0543 Implementing Insomnia Care Paths for Older Adults and People with Dementia

Introduction

Despite the high prevalence of insomnia in older adults and those with dementia, screening and treatment remain inconsistent and suboptimal. Implementing a care path in a health system, though, is difficult. To determine what issues are relevant for implementation, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building.

Methods

All N=20 participants, representing a wide range of stakeholders including research, industry, sleep, primary care, implementation science, and others, voted whether they agreed or disagreed with 36 different statements regarding what issues are important for implementing geriatric insomnia care paths. These represented a range of items addressing strategies for identifying and incentivizing stakeholders, identifying patients in most need and who would receive benefit, addressing comorbidities and multiple specialties, understanding how specific organizations make decisions about and changes to care, size and scope of the care path, determining the process for implementation, how it will improve outcomes, addressing specific needs of primary care, and addressing costs, reimbursements, and liabilities. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree).

Results

Despite the diversity among attendees, median rate of agreement for was 95% (IQR=90-95%). All items were endorsed by >=80% of respondents. Mean score was 0.48 (SD=1.85). 95%CIs were computed for each proportion and compared to the mean. The only item that significantly differed from the mean score indicated that understanding benefits of a care path to the general community is less important of an issue than others (M=0.85).

Conclusion

Implementing an insomnia care path for older adults in an institution will likely require addressing a wide range of issues, including questions about stakeholders, the health system/context, patients, and practical considerations.

Support

Merck Research Labs provided support

1185 Developing A Care Pathway For Insomnia In Older Adults And Adults With Dementia: Results Of A Consensus Meeting

Introduction

Insomnia among older adults and dementia patients carries a high public health burden. Yet, treatment is inconsistent or absent. Standardized, programmatic carepaths can be implemented in clinics/systems/communities to address this after tailoring to local environments. To determine what elements should be included, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building among diverse stakeholders.

Methods

Participants represented a wide range of stakeholders and specialties, including academic research, clinical care, industry, government, payors, sleep medicine, primary care, geriatrics, psychiatry, neurology, nursing, pharmacy, quality, and implementation science. 27 statements regarding key components of carepaths for insomnia in elderly and dementia populations were presented and discussed. These represented items addressing identification of patients, screening and assessment, deciding treatment modality and delivery, providing behavioral treatment, providing pharmacotherapy, addressing combined therapy, addressing comorbidities, and incorporating outcome evaluation. All N=20 participants voted individually whether they agreed or disagreed with each statement. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree.

Results

Despite diversity among attendees, median rate of agreement was 95% (IQR=85-95%). Mean score was 0.69 (SD=0.31). 95%CIs were computed for each proportion and compared to the mean. The following elements were significantly different from the mean (p<0.05): medication decision trees (M=0.25), accounting for comorbidities (M=0.26), include outcome evaluation (M=0.30), utilization of EMR (M=0.40), incorporate caregiver (M=0.42), and differ across parts of the system (M=1.79).

Conclusion

Insomnia carepaths for older adults should address identification, screening and assessment, treatment decisions, treatment type and delivery, and evaluation. Organizations should consider these elements when designing carepaths for insomnia among older adults and dementia patients. Consensus-building should begin during the process of prioritizing care path components.

Support

Merck Research Labs provided support

A Cross-Sectional Population Study of Geographic, Age-Specific, and Household Risk Factors for Asymptomatic Plasmodium falciparum Malaria Infection in Western Kenya

The burden of Plasmodium falciparum (Pf) malaria in Kenya is decreasing; however, it is still one of the top 10 causes of morbidity, particularly in regions of western Kenya. Between April 2015 and June 2016, we enrolled 965 apparently healthy children aged 0-15 years in former Nyanza and Western Provinces in Kenya to characterize the demographic, geographic, and household risk factors of asymptomatic malaria as part of an epidemiologic study to investigate the risk factors for endemic Burkitt lymphoma. The children were sampled using a stratified, multistage cluster sampling survey design. Malaria was assessed by rapid diagnostic test (RDT) and thick-film microscopy (TFM). Primary analyses of Pf malaria prevalence (pfPR) are based on RDT. Associations between weighted pfPR and potential risk factors were evaluated using logistic regression, accounting for the survey design. Plasmodium falciparum malaria prevalence was 36.0% (27.5%, 44.5%) by RDT and 22.3% (16.0%, 28.6%) by TFM. Plasmodium falciparum malaria prevalence was positively associated with living in the lake-endemic area (adjusted odds ratio [aOR] 3.46; 95% confidence interval [95% CI] 1.63, 7.37), paternal occupation as peasant farmer (aOR 1.87; 1.08, 3.26) or manual laborer (aOR 1.83; 1.00, 3.37), and keeping dogs (aOR 1.62; 0.98-2.69) or cows (aOR 1.52; 0.96-2.40) inside or near the household. Plasmodium falciparum malaria prevalence was inversely associated with indoor residual insecticide spraying (IRS) (aOR 0.44; 0.19, 1.01), having a household connected to electricity (aOR 0.47; 0.22, 0.98), and a household with two (aOR 0.45; 0.22, 0.93) or ≥ three rooms (aOR 0.41; 0.18, 0.93). We report high but geographically heterogeneous pfPR in children in western Kenya and significant associations with IRS and household-level socioeconomic factors.

An evaluation of the hepatitis C testing, care and treatment program in the country of Georgia's corrections system, December 2013 - April 2015

BACKGROUND

The country of Georgia has a high burden of chronic hepatitis C virus (HCV) infection, and prisoners are disproportionately affected. During 2013, a novel program offering no cost screening and treatment of HCV infection for eligible prisoners was launched.

METHODS

The HCV treatment program implemented a voluntary opt-in anti-HCV testing policy to all prisoners. Anti-HCV positive persons received HCV RNA and genotype testing. Transient elastography was also performed on prisoners with positive HCV RNA results. Prisoners with chronic HCV infection who had ≥F2 Metavir stage for liver fibrosis and a prison sentence ≥ 6 months were eligible for interferon-based treatment, which was the standard treatment prior to 2015. We conducted an evaluation of the HCV treatment program among prisoners from the program's inception in December 2013 through April 2015 by combining data from personal interviews with corrections staff, prisoner data in the corrections database, and HCV-specific laboratory information.

RESULTS

Of an estimated 30,000 prisoners who were incarcerated at some time during the evaluation period, an estimated 13,500 (45%) received anti-HCV screening, of whom 5175 (38%) tested positive. Of these, 3840 (74%) received HCV RNA testing, 2730 (71%) tested positive, and 880 (32%) met treatment eligibility. Of these, 585 (66%) enrolled; 405 (69%) completed treatment, and 202 (50%) achieved a sustained virologic response at least 12 weeks after treatment completion.

CONCLUSIONS

HCV infection prevalence among Georgian prisoners was high. Despite challenges, we determined HCV treatment within Georgian Ministry of Correction facilities was feasible. Efforts to address HCV infection among prison population is one important component of HCV elimination in Georgia.

Burkitt lymphoma research in East Africa: highlights from the 9(th) African organization for research and training in cancer conference held in Durban, South Africa in 2013

A one-day workshop on Burkitt lymphoma (BL) was held at the 9(th) African Organization for Research and Training in Cancer (AORTIC) conference in 2013 in Durban, South Africa. The workshop featured 15 plenary talks by delegates representing 13 institutions that either fund or implement research on BL targeting AORTIC delegates primarily interested in pediatric oncology. The main outcomes of the meeting were improved sharing of knowledge and experience about ongoing epidemiologic BL research, BL treatment in different settings, the role of cancer registries in cancer research, and opportunities for African scientists to publish in scientific journals. The idea of forming a consortium of BL to improve coordination, information sharing, accelerate discovery, dissemination, and translation of knowledge and to build capacity, while reducing redundant efforts was discussed. Here, we summarize the presentations and discussions from the workshop.

Performance of permeable media rotating reactors used for pretreatment of wastewaters

The impact of organic loading rate (OLR) on carbonaceous materials and ammonia removal was assessed in bench scale rotating media biofilm reactors treating real wastewater. Media composition influences biofilm structure and therefore performance. Here, plastic mesh, reticulated coarse foam and fine foam media were operated concurrently at OLRs of 15, 35 and 60 g sCOD m(-2)d(-1) in three bench scale shaft mounted advanced reactor technology (SMART) reactors. The sCOD removal rate increased with loading from 6 to 25 g sCOD m(-2)d(-1) (P < 0.001). At 35 g BOD5m(-2)d(-1), more than double the arbitrary OLR limit of normal nitrifying conditions (15 g BOD5m(-2)d(-1)); the removal efficiency of NH(4)-N was 82 ± 5, 27 ± 19 and 39 ± 8% for the mesh, coarse foam and fine foam media, respectively. Increasing the OLR to 35 gm(-2)d(-1) decreased NH(4)-N removal efficiency to 38 ± 6, 21 ± 4 and 21 ± 6%, respectively. The mesh media achieved the highest stable NH(4)(+)-N removal rate of 6.5 ± 1.6 gm(-2)d(-1) at a sCOD loading of 35 g sCOD m(-2)d(-1). Viable bacterial numbers decreased with increasing OLR from 2 × 10(10)-4 × 10(9) cells per ml of biofilm from the low to high loading, suggesting an accumulation of inert non-viable biomass with higher OLR. Increasing the OLR in permeable media is of practical benefit for high rate carbonaceous materials and ammonia removal in the pretreatment of wastewater.

Predicted mobility edges in one-dimensional incommensurate optical lattices: an exactly solvable model of anderson localization

Localization properties of noninteracting quantum particles in one-dimensional incommensurate lattices are investigated with an exponential short-range hopping that is beyond the minimal nearest-neighbor tight-binding model. Energy dependent mobility edges are analytically predicted in this model and verified with numerical calculations. The results are then mapped to the continuum Schrödinger equation, and an approximate analytical expression for the localization phase diagram and the energy dependent mobility edges in the ground band is obtained.

Evaluation of methods to identify the Klebsiella pneumoniae carbapenemase in Enterobacteriaceae

The Klebsiella pneumoniae carbapenem (KPC) beta-lactamase occurs in Enterobacteriaceae and can confer resistance to all beta-lactam agents including carbapenems. The enzyme may confer low-level carbapenem resistance, and the failure of susceptibility methods to identify this resistance has been reported. Automated and nonautomated methods for carbapenem susceptibility were evaluated for identification of KPC-mediated resistance. Ertapenem was a more sensitive indicator of KPC resistance than meropenem and imipenem independently of the method used. Carbapenemase production could be confirmed with the modified Hodge test.

Why most workers with occupational repetitive trauma do not file for workers' compensation

Despite the availability of no fault insurance for wage replacement and medical care costs, the majority of workers diagnosed with an occupational disease do not apply for workers' compensation. The objective of the study was to determine the reasons why workers diagnosed with work-related musculoskeletal disease did not apply for workers' compensation benefits. A cross-sectional study of 1598 individuals diagnosed with neck, upper extremity, and low back work-related musculoskeletal disease from April to June 1996 was performed. All individuals were interviewed over the telephone using a standardized questionnaire. The questionnaire included questions about the precipitating event; demographics; health limitations; mood; pain level; and attitudes toward their health care provider, fellow workers, management, work environment, and filing for workers' compensation. Whenever possible, standardized questions from previous surveys were used. The interviewed individuals with work-related musculoskeletal disease were reported by health care practitioners as required by the state of Michigan's occupational disease reporting law. Workers reported during 12 weeks in the spring of 1996 by a Michigan health care professional as having a neck, back, or upper extremity musculoskeletal disorder were eligible to participate. Among the 2703 reports received, 490 individuals could not be reached, 22 did not speak English, 12 had died or were too incapacitated by other medical conditions, and 581 refused. We interviewed 59% of all eligible workers and 73% of all workers who were reachable and capable of responding in English. Only 25% of workers diagnosed with musculoskeletal disease filed a workers' compensation claim. The factors significantly associated with filing a claim were (1) increased length of employment (> 21 years: odds ratio [OR], 3.01, 95% confidence interval [CI], 1.31 to 6.90); 11 to 20 years: OR, 2.34, 95% CI, 1.01 to 5.47; 6 to 10 years: OR, 1.76, 95% CI, 0.73 to 4.25; 1 to 5 years: OR, 2.36, 95% CI, 1.03 to 5.42; < 1 year: OR, 1.00; (2) lower annual income (< $40,000: OR, 1.75, 95% CI, 1.06 to 2.88 vs > or = $80,000: OR, 1.00); (3) workers' dissatisfaction with coworkers (OR, 1.76, 95% CI, 1.01 to 3.06); (4) physician restrictions on activity (OR, 2.16, 95% CI, 1.55 to 3.00); (5) type of physician providing treatment (specialist, including surgeon or orthopedist: OR, 3.63, 95% CI, 2.37 to 5.55); physical and occupational therapist: OR, 2.15, 95% CI, 1.35 to 3.43); family practitioner: OR, 1.33, 95% CI = 0.89 to 2.01; company physician: OR = 1.00); (6) off work > or = 7 days (OR, 14.85, 95% CI, 10.57 to 20.85); (7) decreased current health status (OR, 0.82, 95% CI, 0.70 to 0.96); and (8) increased severity of illness (OR, 1.24, 95% CI, 1.06 to 20.88). This study showed that only 25% of workers with a work-related musculoskeletal condition filed for workers' compensation and refutes the common perception that an individual with a work-related problem is likely to file a workers' compensation claim. The strongest predictors of who would file were those factors associated with the severity of the condition. Other factors were increasing length of employment, lower annual income, and worker dissatisfaction with coworkers. Our study population consisted mainly of unionized autoworkers, and our findings may not be generalizable to the total workforce.

What percentage of workers with work-related illnesses receive workers' compensation benefits?

This study estimates the rate at which workers suffering from occupational illnesses file for workers' compensation lost wage benefits and identifies some of the factors that affect the probability that a worker with an occupational illness will file. A database of reports of known or suspected cases of occupational illness is matched with workers' compensation claims data. Overall, between 9% and 45% of reported workers file for benefits. Data limitations prevent a more precise estimate of this rate, but a large proportion of workers with occupational illnesses clearly does not utilize the worker's compensation system. Logit analysis of a choice-based sample shows that women and employees of small firms are more likely than others to file for worker's compensation and that filing rates vary considerably across industries and diagnostic categories. Acute conditions related to the current job are no more likely to lead to claims than chronic conditions with long latency periods between exposure and development of disease.

Comparison of traditional and molecular methods of typing isolates of Staphylococcus aureus

Fifty-nine Staphylococcus aureus isolates and 1 isolate of Staphylococcus intermedius were typed by investigators at eight institutions by using either antibiograms, bacteriophage typing, biotyping, immunoblotting, insertion sequence typing with IS257/431, multilocus enzyme electrophoresis, restriction analysis of plasmid DNA, pulsed-field or field inversion gel electrophoresis, restriction analysis of PCR-amplified coagulase gene sequences, restriction fragment length polymorphism typing by using four staphylococcal genes as probes, or ribotyping. Isolates from four well-characterized outbreaks (n = 29) and a collection of organisms from two nursing homes were mixed with epidemiologically unrelated stock strains from the Centers for Disease Control and Prevention. Several isolates were included multiple times either within or between the sets of isolates to analyze the reproducibilities of the typing systems. Overall, the DNA-based techniques and immunoblotting were most effective in grouping outbreak-related strains, recognizing 27 to 29 of the 29 outbreak-related strains; however, they also tended to include 3 to 8 epidemiologically unrelated isolates in the same strain type. Restriction fragment length polymorphism methods with mec gene-associated loci were less useful than other techniques for typing oxacillin-susceptible isolates. Phage typing, plasmid DNA restriction analysis, and antibiogram analysis, the techniques most readily available to clinical laboratories, identified 23 to 26 of 29 outbreak-related isolates and assigned 0 to 6 unrelated isolates to outbreak strain types. No single technique was clearly superior to the others; however, biotyping, because it produced so many subtypes, did not effectively group outbreak-related strains of S. aureus.

Single-dose treatment of uncomplicated acute gonococcal urethritis in Ethiopian men: comparison of rosoxacin, spectinomycin, penicillin, and ampicillin

A total of 140 Ethiopian men with gonococcal urethritis were randomly assigned to treatment with aqueous procaine penicillin G (4.8 X 10(6) units intramuscularly [im] plus 1.0 g of oral probenicid); oral ampicillin (3.5 g plus 1.0 g of oral probenicid); spectinomycin (2.0 g im); or oral rosoxacin (Acrosoxacin; 300 mg). Failure rates were 24%, 19%, zero, and 3%, respectively. Forty-four (31.4%) patients were infected with penicillinase-producing Neisseria gonorrhoeae (PPNG) and were evenly distributed in the treatment groups. All 39 PPNG strains analyzed for plasmid content possessed a 2.6-Mdalton plasmid; 28 (71.8%) had a 3.2-Mdalton beta-lactamase-encoding plasmid, ten (25.6%) had a 4.4-Mdalton plasmid (three with and seven without a 24.5-Mdalton plasmid), and one had only a 24.5-Mdalton plasmid. Two patients were infected with N. gonorrhoeae-possessing plasmids apparently capable of encoding but not producing beta-lactamase. Both spectinomycin and rosoxacin are excellent single-dose treatment regimens for gonococcal urethritis in men. All people receiving these drugs in Ethiopia should be tested serologically for syphilis, however, as eight (11.8%) of 68 men in this study also had active latent syphilis.

Outbreak of penicillinase-producing Neisseria gonorrhoeae with an African connection

Previous outbreaks of penicillinase-producing gonococcal infection in the United States have generally been attributed to importation of Southeast Asian strains. During July 1982 through July 1983, 110 cases of gonorrhea caused by penicillinase-producing strains were reported in metropolitan Atlanta, Georgia. Among the 53 infected women, 14 (26%) had pelvic inflammatory disease (PID). Compared to other infected women, those with PID experienced a greater delay from the time of last sexual exposure (19.1 vs 8.1 days) to receipt of appropriate antibiotic therapy (P less than .01). At least 22 prostitutes were involved in the outbreak. Sixteen (76%) of 21 isolates tested were serogroup 1A; 15 required arginine and proline for growth; and 17 (81%) possessed a 3.2 megadalton plasmid. Our data suggest that this outbreak was associated with both African and Southeast Asian strains.

Treating gonococcal infections resistant to penicillin in Bangkok: comparison of cefuroxime and spectinomycin

Gonococcal organisms have become resistant to antimicrobials throughout the world. Such resistance is common in Thailand, where 40% of gonococci produce penicillinase (PPNG strains) and over half the remainder have MICs of penicillin greater than or equal to 1 mg/l. To evaluate the effectiveness of cefuroxime against such resistant organisms, a controlled clinical trial comparing spectinomycin and cefuroxime was conducted at Bangrak Hospital, Bangkok, in 1982-3. Of 472 patients who were randomly assigned to treatment, 365 (77%) yielded positive cultures before treatment and returned for follow up evaluation three to 13 days after treatment. Of the 365 patients, 359 (98%) were cured, and no difference between the two treatment regimens was found either by the sex of the patient or by the presence of PPNG strains. The MIC of cefuroxime against all organisms was less than or equal to 1 mg/l. In vitro susceptibilities of gonococci in Bangkok have not changed appreciably during the past two years. Regimens of cefuroxime and spectinomycin are highly effective even for the relatively resistant gonococci in Bangkok. The pharmacokinetics, in vitro susceptibilities, and effectiveness of cefuroxime encourage evaluation of lower doses of the drug.

Common beta-lactamase-specifying plasmid in Haemophilus ducreyi and Neisseria gonorrhoeae

Eighty-nine strains of Haemophilus ducreyi from a chancroid epidemic in Orange County, California, were examined for plasmid content. Seventy-eight (88%) of these isolates were found to contain a plasmid of 3.2 megadaltons which conferred beta-lactamase production. Restriction endonuclease digests indicated that this was the same plasmid that was found in some strains of beta-lactamase-producing Neisseria gonorrhoeae.

Plasmid profile, serogrouping, and auxotyping of Neisseria gonorrhoeae isolates from Africa

The plasmid patterns of 90 isolates of Neisseria gonorrhoeae (including 39 penicillinase-producing strains) originating from various countries in Africa were determined. Serogrouping by coagglutination and auxotyping were used to characterise the isolates. The 4.4-megadalton plasmid was present in seven isolates out of 39 penicillinase-producing strains, two of which occurred with a conjugative 24.5-megadalton plasmid. The African strains were predominantly serogroup WI and wild type. Arginine-dependent isolates were as common as proline-dependent types.

Antimicrobial resistance of Neisseria gonorrhoea in Bangkok: is single-drug treatment passé

201 gonococcal isolates obtained from patients attending clinics in Bangkok were tested for in-vitro antimicrobial susceptibility. 42% of these isolates were penicillinase-producing Neisseria gonorrhoeae (PPNG); of the 116 isolates of non-PPNG 53% had a penicillin minimum inhibitory concentration (MIC) greater than or equal to 1 microgram/ml and the remainder had MIC greater than or equal to 0.06 microgram penicillin/ml. Similarly high in-vitro resistance was found for six of eight other antimicrobial agents tested. These high antimicrobial MICs reflect the difficulties encountered in selecting therapeutic agents for the control of gonorrhoea in Thailand. Single-drug treatment for gonorrhoea may no longer be effective in some settings. There is an urgent need to evaluate combination therapies appropriate to such settings.

Antimicrobial susceptibility of gonococci isolated in the Central African Republic

Using agar dilution techniques, we determined the minimum inhibitory concentrations (MIC) of 11 antimicrobials for 70 isolates of Neisseria gonorrhoeae obtained in Bangui, Central African Republic. These gonococci were found to be fairly susceptible to commonly used antibiotics: only 3 isolates (4%) had a penicillin MIC >/= 1.0 mug/ml and 6 (9%) had a tetracycline MIC >/= 2.0 mug/ml. With regard to other antibiotics, 54 isolates (77%) had an erythromycin MIC >/= 0.25 mug/ml, all had a spectinomycin MIC </= 16 mug/ml, and 32 (46%) had a sulfamethoxazole/trimethoprim MIC >/= 9.5/0.5 mug/ml. None of these isolates produced penicillinase.This study has helped to provide a rational basis for establishing national gonorrhoea treatment recommendations in the Central African Republic.

Evidence for two distinct types of penicillinase-producing Neisseria gonorrhoeae

Since their recognition early in 1976, penicillinase (beta-lactamase)-producing Neisseria gonorrhoeae (P.P.N.G.) have been isolated in more than 15 countries. Most strains isolated in or epidemiologically linked with the Far East are relatively resistant to tetracycline in vitro, are phenotypically wild-type or proline-dependent auxotypes, and carry a plasmid with a molecular weight of 5800 000 (5-8 X 10(6)) daltons coding for beta-lactamase production. In contrast, P.P.N.G. epidemiologically linked with West Africa are more susceptible to tetracycline, require arginine for growth, and their gene coding for beta-lactamase synthesis is contained in a smaller 3-2 X 10(6) dalton plasmid. Moreover, 43% of the Far Eastern strains, but none of those from West Africa, have an additional 24-5 X 10(6) dalton conjugative plasmid which transfers the beta-lactamase R factor(s) to other gonococci. The presence of this conjugative plasmid may explain the relatively high prevalence of P.P.N.G. in certain areas of the Far East.