The Impact of a Multidisciplinary Opioid Use Disorder Prenatal Clinic on Breastfeeding Rates and Postpartum Care

OBJECTIVE

 To evaluate the hypothesis that patients with opioid use disorder (OUD), who receive prenatal care in a multidisciplinary, prenatal OUD clinic, have comparable postpartum breastfeeding rates, prenatal and postpartum visit compliance, and postpartum contraceptive use when compared with matched controls without a diagnosis of OUD.

STUDY DESIGN

 This was a retrospective, matched, cohort study that included all patients who received prenatal care in a multidisciplinary, prenatal OUD clinic-Clinic for Acceptance Recovery and Empowerment (CARE)-between September 2018 and August 2020. These patients were maintained on opioid agonist therapy (OAT) throughout their pregnancy. CARE patients were matched to controls without OUD in a 1:4 ratio for mode of delivery, race, gestational age ± 1 week, and delivery date ± 6 months. The primary outcome was rate of exclusive breastfeeding at maternal discharge. Secondary outcomes included adherence with prenatal care (≥4 prenatal visits), adherence with postpartum care (≥1 postpartum visit), postpartum contraception plan prior to delivery, and type of postpartum contraceptive use. Conditional multivariate logistic regression was used to account for possible confounders in adjusted calculations.

RESULTS

 A total of 210 patients were included (42 CARE and 168 matched controls). Despite having lower rates of adequate prenatal care, 40 CARE patients (95%) were exclusively breastfeeding at discharge resulting in CARE patients being significantly more likely to be breastfeeding at discharge (adjusted relative risk (aRR): 1.28, 95% confidence interval [CI]: 1.05-1.55). CARE patients and controls demonstrated no difference in postpartum visit compliance (86 vs. 81%, aRR: 1.03, 95% CI: 0.76-1.40) or effective, long-term contraception use (48 vs. 48%; aRR: 0.81, 95% CI: 0.36-1.84).

CONCLUSION

 In the setting of multidisciplinary OUD prenatal care during pregnancy, patients with OUD were more likely to be breastfeeding at the time of discharge than matched controls, with no difference in postpartum visit compliance or effective, long-term contraception.

KEY POINTS

· Women with OUD are more likely to breastfeed when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in LARC use when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in postpartum visit rate in a multidisciplinary prenatal clinic..

County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri

Background

Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates.

Methods

In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates).

Results

Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates.

Conclusions

The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.

Drivers of decision-making regarding infant sleep practices among mothers with opioid use disorder

OBJECTIVE

To understand the perspectives and perceived facilitators of and barriers to following safe infant sleeping practices among mothers with opioid use disorder (OUD).

STUDY DESIGN

Using the Theory of Planned Behavior (TPB) framework, we conducted qualitative interviews with mothers with OUD regarding infant sleep practices. We created codes and generated themes, concluding data collection upon achieving thematic saturation.

RESULTS

Twenty-three mothers with infants 1-7 months of age were interviewed from 08/2020 to 10/2021. Mothers chose sleeping practices they perceived made their infants safer, more comfortable, and minimized infant withdrawal symptoms. Mothers in residential treatment facilities were influenced by facility infant sleep rules. Hospital sleep modeling and varied advice by providers, friends and family influenced maternal decisions.

CONCLUSIONS

Mothers reported factors unique to their experience with OUD that influenced their decisions about infant sleep that should be considered when developing tailored interventions to promote safe infant sleep in this population.

Number of buprenorphine induction attempts impacts maternal and neonatal outcomes: a multicenter cohort study

BACKGROUND

Buprenorphine can be used to treat maternal opioid use disorder effectively and decrease obstetrical risks. Compared with the use of other medications to treat opioid use disorder, the use of buprenorphine results in improved neonatal outcomes; however, its use is associated with higher rates of treatment attrition. Initiation of buprenorphine, termed "induction," is a high-risk time for treatment dropout and can require repeated attempts.

OBJECTIVE

This study aimed to evaluate the effect of multiple buprenorphine induction attempts on maternal and neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of all pregnant patients who underwent sublingual buprenorphine induction for the treatment of opioid use disorder from June 18, 2018, to January 1, 2021, at 3 tertiary care centers. Patients who required only 1 attempt for successful buprenorphine induction were compared with those who required multiple attempts but ultimately were successful in the treatment initiation during pregnancy, confirmed by urine drug screening. The primary outcome was nonprescribed opioid use at the time of delivery. The secondary outcomes included obstetrical and neonatal outcomes associated with opioid use disorder. Background characteristics were compared using Fisher exact, chi-square, Mann-Whitney U, and Student t tests. The outcomes were compared using multivariable logistic regression, and time to delivery after initiation of prenatal care was compared between groups using Kaplan-Meier curves and a Cox proportional-hazards model.

RESULTS

Overall, 63 patients undergoing buprenorphine induction during pregnancy were included, with 38 (60.3%) patients with 1 attempt and 25 patients (39.7%) with multiple attempts. There was no statistical difference between the 2 groups in terms of background characteristics. Compared with a single successful attempt, multiple attempts at buprenorphine induction were associated with a significantly increased odds of nonprescribed opioid use at the time of delivery (76.0% vs 15.8%; adjusted odds ratio, 30.00; 95% confidence interval, 5.50-163.90), increased risk of preterm birth (48.0% vs 15.8%; adjusted hazard ratio, 3.24; 95% confidence interval, 1.17-8.95), and decreased rate of breastfeeding at both maternal discharge (24.0% vs 78.9%; adjusted odds ratio, 0.06; 95% confidence interval, 0.00-0.30) and infant discharge (24.0% vs 55.3%; adjusted odds ratio, 0.23; 95% confidence interval, 0.10-0.80).

CONCLUSION

Requiring multiple attempts for buprenorphine induction significantly increases the odds of nonprescribed opioid use at the time of delivery and preterm birth and decreases the odds of breastfeeding. As the buprenorphine induction process may affect obstetrical outcomes for patients induced during pregnancy, investigating the techniques that increase the likelihood of successful induction is crucially needed to improve outcomes in patients with maternal opioid use disorder.

Understanding cigarette smoking among mothers with opioid use disorder

BACKGROUND

Cigarette smoking is highly prevalent among mothers with opioid use disorder (OUD). Organizations such as the American College of Obstetrics and Gynecology recommend cessation of cigarettes during the pre- and postnatal periods. Factors that inform decisions to continue or stop smoking cigarettes among pregnant and postpartum mothers with OUD are unclear.

AIMS

This study aimed to understand (1) the lived experience of mothers with OUD regarding cigarette smoking and (2) barriers and facilitators to reduction of cigarette smoking during the pre- and postnatal periods.

METHODS

Guided by the Theory of Planned Behavior (TPB) framework, we completed semi-structured, in-depth interviews with mothers with OUD with infants 2-7 months of age. We used an iterative approach to analysis by conducting interviews and developing and revising codes and themes until we reached thematic saturation.

RESULTS

Fifteen of 23 mothers reported smoking cigarettes prenatally and postnatally, 6 of 23 smoked cigarettes during the prenatal period only, and 2 mothers were non-smokers. We found that mothers: 1) believed that smoke exposure had negative health consequences and may exacerbate withdrawal symptoms for their infants; 2) implemented risk mitigation practices, which were dictated both by themselves and by outside rules, to reduce the harmful effects of smoke around infants; 3) were motivated to quit or cut-down on smoking because of the desire to optimize the health and well-being of their infants; 4) continued to smoke because they felt that the stress related to caregiving and their own recovery were a higher priority than quitting smoking; and 5) were influenced by exposure to smokers with whom they lived, as well as by the varied advice of medical providers, family, and friends.

CONCLUSION

While mothers with OUD acknowledged the negative health impact of cigarette smoke exposure to their infants, many experienced stressors related to recovery and caregiving unique to those with OUD that impacted their cigarette smoking behaviors.

Breastfeeding Decision-Making Among Mothers with Opioid Use Disorder: A Qualitative Study

Background: Factors that contribute to low initiation and continuation of breastfeeding among mothers with opioid use disorder (OUD) are poorly understood. Objective: To understand barriers and facilitators to breastfeeding initiation and continuation beyond the birth hospitalization for mothers with OUD. Materials and Methods: We conducted 23 in-depth, semistructured interviews with mothers with OUD who cared for their infants at home 1-7 months after birth. Our interview guide was informed by the Theory of Planned Behavior (TPB) framework, which has been used to understand decision-making regarding breastfeeding. An iterative approach was used to develop codes and themes. Results: Among 23 participants, 16 initiated breastfeeding, 10 continued after hospital discharge, and 4 continued beyond 8 weeks. We identified factors influencing breastfeeding decisions in the four TPB domains. Regarding attitudes, feeding intentions were based on beliefs of the healthiness of breastfeeding particularly pertaining to infant withdrawal or exposure to mothers' medications. Regarding social norms, breastfeeding was widely recommended, but mothers had varying levels of trust in medical professional advice. Regarding perceived control, infant withdrawal and maternal pain caused breastfeeding to be difficult, with decisions to continue modulated by level of outside support. Regarding self-efficacy, mothers weighed their own recovery and well-being against the constant demands of breastfeeding, impacting decisions to continue. Conclusion: Mothers with OUD face unique barriers to breastfeeding related to their infants' withdrawal as well as their own health, recovery, and social context. Overcoming these barriers may serve as future intervention targets for breastfeeding promotion among this high-risk population.

Medicaid and moms: the potential impact of extending medicaid coverage to mothers for 1 year after delivery

The American Rescue Plan provides a pathway for states to expand postpartum Medicaid coverage for low-income mothers through 12 months after delivery. Data suggests that extension of post-partum Medicaid coverage should improve access to outpatient health care services, increase healthcare utilization, improve chronic disease management for at-risk mothers, and reduce disparities in care for racial/ethnic groups over-represented in Medicaid. Opportunities to provide increased preventive care for perinatal mood disorders and smoking cessation also exist. Further, this policy may reduce the burden of late maternal mortality. While improved access to contraceptive service postpartum provides a potential mechanism by which birth outcomes may improve, the effect of this policy on NICU admission, low birth weight (LBW) infants, and preterm birth is unknown. We discuss possible birth, infant and maternal health outcomes which may result from this expansion, drawing on data from the 2010 Medicaid Expansion via the Affordable Care Act.

Length of Resuscitation for Severely Depressed Newborns

OBJECTIVE

Current guidelines for neonatal resuscitation suggest it may be reasonable to stop resuscitation after 10 minutes in infants born with no detectable heartbeat. This study describes the length of resuscitation provided in a cohort of profoundly compromised newborn infants.

STUDY DESIGN

Chart review of a regional hospital system database of newborn infants from 2010 to 2017 with a documented 10-minute Apgar score of 0 or 1.

RESULTS

From a total birth population of 49,876 infants, 172 newborns were identified. Of these, 133 infants did not receive resuscitation and died while receiving comfort care. In the 39 resuscitated infants, 15 (38%) achieved return of spontaneous circulation (ROSC) at an average of 20 minutes; 32 of these 39 newborns (82%) died within 24 hours. Average time to ROSC for survivors was 17.8 minutes. Death or severe neurologic disability at 15 to 24 months of age was present in 92% (36/39) of resuscitated infants.

CONCLUSION

Prolonged resuscitation of newborns is rare. In this cohort, 92% died or had severe neurodevelopmental disability. Infants with ROSC received 20 minutes of resuscitation. Infants with ROSC typically did not survive beyond 24 hours unless they survived to discharge. To increase the number of infants with ROSC, continuing resuscitation beyond 10 minutes may be reasonable.

Pharmacologic treatment of infants with neonatal abstinence syndrome in community hospitals compared to academic medical centers

OBJECTIVE

To compare length of hospital stay (LOS), LOS due to neonatal abstinence syndrome (NAS), and duration of pharmacologic treatment in community or academic settings.

STUDY DESIGN

One hundred-two infants exposed to opioids in utero at two community hospitals were compared to 256 from eight academic centers. All infants were managed with non-pharmacologic care followed by similar pharmacologic treatment options.

RESULTS

Two hundred-twelve infants received pharmacologic treatment for NAS. Mean LOS (24.7 ± 8.5 vs. 24.5 ± 11.3 days), LOS due to NAS (24.0 ± 8.2 vs. 23.3 ± 9.2 days), and duration of NAS treatment (19.3 ± 8.0 vs. 18.9 ± 9.2 days) were similar in community compared to academic medical centers.

CONCLUSIONS

No significant differences were found in infants managed in the community compared to academic care settings. These findings support caring for opioid-exposed infants in both community and academic settings with the use of standardized care protocols.

Quantum walks: The first detected passage time problem

Even after decades of research, the problem of first passage time statistics for quantum dynamics remains a challenging topic of fundamental and practical importance. Using a projective measurement approach, with a sampling time τ, we obtain the statistics of first detection events for quantum dynamics on a lattice, with the detector located at the origin. A quantum renewal equation for a first detection wave function, in terms of which the first detection probability can be calculated, is derived. This formula gives the relation between first detection statistics and the solution of the corresponding Schrödinger equation in the absence of measurement. We illustrate our results with tight-binding quantum walk models. We examine a closed system, i.e., a ring, and reveal the intricate influence of the sampling time τ on the statistics of detection, discussing the quantum Zeno effect, half dark states, revivals, and optimal detection. The initial condition modifies the statistics of a quantum walk on a finite ring in surprising ways. In some cases, the average detection time is independent of the sampling time while in others the average exhibits multiple divergences as the sampling time is modified. For an unbounded one-dimensional quantum walk, the probability of first detection decays like (time)^{(-3)} with superimposed oscillations, with exceptional behavior when the sampling period τ times the tunneling rate γ is a multiple of π/2. The amplitude of the power-law decay is suppressed as τ→0 due to the Zeno effect. Our work, an extended version of our previously published paper, predicts rich physical behaviors compared with classical Brownian motion, for which the first passage probability density decays monotonically like (time)^{-3/2}, as elucidated by Schrödinger in 1915.

The first polluted river? Repeated copper contamination of fluvial sediments associated with Late Neolithic human activity in southern Jordan

The roots of pyrometallurgy are obscure. This paper explores one possible precursor, in the Faynan Orefield in southern Jordan. There, at approximately 7000cal. BP, banks of a near-perennial meandering stream (today represented by complex overbank wetland and anthropogenic deposits) were contaminated repeatedly by copper emitted by human activities. Variations in the distribution of copper in this sequence are not readily explained in other ways, although the precise mechanism of contamination remains unclear. The degree of copper enhancement was up to an order of magnitude greater than that measured in Pleistocene fluvial and paludal sediments, in contemporary or slightly older Holocene stream and pond deposits, and in the adjacent modern wadi braidplain. Lead is less enhanced, more variable, and appears to have been less influenced by contemporaneous human activities at this location. Pyrometallurgy in this region may have appeared as a byproduct of the activity practised on the stream-bank in the Wadi Faynan ~7000years ago.

Endotoxin induced cytotoxicity of macrophages is due to apoptosis caused by nitric oxide production

Bacterial LPS is one of the most powerful immunostimulators in nature and causes a wide spectrum of acute pathophysiological effects recognized as toxic properties. At the cellular level, LPS also is cytotoxic for a variety of cells. However, the molecular mechanisms responsible for LPS cytotoxicity are not well understood. In this study, possible mechanisms of LPS cytotoxicity for mouse macrophages were examined in comparison with the effect of detoxified LPS (DeLPS). Mouse peritoneal exudate macrophages cultured with 10 μg/ml of LPS for 48 h evinced approximately 40% cell death as measured by the tetrazolium dye reduction assay. Co-treatment of the macrophages with IFNγ enhanced LPS-associated toxicity so that as little as 0.1 μg/ml of LPS induced a significant toxicity. In contrast, neither DeLPS alone nor the combination of DeLPS and IFNγ induced any cytotoxicity even at a high concentration of DeLPS, such as 100 μg/ml, and a relatively long incubation period such as 72 h. Examination of nitric oxide (NO) production demonstrated a dose-response production of NO in culture supernatants of LPS treated macrophages but not in DeLPS macrophages. However, when the macrophages were primed with IFNγ and stimulated with LPS, more NO production was observed as compared to stimulation with LPS alone. Macrophages were cultured with LPS in the presence of anti-IFNβ; cytotoxicity as well as NO production was significantly reduced. Treatment with the NO inhibitor, NG-monomethyl-L-arginine, completely blocked production of NO and, furthermore, diminished the cytotoxicity induced by either the combination of IFNγ and LPS or LPS alone. Investigation of the possible mechanism of LPS induced cytotoxicity implicated the involvement of apoptosis as shown by DNA fragmentation. Furthermore, treatment with the NO inhibitor completely blocked DNA fragmentation induced by LPS and IFNγ. The data obtained suggest that LPS-induced cytotoxicity of macrophages may be due to apoptosis caused by excessive production of NO.

Impact of the human immunodeficiency virus on early multidrug-resistant tuberculosis treatment outcomes in Botswana

SETTING

The impact of the human immunodeficiency virus (HIV) on multidrug-resistant tuberculosis (MDR-TB) treatment outcomes in sub-Saharan Africa, where extensive rollout of highly active antiretroviral therapy (HAART) has occurred, remains unclear.

OBJECTIVE

To compare the time to initial culture conversion among patients with and those without HIV infection in a setting of individualized MDR-TB care in Botswana.

DESIGN

Prospective cohort study of MDR-TB patients receiving ambulatory, integrated TB-HIV care at two public clinics in Botswana. The time to culture conversion was compared by HIV status using Cox proportional hazard ratios (HRs).

RESULTS

A total of 40 HIV-infected and 30 non-HIV-infected patients with MDR-TB and follow-up cultures were identified. The median time to initial culture conversion was 78 days (interquartile range [IQR] 42-186) for HIV-infected and 95 days (IQR 70-133) for non-HIV-infected individuals (log rank P > 0.5; unadjusted HR 0.9, 95%CI 0.5-1.5). Adjusting for age, sex, treatment history and number of active anti-tuberculosis drugs did not change this result (adjusted HR 0.8, 95%CI 0.4-1.4).

CONCLUSION

We found no difference in the proportion of or time to initial sputum culture conversion between an HIV-infected and a non-infected cohort of MDR-TB patients in Botswana, suggesting that outcomes may be comparable in similar settings with access to individualized anti-tuberculosis treatment and HAART.

Micro- and nano-spheres of low melting point metals and alloys, formed by ultrasonic cavitation

Metals and alloys of low melting points (<430 °C) can be melted in hot silicone oil to form two immiscible liquids. Irradiation of the system with ultrasonic energy induces acoustic cavitation in the oil, which disperses the molten metals into microspheres that solidify rapidly upon cooling. This method has been applied to seven pure metals (Ga, In, Sn, Bi, Pb, Zn, Hg) and two eutectic alloys of gold (Au-Ge and Au-Si). The morphology and composition of the resulting microspheres were examined by SEM and EDS. Eutectic Au-Si formed also crystalline Au nanoparticles, which were separated and studied by HRTEM.