Usability and feasibility of a take-home methadone web-application for opioid treatment program patients: A Small Business Innovation Research mixed methods study

BACKGROUND

Most patients in opioid treatment programs (OTPs) attend daily for observed dosing. A Stage IA (create and adapt) and a Stage IB (feasibility and pilot) mixed method studies tested a web-application (app) designed to facilitate access to take-home methadone.

METHODS

A Stage IA, intervention development study, used qualitative interviews to assess the usability (ease of use) and feasibility (ability to implement) of a take-home methadone app. The Stage IA market research was a two-week test with 96 patient participants from four OTPs. Qualitative interviews were completed with 20 systematically selected individuals who used the take-home app and 20 OTP clinicians (five each from the four OTPs). The Stage IB Small Business Innovation Research (SBIR) study (24 patients and 8 clinicians in a single OTP) included quantitative assessments of the app's usability, acceptability, appropriateness, and feasibility. Thematic analysis coded participant and staff assessments of the take-home app.

RESULTS

Stage IA patients (mean age = 41 years; 52 % men, 57 % White) and IB patients (mean age = 38 years, 54 % men, 79 % White) described the app as "easy to use." Compared to unsupervised take-homes, some patients preferred using the take-home app. In Stage IB, patients rated the app highly on standardized measures of usability, acceptability, appropriateness, and feasibility. Clinician ratings were more ambivalent. Patients rated in-clinic dosing as more disruptive than unsupervised take-homes and take-homes using the app.

DISCUSSION

A Stage IA study informed the development and maturation of a Stage IB feasibility pilot study. Overall, the take-home app's usability, acceptability, appropriateness, and feasibility were rated positively. Clinical staff ratings were less positive, but individuals commented that using the app a) enhanced patient quality of life, b) provided new tools for counselors, and c) offered competitive advantages. The SBIR award enhanced market research with more complete and systematic data collection and analysis.

A comparison of the efficacy of trastuzumab deruxtecan in advanced HER2-positive breast cancer: active brain metastasis versus progressive extracranial disease alone

BACKGROUND

Trastuzumab deruxtecan (T-DXd) has demonstrated efficacy in patients with brain metastasis (BM), a group historically with poor outcomes. The prevalence of BMs in patients commencing T-DXd is currently unknown. No direct comparisons have been made of the activity of T-DXd in patients with active BM versus those with extracranial progression alone. This real-world study explored the prevalence of BMs in patients commencing T-DXd, the efficacy of T-DXd in active BM versus extracranial progression alone and the safety of T-DXd.

PATIENTS AND METHODS

Patients with human epidermal growth factor receptor 2-positive advanced breast cancer treated with T-DXd between June 2021 and February 2023 at our specialist cancer hospital were identified and notes reviewed. Clinicopathological information, prior treatment, the presence or absence of central nervous system (CNS) disease, outcomes and treatment-emergent adverse events (TEAEs) were recorded.

RESULTS

Twenty-nine female patients, with a median age of 52 years (interquartile range 44-62 years), were identified; the prevalence of BM was 41%. Median number of lines of prior therapy was 2 (range 2-6). At a median follow-up of 13.8 months, median progression-free survival (PFS) for the overall population was 13.9 months [95% confidence interval (CI) 12.4 months-not estimable (NE)], 16.1 months (95% CI 15.1 months-NE) for active BMs and 12.4 months (95% CI 8.3 months-NE) for progressive extracranial disease alone. The 12-month overall survival (OS) rate was 74% (95% CI 59% to 95%) in the overall population, and 83% (95% CI 58% to 100%) and 66% (95% CI 45% to 96%) for active BMs and extracranial disease only, respectively. Most common TEAEs were fatigue, alopecia, and constipation. In nine patients (31%, including two deaths), pneumonitis occurred.

CONCLUSION

In this real-world population, we demonstrate T-DXd to be effective in patients with active BMs and those with progressive extracranial disease alone. PFS and OS were numerically longer in those with active BMs. These data demonstrate that patients with active BM treated with T-DXd have at least comparable outcomes to those with extracranial disease alone. The high rate of pneumonitis warrants further consideration.

Magnetic resonance quantification of skeletal muscle lipid infiltration in a humanized mouse model of Duchenne muscular dystrophy

Rodent models of Duchenne muscular dystrophy (DMD) often do not recapitulate the severity of muscle wasting and resultant fibro-fatty infiltration observed in DMD patients. Having recently documented severe muscle wasting and fatty deposition in two preclinical models of muscular dystrophy (Dysferlin-null and mdx mice) through apolipoprotein E (ApoE) gene deletion without and with cholesterol-, triglyceride-rich Western diet supplementation, we sought to determine whether magnetic resonance imaging and spectroscopy (MRI and MRS, respectively) could be used to detect, characterize, and compare lipid deposition in mdx-ApoE knockout with mdx mice in a diet-dependent manner. MRI revealed that both mdx and mdx-ApoE mice exhibited elevated proton relaxation time constants (T2 ) in their lower hindlimbs irrespective of diet, indicating both chronic muscle damage and fatty tissue deposition. The mdx-ApoE mice on a Western diet (mdx-ApoEW ) presented with greatest fatty tissue infiltration in the posterior compartment of the hindlimb compared with other groups, as detected by MRI/MRS. High-resolution magic angle spinning confirmed elevated lipid deposition in the posterior compartments of mdx-ApoEW mice in vivo and ex vivo, respectively. In conclusion, the mdx-ApoEW model recapitulates some of the extreme fatty tissue deposition observed clinically in DMD muscle but typically absent in mdx mice. This preclinical model will help facilitate the development of new imaging modalities directly relevant to the image contrast generated in DMD, and help to refine MR-based biomarkers and their relationship to tissue structure and disease progression.

999 ACUTE FRAILTY ASSESSMENT UNIT: A 6-MONTH QUALITATIVE STUDY OF READMISSIONS WITHIN 28 DAYS OF DISCHARGE & COLLECTIVE CASE ANALYSIS

Introduction

Readmissions can have a negative impact on the care of frail individuals in regards to increased length of stay, healthcare-related harm, reduced quality of life and mortality. Review of frailty readmissions should lead to improvements of frailty care and clinical effectiveness.

Method

We conducted a retrospective, qualitative analysis of readmissions of frail individuals discharged from our Acute Frailty Unit (AFU) over a six-month period. This is a collective case study in which we used instrumental cases to highlight specific learning points. We used the Electronic Patient Records database to measure the total number of readmissions related to AFU discharges. The Framework methodology was then utilised to further analyse and cluster cases. Common themes linked to readmissions and the time-to-readmission were studied, leading to structured (SMART) quality improvement interventions.

Results

Four hundred and thirty individuals were discharged from AFU. Eighty-nine (21%) were readmitted within 28 days of index hospital admission. Fifty-eight percent (50/89) of individuals were readmitted to hospital (any ward) with a different presenting complaint compared to index admission. Twenty-two (25%) cases were readmitted with the same initial complaint, while nine (10%) experienced problems due to ineffective discharge planning. In eight (7%) cases, readmission was linked to healthcare-associated complications. Forty (45%,40/89) individuals stayed at home for <7 days after their index discharge, whilst the remaining forty-nine (55%) returned to hospital after 7–28 days. Only eight (9%) readmissions were from care home settings. A bundle of SMART interventions has been developed, including post-discharge support with acute frailty clinics, enhanced frailty dietetic support and improved communication with community partners.

Conclusion

(s) This collective case study shares important learnings related to the readmission patterns of acute frailty units. Individual case studies are essential in understanding the ways that patient-centred care should be tailored to become more effective.

SARS-CoV-2 monitoring at three sewersheds of different scales and complexity demonstrates distinctive relationships between wastewater measurements and COVID-19 case data

Wastewater monitoring of SARS-CoV-2 presents a means of tracking COVID-19 community infection dynamics on a broader geographic scale. However, accounting for environmental and sample-processing losses may be necessary for wastewater measurements to readily inform our understanding of infection prevalence. Here, we present measurements of the SARS-CoV-2 N1 and N2 gene targets from weekly wastewater samples at three sites in Hamilton County, Ohio, during an increase and subsequent decline of COVID-19 infections. The concentration of N1 or N2 RNA in wastewater, measured over the course of six months, ranged from below the detection limit to over 10⁴ gene copies/l, and correlated with case data at two wastewater treatment plants, but not at a sub-sewershed-level sampling site. We also evaluated the utility of a broader range of variables than has been reported consistently in previous work, in improving correlations of SARS-CoV-2 concentrations with case data. These include a spiked matrix recovery control (OC43), flow-normalization, and assessment of fecal loading using endogenous fecal markers (HF183, PMMoV, crAssphage). We found that adjusting for recovery, flow, and fecal indicators increased these correlations for samples from a larger sewershed (serving ~488,000 people) with greater industrial and stormwater inputs, but raw N1/N2 concentrations corresponded better with case data at a smaller, residential-oriented sewershed. Our results indicate that the optimal adjustment factors for correlating wastewater and clinical case data moving forward may not be generalizable to all sewersheds.

293 A Reflection of Experience Gained in Emergency General Surgery During The COVID-19 Pandemic at A London University Hospital

Background

During COVID-19, acute surgical services witnessed an overhaul of practice due to constraints on staff and resource (beds, imaging, and theater) availability. Fear of COVID-19, among general population potentially added to delay in patients seeking medical assistance. This study describes experiences of acute general surgery at a COVID-19 designated tertiary institution wherein elective surgical work was put on hold and emergency on-call rota was modified during the pandemic.

Method

A retrospective analysis (March-April 2019 vs 2020) of the surgical work from a prospectively maintained surgical database during COVID-19 was performed.

Results

Emergency surgical admissions during March 2020 vs 2019 was 106 vs 207. Comparing the workload March-April 2020 vs 2019, emergency referrals were 266 vs 341, operations performed 71 vs 92. 31.5% (84/266) of patients were tested for COVID and 30% (25/84) were positive. Emergency surgery was performed in 71 patients (including appendectomies (28), hernia repair(3), laparotomy(3), Hartman’s procedure(3), hemicolectomy(7) and anterior resection with covering ileostomy(2)). In this group, a male preponderance was noted (M:F 1.84:1), the average age was 43.2 years (6-91), length of stay 4.8 days (<23 hours-34 days). In the operative group, the 30-day mortality was 4.23% (3/71) and the morbidity was 31%.

Conclusions

With local changes, stopping elective services, modifying on-call rota, a surgical department can continue to be functional and offer emergency surgical service for a sustained period during a pandemic. During the COVID pandemic, the average number of referrals, admissions and surgeries were lower when compared to the non-covid period.

Kidney function decline in heart failure patients: an audit of out-patient heart failure services

Funding Acknowledgements

Type of funding sources: None.

Background

A bidirectional relationship exists between the kidney and the heart; the lower the eGFR the more challenging it is to manage the heart failure (HF) patient. Worsening renal function is common in HF patients and associated with a two-fold increase in mortality and a lower likelihood of being prescribed efficacious HF therapy. The role of cardio-renal interactions in HF is essential to identify risk and subsequent treatment strategies.

Purpose

The purpose of this audit is to provide insights into the assessment of renal function in a real world heart failure population by identifying the degree of renal dysfunction and changes in renal function over a five year time frame.

Methods

A retrospective audit included patients with HFrEF attending a heart failure service. These patients were classified using KIDGO criteria CKD 1-5. A current eGFR sample was compared with a sample taken five years earlier, identified using the electronic laboratory record. Ethical approval was granted from the Research Ethics Committee.

Resultss

100 patients with HFrEF attending a heart failure service fulfilled the selection criteria of which sixty three patients with an eGFR &gt;60ml/min/1.73 m2 were audited. Of this group 43 were CKD class 2 and 20 were CKD class 1. Thirty seven patients had an eGFR &lt;60ml/min/1.73 m2 of which 9 were class 3b, 9 were CKD class 4 and 1 was CKD Class 5.

Of the 100 patients enrolled, 6 were excluded from the analysis of kidney function decline as an eGFR from five years earlier was unavailable. Within a five year time span, 44 patients did not change their CKD class, 31 patients declined by one class, 9 patients declined by two classes, 3 patients declined by three classes and 7 patients improved their kidney function.

GFR &lt; 60mL/min/1.73m2,

n = 37

GFR &gt; 60mL/min/1.73m2, n = 63

Age – mean (range)

77.8 (49-94)

66.5 (45-89)

Gender – female (%)

12 (32%)

16 (25%)

Average renal function measurements (mean, range)

6.4

6.7

Total albumin

creatinine ratio measurements

8

6

Actively attending renal service

6

0

Conclusion

Nurses should be aware of the increasing risk conferred by the dual diagnosis of heart failure and chronic kidney disease. Patients with heart failure who have decreasing eGFR levels (especially less than 30 mL/min), should have collaborative management with nephrology services to optimise outcomes. Recognition of CKD in our institution and referral to nephrology services was suboptimal and further work is necessary to optimise the management of these patients.

0257 Preliminary Findings: Attentional Bias for Food Cues Unrelated to Time Awake or Circadian Phase During Forced Desynchrony in Adolescents

Introduction

Sleep quantity and quality influence attentional bias, and attentional bias for food cues has been associated with body weight. Whether the endogenous circadian cycle and/or time from awakening to bedtime contribute to attentional bias for food and differences in weight remain unclear. Using a 28-h forced desynchrony (FD) design, we hypothesized that adolescents with overweight (OW) and obesity (O) would have more attentional bias for food cues later in the wake episode and at a later circadian phase compared to adolescents with a healthy weight (HW).

Methods

50 (28 male) adolescents (12-15yr) completed 7 FD cycles. Participants completed an attentional bias task that included three food word categories (savory, sweet, fruits/vegetables) and one non-food word category (school supplies). The task was completed at 6 fixed times each cycle: Task 1 was 1.3h after scheduled awaking, Task 2 was 2h after Task 1, and Tasks 3–6 followed at 3-h intervals. Weight categorization used body mass index (BMI) percentiles (CDC): HW (&gt;5th and &lt;85th; n=24), OW (85th and &lt;95th; n=13), or O (≥95th; n=14). Endogenous circadian period was determined using salivary melatonin onsets (Mean: HW=23.88h; OW=24.01h; O=23.86h). Effect of circadian phase and time since scheduled awakening was assessed by mixed effects modeling using 6 circadian and 6 time-awake bins.

Results

We found no significant differences between weight groups in attentional bias for any of the food categories (p’s &gt;.05). We also saw no significant time awake effects or circadian influence on attentional bias, nor did time awake or circadian phase moderate the associations between weight category and attentional bias (p’s &gt;.05).

Conclusion

Weight groups did not impact food-related attentional bias across the wake episode or circadian phase. Future directions will explore whether attentional bias for food types predicts food choice and food consumption in this study.

Support

DK101046

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Basiliximab treatment for autoimmune bowel disease in a pediatric heart transplant patient

Autoimmune-mediated bowel disease has been reported after pediatric heart transplantation. Recognition and treatment of these patients has been difficult. We describe a patient who responded to steroids and basiliximab therapy after an inflammatory process secondary to abnormal T-cell activation. Our patient is a 28-month-old female who received a heart transplant at five wk of age. At 24 months post-transplant, she developed fever and bloody stools. Initial investigations were significant for an elevated ESR (>120) and CRP (15.2). Symptoms persisted despite bowel rest and mycophenolate discontinuation. Endoscopic evaluation revealed discontinuous ulcerative disease involving esophagus, terminal ileum, right and left colon, necessitating extensive bowel resection. She had additional airway inflammation leading to a TEF at the site of esophageal ulceration, requiring tracheostomy. Immune evaluation revealed autoimmune dysregulation that responded to parenteral methylprednisolone. Chronic basiliximab therapy allowed for successful weaning of steroids with sustained remission. She has been transitioned to sirolimus and tacrolimus maintenance immunosuppression with plans to discontinue basiliximab once off steroids. In conclusion, bowel disease in the setting of pediatric heart transplantation can be severe and refractory to traditional treatment methods. Tailoring immune therapy to activated T cells can result in remission. Basiliximab therapy was used in our patient to maintain steroid-induced remission, but long-term complications of this disease process are unknown.

Violent and non-violent crime against adults with severe mental illness

BACKGROUND

Little is known about the relative extent of crime against people with severe mental illness (SMI).

AIMS

To assess the prevalence and impact of crime among people with SMI compared with the general population.

METHOD

A total of 361 psychiatric patients were interviewed using the national crime survey questionnaire, and findings compared with those from 3138 general population controls participating in the contemporaneous national crime survey.

RESULTS

Past-year crime was experienced by 40% of patients v. 14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0-3.8); and violent assaults by 19% of patients v. 3% of controls (adjusted OR = 5.3, 95% CI 3.1-8.8). Women with SMI had four-, ten- and four-fold increases in the odds of experiencing domestic, community and sexual violence, respectively. Victims with SMI were more likely to report psychosocial morbidity following violence than victims from the general population.

CONCLUSIONS

People with SMI are at greatly increased risk of crime and associated morbidity. Violence prevention policies should be particularly focused on people with SMI.

Laparoscopic incisional and ventral hernia repair in a district general hospital

INTRODUCTION

The laparoscopic approach to repairing ventral and incisional hernias has gained increasing popularity worldwide. We reviewed the experience of laparoscopic ventral hernia repair at a district general hospital in the UK with particular reference to patients with massive defects (diameter ≥15cm) and the morbidly obese.

METHODS

A total of 144 patients underwent laparoscopic ventral (incisional or umbilical/paraumbilical) hernia repair between April 2007 and September 2012.

RESULTS

The prevalence of conversion to open surgery was 2.8%. The prevalence of postoperative complications was 3.5%. Median postoperative follow-up was 30.2 months. A total of 5.6% cases suffered late complications and 2.8% developed recurrence. Thirty-four patients underwent repair of defects ≥10cm in diameter with a prevalence of recurrence of 5.6%. Sixteen patients underwent repair of 'massive' incisional hernia (diameter ≥15cm) with a prevalence of recurrence of 12.5%. Sixteen patients with a body mass index (BMI) ≥40kg/m(2) (range, 40-61kg/m(2)) underwent laparoscopic repair with a prevalence of recurrence of 6.3% (p>0.05 vs BMI <40kg/m(2)).

CONCLUSIONS

Laparoscopic ventral hernia repair can be carried out safely with a low prevalence of recurrence. It may have advantages in morbidly obese patients in whom open repair would represent a significant undertaking. Laparoscopic ventral hernia repair may be used in cases of large and massive hernias, in which the risk of recurrence increases but is comparable with open repair and associated with low morbidity.

Domestic and sexual violence against patients with severe mental illness

BACKGROUND

Domestic and sexual violence are significant public health problems but little is known about the extent to which men and women with severe mental illness (SMI) are at risk compared with the general population. We aimed to compare the prevalence and impact of violence against SMI patients and the general population.

METHOD

Three hundred and three randomly recruited psychiatric patients, in contact with community services for ⩾ 1 year, were interviewed using the British Crime Survey domestic/sexual violence questionnaire. Prevalence and correlates of violence in this sample were compared with those from 22 606 general population controls participating in the contemporaneous 2011/12 national crime survey.

RESULTS

Past-year domestic violence was reported by 27% v. 9% of SMI and control women, respectively [odds ratio (OR) adjusted for socio-demographics, aOR 2.7, 95% confidence interval (CI) 1.7-4.0], and by 13% v. 5% of SMI and control men, respectively (aOR 1.6, 95% CI 1.0-2.8). Past-year sexual violence was reported by 10% v. 2.0% of SMI and control women respectively (aOR 2.9, 95% CI 1.4-5.8). Family (non-partner) violence comprised a greater proportion of overall domestic violence among SMI than control victims (63% v. 35%, p < 0.01). Adulthood serious sexual assault led to attempted suicide more often among SMI than control female victims (53% v. 3.4%, p < 0.001).

CONCLUSIONS

Compared to the general population, patients with SMI are at substantially increased risk of domestic and sexual violence, with a relative excess of family violence and adverse health impact following victimization. Psychiatric services, and public health and criminal justice policies, need to address domestic and sexual violence in this at-risk group.

[Coagulation disorders in the intensive care station]

Coagulation disorders are frequently encountered in the intensive care unit (ICU) and are challenging due to a variety of potential etiologies. Critically ill patients with coagulation abnormalities may present with an increased risk of bleeding, show coagulation activation resulting in thromboembolism, or have no specific symptoms. Hemostatic abnormalities observed in ICU patients range from isolated thrombocytopenia or prolonged global clotting tests to complex and life-threatening coagulation defects. Successful management of coagulation disorders requires prompt and accurate identification of the underlying cause. This review describes the most frequently occurring diagnoses found in intensive care patients with thrombocytopenia and coagulation test abnormalities and summarizes appropriate diagnostic interventions and current approaches to differential diagnosis.

Inborn Error of Metabolism (IEM) screening in Singapore by electrospray ionization-tandem mass spectrometry (ESI/MS/MS): An 8 year journey from pilot to current program

IEM screening by ESI/MS/MS was introduced in Singapore in 2006. There were two phases; a pilot study followed by implementation of the current program. The pilot study was over a 4 year period. During the pilot study, a total of 61,313 newborns were screened, and 20 cases of IEM were diagnosed (detection rate of 1:3065; positive predictive value (PPV) of 11%). Regular self-review, participation in external quality assessment and the Region 4 Genetic collaborative programs (http://www.region4genetics.org/) had led to the robust development of our current NBS MS/MS program. Overall, from July 2006 to April 2014, we screened a total of 177,267 newborns. The mean age at the time of sampling was 47.9h. Transportation of samples to the testing laboratory averaged 0.92 day. Upon receipt of sample, the NBS result was available within 1.64 days and within 3.8 days if a second tier test was required. Using absolute cut-off values in place of the initial 99th percentile reference range for the analyte markers and the introduction of two 2nd tier tests (MMA and Succinylacetone) had significantly reduced the high recall rate from an initial 1.5% during the period 2006-07 to 0.12% in 2013. The NBS MS/MS program was supported by a centralized confirmatory/diagnostic testing laboratory and a rapid response team of metabolic specialists. The detection rate was 1: 3165 (1:2727 if maternal conditions were also included). There were 23 newborns affected with organic acidemias (incidence: 1:6565), 23 with fatty acid oxidation disorders (incidence: 1:6565), and 10 with amino acidopathies (incidence 1:17,726). The performance metrics for the screening test were acceptable (sensitivity: 95.59%, specificity: 99.85%, PPV: 20%, FPR: 0.15). Participation in the NBS MS/MS program by hospitals was voluntary, and in 2013, the uptake rate was 71% of the annual births. We hope that newborn screening by MS/MS will become a standard of care for all babies in Singapore.