated pain.

Methods

We will recruit 30 women with endometriosis-associated pain over a 6-month period. All participants will receive approximately 6.25 mg/kg oral DCA capsules twice daily for 6 weeks, with a dose increase to approximately 12.5 mg/kg twice daily for a further 6 weeks if their pain has not been adequately controlled on this dose regime and side-effects are acceptable. If pain is adequately controlled with minimal side-effects, the lower dose will be continued for a further 6 weeks. The primary objective is to determine whether it is possible to achieve acceptable recruitment and retention rates within the defined exclusion and inclusion criteria. Secondary objectives are to determine the acceptability of the trial to participants, including the proposed methods of recruitment, treatment, follow-up frequency and number of questionnaires. The recruitment rate will be determined by the proportion of patients recruited from the pool of eligible women. The retention rate will be determined by the proportion of participants who attended the final trial visit.

Discussion

This is a feasibility study to explore effectiveness and acceptability of the proposed field methodology (recruitment, retention, study processes and compliance with treatment). The results will be used to inform the design of a future RCT.

Trial registration

ClinicalTrials.gov, NCT04046081 Registered 6 August 2019

Ultrafiltration pretreatment enhances membrane distillation flux, resilience and permeate quality during water recovery from concentrated blackwater (urine/faeces)

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UF is used as a pre-treatment to reduce membrane distillation fouling.

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UF removes particles and colloids from blackwater but low MW fraction increases.

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Whilst UF treated blackwater high in organics, flux and water quality is stable.

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Without UF pre-treatment, severe fouling reduces flux, which reduces quickly.

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With UF pre-treatment, permeate quality consistently meets treatment quality.

In this study, the pretreatment of concentrated blackwater using ultrafiltration (UF) was shown to improve the permeability, selectivity and robustness of membrane distillation (MD) for application to wastewater treatment. Concentrated blackwater comprises urine and faeces, with minimal flushwater added. The faecal contribution increased the soluble organic fraction and introduced coarse and colloidal particles into the urine, which increased resistance to filtration during dead-end UF. Ultrafiltration removed the particulate and colloidal fractions (MW > 500 kDa) from the blackwater, which permitted similar permeability and robustness for MD to that observed with urine (29.9 vs 25.9 kg m⁻² h⁻¹), which comprises a lower colloidal organic concentration. Without UF pretreatment, a higher density organic layer formed on the MD surface (197 vs 70 gCOD m⁻²) which reduced mass transfer, and transformed the contact angle from hydrophobic to hydrophilic (144.9° to 49.8°), leading to pore wetting and a dissipation in product water quality due to breakthrough. In comparison, with UF pretreatment, MD delivered permeate water quality to standards satisfactory for discharge or reuse. This is particularly timely as the ISO standard for non-sewered sanitation has been adopted by several countries at a national level, and to date there are relatively few technologies to achieve the treatment standard. Membrane distillation provides a robust means for concentrated blackwater treatment, and since the energy required for separation is primarily heat, this advanced treatment can be delivered into areas with more fragile power networks.

Managing power dissipation in closed-loop reverse electrodialysis to maximise energy recovery during thermal-to-electric conversion

Whilst the efficiency of reverse electrodialysis (RED) for thermal-to-electrical conversion has been theoretically demonstrated for low-grade waste heat, the specific configuration and salinity required to manage power generation has been less well described. This study demonstrates that operating RED by recycling feed solutions provides the most suitable configuration for energy recovery from a fixed solution volume, providing a minimum unitary cost for energy production. For a fixed membrane area, recycling feeds achieves energy efficiency seven times higher than single pass (conventional operation), and with an improved power density. However, ionic transport, water flux and concentration polarisation introduce complex temporal effects when concentrated brines are recirculated, that are not ordinarily encountered in single pass systems. Regeneration of the concentration gradient at around 80% energy dissipation was deemed most economically pragmatic, due to the increased resistance to mass transport beyond this threshold. However, this leads to significant exergy destruction that could be improved by interventions to better control ionic build up in the dilute feed. Further improvements to energy efficiency were fostered through optimising current density for each brine concentration independently. Whilst energy efficiency was greatest at lower brine concentrations, the work produced from a fixed volume of feed solution was greatest at higher saline concentrations. Since the thermal-to-electrical conversion proposed is governed by volumetric heat utilisation (distillation to reset the concentration gradient), higher brine concentrations are therefore recommended to improve total system efficiency. Importantly, this study provides new evidence for the configuration and boundary conditions required to realise RED as a practical solution for application to sources of low-grade waste heat in industry.

Donation after circulatory death hearts recipients compared to donation after brain death heart recipients have comparable systolic left ventricular function and better myocardial strain at 1 year

Purpose

Cardiac transplantation from donation after circulatory death (DCD) has been implemented at our hospital since February 2015. Despite encouraging results some concerns may be raised about the impact of the warm ischemia and reperfusion injury on the myocardium status at longer follow-up. Therefore, we aimed to analyse systolic performance of the left ventricle at 1 year follow in DCD and donation after brain death (DBD) cardiac recipients, as assessed by echocardiography with myocardial deformation imaging.

Methods

We identified 46 consecutive DCD cardiac recipients who were transplanted from February 2015 to August 2018 and we matched them with 46 DBD cardiac recipients. Six and 7 patients from DCD and DBD group, respectively, died in the first-year post transplant. In the remaining patients we have compared the classical echocardiographic measurements as well as global longitudinal strain (GLS) and global circumferential strain (GCS) at 1-year follow-up.

Results

DCD and DBD patients did not present with differences in terms of classical echocardiographic parameters of left ventricular (LV) structure and systolic function at one-year follow-up. LVEDV was similar in DCD and DBD patients (101±24 vs. 95±32 ml, p=0.4 respectively), as well as LVESV (42±13 vs. 42±16 ml, p=0.9, respectively), LV ejection fraction (58±6 vs. 56±8%, p=0.22) and LV mass (156±39 vs. 163±38 gr, p=0.2, respectively). In contrast, myocardial deformation parameters, such as GLS and GCS, were better in DCD than in DBD (16.1 vs. −14.5%, p&lt;0.01; and −25.2 vs. 22.3%, p&lt;0.05, respectively). The diastolic LV function parameters were similar in DCD and DBD group, as evidenced by E wave velocity, A wave velocity and deceleration time of mitral inflow, however E over E prime was lower in DCD than in DBD recipients (7.7±8.7, p&lt;0.05). Fractional area change of the right ventricle was higher in DCD in comparison with DBD (46±7 vs. 40±7%, p&lt;0.01) while right atrial volume index was lower in DCD than in DBD (25±8 vs. 29±9 ml/m2, p&lt;0.01). Other parameters of RV function (systolic excursion of the tricuspid annulus, TAPSE) were similar in both groups.

Conclusion

DCD and DBD heart recipients present with similar systolic LV function at 1-year follow, as assessed by classical echocardiographic parameters. DCD cardiac recipients have better myocardial deformation parameters as assessed by the speckle tracking, better systolic right ventricular function and lower filling pressures of the left ventricle.

Funding Acknowledgement

Type of funding source: None