040 MS disease modifying therapy (DMT) sequencing – natalizumab to cladribine tablets – experience in 20 patients

Background

Natalizumab has been used for treatment of rapidly evolving sever relapsing remitting multiple sclerosis (MS) and is associated with risk of progressive multifocal leukoencephalopathy (PML). Patients can switch treatment after two years if JCV antibody-index is positive. One of the alternative treatment options include a weight based adjusted cladribine tablets that have been approved for treatment of highly active relapsing-remitting MS in Europe since 2017.

Methods

We reviewed 20 patients with prior natalizumab-treatment that switched to oral cladribine. The objective for treatment modification was JCV-index positivity. Data was collected regarding MS relapses, disease progression, or any possible adverse events.

Results

Patients started cladribine treatment between 01/2018 and 07/2019 with a follow-up observation period from 3 weeks to 18 months. Treatment was well tolerated and there were no severe opportunistic infections.

Conclusion

According to this review of 20 patients, treatment with cladribine tablets was safe even when used in patients previously treated with natalizumab and at high risk for PML. So far, no serious adverse events other than transient lymphopenia have been observed, especially no cases of PML.

j.das@doctors.org.uk

Modeling the Multiple Sclerosis Specialist Nurse Workforce by Determination of Optimum Caseloads in the United Kingdom

Background

It is estimated that there are more than 100,000 people in the United Kingdom who have multiple sclerosis (MS). Patient experience and outcome are improved by access to a specialist nursing service. The aim of this study was to perform demand modeling to understand the need for MS nursing interventions, and thus inform modeling of the future UK MS nursing workforce.

Methods

Existing national data and specific workload and service data were collected from 163 MS specialist nurses who completed a questionnaire on activity and complexity of work both done and left undone.

Results

Data were received from across all of the United Kingdom. Twenty-nine percent of respondents were specialist nurses in the field for 3 years or less. Unpaid overtime was regularly performed by 83.4% of respondents. The MS specialist nurse was part of all areas of the patient journey. Areas of work left undone were psychological interventions, physical assessments, social interventions/benefits, and recommending or prescribing medications.

Conclusions

The current recommended caseload of 358 people with MS per full-time equivalent seems to be too high, with a considerable amount of work left undone, particularly psychosocial care. Factors such as travel time, complexity of caseload, changing drug therapies, and societal issues such as the benefits system contributed to driving demand/workload.

The Use of Digital and Remote Communication Technologies as a Tool for Multiple Sclerosis Management: Narrative Review

Despite recent advances in multiple sclerosis (MS) care, many patients only infrequently access health care services, or are unable to access them easily, for reasons such as mobility restrictions, travel costs, consultation and treatment time constraints, and a lack of locally available MS expert services. Advances in mobile communications have led to the introduction of electronic health (eHealth) technologies, which are helping to improve both access to and the quality of health care services. As the Internet is now readily accessible through smart mobile devices, most people can take advantage of eHealth apps. The development of digital applications and remote communication technologies for patients with MS has increased rapidly in recent years. These apps are intended to complement traditional in-clinic approaches and can bring significant benefits to both patients with MS and health care providers (HCPs). For patients, such eHealth apps have been shown to improve outcomes and increase access to care, disease information, and support. These apps also help patients to participate actively in self-management, for example, by tracking adherence to treatment, changes in bladder and bowel habits, and activity and mood. For HCPs, MS eHealth solutions can simplify the multidisciplinary approaches needed to tailor MS management strategies to individual patients; facilitate remote monitoring of patient symptoms, adverse events, and outcomes; enable the efficient use of limited resources and clinic time; and potentially allow more timely intervention than is possible with scheduled face-to-face visits. These benefits are important because MS is a long-term, multifaceted chronic condition that requires ongoing monitoring, assessment, and management. We identified in the literature 28 eHealth solutions for patients with MS that fall within the four categories of screening and assessment, disease monitoring and self-management, treatment and rehabilitation, and advice and education. We review each solution, focusing on any clinical evidence supporting their use from prospective trials (including ASSESS MS, Deprexis, MSdialog, and the Multiple Sclerosis Performance Test) and consider the opportunities, barriers to adoption, and potential pitfalls of eHealth technologies in routine health care.

Effect of a New Purified Collagen Matrix With Polyhexamethylene Biguanide on Recalcitrant Wounds of Various Etiologies: A Case Series

INTRODUCTION

The management of chronic, nonhealing wounds in patients with multiple comorbidities continues to be a challenge for health care practitioners. Chronic wounds typically do not progress through the normal phases of wound healing and generally remain stagnant during the inflammatory phase, resulting in an increase in proteolytic enzymes with degradation of the extracellular matrix. Bacterial biofilm has been documented to be one of the main factors delaying wound healing, resulting in the prolongation of the inflammatory phase.

OBJECTIVE

In order to control biofilm formation, sequester proteolytic enzymes, and provide a biocompatible scaffold to support healing, the investigators utilize a purified collagen matrix containing polyhexamethylene biguanide (PCMP) in a case series of 9 wounds on 8 patients with multiple comorbidities who did not respond to previous conventional or adjuvant therapy.

MATERIALS AND METHODS

Wound etiologies included 3 pressure ulcers, 1 diabetic foot ulcer, 1 venous leg ulcer, 2 postsurgical wound dehiscences, 1 ulcer secondary to calciphylaxis, and 1 traumatic wound secondary to hematoma. The average wound size at the first PCMP application was 34.0 cm2, and the wounds were present for an average of 9.2 weeks prior to the first PCMP application.

RESULTS

Patients received an average of 5.8 PCMP applications. Of the 6 wounds that healed, average time to closure from the first PCMP application was 10 weeks. The remaining 3 wounds demonstrated improved wound appearance with 100% granulation tissue and an average area reduction during PCMP treatment of 61.4%.

CONCLUSIONS

This case series demonstrated that PCMP along with good wound care supported both wound closure and improvements in wound bed condition and area reduction on recalcitrant, nonhealing wounds of various etiologies.

183 EXERCISE INFLUENCES EMBRYO QUALITY IN MARES

Athletic mares are commonly utilized in an embryo transfer regimen during the breeding season, which allows owners to continue to train and compete with these animals. Exercising mares in a hot and humid environment has proven detrimental to embryo recovery rates. However, the effects of exercise under milder temperatures have not been examined. Our goal was to compare embryo recovery rates and embryo quality scores of mares under mild environmental conditions of 2 differing exercise regimens v. a single control group (n = 5). One treatment group (full exercise) consisted of mares (n = 5) exercised 6 days a week throughout the duration of the project. The partial-exercise group (n = 5) was exercised throughout the duration of the project 7 days a week, with full rest from day of detected ovulation to the proceeding embryo collection attempt. This was to limit any deleterious effects exercise may potentially have on the mare and subsequent early developing equine embryo. Exercise resumed the day after an embryo collection attempt for the partial-exercise group. Exercised mares were given a 1-month training period prior to the beginning of this project and were moderately exercised for 30 min in a mechanical exercise pen (free exerciser). Control mares were managed similarly as the other groups, however were not exercised. Mares were bred via artificial insemination and embryos were nonsurgically collected 7 d post-ovulation. Mean environmental temperature during the duration of this study was 27.1°C with average 60% humidity. Immediately following completion of exercise, mares in the full exercise group had a mean temperature increase of 1.0°C and partial-exercised mares increased 0.9°C. Exercise had a significant effect on embryo quality (P < 0.05, Table 1) but did not influence embryo recovery rate. The mean embryo quality score for the control group was 1.1, whereas the full-exercised group was 1.85 and partial-exercised group was 2.5. It appears from these data that exercise has a negative effect on embryo quality, thus lowering the availability of transferable embryos. Embryos of lower quality (≥3) have been shown to result in poor pregnancy rates in horses. Additionally, rest from ovulation to an embryo collection attempt did not improve embryo quality. Table 1.Embryo recovery rate and quality score of embryos from control and exercised mares

Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: challenges and lessons learned

Integrating HIV prevention into the clinical care of people living with HIV has emerged as a priority in the US As part of a cross-site evaluation this study examined the processes by which 15 clinic-based projects implemented interventions funded under the Health Resources and Services Administration's (HRSA) HIV Prevention with Positives (PwP) in Clinical Settings Initiative. We conducted 61 in-depth interviews with researchers and interventionists across the 15 projects. Intervention implementation was feasible assuming several key components were in place: (1) internal leadership to overcome resistance and foster interest and motivation among clinical providers and staff; (2) adequate attention to creating seamless flow between clinic practice and intervention; and (3) ongoing training that met clinician and staff needs as prevention interventions become a regular part of care. Interventions well matched to the clinical environment and the patient populations were feasible and acceptable to health care providers, prevention interventionists, and clinic staff.

HIV surveillance in theory and practice: assessing the acceptability of California's non-name HIV surveillance regulations

In 2002, California adopted a non-name system for HIV case reporting. This study focused on the acceptability of a non-name reporting system among key stakeholders implementing the system. We conducted qualitative research during the pre- and post-implementation period of the non-name HIV reporting regulations. During both study periods we conducted key informant in-depth interviews (n = 48 and 52, respectively) with health department surveillance staff, laboratory personnel, health care providers and clinic staff; and we conducted four focus group discussions (n = 28 and 30, respectively) with representatives of community-planning group members and advocacy groups. We found that overall, California's non-name HIV reporting regulations were acceptable to most key stakeholders. Acceptability of a non-name system was highest among advocates and healthcare providers. Views of health department staff varied across the four counties, with some expressing a strong preference of a names based system and others accepting the non-name system.

What's community got to do with it? Implementation models of syringe exchange programs

Syringe exchange programs (SEPs) have been shown to be highly effective in reducing HIV transmission among injection drug users (IDUs). Despite this evidence, SEPs have not been implemented in many communities experiencing HIV epidemics among IDUs. We interviewed 17 key informants in nine U.S. cities to identify factors and conditions that facilitated or deterred the adoption of SEPs. Cities were selected to represent diversity in size, geographic location, AIDS incidence rates, and SEP implementation. Key informants included HIV prevention providers, political leaders, community activists, substance use and AIDS researchers, and health department directors. SEPs were established by one or more of three types of implementation models: (a) broad community coalition support, (b) community activist initiative, and (c) top-down decision making by government authorities. In each model, coalition building and community consultation were critical steps for the acceptance and sustainability of SEPs. When others were not prepared to act, community activists spearheaded SEP development, taking risks in the face of opposition, but often lacked the resources to sustain their efforts. Leadership from politicians and public health officials provided needed authority, clout, and access to resources. Researchers and scientific findings lent force and legitimacy to the effort. Rather than adopting adversarial positions, successful SEP implementers worked with or avoided the opposition. Fear of repercussions and lack of leadership were the greatest barriers to implementing SEPs. Communities that successfully implemented SEPs were those with activists willing to push the agenda, public officials willing to exercise leadership, researchers able to present authoritative findings, and proponents who effectively mobilized resources and worked to build community coalitions, using persistent but nonadversarial advocacy.

Missed Opportunities: Prevention With HIV-Infected Patients in Clinical Care Settings

OBJECTIVE

To assess current practices related to prevention with HIV-positive patients in Ryan White-funded primary care settings and the barriers to providing such services.

METHOD

Exit surveys about HIV prevention services were conducted with 618 HIV-infected patients at 16 primary HIV care clinics receiving Ryan White CARE Act funding. To place the exit survey findings in context, qualitative in-depth interviews were conducted with 16 clinic administrators, 32 primary care providers, 32 support service providers, and 64 patients.

RESULTS

One quarter of patients reported having had a general discussion of "safer sex and ways to prevent transmission to others" during that day's primary care visit. However, only 6% reported discussing specific sexual activities. HIV prevention counseling was less common than counseling for adherence to antiretroviral therapy, emotional issues, and diet and nutrition (P < 0.001). Patients in clinics with established procedures for HIV prevention counseling were significantly more likely to report receiving such services (odds ratio = 2.17). Qualitative interviews identified barriers to providing prevention services as lack of time, training, funding for staffing, and providers' understanding of their roles and responsibility.

CONCLUSIONS

HIV prevention counseling is not routine in most clinics, and the low frequency of such services represents missed opportunities for HIV prevention.

Why HIV Infections Have Increased Among Men Who Have Sex with Men and What to Do About It: Findings from California Focus Groups

A resurgence of sexual risk taking, STDs, and HIV incidence has been reported among men who have sex with men (MSM) in several countries. We asked 113 MSM in 12 focus groups conducted in five California cities to identify factors leading to increased risk taking and assess prevention messages to reduce risk in this population. Participants perceived that HIV risk taking has increased because (1) HIV is not the threat it once was due to more effective therapies, (2) MSM communicate less about HIV, and social support for being safe has decreased, and (3) community norms have shifted such that unsafe sex is more acceptable. The prevention messages ranked most likely to motivate risk reduction encouraged individuals to seek social support from friends. Themes ranked least likely to succeed were those that described the negative consequences of HIV or reinforced existing safer sex messages.

Attitudes to long-term care in multiple sclerosis

At a recent conference workshop, a group of specialist nurses examined their attitudes towards individuals with multiple sclerosis moving into long-term care. This article summarises how the group members examined their attitudes, the literature reviewed and what was learnt by sharing experiences. It also suggests how nurses could promote positive attitudes towards, and ease, the transition of patients into long-term residential care.

Specialist nurse network improves MS practice

This article looks at the development of a group dedicated to meeting the clinical supervision and networking needs of multiple sclerosis nurse specialists. It describes the evolution of the group, the structure and content of group meetings and how they have both improved practice and reduced the isolation of MS specialists who work independently. The nurses involved have found that working collaboratively and developing an interactive network has not only significantly affected their clinical practice but also helped to address work-related stress.

Drug users talk about HIV testing: motivating and deterring factors

Injection drug use plays a critical role in the spread of HIV/AIDS, with an estimated 19,000 drug users infected each year. Counselling and testing services can be an important gateway for engaging HIV-infected individuals into medical care and can positively influence the preventive behaviours of IDUs. This study seeks to document and understand the complexity and range of motivations and deterrents to HIV testing among IDUs. Participants were recruited using a convenience sampling method. Interviews consisted of a qualitative guide and a quantitative survey to collect HIV testing histories, sex and drug risk behaviours, and demographic information. Interview data was coded and content analyzed to identify emerging themes and clarify the processes that drug users employ in deciding whether or not to test. Sixty-six drug users were interviewed. The sample reported a median of four lifetime HIV tests. Participants described a range of motivating and deterring factors to HIV testing across personal, interpersonal and structural categories. Drug users' decision to test is influenced by a complex network of factors. Better understanding of these motivators and deterrents can help providers develop a more holistic approach to targeting this high-risk population for HIV prevention efforts.

Voices from the field: providers discuss HIV counseling and testing programs for drug users

The use of illicit drugs plays a critical role in the spread of HIV, with approximately one-half of all new HIV infections in the United States attributed to this mode of transmission. There is a renewed emphasis on developing special HIV counseling and testing (C&T) programs for drug users. We conducted a qualitative study of C&T providers to identify client-centered and structural barriers to providing HIV C&T to high-risk drug users. Interviews focused on obtaining a detailed description of the services; successful and problematic forms of organization, financing, and service delivery; client access and barriers to C&T services; recommendations for increasing C&T accessibility and utilization by drug users; and linkages between C&T and other HIV-prevention and intervention services. The results of our interviews illustrate that it is tremendously complex and challenging work to provide C&T to populations with multiple and immediate needs within a context of layered constraints on individual behavior, provider resources, and service delivery. Providers clearly understand client-centered and structural barriers and have demonstrated a commitment to overcoming the barriers related to AIDS stigma, confidentiality, material needs, and fear when delivering HIV C&T services.

A method for determining patient oral care skills: The University of Mississippi Oral Hygiene Index

The plaque control record (O'Leary index) appears to be a commonly used oral hygiene index for assessing oral health skills. This index provides sufficient information for patient education; however, the time involved in data collection reduces its value. Most other indices limit the number of teeth and surfaces and function well for researchers, but are limited for patient education. A new oral hygiene index was developed based on the concepts of the Periodontal Screening and Recording (PSR). The highest score obtained in each buccal and lingual sextant is recorded. In addition, proximal and gingival plaque are noted separately. This study assesses the index for inter- and intrarater reliability and validity. Two calibrated hygienists examined 47 patients 3 times. The University of Mississippi Oral Hygiene Index (UM-OHI) was recorded for times 1 and 3, the O'Leary for time 2. There was a strong positive correlation between scores obtained for both hygienists for each method and repetition. The intrarater reliability was high for the 2 methods and also over time for the UM-OHI. Pearson's correlation coefficients ranged from 0.79 to 0.92. Paired t-tests used to compare scores for the 2 hygienists over time showed significant differences. Despite observer bias, these data seem to indicate that the UM-OHI has sufficient reliability and validity to be used as a health education teaching tool.

Ultrastructural localization of Helix pomatia agglutinin (HPA)-binding sites in human breast cancer cell lines and characterization of HPA-binding glycoproteins by western blotting

Ultrastructurally, cells of five human breast cancer cell lines (MCF7, BT549, BT20, T47D, and HBL100) generally displayed many characteristics of their epithelial origin. The most distinctive features were observed in MCF7 cells, which consistently showed microvilli and submembranous granules. These ultrastructural findings served as a basis for localizing the binding sites of the lectin Helix pomatia agglutinin (HPA). After use of the pre-embedding method consistent HPA labeling of the cell membrane was obtained in all the cell lines, and in association with microvilli and submembranous granules in the MCF7 cells. The HBL 100 cells were not labeled by HPA irrespective of the method used. In addition, lysates from these cell lines were subjected to polyacrylamide gel electrophoresis and Western blotting with HPA to analyze these binding sites further. In the Western blots, however, lysates of JBL100 cells, in common with all those from the other cell lines, revealed a number of HPA-reactive bands, indicating the greater sensitivity of Western blots compared with the histochemical preparation. The principal band was of approximately 90 kDa, and it was suggested that this could be related to the transferrin receptor.

Microbes at work: micro-organisms, the D.S.I.R. and industry in Britain, 1900-1936

The study of micro-organisms in Britain in the early twentieth century was dominated by medical concerns, with little support for non-medical research. This paper examines the way in which microbes came to have a place in industrial contexts in the 1920s and early 1930s. Their industrial capacity was only properly recognized during World War I, with the development of fermentation processes to make required organic chemicals. Post-war research sponsored by chemical and food industries and the D.S.I.R established the industrial significance of microbes. The primary focus here is the D.S.I.R. work which aimed to pull microbes away from medical concerns and promote the role of microbes in British industry.