Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial

BACKGROUND

Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention.

METHODS

Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems.

RESULTS

Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040].

CONCLUSION

Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

0045 Biobehavioral Markers for Sleep/Wake Disturbance and Fatigue in Young Childhood Brain Tumor Survivors

Introduction

Survivors of childhood and adolescent brain tumors and subsequent treatment may experience many neurological processes involving the forebrain, brainstem, and hypothalamus as well as the symptom cluster of stress, sleep, and fatigue. As a result, the impact of brain tumor treatment (chemotherapy/biotherapy, radiotherapy, and surgery) may have lasting biobehavioral effects. Description of symptoms during early survivorship is not always evident in the literature.

Methods

Convenience sampling and the following inclusion criteria were utilized: brain tumor survivors ages 8–17 years; ≥6 months, <6 years from completion of treatment; disease free or stable disease. Participants completed polysomnography (PSG) followed by a multiple sleep latency test (MSLT), and subjective measures of sleep, fatigue, stress, and pubertal status. Collection of salivary biomarkers for stress (cortisol) and sleep (melatonin) was completed the evening of and morning after the PSG.

Results

Analysis of the first 12 participants (5 males; 3 Hispanic/Latino; average age 14 years; 9–72 months post treatment) revealed mean (minutes) total sleep time (TST) 442, sleep latency (SL) 42 and waking (WASO) 88; sleep efficiency (SE) mean 83%, There were large magnitude correlations between several variables of interest, notably PM Cortisol with fatigue, TST (r= .472; -.453); AM Cortisol with SL (r=.479); AM Melatonin with SE, SL, WASO (r= -.459; .692; .458). Average AM melatonin level (26.6 pg/dl) was higher than PM (6.66 pg/dl). Seven participants were diagnosed with clinical sleep disorders, including one with narcolepsy and two with hypersomnia.

Conclusion

During early survivorship after pediatric brain tumor treatment, survivors may be at high risk for sleep/wake disturbance (SWD). Morning melatonin and biomarker correlations with sleep and fatigue in this sample warrant further exploration and may be related to first night effect versus circadian rhythm differences or clinical sleep disorder. Recommendations for future practice include developmentally matched protocols and routine screening of biobehavioral markers to assess risk for stress, SWD, and fatigue.

Support

1. Center for Oncology Education and Research Harris College of Nursing & Health Sciences Texas Christian University 2. Neuro-Oncology Program Hematology/Oncology Center Cook Children’s Health Care System 3. Nursing Research and Evidence-Based Practice James A. “Buddy” Davidson Endowed Fund

Use of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Acute Kidney Disease after an Episode of AKI: A Multicenter Prospective Cohort Study

BACKGROUND

Persistence of acute kidney disease (AKD) after an episode of acute kidney injury (AKI) is associated with adverse outcomes. Multiple factors contribute to AKD after AKI, but the role of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB) remains controversial. We examined if acute exposure to an ACEI/ARB associates with persistent AKD in survivors of AKI.

METHODS

Multicenter prospective cohort study of patients whose hospitalization was complicated by AKI and who attended specialized AKI follow-up clinics between 2013 and 2018. Acute exposure was defined as ACEI/ARB exposure for ≥48 h before or during the AKI episode. The primary outcome was AKD (serum creatinine ≥1.5 times above pre-AKI baseline) at the first clinic visit. We used multivariable logistic regression to adjust for potential confounders.

RESULTS

We included 345 survivors of AKI, 112 with persistent AKD at the first outpatient visit. Among 163 patients who were prescribed an ACEI/ARB before hospitalization, only 23% were discharged on an ACEI/ARB. There was no difference in the rate of AKD in patients discharged versus not discharged on an ACEI/ARB (12.5 vs. 15.0%, p = 0.530). Of the patients with AKD, 22 (19.6%) patients had acute ACEI/ARB exposure during the hospitalization. In fully adjusted models, acute exposure to an ACEI/ARB was not associated with AKD at the time of first clinic visit (median [interquartile range] 33 [18-54] days from hospital discharge).

CONCLUSION

Acute exposure to an ACEI/ARB before or during an episode of AKI was not associated with persistent AKD at the time of first clinic visit suggesting that the receipt of such agents does not impede kidney recovery following AKI. Contrary to prevailing recommendations and current practice, the continued administration of an ACEI/ARB during an episode of AKI or initiation of these agents prior to discharge may be safe.

A magic-themed upper limb intervention for children with unilateral cerebral palsy: The perspectives of parents

AIM

To explore parent's perspective of their child's participation in a magic-themed intervention called Amazing Magic Club (AMC), and to further our understanding of motivated engagement and the impact of themed group-based interventions for children with unilateral cerebral palsy (CP).

METHODS

Twenty-nine parents of children with unilateral CP completed semi-structured interviews. The child participants (n = 28) attended one of three AMCs; average age of the children was 10y 6mo (SD 2y 2mo). The parent interviews were analysed using thematic analysis.

RESULTS

The three themes are: "It's okay to be me", the magic effect and "I can do it". Parents observed their children to belong and learn about their abilities. The importance of the magicians and the performance is described. Parents observed their children to have increased self-belief and a new willingness to attempt difficult tasks.

DISCUSSION

AMC appears to capture intrinsic motivation for children with unilateral CP to complete challenging tasks.

Upper Limb Function of Children with Unilateral Cerebral Palsy After a Magic-Themed HABIT: A Pre-Post-Study with 3- and 6-Month Follow-Up

Aims: To examine changes in upper limb function, and performance in everyday tasks, for children with unilateral cerebral palsy who participated in a magic-themed hand-arm bimanual intensive therapy (HABIT). Methods: Twenty-eight children participated; mean age 10 y 6 mo (SD 2 y 2 mo), n = 15 male and n = 13 female. Using a single group, pre-and post-test design, the magic-themed HABIT was delivered for 60 hours over 10 days. Bimanual and unimanual hand function were measured using the Assisting Hand Assessment (AHA) and Box and Blocks Test (BBT). Occupational performance was rated using the Canadian Occupational Performance Measure (COPM). Two parent questionnaires explored change in bimanual hand use in everyday activities; ABILHAND-Kids and Children's Hand-use Experience Questionnaire (CHEQ). Assessments were completed pre-, immediately post, 3 months and 6 months after the intervention. Results: Friedman's ANOVA revealed a significant improvement for COPM and CHEQ grasp subscale. Repeated measures ANOVA revealed a significant improvement in BBT, and ABILHAND-Kids, and no significant change for AHA. Conclusions: Children who participated in the magic-themed HABIT experienced improved occupational performance, unimanual skills, and parent ratings of performance in challenging everyday tasks.

Use of bioindicators and passive sampling devices to evaluate ambient ozone concentrations in north central Pennsylvania

Ambient concentrations of tropospheric ozone and ozone-induced injury to black cherry (Prunus serotina) and common milkweed (Asclepias syriaca) were determined in north central Pennsylvania from 29 May to 5 September 2000 and from 28 May to 18 September 2001. Ogawa passive ozone samplers were utilized within openings at 15 forested sites of which six were co-located with TECO model 49 continuous ozone monitors. A significant positive correlation was observed between the Ogawa passive samplers and the TECO model 49 continuous ozone monitors for the 2000 (r=0.959) and 2001 (r=0.979) seasons. In addition, a significant positive correlation existed in 2000 and 2001 between ozone concentration and elevation (r=0.720) and (r=0.802), respectively. Classic ozone-induced symptoms were observed on black cherry and common milkweed. In 2000, initial injury was observed in early June, whereas for the 2001 season, initial injury was initially observed in late June. During both seasons, injury was noted at most sites by mid- to late-July. Soil moisture potential was measured for the 2001 season and a significant positive relationship (P<0.001) showed that injury to black cherry was a function of cumulative ozone concentrations and available soil moisture.

Transformation of Rickettsia prowazekii to erythromycin resistance encoded by the Escherichia coli ereB gene

Rickettsia prowazekii, the etiologic agent of epidemic typhus, is an obligate, intracytoplasmic, parasitic bacterium. Recently, the transformation of this bacterium via electroporation has been reported. However, in these studies identification of transformants was dependent upon either selection of an R. prowazekii rpoB chromosomal mutation imparting rifampin resistance or expression of the green fluorescent protein and flow cytometric analysis. In this paper we describe the expression in R. prowazekii of the Escherichia coli ereB gene. This gene codes for an erythromycin esterase that cleaves erythromycin. To the best of our knowledge, this is the first report of the expression of a nonrickettsial, antibiotic-selectable gene in R. prowazekii. The availability of a positive selection for rickettsial transformants is an important step in the characterization of genetic analysis systems in the rickettsiae.

Sexual dysfunction induced by serotonin reuptake antidepressants

Serotonin reuptake inhibitor (SRI) antidepressants have been associated with sexual dysfunction, though there have been few prospective reports specifically examining this problem. The purpose of this study was to determine if three SRIs affected sexual function in patients with an anxiety disorder or major depressive disorder over a 3-month period. Sixty-one patients were evaluated for at least 2 months in a prospective study of the effects of fluoxetine, sertraline, and paroxetine on five aspects of sexual function: libido, erection/lubrication, orgasm quality, orgasm delay, and sexual frequency. Measurements were made at baseline and at each month on visual analog scales. For men and women, orgasm quality was lower and orgasm delay longer at Months 1, 2, and 3 compared with baseline (p < .001). Erection scores were lower over time (p < .02) but this change was less dramatic. Lubrication, libido, and sexual frequency were not appreciably changed over 3 months. Anorgasmia was significantly more common in women than men at Months 1 and 2. Orgasm appears to be a primary sexual function affected by SRIs.

Bupropion treatment of serotonin reuptake antidepressant-associated sexual dysfunction

Serotonin reuptake inhibitor (SRI)-induced sexual dysfunction is common, and a number of pharmacologic adjunctive strategies have been employed to treat this vexing problem. This open label study tested the efficacy of adjunctive bupropion across several measures of sexual function. Patients taking SRIs for various mood or anxiety disorders who reported prospective decline in sexual function after at least 2 months on SRIs were offered treatment with bupropion, 75 mg/day. Eight patients were treated, and sexual function was measured by use of a visual analog scale at 1 month of treatment. Four of eight patients experienced marked improvement in sexual dysfunction following adjunctive bupropion treatment. Bupropion may be a pharmacologic option for treating SRI-associated sexual dysfunction, though controlled clinical trials are needed.

Molecular evidence for a Mediterranean origin of the Macaronesian endemic genus Argyranthemum (Asteraceae)

The internal transcribed spacers (ITS) of nuclear ribosomal DNA were sequenced for 52 species from 32 genera and eight subtribes of Anthemideae. Phylogenetic analyses of ITS data generated trees that are largely incongruent with the recent classification of Anthemideae; most of the subtribes examined are not resolved as monophyletic. However, ITS trees are congruent with morphological, isozyme, phytochemical, and chloroplast DNA (cpDNA) restriction site data in supporting a Mediterranean origin for Argyranthemum, the largest endemic genus of the Atlantic oceanic islands. A combined analysis of ITS sequences and cpDNA restriction sites indicates that Argyranthemum is sister to the other three genera of Chrysantheminae (i.e., Chrysanthemum, Heteranthemis, and Ismelia). Times of divergence of Argyranthemum inferred from the ITS sequences ranged between 0.26 and 2.1 million years ago (mya) and are lower than values previously reported from isozyme and cpDNA data (1.5-3.0 mya). It is likely that rate heterogeneity of the ITS sequences in the Anthemideae accounts for the low divergence-time estimates. Comparison of data for 20 species in Argyranthemum and Chrysantheminae indicates that the cpDNA restriction site approach provided much more phylogenetic information than ITS sequences. Thus, restriction site analyses of the entire chloroplast genome remain a valuable approach for studying recently derived island plants.

The establishment of a population-based Cancer Registry for North Carolina

In 1984 the North Carolina Medical Society's House of Delegates adopted Report S, which called for the North Carolina Legislature to fund a statewide cancer incident reporting system. The Cancer Committee continues to be advisory to the Division of Adult Health. A subcommittee of the Cancer Committee advises the Central Cancer Registry.

The distribution of serum alanine aminotransferase levels in a blood donor population

The authors studied the distribution of alanine aminotransferase (ALT) levels in 10,034 volunteer blood donors. The mean +/- SD ALT value was 21.4 +/- 19.3 IU/liter; 549 (5.5%) of the donors had a ALT value greater that 45 IU; 2.5 per cent had ALT values greater than 60 IU. In general, ALT levels were higher in males than in females, and were age related; peak values occurred in the third decade of life for males and between 50-60 years of age in females. ALT values greater than 45 IU were found significantly more often in males, in donors of both sexes 30-40 years of age, in married donors, in non-Caucasians, and in those whose education level was no higher than high school. Follow-up samples in donors with an initial ALT greater than 45 IU, revealed that 67% continued to have ALT values above 45 IU 2-8 weeks following initial sampling, and 40% had an ALT greater than 45 IU when tested again six months after entry into the study. ALT values greater than 60 IU were associated with a significantly increased prevalence of antibody of hepatitis B surface antigen (anti-HBs) and antibody to hepatitis B core antigen (anti-HBc) occurring together. No statistically significant association was found between transaminase activity and the prevalence of anti-HBs or anti-HBc alone, or with hepatitis A antibody. These findings demonstrate that there are defined sociodemographic and serologic features of donors with elevated ALT values.

Detection and characterization of monoclonal antibodies to platelet membrane proteins

We have devised a solid-phase radioimmunoassay for the detection and characterization of monoclonal antibodies directed against platelet surface antigens. Platelet membrane proteins, solubilized with 0.1% Triton X-100, were covalently coupled to cyanogen bromide (CNBr)-activated filter paper disks that were than used as the support in antibody binding assays. SDS PAGE of solubilized membrane proteins taken immediately before and after incubation with activated disks indicated that representative amounts of each membrane protein were bound to the disks. Either monoclonal or heterologous anti-platelet antibody could be detected on disks that had been prepared using as little as 50 micrograms of membrane protein per 100 disks. For the detection of antibody, disks were incubated with test sera for 2 h, washed, and incubated with 125I-labeled anti-immunoglobulin G, and the amount of bound radioactivity was determined. The sensitivity of the disk assay in detecting monoclonal antibodies was far greater than that of a corresponding radioimmunoassay that used whole platelets as the solid phase. By linking other proteins such as fibrinogen or anti-mouse subclass specific antisera to CNBr-activated disks, the method was adapted for antibody characterization. The sensitivity and ease with which the assay can be performed make this technique most suitable for screening and characterizing monoclonal antibodies.