Significantly improved outcomes – both in retention and CGI scores - using Long Acting Buprenorphine (LAB-Buvidal) versus treatment as usual for Opioid Dependence in Wales during the Pandemic

Introduction

We have been using LAB (Buvidal) in Cardiff after its pandemic use was funded by Welsh Government.

Objectives

We wished to review the benefits of introducing LAB (Buvidal) into treatment during the pandemic.

Methods

This service development review of the first 73 patients treated with LAB (24mg/96mg rapid titration Welsh protocol) was analysed using Kaplan-Meier survival curves.

Results

43 (58%) male, 30 (41%) female. <25years=1, 38 (52%) aged 25-40, 34 (47%) 40-55. Prior to LAB 14% (10 people) using Espranor, 8% (6) Buprenorphine, 28% (20) Methadone. 50% (36) illicit opiates (mainly Heroin). We had continuous data for patients for up to 9 months of LAB. Two stopped for non-discontinuation reasons: One wanted to detox, one died of natural causes (LAB-unrelated). Both were excluded from discontinuation rate analysis. 55 people have data for over a month. Of these, 11 discontinued treatment. 80% remained on LAB for 1 month or more [95%CI 67-90%]. Kaplan-Meier plots showed similar discontinuation rates when comparing different OST programmes or none prior to LAB, and comparing by age, sex and initial illness severity (CGI severity). These rates all far exceeded data for traditional OST. CGI scores dramatically improved, even at one week. By month 2 all scores “much improved” or “very much improved”.

Conclusions

Buvidal (LAB) has 80% retention rates, regardless of underlying prescribed/illicit opioid /demographics. The commonly held belief that those on heroin are further from Recovery than those more stable on OAD may be incorrect. LAB may be a more acceptable and useful first line therapy that other OSTs

Disclosure

Dr Melichar has provided consultancy work, presentations, training and chaired panel discussions for all the companies in this area in the UK and some outside the UK. Recent work includes Althea (UK), Britannia (UK), Camurus (UK and Global), Martindale (U

Mental resilience training

This paper will explain the concept behind mental resilience training (MRT) and how the training package was developed and implemented within the British ArmyInfantry Training Centre (ITC) Catterick between 2014 and 2016. MRT is a mindfulness-based psychological skills training package that integrates cognitive behavioural and mindfulness based principles and techniques, which have been proven to improve stress regulation, emotional and cognitive control and self-confidence in military personnel. MRT is based on an extensive evidence base that has demonstrated that psychological skills training delivers tangible improvements in performance in elite sport and in healthcare, business and military contexts. The initial trials at the ITC Catterick have delivered tangible improvements in infantry recruits’ use of psychological skills within real-life training contexts.

Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients

BACKGROUND

Programs to improve quality of care and lower costs for the highest utilizers of health services are proliferating, yet such programs have difficulty demonstrating cost savings.

OBJECTIVE

In this study, we explore the degree to which changes in Patient Activation Measure (PAM) levels predict health care costs among high-risk patients.

PARTICIPANTS

De-identified claims, demographic data, and serial PAM scores were analyzed on 2155 patients from multiple medical groups engaged in an existing Center for Medicare and Medicaid Innovation-funded intervention over 3 years designed to activate and improve care coordination for high-risk patients.

DESIGN

In this prospective cohort study, four levels of PAM (from low to high) were used as the main predictor variable. We fit mixed linear models for log₁₀ of allowed charges in follow-up periods in relation to change in PAM, controlling for baseline PAM, baseline costs, age, sex, income, and baseline risk score.

MAIN MEASURES

Total allowed charges were derived from claims data for the cohort. PAM scores were from a separate database managed by the local practices.

KEY RESULTS

A single PAM level increase was associated with 8.3% lower follow-up costs (95% confidence interval 2.5-13.2%).

CONCLUSIONS

These findings contribute to a growing evidence base that the change in PAM score could serve as an early signal indicating the impact of interventions designed for high-cost, high-needs patients.

Impact-induced muscle damage and urinary pterins in professional rugby: 7,8-dihydroneopterin oxidation by myoglobin

Muscle damage caused through impacts in rugby union is known to increase oxidative stress and inflammation. Pterins have been used clinically as markers of oxidative stress, inflammation, and neurotransmitter synthesis. This study investigates the release of myoglobin from muscle tissue due to force-related impacts and how it is related to the subsequent oxidation of 7,8-dihydroneopterin to specific pterins. Effects of iron and myoglobin on 7,8-dihydroneopterin oxidation were examined in vitro via strong cation-exchange high-performance liquid chromatography (SCX-HPLC) analysis of neopterin, xanthopterin, and 7,8-dihydroxanthopterin. Urine samples were collected from 25 professional rugby players pre and post four games and analyzed for myoglobin by enzyme-linked immunosorbent assay, and 7,8-dihydroneopterin oxidation products by HPLC. Iron and myoglobin oxidized 7,8-dihydroneopterin to neopterin, xanthopterin, and 7,8-dihydroxanthopterin at concentrations at or above 10 μM and 50 μg/mL, respectively. All four games showed significant increases in myoglobin, neopterin, total neopterin, biopterin, and total biopterin, which correlated between each variable (P < 0.05). Myoglobin and iron facilitate 7,8-dihydroneopterin oxidation to neopterin and xanthopterin. In vivo delocalization of myoglobin due to muscle damage may contribute to oxidative stress and inflammation after rugby. Increased concentrations of biopterin and total biopterin may indicate production of nitric oxide and monoamine neurotransmitters in response to the physical stress.

Temperature and precipitation projections over Bangladesh and the upstream Ganges, Brahmaputra and Meghna systems

South Asia is a region of complex atmospheric dynamics and therefore changes resulting from increasing greenhouse gas concentrations, combined with existing vulnerability to extreme weather events such as flooding, could put the region at particular risk from climate change. However, current climate projections for the region show a range of uncertainty, particularly in terms of changes in the variability and extremes of precipitation. Focusing on Bangladesh and the region encompassing parts of the Ganges, Brahmaputra and Meghna river basins, we aim to explore and quantify climate model uncertainty in climate change projections for the 21(st) century. We use results from a 17-member perturbed physics ensemble of projections from a global climate model which have been used to drive a higher resolution (25 km) regional climate model over the south Asia region from 1971 to 2099. The range of temperature and precipitation responses across the ensemble are assessed including representation of the annual cycle, trends, and changes in precipitation extremes. The 17 ensemble members consistently simulate increasing annual mean temperatures by 2100 compared with present day, ranging between 2.6 °C and 4.8 °C. Additionally, all ensemble members indicate increasing annual precipitation by 2100 of between around 8% and 28%, though with interdecadal variability which results in one ensemble member showing a slight decrease in precipitation in the mid-century period. The frequency of light precipitation events is projected to decrease in the future, but with an increase in the frequency of heavy events. Three members of the climate model ensemble, representing a range of projected climate outcomes, have been selected for use in further impacts modelling for the region.

Assessing the Effectiveness of Selected Biomarkers in the Acute and Cumulative Physiological Stress Response in Professional Rugby Union through Non-invasive Assessment

Rugby union is a sport involving high force and frequency impacts making the likelihood of injury a significant risk. The aim of this study was to measure and report the individual and group acute and cumulative physiological stress response during 3 professional rugby games through non-invasive sampling. 24 professional rugby players volunteered for the study. Urine and saliva samples were collected pre and post 3 matches. Myoglobin, salivary immunoglobulin A, cortisol, neopterin and total neopterin (neopterin+7,8-dihydroneopterin) were analysed by high performance liquid chromatography or enzyme linked immunosorbent assay. Significant increases in cortisol, myoglobin, neopterin and total neopterin when urine volume was corrected with specific gravity were observed (p<0.05). Significant decreases in salivary immunoglobulin A concentration were observed for games 1 and 2 while secretion rate decreased after games 2 and 3. Significant decreases were seen with the percent of 7,8-dihydroneopterin being converted to neopterin following games 2 and 3. The intensity of 3 professional rugby games was sufficient to elicit significant changes in the physiological markers selected for our study. Furthermore, results suggest the selected markers not only provide a means for analysing the stress encountered during a single game of rugby but also highlight the unique pattern of response for each individual player.

Diagnosing FASD in adults: the development and operation of an adult FASD clinic in Ontario, Canada

This paper describes the development and operation of an interdisciplinary Fetal Alcohol Spectrum Disorders (FASD) diagnostic clinic focussing specifically on adults. The clinic is embedded within a community-based interdisciplinary health agency specializing in intellectual and developmental disabilities. A review of the clinic’s assessment process is presented describing the steps from intake to feedback and intervention. To date, the clinic has received 93 referrals and given 41 alcohol-related diagnoses including 10 completed using videoconferencing technology. Issues unique to adult diagnosis are discussed as well as some of the challenges, including high rates of cancellations/no-shows for appointments, obtaining background and historical information, establishing maternal alcohol history, working collaboratively with other support sectors such as children’s protective services and the justice system, and finding appropriate follow-up and intervention services in the community. Recommendations for future work to support adults with FASD and their families are presented.

Outbreak of human trichinellosis in Northern California caused by Trichinella murrelli

In October of 2008, an outbreak of trichinellosis occurred in northern California that sickened 30 of 38 attendees of an event at which meat from a black bear was served. Morphologic and molecular testing of muscle from the leftover portion of bear meat revealed that the bear was infected with Trichinella murrelli, a sylvatic species of Trichinella found in temperate North America. Clinical records revealed a high attack rate for this outbreak: 78% for persons consuming any bear meat and 100% for persons consuming raw or undercooked bear meat. To our knowledge, this report is the first published report of a human trichinellosis outbreak in the United States attributed to T. murrelli, and it is the second such outbreak reported worldwide.

A Restaurant‐Associated Outbreak of Brainerd Diarrhea in California

In a rare outbreak of Brainerd diarrhea in California, we identified 23 patients, many of whom had diarrhea persisting for > or =6 months. Case-control studies revealed that illness was associated with 1 local restaurant but not with any specific food or beverage. A Campylobacter species was detected in some patients' stool specimens, but its role in the outbreak remains unclear.