Operational changes to the lupus intervention fatigue trial as a result of COVID-19: An update to the study protocol

Background

The coronavirus disease 2019 (COVID-19) global pandemic drastically impacted the health system and the research community. As a result, research institutions and funding agencies recommended a moratorium on conducting in-person research and study enrollment until protocol changes to protect participant safety were approved and implemented. We detail the operational modifications made to the Lupus Intervention Fatigue Trial (LIFT) protocol and summarize how we met the varied challenges created by COVID-19.

Methods

We evaluated study protocols and determined that scheduling, acquiring consent, in-person assessments and intervention baseline visits, patient reported outcomes, and data processing procedures needed modification.

Results

Operational modifications were made to ensure study progress while adhering to COVID-19 restrictions. Major changes included electronic consent, remote baseline visits for those in the intervention, self-report outcome measures at home via emailed weblinks, and telemedicine physician assessment visits. The collection of safety labs presented the largest challenge since this required an in-person visit to a laboratory. The study team elected to delay this up to one month after the physician assessment. All follow-up visits were completed, and no participants withdrew from the study.

Conclusion

LIFT was severely impacted by COVID-19. We provide insight into how our study protocol was modified without compromising the integrity of the primary and secondary outcomes of the study. The modifications utilized by the LIFT study resulted in efficiencies that will be included in a revised protocol and may serve as a useful example for other behavioral interventions to adapt their research studies.

Brief intervention medication therapy management: Establishment of an opioid misuse intervention model delivered in a community pharmacy

PURPOSE

Medication expertise and close patient contact position community pharmacists to make significant contributions to combatting the opioid epidemic. This position facilitated the development and initial implementation of the Brief Intervention Medication Therapy Management (BIMTM) model to detect and address patient opioid misuse. BIMTM is an intervention consisting of 9 sessions. One medication management session is delivered by a pharmacist in a community pharmacy setting, and the remaining sessions are delivered telephonically by a patient navigator to follow up with goals established with the pharmacist and address concomitant health concerns that increase risk for misuse.

METHODS

We employed the Consolidated Framework for Implementation Research (CFIR) to summarize and present key findings from 4 distinct studies. CFIR domains addressed were (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) process, and (5) characteristics of individuals. The study results show sequential development of evidence for BIMTM.

RESULTS

A multistate cross-sectional pharmacist survey (n = 739) demonstrated limited pharmacist training and/or resources to address misuse, suggesting the need for external intervention development. Our multistakeholder intervention planning project showed limitations of current evidence-based models of care and of intervention implementation, which resulted in construction of the BIMTM. A multisite cross-sectional screening survey of patients (n = 333) established an electronic misuse screening protocol within 4 community pharmacies and identified opioid misuse in 15% of screened patients; among those patients, 98% had concomitant health conditions that contribute to the risk of opioid misuse. Presentation of study results to pharmacy leaders produced commitment for intervention implementation and a partnership to develop a grant proposal supporting this action. Our small-scale randomized trial evinced success in recruitment and retention and BIMTM patient benefit. The small-scale randomized trial likewise showed high levels of satisfaction with BIMTM.

CONCLUSION

The establishment of BIMTM supports community pharmacist identification and intervention with patients engaged in misuse. Continued use of this research-based strategy may further empower pharmacists to address the opioid epidemic.

Abuse-Deterrent Opioid Formulations and the Opioid Crisis: A Pharmacist's Perspective

BACKGROUND

For over 20 years, the United States has suffered the detrimental effects of an opioid epidemic. Extended-release opioid products are particularly prone to abuse due to the high amount of opioid present. By bypassing the controlled-release mechanisms and nonoral administration, individuals experience intense and dangerous "highs." Abuse-deterrent opioid formulations have been recommended as a potential solution to the crisis, but widespread utilization has been stunted and their role in therapy remains unclear owing to limited real-world efficacy data and affordability issues. This review discusses abuse-deterrent opioid formulations, the mechanisms and data underlying available products, and a pharmacist's perspective of their role in the opioid crisis.

METHODS

The authors reviewed PubMed, MEDLINE, and Google Scholar electronic databases for premarketing and postmarketing studies on OxyContin, Xtampza ER, and Hysingla ER.

RESULTS

Studies showed lower rates of abuse (19% reduction), opioid use disorder (27%), overdose (34%), and fatalities (85%) with the reformulated OxyContin when compared with the original product and comparator opioids. However, these studies revealed the potential for bypassing abuse-deterrent mechanisms and diverting abuse to other drugs. Postmarketing studies are unavailable for Xtampza ER or Hysingla ER, although premarketing studies suggested that some controlled-release properties persist when the product is manipulated, indicating that abuse may be more difficult and less rewarding.

CONCLUSIONS

Abuse-deterrent opioid products may lead to reductions in abuse, overdose, and overdose fatalities. However, cost, loopholes in deterrence mechanism, and possible diversion to other substances hinder their role in the opioid crisis. Multiple approaches must be used to improve opioid safety, and further postmarketing and real-world analyses should be performed on available opioid formulations to assess their impact on abuse-related adverse events.

Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol

BACKGROUND

Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD.

METHODS

This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes.

DISCUSSION

This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.

Expanding the clinical and phenotypic heterogeneity associated with biallelic variants in ACO2

OBJECTIVE

We describe the clinical characteristics and genetic etiology of several new cases within the ACO2-related disease spectrum. Mitochondrial aconitase (ACO2) is a nuclear-encoded tricarboxylic acid cycle enzyme. Homozygous pathogenic missense variants in the ACO2 gene were initially associated with infantile degeneration of the cerebrum, cerebellum, and retina, resulting in profound intellectual and developmental disability and early death. Subsequent studies have identified a range of homozygous and compound heterozygous pathogenic missense, nonsense, frameshift, and splice-site ACO2 variants in patients with a spectrum of clinical manifestations and disease severities.

METHODS

We describe a cohort of five novel patients with biallelic pathogenic variants in ACO2. We review the clinical histories of these patients as well as the molecular and functional characterization of the associated ACO2 variants and compare with those described previously in the literature.

RESULTS

Two siblings with relatively mild symptoms presented with episodic ataxia, mild developmental delays, severe dysarthria, and behavioral abnormalities including hyperactivity and depressive symptoms with generalized anxiety. One patient presented with the classic form with cerebellar hypoplasia, ataxia, seizures, optic atrophy, and retinitis pigmentosa. Another unrelated patient presented with ataxia but developed severe progressive spastic quadriplegia. Another patient demonstrated a spinal muscular atrophy-like presentation with severe neonatal hypotonia, diminished reflexes, and poor respiratory drive, leading to ventilator dependence until death at the age of 9 months.

INTERPRETATION

In this study, we highlight the importance of recognizing milder forms of the disorder, which may escape detection due to atypical disease presentation.

The CHD4-related syndrome: a comprehensive investigation of the clinical spectrum, genotype-phenotype correlations, and molecular basis

PURPOSE

Sifrim-Hitz-Weiss syndrome (SIHIWES) is a recently described multisystemic neurodevelopmental disorder caused by de novo variants inCHD4. In this study, we investigated the clinical spectrum of the disorder, genotype-phenotype correlations, and the effect of different missense variants on CHD4 function.

METHODS

We collected clinical and molecular data from 32 individuals with mostly de novo variants in CHD4, identified through next-generation sequencing. We performed adenosine triphosphate (ATP) hydrolysis and nucleosome remodeling assays on variants from five different CHD4 domains.

RESULTS

The majority of participants had global developmental delay, mild to moderate intellectual disability, brain anomalies, congenital heart defects, and dysmorphic features. Macrocephaly was a frequent but not universal finding. Additional common abnormalities included hypogonadism in males, skeletal and limb anomalies, hearing impairment, and ophthalmic abnormalities. The majority of variants were nontruncating and affected the SNF2-like region of the protein. We did not identify genotype-phenotype correlations based on the type or location of variants. Alterations in ATP hydrolysis and chromatin remodeling activities were observed in variants from different domains.

CONCLUSION

The CHD4-related syndrome is a multisystemic neurodevelopmental disorder. Missense substitutions in different protein domains alter CHD4 function in a variant-specific manner, but result in a similar phenotype in humans.

CTCF variants in 39 individuals with a variable neurodevelopmental disorder broaden the mutational and clinical spectrum

Purpose

Pathogenic variants in the chromatin organizer CTCF were previously reported in seven individuals with a neurodevelopmental disorder (NDD).

Methods

Through international collaboration we collected data from 39 subjects with variants in CTCF. We performed transcriptome analysis on RNA from blood samples and utilized Drosophila melanogaster to investigate the impact of Ctcf dosage alteration on nervous system development and function.

Results

The individuals in our cohort carried 2 deletions, 8 likely gene-disruptive, 2 splice-site, and 20 different missense variants, most of them de novo. Two cases were familial. The associated phenotype was of variable severity extending from mild developmental delay or normal IQ to severe intellectual disability. Feeding difficulties and behavioral abnormalities were common, and variable other findings including growth restriction and cardiac defects were observed. RNA-sequencing in five individuals identified 3828 deregulated genes enriched for known NDD genes and biological processes such as transcriptional regulation. Ctcf dosage alteration in Drosophila resulted in impaired gross neurological functioning and learning and memory deficits.

Conclusion

We significantly broaden the mutational and clinical spectrum ofCTCF-associated NDDs. Our data shed light onto the functional role of CTCF by identifying deregulated genes and show that Ctcf alterations result in nervous system defects in Drosophila.

Bi-allelic POLR3A Loss-of-Function Variants Cause Autosomal-Recessive Wiedemann-Rautenstrauch Syndrome

Wiedemann-Rautenstrauch syndrome (WRS), also known as neonatal progeroid syndrome, is a rare disorder of unknown etiology. It has been proposed to be autosomal-recessive and is characterized by variable clinical features, such as intrauterine growth restriction and poor postnatal weight gain, characteristic facial features (triangular appearance to the face, convex nasal profile or pinched nose, and small mouth), widened fontanelles, pseudohydrocephalus, prominent scalp veins, lipodystrophy, and teeth abnormalities. A previous report described a single WRS patient with bi-allelic truncating and splicing variants in POLR3A. Here we present seven additional infants, children, and adults with WRS and bi-allelic truncating and/or splicing variants in POLR3A. POLR3A, the largest subunit of RNA polymerase III, is a DNA-directed RNA polymerase that transcribes many small noncoding RNAs that regulate transcription, RNA processing, and translation. Bi-allelic missense variants in POLR3A have been associated with phenotypes distinct from WRS: hypogonadotropic hypogonadism and hypomyelinating leukodystrophy with or without oligodontia. Our findings confirm the association of bi-allelic POLR3A variants with WRS, expand the clinical phenotype of WRS, and suggest specific POLR3A genotypes associated with WRS and hypomyelinating leukodystrophy.

Phylogeography and mitochondrial DNA (mtDNA) diversity in North American collared lemmings (Dicrostonyx groenlandicus)

Variation in the nucleotide sequence of the mitochondrial control region (250 bp) and the cytochrome b region (870 bp) was examined in collared lemmings (Dicrostonyx groenlandicus) from 19 localities in northern Alaska and the Canadian Arctic. The division of D. groenlandicus in two phylogeographical groups with limited divergence across the Mackenzie River is consistent with the separation of this species in more than one refugial area located to the northwest of the Laurentide ice sheet during the last glaciation. Populations of D.groenlandicus from formerly glaciated areas are no less variable than those in nonglaciated areas. Instead, the low intrapopulation and intraregional diversity estimates in D. groenlandicus are probably a result of regional bottleneck events due to range contractions during Holocene warming events. These results are consistent with findings previously reported on collared lemmings (D. torquatus) from the Eurasian Arctic.

A quality management approach to optimizing delivery and administration of preoperative antibiotics

OBJECTIVE

To optimize the process for delivering and administering preoperative antibiotics in order to prevent potential adverse patient outcomes.

DESIGN

Using a multidisciplinary quality-improvement team, an evaluation of the preoperative medication order and delivery process was conducted. Charts were reviewed by selected time periods, with winter 1994 discharges for orthopedic surgeries (n = 97) and spring 1995 discharges for open heart procedures (n = 50) being used to arrive at baseline data (n = 147). A plan was devised to mainstream the medication-use process so that it would be standardized hospitalwide. A goal of administering preoperative antibiotics within 30 to 60 minutes prior to cut time was established. Following redesign and education, a repeat chart review of orthopedic surgeries (n = 33) and open heart procedures (n = 168) was conducted during April 1997 for discharges from the same diagnosis-related groups to total (n = 201).

SETTING

A nearly 1,000-bed tertiary referral center and teaching hospital with three separate campuses.

RESULTS

We identified multiple ordering mechanisms, multiple medication sources and delivery sites, multiple administration sites and administering personnel, and other logistical conflicts. Thirty-one percent of cases received antibiotics less than 30 minutes prior to start time, 39% between 30 to 60 minutes, and 30% greater than 60 minutes before start time. Following the multidisciplinary redesign and education, an increase from 39% to 61% receiving preoperative antibiotics between 30 to 60 minutes prior to surgery start time and a decrease from 31% to 18% receiving them in less than 30 minutes was documented. The percentage of patients receiving preoperative antibiotics in 60 minutes or less increased from 70% to 80%.

CONCLUSION

A continuous quality-improvement approach that engages all departments involved in patient care is necessary to achieve meaningful change in complicated hospital processes.

Abnormal vaginal bleeding in young women

Abnormal vaginal bleeding is common in young women and there are many possible causes. The most serious cause is cancer of the cervix which is curable in its early stages and this diagnosis should not be missed.

Is HIV testing in antenatal clinics worthwhile? Can we afford it?

Since 0.2-0.4% of pregnant women attending antenatal clinics (ANC) at St Thomas's Hospital are HIV positive, and as the Department of Health (DH) have recommended that universal voluntary HIV testing be made available to women attending ANC in areas of "known or suspected higher prevalence of HIV infection", we examined the implications of the DH initiative in an Inner London Teaching Hospital as well as in a General Practice involved in shared care. The cost of the programme (148,300 pounds to 193,900 pounds), 80% of which relates to the need to obtain informed consent, was approximately 2.7-3.5 times that calculated by the DH. The DH based much of their costing on additional time for counselling rather than calculating the additional staff required. We estimated that 25% of women will require specialized counselling since 17% are of African ethnicity and others are injecting drug users or 'worried well'. Various means of reducing costs were considered but, until such time as explicit, informed consent is no longer considered necessary, the above resources will be required. Unless the DH continues to provide central direction to Providing Agencies to give priority to these recommendations and, where necessary, provides additional funding, we fear that this important public health initiative will be unsuccessful.

Successful pregnancy in a patient with a single ventricle

Single ventricle is an uncommon form of congenital heart disease. We report a successful pregnancy and delivery in a mother with surgically confirmed single ventricle.

Screening of pregnant women for evidence of current hepatitis B infection: selective or universal?

This paper reports the findings of a retrospective survey which assessed the accuracy of the selective screening programme for hepatitis B infection. The survey was undertaken in the antenatal clinics of West Lambeth Health Authority during 1988 and 1990. Forty per cent of hepatitis B positive patients were not screened, which highlights the problems associated with selective screening programmes. The implications for obstetricians and midwives are discussed, and recommendations are made.

Histological differences between colposcopic-directed biopsy and loop excision of the transformation zone (LETZ): a cause for concern

Colposcopic examination and biopsy were performed on 100 patients with abnormal cervical cytology. All were suitable for ablative therapy but were treated by loop excision of the transformation zone (LETZ) as outpatients. Histological comparison between the colposcopic biopsies and LETZ samples showed poor agreement with only 43% of cases illustrating identical degrees of dysplasia. The dysplasia was underestimated by colposcopic biopsy in 16% of cases and overestimated in 41% of cases, when compared to the LETZ specimen. Microinvasive carcinoma was diagnosed in 3 cases on the LETZ histology, having been missed by the preceding colposcopy and colposcopic biopsy. The disparity between histological findings is of great concern and would not have been detected if the patients were treated by ablative therapy. It is the authors' view that LETZ should replace ablative therapy in the treatment of localized cervical dysplasia and that it may avoid the need for pretreatment colposcopic biopsy. LETZ limits the possibility of inadequate treatment and also provides a method of audit for the colposcopist.

The design, preparation, and use of immunopurification reagents

Immunoaffinity chromatography using immobilized monoclonal antibodies has become one of the most powerful macromolecular separation methods available. In many cases, simple one-step immunoaffinity separations will produce a several thousand-fold purification with yields of better than 80%. Monoclonal antibodies are now available with specificities for many different antigens, and the technology for producing new monoclonal antibodies has become widespread througout the world since its invention (1; see vol. 1 of this series). It has been estimated that a new monoclonal antibody is produced every 40 min worldwide.

Maternal and neonatal death due to pneumococcal infection

A 27-year-old woman died from pneumococcal meningitis associated with pneumococcal endometritis two days after being delivered of a .1.75-kg infant. The infant also had pneumococcal septicemia and died six days after birth. The pneumococcus isolated from the mother and the baby was type 8. The membranes had ruptured 21 hours before delivery, and the mother had received a salbutamol infusion in an attempt to inhibit labor with injections of betamethasone to prevent neonatal respiratory distress. This case typified the dramatic onset and lethal nature of some pneumococcal infections.

Failed laparoscopic clip sterilisation

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A case of locked twins managed under lumbar epidural analgesia

A case of locked twins is described in which delivery of the aftercoming head of the first infant, which presented by the breech, was prevented by the presence below it of the head of the second infant, which presented by the vertex. Disimpaction under lumbar epidural analgesia was achieved, the head of the second infant being pushed up out of the pelvis. Both infants survived. This is thought to be the first case to be described in which disimpaction was achieved rapidly under lumbar epidural analgesia, thereby minimising the period of hypoxia to which the first infant was subjected.