The Impact of Addictions Management Following Cardiac Surgery on People Who Inject Drugs and Have Infective Endocarditis

Background

Managing reinfection in patients who inject drugs and have undergone cardiac surgery could reduce mortality. A significant gap exists in the management of addiction in this population and it is rarely addressed during index hospitalization for surgical intervention. This study sought to determine if management of addiction changed rates of readmission for reinfection.

Methods

This study was a retrospective chart review and analysis. Patients who underwent cardiac surgery for infective endocarditis due to injection drug use underwent a full chart review to determine if they received management of their addiction (addictions medicine consultation, social work consultation, medication- and/or opioid-assisted treatment, and community follow-up) following their surgical intervention.

Results

A total of 41 patients were identified who met the inclusion criteria. For addictions management, 43.2% of patients received an addictions medicine consultation, 67.6% received a social work consultation, 40.5% received medication- and/or opioid-assisted treatment, and 56.8% received community follow-up. Overall mortality of these patients was 21.6%, and 56.8% of patients were readmitted with reinfection. Multivariate logistic regression showed that patients who received intervention were 1.6 times more likely to be readmitted with reinfection (odds ratio 1.65, 95% confidence interval 0.29-9.41, P = 0.5736). Female patients had a significantly higher odds of reinfection, when adjusted for gender (odds ratio 9.95, 95% confidence interval 1.42-69.72, P = 0.021).

Conclusions

We demonstrated a nonstandardized approach to consultation and varying approaches to management of addiction. Patients who received intervention for addiction were more likely to be readmitted for reinfection, but this difference was not significant. Future efforts can include promotion of formalized addictions consultation services for high-risk patients.

Parental Alcohol Communication and Student Drinking: Examining Potential Differences between Underage and Legal Drinking Age Students

BACKGROUND

We explored associations between parental alcohol communication (PCA) and student drinking behavior and protective behavioral strategies (PBS) use.

METHODS

College students in the United States, who had talked about alcohol with parents, (N = 251) completed an anonymous online survey in Fall 2021. Participants reported frequency of discussing 14 alcohol-related topics with parents, past 30-day drinking behaviors, and PBS use.

RESULTS

We identified two forms of PCA: general alcohol information and alcohol risk information, with alcohol risk information being more common than general alcohol information. PCA was not significantly associated with drinking behavior but was associated with two types of PBS. Specifically, general alcohol information was associated with greater use of serious harm reduction and stopping or limiting drinking strategies. Additionally, legal drinking age status moderated the associations between both forms of PCA and the use of stopping or limiting drinking strategies. In general, underage students stopping or limiting drinking strategies benefited from general alcohol information but not alcohol risk information. Legal drinking age students stopping or limiting drinking strategies benefited from alcohol risk information.

CONCLUSIONS

Among these students, PCA appears to have a greater impact on PBS use rather than drinking behavior. This may reflect a shift in students' beliefs about parental authority over alcohol and parents' acceptance of alcohol use by their children.

Stigma as a local process: Stigma associated with opioid dependency in a rural-mixed Indiana county

BACKGROUND

Because the nature and magnitude of stigmatizing views associated with opioid dependency vary by social, cultural, and structural factors, strategies to reduce public stigma towards opioid dependency should vary by context. We leverage a unique dataset with evidence of multiple stigmatizing views to understand how to target interventions to reduce stigma in a state disproportionately impacted by the opioid epidemic, with a specific focus on a rural-mixed county.

METHODS

Data come from the representative Person-to-Person Health Study (2018-2020) of 2,050 Indiana residents, 224 from the rural-mixed Fayette County. Bivariate statistics and multivariate regression analyses were used to evaluate the association between Fayette County and measures of stigma (e.g., desire for social distance, prejudice, causal attributions) relative to the rest of Indiana.

RESULTS

Fayette County statistically differed from the rest of Indiana on most demographic characteristics and measures of stigmatizing views. Multivariate regressions revealed that compared to the rest of Indiana, residence in Fayette County was associated with a higher desire for social distance, perceptions of unpredictability, and attributing opioid dependency to genetics and the way the person was raised.

CONCLUSION

Our results contribute to growing evidence supporting the need for local approaches to address stigma. Stigma in Fayette County primarily reflects concerns about how people manage their opioid dependency. Strategies focusing on treatment and recovery potential, accompanied by extending the influence of supportive stakeholders and policies, will become important to address this stigma.

Trauma Experience Among Women Who Have Substance Use Disorders and are Homeless or Near Homeless

Women with substance use disorders (SUDs) who are homeless or near homeless have high rates of mental health, behavioral health, and SUD treatment needs. To effectively respond to these needs, it is critical to understand the population-specific trauma experiences of these women. This descriptive study examined the extent and nature of trauma experience among women who have an SUD and are homeless or near homeless. Results (n = 851 women) indicated high rates of trauma experience. All participants (100%) reported at least one type of trauma experience in their lifetime, with the majority (75.3%) having experienced five to seven of the seven types of trauma experiences assessed. Participants reported high levels of emotional severity related to the majority of traumatic events experienced. The pervasiveness of the trauma experiences and the related emotional impact among women with SUDs who are homeless or near homeless reinforce the necessity for trauma-informed care in treatment settings.

A Research-Informed Approach to Providing Behavioral Healthcare to Women with Extensive Trauma Histories

Translating research to behavioral healthcare practice is vital for improving treatment impact but can be challenging. Current and lifetime histories of trauma need to be considered in behavioral healthcare provision as they can significantly affect an individual's treatment experience. This article provides guidance on how to utilize research findings regarding trauma prevalence and experiences of women who have substance use disorder and who are homeless or near homeless to help guide responsive healthcare and treatment in practice.

Resection of a Large Growing Mediastinal Germ Cell Tumor Using a Multidisciplinary Approach

Mediastinal germ cell tumors (GCTs) are rare. Post-chemotherapy residual masses in patients with a nonseminomatous GCT require resection. A patient with a large mediastinal GCT involving the left subclavian artery, superior vena cava (SVC) and hilum of the right lung is presented. Despite a biochemical response to chemotherapy, the tumor enlarged on serial imaging. With guidance from medical oncology, a multidisciplinary surgical team, including cardiac anesthesia, cardiac surgery and thoracic surgery resected the tumor with a staged reconstruction of the SVC. The procedure was well tolerated and yielded clear margins. The final pathology showed a significant associated component of rhabdomyosarcoma.

An estimation of the endoscopist's musculoskeletal injury risk for right and left lateral decubitus positions during colonoscopy: a field-based ergonomic study

BACKGROUND

Colonoscopy exposes endoscopists to awkward postures and prolonged forces, which increases their risk of musculoskeletal injury. Patient positioning has a significant impact on the ergonomics of colonoscopy. Recent trials have found the right lateral decubitus position is associated with quicker insertion, higher adenoma detection rates, and greater patient comfort compared to the left lateral decubitus position. However, this patient position is perceived as more strenuous by endoscopists.

METHODS

Nineteen endoscopists were observed performing colonoscopies during a series of four-hour endoscopy clinics. Durations of each patient position (right lateral decubitus, left lateral decubitus, prone, and supine) were recorded for all observed procedures (n = 64). Endoscopist injury risk was estimated by a trained researcher for the first and last colonoscopies of the shifts (n = 34) using Rapid Upper Limb Assessment (RULA), an observational ergonomic tool that estimates risk of musculoskeletal injury by scoring postures of the upper body and factors such as muscle use, force, and load. The total RULA scores were compared with a Wilcoxon Signed-Rank test for patient position (right and left lateral decubitus) and time (first and last procedures) with significance taken at p < 0.05. Endoscopist preferences were also surveyed.

RESULTS

The right lateral decubitus position was associated with significantly higher RULA scores than the left lateral decubitus position (median 5 vs. 3, p < 0.001). RULA scores were not significantly different between the first and last procedures of the shifts (median 5 vs. 5, p = 0.816). 89% of endoscopists preferred the left lateral decubitus position, primarily due to superior ergonomics and comfort.

CONCLUSION

RULA scores indicate an increased risk of musculoskeletal injury in both patient positions, with greater risk in the right lateral decubitus position.

"It Was Just Really Hard to Be Pregnant in a Smaller Town …": Pregnant and Parenting Teenagers' Perspectives of Social Support in Their Rural Communities

Teenage pregnancy has a history of being a "social problem" in the United States, with there being higher rates in rural communities. Social support, a contributor to improving mental health outcomes, can significantly impact a teenager's pregnancy and parenting experience. Using House's (1981) social support framework, this study explores the teenagers' perceptions of how their rural community reacted and responded to them as pregnant and parenting teenagers. The results were formulated through the thematic analysis of semi-structured interviews (n = 26) with current and former pregnant and/or parenting teenagers. The participants reported experiencing both positive and negative social support. There were more reports of emotional support and instrumental support among the forms of positive support than there were in the other categories. Informational support was lacking. The appraisal support from community members was negative. There is a need for rural communities to develop effective social support strategies to provide positive support for pregnant and parenting teenagers.

Perceived COVID-19 vaccine attributes associated with early adoption among adults in rural Indiana

2019 Novel coronavirus (COVID-19) vaccination rates in the United States have plateaued in specific populations, including rural areas. To improve COVID-19 vaccination rates and to encourage early vaccine uptake in future pandemics, this study aimed to examine vaccine attributes associated with early adoption. Data are from an anonymous online survey of adults using targeted Facebook pages of rural southern Indiana towns in January and February 2021 (n = 286). The diffusion of innovation theory states that the rate of adoption of a product in a specific population is explained by five perceived attributes: relative advantage, compatibility, observability, complexity and trialability. Binary logistic regression analyses were used to examine the association of Diffusion of Innovation theory attributes of the COVID-19 vaccine on early adoption. Results indicated that trialability [odds ratio (OR) = 3.307; 95% confidence interval (CI) = 1.964-5.571; P < 0.001], relative advantage (OR = 2.890; 95% CI = 1.789-4.667; P < 0.001) and compatibility (OR = 2.606; 95% CI = 1.476-4.601; P < 0.001) showed significant independent associations with early adoption. Furthermore, age and political ideology were significant moderators of complexity and relative advantage, respectfully. Health education strategies for early vaccine uptake should focus on building trust in vaccine safety, increasing short-term benefits of vaccination and promoting relatability to personal values.

Optimizing cecal views during colonoscopy using patient position change

BACKGROUND

Patient positioning has been found to be a simple technique to improve luminal distention and visualization during colonoscopy. This study examined which position provided the cleanest image of the cecum using the Boston Bowel Prep Scale (BBPS) and the best view of the cecum overall as ranked by blinded assessors.

METHODS

A sample of 90 sets of cecal images were obtained from patients undergoing a non-urgent colonoscopy. Each set included cecal images of patients while lying in three positions-right lateral decubitus, left lateral decubitus, and supine. Two authors reviewed these sets of images and excluded those that were unclear. A third author, blinded to the position, selected the final 33 sets of images. Two experienced endoscopists completed a blinded survey of each image set. They used the BBPS to assess and score each image as the primary outcome measure. The endoscopists also ranked each image set in terms of the best overall view of the cecum. Data were collected using Qualtrics software. Nonparametric tests were used to analyze the data using SPSS software (v.25). A p-value of ≤ 0.05 was considered significant.

RESULTS

The BBPS showed a significant difference between patient positions when tested by Kruskal-Wallis. Subsequent Mann Whitney U tests indicated that the right lateral decubitus position was ranked higher than left lateral decubitus or supine positions. There was no significant difference in the left and supine positions. Cohen's Kappa suggested moderate agreement between raters. The raters also favored the right lateral position over the other positions when assessing overall image preference displaying the cecum.

CONCLUSION

These results indicate that positioning patients in the right lateral decubitus position provides the best view of the cecum during colonoscopy.

Cardiovascular Outcomes in Nova Scotia during the Early Phase of the COVID-19 Pandemic

Background

This study sought to determine the impact of the pandemic response to healthcare delivery on outcomes in patients with cardiovascular disease.

Methods

This is a population-based cohort study performed in the province of Nova Scotia (population 979,499), between Pre-COVID (March 1, 2017 - March 16, 2020) and in-COVID (March 17, 2020 - December 31, 2020) periods. Adult patients (≥18 years) with new onset or existing cardiovascular disease were included for comparison between periods. The main outcome measures included: cardiovascular emergency department visits or hospitalizations, mortality, and out-of-hospital cardiac arrest.

Results

In the first month of the in-COVID period, emergency department visits (n=51,750) for cardiac symptoms decreased by 20.8% (95% CI 14.0% - 27.0%, p<0.001). Cardiovascular hospitalizations (n=20 609) declined by 48.1% (95% CI 40.4% to 54.9%, p<0.001). In-hospital mortality rate increased in patients with cardiovascular admissions in secondary care institutions by 55.1% (95%CI 10.1%-118%, p=0.013). A decline of 20.4% - 44.0% occurred in cardiovascular surgical/interventional procedures. Out-of-hospital cardiac arrests (n=5528) increased from a monthly mean of 115±15 to 136±14, beginning in May, 2020. Mortality for ambulatory patients awaiting cardiac intervention (n=14,083) increased from 0.16% (n=12501) to 2.49% (n=361) in the in-COVID period (p<0.0001).

Conclusion

This study demonstrates increased cardiovascular morbidity and mortality during restrictions maintained during COVID-19, in an area with low burden of COVID-19 disease. As the healthcare system recovers or enters subsequent waves of COVID-19, these findings should inform communication to the public regarding cardiovascular symptoms and policy for delivery of cardiovascular care.

Realizing topologically ordered states on a quantum processor

[Figure: see text].

Evaluation of the Content Validity and Cross-Cultural Validity of the Study Participant Feedback Questionnaire (SPFQ)

Objectives

The Study Participant Feedback Questionnaire (SPFQ) is a patient-completed tool designed to assess patient experiences and satisfaction with aspects associated with being involved in a clinical trial. Originally developed in oncology and among English-speaking participants, the aim of the current study was to evaluate the content and cross-cultural validity of the SPFQ in other indications and non-English-speaking countries.

Methods

Semi-structured qualitative telephone interviews were conducted with 80 participants across eight non-English-speaking countries (in Europe, South America and Asia) who had received an investigational medicinal product as part of a clinical trial in the past three years. Interviews comprised concept elicitation to identify concepts of importance to participants’ trial experiences, and cognitive debriefing to assess understanding and perceived importance of SPFQ instructions, items and response options.

Results

Concept elicitation findings supported the content validity of the SPFQ. During cognitive debriefing, SPFQ instructions and the majority of items were well understood by participants. Participants generally considered the SPFQ items important to their clinical trial experience, albeit a handful of items assessed concepts that had not been experienced by trial participants or were redundant with other SPFQ items. The instructions, response options and recall period of the SPFQ were generally well understood. No country-level differences in understanding or importance were apparent.

Conclusion

Study findings provide evidence for the content and cross-cultural validity of the SPFQ and support implementation of the SPFQ as a means of obtaining participant feedback across global development programmes in a variety of indications.

Electronic supplementary material

The online version of this article (10.1007/s43441-020-00179-3) contains supplementary material, which is available to authorized users.

Amplifying the Voice of the Patient in Clinical Research: Development of Toolkits for Use in Designing and Conducting Patient-Centered Clinical Studies

Incorporating patient perspectives into clinical studies is recognized as important to the development of high-quality, safe, and effective fit-for-patient medicines. However, no widely accepted methodology to help design more patient-centered studies has been established systematically. TransCelerate Biopharma Inc., a non-profit organization promoting collaboration across biopharmaceutical companies, organized a Patient Experience (PE) Initiative to create tools to intentionally include the patient perspective into the design and implementation of clinical studies. The resulting tools include the Patient Protocol Engagement Toolkit (P-PET), to engage patients early in protocol development, and the Study Participant Feedback Questionnaire (SPFQ), to assess patient experiences during clinical studies. To develop these toolkits, TransCelerate conducted a literature review and identified aspects of clinical studies that patients find either valuable or burdensome, or that affect participation, adherence, and engagement in a clinical study. The concepts identified were refined through elicitation of feedback from patient advisors, clinical study site advisors, and subject matter experts from member companies (MCs) of TransCelerate. This feedback was considered in identifying gaps, defining scientific methodology to understand how to evaluate patients' needs, and developing and refining the P-PET and the SPFQ. As part of the development process, descriptions/drafts of the tools were shared with patients, clinical site advisory groups, MCs, and the US Food and Drug Administration, and then revised. MCs simulated use of the tools, and feedback was incorporated into the final versions of the P-PET and SPFQ prior to public release. The P-PET and SPFQ are available free on the TransCelerate website.

A randomized controlled trial comparing right and left lateral decubitus starting position on outcomes in colonoscopy

BACKGROUND

Patient positioning in colonoscopy has been proposed as a simple and inexpensive technique to increase luminal distention and improve navigation through the large bowel. We sought to determine if the right lateral (RL) starting position compared to the standard left lateral (LL) starting position could improve outcomes in colonoscopy.

METHODS

We conducted a randomized controlled trial of 185 patients who were undergoing an elective colonoscopy. Patients were randomized to either a right lateral decubitus starting position or a left lateral decubitus starting position and the primary outcome measure was cecal intubation time. Secondary outcome measures included cecal intubation rate, patient discomfort, and sedation dosage. All colonoscopists who had successfully completed a colonoscopy skills improvement course were included in the trial. A sample size was calculated prior to the start of the study and outcomes were analyzed using univariate and multiple regression analyses.

RESULTS

A total of 94 patients were randomized to RL starting position and 91 patients were randomized to LL starting position. No difference was found in time to cecal intubation comparing the RL starting position (542.6 s, SD 360.7 s) to LL starting position (497.85 s, SD 288.3 s) (p = 0.354). Variables associated with prolonged cecal intubation time included female gender, General Surgery specialty, less than 5 years of endoscopist experience, a high patient discomfort score, amount of water used, and number of position changes required to reach the cecum. There was no difference in any of the secondary outcome measures aside from the amount of midazolam used, with more midazolam used for patients starting in the right lateral decubitus position.

CONCLUSION

This study failed to show an association between cecal intubation time and patient position comparing right and left lateral starting position.

Conception, fetal growth, and calving seasonality of harbor porpoise (Phocoena phocoena) in the Salish Sea waters of Washington, USA, and southern British Columbia, Canada

We evaluated harbor porpoise (Phocoena phocoena (Linnaeus, 1758)) strandings in the Salish Sea to determine calving seasonality (1980–2015). A total of 443 strandings were analyzed, of which 134 were calves and 53 were neonates. Stranded calves were reported every month, but peaked in July, August, and September. Based on fetal size and an estimated fetal growth rate of 80 mm/month, mean (±SD) conception date (and range) was back-calculated to 11 October ± 30 days (16 August – 31 December) and was later than in most other studies. Using mean (±SD) length at birth (80 ± 5.8 cm), gestation was estimated to be approximately 10.8 months. Estimated birthing period was 16 July – 27 November, with a mean (±SD) birth date of 10 September (±30.7 days) and a birth length of 80.0 cm. Estimated pregnancy rate (0.28–0.29) is lower than reported in other areas and is likely an underestimate due to missed early embryos, poor postmortem condition of a large proportion of the stranded adult females, and potential biases related to the animals that strand and are available. This study of harbor porpoise reproduction and calving in the Salish Sea is the first assessment of calving seasonality for this species in the northeast Pacific Ocean.

Economic Evaluation of the Juvenile Drug Court/Reclaiming Futures (JDC/RF) Model

Juvenile drug court (JDC) programs are an increasingly popular option for rehabilitating juvenile offenders with substance problems, but research has found inconsistent evidence regarding their effectiveness and economic impact. While assessing client outcomes such as reduced substance use and delinquency is necessary to gauge program effectiveness, a more comprehensive understanding of program success and sustainability can be attained by examining program costs and economic benefits. As part of the National Cross-Site Evaluation of JDC and Reclaiming Futures (RF), an economic analysis of five JDC/RF programs was conducted from a multisystem and multiagency perspective. The study highlights the direct and indirect costs of JDC/RF and the savings generated from reduced health problems, illegal activity, and missed school days. Results include the average (per participant) cost of JDC/RF, the total economic benefits per JDC/RF participant, and the net savings of JDC/RF relative to standard JDC.

Should I apply to medical school? High school students and barriers to application

INTRODUCTION

A major goal of the Faculty of Medicine at the Memorial University of Newfoundland is to produce physicians who will return to rural areas that are currently underserviced. Research shows that the strongest indicator of practice in a rural area is a rural background, and thus it is important that rural students apply to medical school. We investigated what high school students believe to be preventing them from pursuing medical education.

METHODS

Between September 2013 and June 2014, we administered a paper survey to high school students in Newfoundland and Labrador, New Brunswick and Prince Edward Island.

RESULTS

A total of 665 participants completed the survey. We found that fewer rural students (75.6%) than urban students (98.6%) believed that they could gain admission to medical school (p < 0.01) and that medicine was promoted as a career choice in fewer rural schools (55.7%) than urban schools (69.7%). Also, 55.4% of urban students, but only 44.4% of rural students, believed that rural students were disadvantaged when applying to medical school.

CONCLUSION

In our study, rural students believed they were less likely to be accepted into medical school than urban students, and fewer rural students felt that medicine was promoted as a potential career choice. Our results may be explained by a lack of role models or perhaps by financial barriers, although further research is needed.

95 ROLE OF POLYAMINES IN BOVINE PRE-IMPLANTATION DEVELOPMENT

Polyamines are involved in trophectoderm attachment and outgrowth, but little is known about their role in earlier stages of development. The objective of this study was to evaluate the effects of an inhibitor of polyamine synthesis (difluoromethylornithine, DFMO) on development (blastocyst formation and hatching) and cell allocation to the trophectoderm (TE, CDX2-positive) and inner cell mass (ICM, SOX2-positive) in the bovine embryo. Cumulus-oocyte complexes (COCs) were recovered from slaughterhouse ovaries and matured for 24 h in a defined maturation medium (5.0 mM glucose, 0.6 mM cysteine, 0.5 mM cysteamine, 0.1 IU mL–1 FSH, 50 ng mL–1 EGF, and 2.5 mg mL–1 recombinant human albumin). Frozen-thawed spermatozoa were processed by gradient centrifugation and co-incubated (2 × 106 mL–1) with COC [10 COC/50 µL; 7.5 µg mL–1 heparin, 2 mM caffeine, and 8.0 mg mL–1 fatty-acid free (FAF) BSA] for 20 to 22 h. After removing cumulus cells, zygotes were cultured (10 embryos/20 µL) in a medium for cleavage stage bovine embryos (0.5 mM glucose, 0.3 mM pyruvate, 6.0 mM lactate, 0.25 mM citrate, 1.0 mM alanyl-glutamine, 0.25 × MEM nonessential and essential amino acids, 5 µM EDTA, and 8.0 mg mL–1 FAF BSA). After 72 h, embryos with >4 cells were randomly allocated (5 embryos/20 µL) to a culture medium for compaction and blastocyst formation (3.0 mM fructose, 0.1 mM pyruvate, 6.0 mM lactate, 0.5 mM citrate, 1.0 mM alanyl-glutamine, 1× MEM nonessential amino acids, 0.5× MEM essential amino acids, 0.075 mM myo-inositol, and 8.0 mg mL–1 FAF BSA) containing 0 (control), 5, or 10 mM DFMO. Embryonic development was evaluated at 192 h post-insemination (96 h in the second medium containing DFMO treatments), and hatching or hatched blastocysts were fixed for analysis of cell allocation. All data were analysed by ANOVA and P < 0.05 was considered significant. Blastocyst formation and hatching (% of embryos cultured in the presence of treatments) were both inhibited (P < 0.05) when embryos (n = 157/treatment) were cultured with 5 (39.5 ± 3.9%, 14.6 ± 2.8%) or 10 (39.5 ± 3.9%, 14.0 ± 2.8%) mM DFMO compared with embryos cultured without DFMO (53.5 ± 4.0%, 26.1 ± 3.5%). The number of TE cells was also reduced (P < 0.05) in the presence of 5 (121.4 ± 7.2) and 10 (123.6 ± 6.7) mM DFMO compared with embryos cultured without DFMO (152.4 ± 9.7), but the number of ICM cells (45.2 to 54.0) and the total number of cells (TE+ICM, 168.8 to 201.1) were not affected (P > 0.05). In a second experiment (n = 163 to 165/treatment), the negative effects of DFMO on hatching (17.0 ± 2.9%; P < 0.05, v. control, 30.7 ± 3.6%) could be partially reversed when embryos were cultured with both 10 mM DFMO and an exogenous polyamine (100 µM putrescine, 23.0 ± 3.3% DFMO+Put; P > 0.05 v. control). The number of TE cells for embryos cultured with DFMO+Put (153.9 ± 8.7) was intermediate between embryos cultured with (138.0 ± 6.9) or without DFMO (control, 161.6 ± 8.7), but these differences were not significant (P > 0.05). These results provide the first evidence of a role for polyamines during blastocyst formation and hatching of bovine embryos, with specific effects on trophectoderm proliferation and hatching.

Considerations for Requiring Subjects to Provide a Response to Electronic Patient-Reported Outcome Instruments

The increase in the use of electronic patient-reported outcome (ePRO) instruments has presented study teams with considerations not previously encountered with paper. Specifically, in an effort to minimize missing data, there is now the opportunity of requiring subjects to provide a response to an item before allowing the subject to proceed to the next item. While the ability to require subjects to respond to ePRO items would seem to guarantee a complete data set, it raises questions about the conditions under which it is appropriate to require subjects to respond to the items in an instrument. This article provides guidance on the circumstances under which allowing a subject to opt out of responding to ePRO items may be appropriate. Three main scenarios are discussed: (1) requiring subjects to complete all items in all the instruments in the study, (2) allowing subjects to opt out of at least some selective items that do not support key primary or secondary endpoints, and (3) allowing subjects to opt out of responding to any or all items in the study. For either of the 2 scenarios allowing the subject to opt out of responding to an item, the use of programmed edit checks is highly recommended to confirm that the subject intended to "skip" or "opt out of" the item. This ensures that, at the end of the study, the database contains an explicit data point indicating when a subject has actively decided to skip an item. While this article is focused on patient-reported outcomes, the issues raised could also apply to other clinical outcome assessments, such as clinician- and observer-reported outcomes.

Integrating adolescent substance abuse treatment with HIV services: evidence-based models and baseline descriptions

Adolescents with substance use disorders are at high risk for contracting Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and other sexually transmitted infections (STIs). Adolescence is the period of sexual maturation that compounds the issues associated with infection transmission for this risk-taking group. Integrated treatment models for implementing HIV education, counseling, and testing is a promising approach. This study describes four substance abuse treatment programs of varying levels of care that integrated HIV services for adolescents. Additionally, the evidence-based substance abuse treatment and HIV models are discussed and the baseline characteristics presented. The authors provide a discussion and offer recommendations for service implementation and additional research.

Psychological Correlates of Mental Stress-induced Ischemia in the Laboratory: The Psychophysiological Investigation of Myocardial Ischemia (PIMI) Study

Participants consisted of 184 patients (160 males, 24 females) with positive angiograms or prior myocardial infarctions who displayed at least 1 mm of ST segment depression on a standardized treadmill test. Mean scores on the Reward Dependence subscale of the Tridimensional Personality Questionnaire were higher in patients displaying ischemia during mental stress. Patients who reported higher levels of irritability/anger in response to the Speech stressor were also more likely to display ischemia. However, this result was primarily a result of the females in the sample whose ratings of interest and irritability were associated with ischemia during the Speech task. Psychometric measures previously found in prospective studies to predict acute cardiac events were unrelated to mental stress-induced ischemia in the laboratory.

Do managed clinical networks improve quality of diabetes care? Evidence from a retrospective mixed methods evaluation

PROBLEM

System-wide improvement of chronic disease care is challenging because it requires collaboration and communication across organisational and professional boundaries. Managed clinical networks are one potential solution, but there is little evidence of their effectiveness.

DESIGN AND SETTING

Retrospective, mixed-methods evaluation of the form and impact of quality improvement in the Tayside Diabetes Managed Clinical Network (MCN) 1998-2005.

STRATEGIES FOR CHANGE

Progressive implementation of multiple quality improvement strategies predominately directed at individuals and clinical teams (guideline development and dissemination, education, clinical audit, encouragement of multidisciplinary team working, task redesign). Information technology played an important role in supporting QI activity, but participants identified it as facilitative rather than delivering QI by itself. More important was achieving widespread clinical engagement through persuasion and appeal to shared professional values by clinical leaders.

EFFECTS OF CHANGE

Simple process measures such as glycated haemoglobin measurement rapidly improved. More complex process measures such as eye screening improved more slowly, and were more dependent on redesign of the care pathway. Improvement was greater for type 2 than type 1 diabetes. Significant shifts of care for type 2 diabetes into primary care were achieved, but were harder to achieve without additional resources.

LESSONS LEARNT

Delivering better care to whole populations across organisational and professional boundaries required sustained work over long periods, and at all levels of the system of care. Past network focus on clinical collaboration has been effective at improving clinical process and outcome, and the network is now prioritising work with managers and patients to support future redesign.

Clinical effectiveness and cost-effectiveness of continuous subcutaneous insulin infusion for diabetes: systematic review and economic evaluation

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) was reviewing its previous guidance on continuous subcutaneous insulin infusion (CSII). The review provided an assessment of evidence which had been published since the previous NICE appraisal (TA 151) in 2007.

OBJECTIVES

To examine the clinical effectiveness and cost-effectiveness of using CSII to treat diabetes. To update the previous assessment report by reviewing evidence that has emerged since the last appraisal, and to take account of developments in alternative therapies, in particular the long-acting analogue insulins, which cause fewer problems with hypoglycaemia.

DATA SOURCES

A systematic review of the literature and an economic evaluation were carried out. The bibliographic databases used were MEDLINE and EMBASE, 2002 to June 2007. The Cochrane Library (all sections), the Science Citation Index (for meeting abstracts only) and the website of the 2007 American Diabetes Association were also searched.

REVIEW METHODS

The primary focus for type 1 diabetes mellitus (T1DM) was the comparison of CSII with multiple daily injection (MDI), based on the newer insulin analogues, but trials of neutral protamine Hagedorn (NPH)-based MDI that had been published since the last assessment were identified and described in brief. For type 2 diabetes mellitus (T2DM), all trials of MDI versus CSII were included, whether the long-acting insulin was analogue or not, because there was no evidence that analogue-based MDI was better than NPH-based MDI. Trials that were shorter than 12 weeks were excluded. Information on the patients' perspectives was obtained from four sources: the submission from the pump users group--Insulin Pump Therapy (INPUT); interviews with parents of young children who were members of INPUT; some recent studies; and from a summary of findings from the previous assessment report. Economic modelling used the Center for Outcomes Research (CORE) model, through an arrangement with the NICE and the pump manufacturers, whose submission also used the CORE model.

RESULTS

The 74 studies used for analysis included eight randomised controlled trials (RCTs) of CSII versus analogue-based MDI in either T1DM or T2DM, eight new (since the last NICE appraisal) RCTs of CSII versus NPH-based MDI in T1DM, 48 observational studies of CSII, six studies of CSII in pregnancy, and four systematic reviews. The following benefits of CSII were highlighted: better control of blood glucose levels, as reflected by glycated haemoglobin (HbA1c) levels, with the size of improvement depending on the level before starting CSII; reduction in swings in blood glucose levels, and in problems due to the dawn phenomenon; fewer problems with hypoglycaemic episodes; reduction in insulin dose per day, thereby partly off-setting the cost of CSII; improved quality of life, including a reduction in the chronic fear of severe hypoglycaemia; more flexibility of lifestyle--no need to eat at fixed intervals, more freedom of lifestyle and easier participation in social and physical activity; and benefits for the patients' family. The submission from INPUT emphasised the quality of life gains from CSII, as well as improved control and fewer hypoglycaemic episodes. Also, there was a marked discrepancy between the improvement in social quality of life reported by successful pump users, and the lack of convincing health-related quality of life gains reported in the trials. With regard to economic evaluation, the main cost of CSII is for consumables, such as tubing and cannulas, and is about 1800-2000 pounds per year. The cost of the pump, assuming 4-year life, adds another 430-720 pounds per annum. The extra cost compared with analogue-based MDI averages 1700 pounds. Most studies, assuming a reduction in HbA1c level of 1.2%, found CSII to be cost-effective.

LIMITATIONS

The most important weakness of the evidence was the very small number of randomised trials of CSII against the most modern forms of MDI, using analogue insulins.

CONCLUSIONS

Based on the totality of evidence, using observational studies to supplement the limited data from randomised trials against best MDI, CSII provides some advantages over MDI in T1DM for both children and adults. However, there was no evidence that CSII is better than analogue-based MDI in T2DM or in pregnancy. Further trials with larger numbers and longer durations comparing CSII and optimised MDI in adults, adolescents and children are needed. In addition, there should be a trial of CSII versus MDI with similar provision of structured education in both arms. A trial is also needed for pregnant women with pre-existing diabetes, to investigate using CSII to the best effect.

Health inequalities in England, Scotland and Wales: stakeholders' accounts and policy compared

OBJECTIVES

The election of a Labour government in 1997 brought the issue of health inequalities firmly back on to the policy agenda across the UK. Since then, in the wake of devolution, the need to tackle health inequalities has been highlighted as a policy priority in all three mainland UK countries, albeit with varying degrees of emphasis. This paper reports on a major cross-national study, funded by the Economic and Social Research Council, investigating how National Health Service bodies, local councils and partnerships make sense of their work on health inequalities, and examining the difference made by the contrasting approaches that have been taken to performance assessment in England, Wales and Scotland.

STUDY DESIGN

Case studies, semi-structured interviews and analysis of key policy statements.

METHODS

In order to explore how health inequalities have been approached by the three governments (noting that there was a change in governments in Wales and Scotland during this time), key policy statements published between May 1997 and May 2007 were analysed. Concurrently, data from stakeholder interviews carried out in 2006 in case study areas in each country were analysed to determine the extent of alignment between policy and practice at local level.

RESULTS

This paper suggests that claims about the extent of health policy divergence in post-devolution Britain may have been exaggerated. It finds that, whilst the three countries have taken differing approaches to performance assessment and the setting of targets, policy approaches to health inequalities up until 2007 appear to have been remarkably similar. Furthermore, the first round of interview data suggest that variations in local understandings of, and responses to, health inequalities cannot always be clearly distinguished along national lines.

CONCLUSIONS

Based on the policy analysis, devolution in the UK does not appear to have resulted in substantively different national policy approaches to health inequalities. Indeed, the overall analysis suggests that (prior to the 2007 elections in Scotland and Wales) the differences between local areas within countries may be of as much interest as those between countries.

Characterizing the burden of premature ejaculation from a patient and partner perspective: a multi-country qualitative analysis

Background

Premature ejaculation (PE) is a common sexual dysfunction among men which affects men and their partners. Little qualitative data are available to characterize the impact of PE on men and their partners about ejaculatory control, sexual satisfaction, emotional distress and relationships. The objective of this study was to assess the impact of PE from the perspective of men with PE and the female partners of men with PE on their sexual experience, distress and relationships.

Methods

Qualitative data were collected through 14 focus groups in the US and through one-on-one interviews in the US, UK, Italy, France, Germany, and Poland. Study participants included heterosexual men with PE and female partners of males with PE. All participants were asked about how PE affects their daily life, including emotional impacts. One-on-one interviews also included obtaining feedback on the male and female versions of 4-single item measures of PE focusing on ejaculatory control, satisfaction with intercourse, interpersonal distress, and relationship difficulty.

Results

Participants included 172 males with PE and 67 female partners of men with PE. Lack of control over ejaculation and dissatisfaction with intercourse emerged as central themes of PE. Lack of ejaculatory control resulted in greater dissatisfaction and greater emotional distress, including feelings of inadequacy, disappointment, and anxiety. Continued PE ultimately leads to greater problems with partners and often disrupts partner relationships. Participants indicated that PE was keeping them from attaining complete intimacy in their relationships even when their partners were generally satisfied with sexual intercourse. Impacts of PE on sexual satisfaction, emotional distress and partner relationships were consistent across countries. Feedback on the single-item PE measures confirmed relevance of the item content and further confirmed major themes identified from the qualitative data.

Conclusion

This qualitative study provides valuable insights on the substantial psychosocial burden of PE in the US and the Europe. Lack of control over ejaculation resulted in dissatisfaction with intercourse and increased emotional distress, and wide-ranging impact for both men with PE and their partners of men with PE. Data collected in this study may help inform the content of new patient reported measures for use in PE research.

A pilot study of nonmyeloablative allogeneic hematopoietic stem cell transplant for advanced systemic mastocytosis

Systemic mastocytosis (SM) is a disease characterized by tissue infiltration of neoplastic mast cells originating from hematopoietic stem cells. Patients with advanced SM have a poor prognosis, and there is no mast cell ablative therapy available for most patients who carry an activating point mutation in the c-kit gene. We report results of a prospective study evaluating the safety, engraftment, and possibility of inducing a graft-versus-mast cell (GvMC) effect after allogeneic nonmyeloablative hematopoietic cell transplantation (HCT) from an HLA-identical sibling. Three patients with advanced SM were transplanted. All achieved complete donor T cell chimerism followed by clinical evidence for GvMC effect. However, all patients experienced disease progression with the longest response duration of 39 months. The GvMC effect can be observed after nonmyeloablative HCT with limited efficacy. Effective cytoreductive therapy prior to HCT may be required for long-term disease control and cure.

The graft-versus-leukemia effect of nonmyeloablative stem cell allografts may not be sufficient to cure chronic myelogenous leukemia

We treated 12 patients with chronic myelogenous leukemia (CML) with a low-intensity preparative regimen followed by allogeneic stem cell transplantation in an attempt to confer a curative graft-versus-leukemia (GVL) effect with minimum morbidity. Seven patients in first chronic phase (CP1) and five in second chronic phase (CP2) (age 15-68 years) received a nonmyeloablative conditioning regimen of fludarabine and cyclophosphamide, followed by a G-CSF-mobilized peripheral blood stem cell (PBSC) transplant from an HLA-identical sibling. Cyclosporine (CsA) was used for graft-versus-host disease (GVHD) prophylaxis. Median follow-up was 384 days. Neutrophil recovery occurred at a median of 12 days. There was no transplant-related mortality. Of the seven CP1 patients transplanted, seven achieved a stable molecular remission; two with no post-transplant intervention, three after donor lymphocytes, imatinib and interferon, and two after a myeloablative stem cell transplant. Four of five CP2 patients died in blast crisis and one survived in molecular remission. Of the 12 patients with durable engraftment, six had Grades II-IV acute GVHD; six had limited chronic GVHD. These results suggest that cytoreduction is required to optimize the curative effect of allogeneic stem cell transplantation for CML.

The outpatient bleeding risk index: validation of a tool for predicting bleeding rates in patients treated for deep venous thrombosis and pulmonary embolism

BACKGROUND

Long-term anticoagulation prevents recurrent thrombosis in patients with idiopathic deep venous thrombosis or pulmonary embolism, but with a risk of clinically important so-called major bleeding. Physician- and patient-based decisions on the optimal duration of therapy are sensitive to the bleeding risk. The Outpatient Bleeding Risk Index potentially provides a means of calculating the potential risk of bleeding using easily elicited clinical findings, but, to our knowledge, the authors of the index have provided the only published validation of it. We sought to determine the accuracy of the index in our population of patients.

METHODS

We prospectively applied the Outpatient Bleeding Risk Index to consecutive patients in our clinic who had been objectively diagnosed as having pulmonary embolism or deep venous thrombosis and who were about to undergo standard therapy. Standard therapy consisted of a minimum of 5 days of low-molecular-weight heparin therapy overlapped with warfarin sodium therapy, and continuation of warfarin therapy for at least 3 months, with a target international normalized ratio of 2.5. Patients were placed in 3 risk groups (low, moderate, or high), as defined by the index. The survival curves of the groups, using major hemorrhages as the events, were then compared by the log-rank test.

RESULTS

Bleeding rates were lower than expected, but the index did discriminate between low- and moderate-risk groups (P =.03, log-rank test). The rate of major hemorrhage per 100 person-years was 0% (95% confidence interval, 0%-2.8%) in the low-risk group and 4.3% (95% confidence interval, 1.1%-11.1%) in the moderate-risk group. The rate in the high-risk group could not be defined because only 2 patients were at high risk.

CONCLUSION

The Outpatient Bleeding Risk Index discriminates between low- and moderate-risk patients, and could be used to guide decisions on the optimal duration of anticoagulant therapy.

Coprescription of triptans with potentially interacting medications: a cohort study involving 240,268 patients

BACKGROUND

Little information exists about the actual prescription of triptans within large, geographically diverse populations, in terms of demographic characteristics and co-prescriptions with other medications with potential interactions.

OBJECTIVES

To investigate the demographic characteristics associated with triptan use, and examine the rate of co-prescription of triptans with specified pharmacologic agents with the potential for drug interactions.

METHODS

This study examined the rate of co-prescription of triptans available in the US up to May 2001 (sumatriptan, naratriptan, rizatriptan, and zolmitriptan) with specified agents with potential for drug interactions. A cohort of 240,268 patients receiving pharmacy benefits from Merck-Medco (N = 65 + M) was followed over a one-year period. This analysis included patients who received at least two triptan prescriptions during the study (6/00-5/01). Ninety-one percent of the cohort remained on the same triptan during the study period. 'Co-prescription' was defined as any fill for a medication that was contraindicated or could potentially adversely interact with a triptan, obtained between and during the first and last triptan fills throughout the study period.

RESULTS

Mean patient age was 43 (SD +/- 11.6) and 82% were female. Twenty-one percent were co-prescribed selective serotonin reuptake inhibitors, reflecting the considerable co-morbidity of migraine and depression. Patients taking triptans were almost never co-prescribed monoamine oxidase inhibitors (0.02%), and co-prescription of ergots was also low (1.45%). Less than one percent (0.45%) received cimetidine while taking zolmitriptan, while 2.7% of patients taking rizatriptan 10 mg also took propranolol. While agents unavailable in the U.S. were not evaluated in this cohort, six percent of patients were treated with potent CYP 3A4 inhibitors, which would not be expected to cause any problems with the triptans in the survey. However, such agents are specifically contraindicated for use with one triptan (eletriptan), recently launched in the EU, suggesting that continued vigilance will be necessary to avoid coprescription of medicines with the potential for producing adverse side effects.

CONCLUSIONS

Triptan use mirrors migraine demographics. The frequency of co-prescription of triptans with SSRIs is about 20%. Continued vigilance will be necessary to avoid co-prescription of medicines with the potential for producing adverse drug events.