Mixed-methods needs assessment for development of school-based mental health implementation science capacity in low- and middle-income countries: Vietnam as a case example

Worldwide, the majority of youth reside in low- and middle-income countries (LMIC). School-based mental health (SBMH) services are particularly important in LMIC, in part because of LMIC's limited mental health infrastructure. Among the challenges to developing SBMH in LMIC are limited implementation science (IS) capacity, critical for identifying barriers to evidence-based intervention (EBI) use and dissemination, etc., specific to the local country context. A key step in IS capacity development is conducting a needs assessment, to identify barriers (and their solutions) to IS development itself within the local context. The present study conducted an IS needs assessment focused on SBMH in the Southeast Asian LMIC of Vietnam. Seventy-five Vietnamese mental health professionals in SBMH-related fields participated in a mixed-methods study. Vietnamese SBMH researchers and practitioners most likely to have experience and/or interest in IS were selected for study recruitment. Professionals' formal understanding of and experience with IS as a scientific field was highly limited. However, after reading a brief but detailed description of IS, participants' interest in IS training was high, and their mean rating of its potential utility for Vietnam to develop SBMH was 4.7 on a 1-5 scale. Participants also reported on barriers and potential solutions for EBI use in SBMH in Vietnam. Contrary to expectations, the most frequent and severe barriers were not financial but related to limited stakeholder engagement. Overall, these and other study results provide some suggestions how IS capacity to support SBMH may be most efficiently developed in settings such as Vietnam. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Study Review of the Appropriateness of Oral Antibiotic Discharge Prescriptions in the Emergency Department at a Rural Hospital in Mississippi, USA

Antimicrobial therapy in emergency departments (EDs) is usually empiric in nature. Due to workload and a goal to reduce patient wait times, providers often make rapid decisions regarding antibiotic prescriptions for discharge. A review of current empiric prescribing practices would determine the appropriateness of oral antibiotic discharge prescriptions from EDs. A single-center retrospective electronic health record review of all adult patients with an ED visit from 1 June 2019, to 30 June 2021 who received at least one oral antibiotic prescription at discharge from Baptist Memorial Hospital-Golden Triangle was conducted. The primary outcome was the assessment of appropriate antibiotic discharge prescriptions. The parameters for appropriateness included empiric drug selection, dosage, frequency, duration, and subsequent cultures and sensitivities. Of the 18,289 identified records, 421 patients were randomly sampled with 400 patients included in the final analysis. Of these, 190 (47.8%) discharge oral antibiotic prescriptions were assessed as appropriate and 209 (52.3%) discharge oral antibiotic prescriptions were assessed as inappropriate based on the guideline recommendations. With approximately half of the patients receiving discharge antibiotics that did not fully follow the guideline recommendations, there is a need for provider education, pharmacist intervention, and antimicrobial stewardship programs focusing on this practice.

Particle-sounding of the spatial structure of kinetic Alfvén waves

Kinetic Alfvén waves (KAWs) are ubiquitous throughout the plasma universe. Although they are broadly believed to provide a potential approach for energy exchange between electromagnetic fields and plasma particles, neither the detail nor the efficiency of the interactions has been well-determined yet. The primary difficulty has been the paucity of knowledge of KAWs' spatial structure in observation. Here, we apply a particle-sounding technique to Magnetospheric Multiscale mission data to quantitatively determine the perpendicular wavelength of KAWs from ion gyrophase-distribution observations. Our results show that KAWs' perpendicular wavelength is statistically 2.4[Formula: see text] times proton thermal gyro-radius. This observation yields an upper bound of the energy the majority proton population can reach in coherent interactions with KAWs, that is, roughly 5.76 times proton perpendicular thermal energy. Therefore, the method and results shown here provide a basis for unraveling the effects of KAWs in dissipating energy and accelerating particles in a number of astrophysical systems, e.g., planetary magnetosphere, astrophysical shocks, stellar corona and wind, and the interstellar medium.

A review of factors associated with methadone maintenance treatment adherence and retention in Vietnam

BACKGROUND

Starting in 2008, Vietnam's national MMT program expanded quickly, but it is struggling with increasing attrition rates and poor adherence among patients. Several studies have reported on MMT retention and adherence, but no overview has yet been published. The objective of this study is to fill that gap and to review factors associated with retention and adherence in MMT in Vietnam.

METHODS

A systematic search was conducted using databases of literature - Pubmed, Cochrane, Scopus, Academic search premiere, and SoINDEX. Peer-reviewed empirical studies with full text in English discussing retention attrition and adherence regarding MMT in Vietnam were selected. The results were synthesized using qualitative methods.

RESULTS

Adherence and retention rates varied among the 11 included studies. In general, patients in mountainous provinces had lower adherence and retention rates than those in big cities. Retention rates decreased with the studies' follow-up period and had a downward trend over time. Factors associated with adherence and retention can be classified into three groups: individual, community, and institutional factors. Important individual factors areage, education, awareness of MMT and HIV, and co-occurring disorders and comorbidities. Stigma is the major community risk factor, and methadone daily dose, the distance between home and clinic, and clinic's service hours are the three most important institutional factors.

CONCLUSIONS

The literature reviewed identifies important factors associated with MMT adherence and retention in Vietnam. The findings suggest further research exploring both subjective and objective factors and more policies to remove social and structural barriers to enhance treatment outcomes.

2211. High prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae identified through routine screening for rectal, pharyngeal, and urethral infections within a HIV pre-exposure prophylaxis program in Hanoi, Vietnam

Background

Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention and is being scaled up globally. Patients on PrEP have high rates of bacterial STIs, like Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), thus routine screening is recommended. However, access to screening tests for STIs are limited in many low-resource settings. The objectives of this study were to determine the prevalence of CT and NG among participants in Vietnam’s first PrEP program.

Methods

From January through April 2022 participants in the PrEP program at the Sexual Health Promotion Clinic in Hanoi, Vietnam were recruited to study STI prevalence. Study participants completed a survey collecting demographic, behavioral and clinical characteristics. Participants self-collected urine, rectal, and pharyngeal specimens for nucleic-acid testing. Participants positive for NG had an additional specimen collected for culture and antibiotic susceptibility.

Results

In total, 108 participants were enrolled, median age was 24 years (IQR: 22– 28). All were male and reported having sex with men in the prior 12 months. The median number of sex partners in the prior 1 month was 1 (IQR: 1 – 2). Symptoms within the prior week were reported by 41.7% (45/108) – 19.4% reported rectal, 15.7% reported urethral, and 26.9% reported pharyngeal symptoms. The overall prevalence of CT or NG infections was 31.5% (34/108). The prevalence of CT was 24.1% (26/108); by anatomic site, there were 17 (15.7%) rectal, 10 (9.3%) pharyngeal, and 6 (5.6%) urethral infections. The prevalence of NG was 13.0% (14/108); there were 12 (11.1%) pharyngeal, 9 (8.3%) rectal, and 0 urethral infections. Among participants reporting any symptoms, CT prevalence was 26.7% (12/45) and NG prevalence 13.3% (6/45). All infections were treated.

Conclusion

The prevalence of CT and NG was very high among this population of young MSM in a PrEP program in Hanoi, Vietnam. A high proportion of CT infections were rectal (65%) and 86% of NG infections were pharyngeal. These findings highlight the need for expanded access to extragenital nucleic-acid testing among PrEP programs in low- and middle-income countries. Studies demonstrating the benefit of CT/NG screening and treatment within PrEP programs are urgently needed.

Disclosures

Jeffrey Klausner, MD MPH, Cepheid: Advisor/Consultant|Cepheid: Grant/Research Support|Cepheid: Research equipment and supplies.

OGC P13 Outcomes of Endoscopically Guided Stent Insertion in the Upper GI Tract in a Single Centre

Background

Self-expanding metal stents (SEMS) are useful for palliation in patients suffering from dysphagia for malignant disease in the upper gi tract. Patients can resume oral intake, so improving nutrition and quality of life. Establishing the efficacy and complication rate of stents are important for informing patients to aid decision making when giving consent for SEMS insertion in the scenario of a short life expectancy.

Methods

A single centre's records were interrogated over a 10 year period for stents inserted in the upper gi tract. Data for stents inserted between 2011 and 2021 was retrospectively collected from electronic records for baseline demographics and outcomes in terms of complications and then subject to analysis. There was missing data in a number of domains and analysis was done on data available, no imputation of data was performed.

Results

Five hundred and sixty eight patient episodes were identified with a mean age of 73. There were 386 males and 170 females. Sites of obstruction were Lower Third of the oesophagus 279, mid-oesophagus 71, GOJ 37, upper oesophagus 15, unknown 9, duodenum 3, Cardia 1, and stomach other 1. Surgeons inserted 394 (70%) of stents and gastroenterologists 167 (30%). There were 212 covered stents, 248 not specified, 29 partially covered and 3 uncovered.

When outcomes were measured, 276 had no complication (69%), 105 had a (any) complication (25%) and 32 had missing data (8%). There were 14 cases of bleeding (3%). There were 25 cases of stent migration (6%) and 54 cases of tumour overgrowth (13%). There were 43 cases of stent obstruction (10.4%), 3 cases of some stricturing (0.73%) and 366 with no blockage or stricture reported (88.6%), 1 case could not be determined. There were 2 cases of perforation (0.48%). Median survival was 105 days with IQR 44–210.

Conclusions

Our results for adverse events are not too dissimilar to the literature however there may be an under-reporting of some adverse events due to the terminal nature of the disease process the majority of the patients in this group have. Stents can relieve dysphagia and help regain quality of life. However there is a significant complication rate that should be taken into account. This information from a large dataset is useful to inform potential stent patients to aid decision-making. Data for significant known symptoms such as reflux and retrosternal chest pain were not reliably available and a prospectively kept database measuring PROMs information including relief of dysphagia will better inform patients.

Vaccine-induced thrombosis and thrombocytopenia (VITT) in Ireland: A review of cases and current practices

Since the beginning of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2) virus pandemic, several highly effective and safe vaccines have been produced at remarkable speed. Following global implementation of vaccination programmes, cases of thrombosis with thrombocytopenia following administration of adenoviral vector-based vaccines started being reported. In this review we discuss the known pathogenesis and epidemiology of so-called vaccine induced thrombocytopenia and thrombosis (VITT). We consider the available guidelines, diagnostic laboratory tests and management options for these patients. Finally, we discuss important unanswered questions and areas for future research in this novel pathoclinical entity.

809 Evaluation of the Two Week Wait Colorectal Cancer Pathway in a District General Hospital

Introduction

Updated guidelines published by the National Institute for Health and Care Excellence in 2015 widened the referral criteria for the two week wait (2WW) pathway for suspected lower gastrointestinal cancer, in an attempt to increase early diagnosis. The aim of this study was to evaluate the compliance of referrals received via the (2WW) pathway for suspected lower gastrointestinal cancer.

Method

We conducted a retrospective study which utilised a local cancer registry to identify all patients who had been referred to United Lincolnshire Hospitals Trust over a two-month period. Electronic patient records were checked to establish whether patients fulfilled the 2015 referral criteria.

Results

Out of 615 patients referred, 51 (8%) had colorectal cancer. 92 (15%) referrals did not meet the criteria for the 2WW pathway. Whether or not the referral was ‘appropriate’ had no significant effect on the diagnoses of bowel cancer (X2 = .003, p>.05).

Conclusions

16% of all referrals did not meet criteria. This may appear as an inefficient use of resources, however there was no difference in rates of cancer between appropriate and inappropriate referrals. The referral criteria are likely to evolve over the course of time, and perhaps clinicians’ judgement should be taken into account.

Physicochemical and Microbiological Stability of Compounded Metronidazole Suspensions in PCCA SuspendIt

Metronidazole is indicated for the treatment of trichomoniasis, amebiasis, and anaerobic bacterial infections. The dosage regimen of metronidazole needs to be individualized in the treatment of trichomoniasis, in patients with hepatic impairment, and in pediatric as well as geriatric patients. A review of the therapeutic uses of metronidazole reveals the need for flexibility in dosing. This flexibility is readily achieved using an oral liquid dosage form. However, no commercial liquid dosage form of metronidazole currently exists. Metronidazole is commercially available only as 250-mg and 500-mg film-coated tablets. An extemporaneously compounded suspension from pure drug powder or commercial tablets would provide a convenient option to meet unique patient needs. The purpose of this study was to determine the physicochemical and microbiological stability of extemporaneously compounded metronidazole suspensions in PCCA SuspendIt. This base is a sugar-free, paraben-free, dye-free, and gluten-free thixotropic vehicle containing a natural sweetener obtained from the monk fruit. The study design included two metronidazole concentrations to provide stability documentation over a bracketed concentration range for eventual use by compounding pharmacists. A robust stability-indicating ultra-performance liquid chromatographic assay for the determination of the chemical stability of metronidazole in PCCA SuspendIt was developed and validated. Suspensions of metronidazole were prepared in PCCA SuspendIt at 25-mg/mL and 50-mg/mL concentrations, selected to represent a range within which the drug is commonly dosed. Samples were stored in plastic amber prescription bottles at two temperature conditions (5ÆC and 25ÆC). Samples were assayed initially and on the following time points (days): 7, 14, 28, 42, 59, 90, 122, and 180. Physical data such as pH, viscosity, and appearance were also noted. Microbiological stability was also tested. All measurements were obtained in triplicate. A stable extemporaneous product is defined as one that retains at least 90% of the initial drug concentration throughout the sampling period and is protected against microbial growth. The study showed that metronidazole concentrations did not go below 97% of the label claim (initial drug concentration) at both temperatures studied. No microbial growth was observed. Viscosity and pH values also did not change significantly. This study demonstrates that metronidazole is physically, chemically, and microbiologically stable in PCCA SuspendIt for 180 days in the refrigerator and at room temperature, thus providing a viable, compounded alternative for metronidazole in a liquid dosage form, with an extended beyond-use-date to meet patient needs.

Physicochemical Stability of Compounded Allopurinol Suspensions in PCCA Base, SuspendIt

Allopurinol is an orally administered inhibitor of xanthine oxidase used primarily in the treatment of hyperuricemia associated with gout. Allopurinol reduces serum and urinary uric acid concentrations. Its use should be individualized for each patient. The dosage of allopurinol to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease, and needs to be flexible to permit precise, customized dose titration for individual patients. This flexibility is readily achieved using an oral liquid dosage form. However, no commercial liquid dosage form of allopurinol currently exists. Allopurinol is commercially available as 100-mg and 300-mg scored tablets. An extemporaneously compounded suspension from pure drug powder or commercial tablets would provide a convenient option to meet unique patient needs. The purpose of this study was to determine the physicochemical stability of extemporaneously compounded allopurinol suspensions in the PCCA Base SuspendIt. This base is a sugar-free, paraben-free, dye-free, and gluten-free thixotropic vehicle containing a natural sweetener obtained from the monk fruit. The study design included two allopurinol concentrations to provide stability documentation over a bracketed concentration range for eventual use by compounding pharmacists. A robust stability-indicating ultra-performance liquid chromatography assay for the determination of the chemical stability of allopurinol in SuspendIt was developed and validated. Suspensions of allopurinol were prepared in SuspendIt at 10.0-mg/mL and 20.0-mg/mL concentrations, selected to represent a range within which the drug is commonly dosed. Samples were stored in plastic amber prescription bottles at two temperature conditions (5°C and 25°C). Samples were assayed initially and at the following time points: 7 days, 14 days, 30 days, 45 days, 60 days, 88 days, 120 days, and 182 days. Physical data such as pH, viscosity, and appearance were also noted. All measurements were obtained in triplicate. A stable extemporaneous product is defined as one that retains at least 90% of the initial drug concentration throughout the sampling period. The study showed that allopurinol concentrations did not go below 93% of the label claim (initial drug concentration) at both temperatures studied. Viscosity and pH values also did not change significantly. This study demonstrates that allopurinol is physically and chemically stable in SuspendIt for 180 days in the refrigerator and at room temperature, thus providing a viable, compounded alternative for allopurinol in a liquid dosage form, with an extended beyond-use-date to meet patient needs.

Comparative Analysis of the Vlasiator Simulations and MMS Observations of Multiple X-Line Reconnection and Flux Transfer Events

The Vlasiator hybrid-Vlasov code was developed to investigate global magnetospheric dynamics at ion-kinetic scales. Here we focus on the role of magnetic reconnection in the formation and evolution of magnetic islands at the low-latitude magnetopause, under southward interplanetary magnetic field conditions. The simulation results indicate that (1) the magnetic reconnection ion kinetics, including the Earthward pointing Larmor electric field on the magnetospheric side of an X-point and anisotropic ion distributions, are well-captured by Vlasiator, thus enabling the study of reconnection-driven magnetic island evolution processes, (2) magnetic islands evolve due to continuous reconnection at adjacent X-points, "coalescence" which refers to the merging of neighboring islands to create a larger island, "erosion" during which an island loses magnetic flux due to reconnection, and "division" which involves the splitting of an island into smaller islands, and (3) continuous reconnection at adjacent X-points is the dominant source of magnetic flux and plasma to the outer layers of magnetic islands resulting in cross-sectional growth rates up to + 0.3 RE 2/min. The simulation results are compared to the Magnetospheric Multiscale (MMS) measurements of a chain of ion-scale flux transfer events (FTEs) sandwiched between two dominant X-lines. The MMS measurements similarly reveal (1) anisotropic ion populations and (2) normalized reconnection rate ~0.18, in agreement with theory and the Vlasiator predictions. Based on the simulation results and the MMS measurements, it is estimated that the observed ion-scale FTEs may grow Earth-sized within ~10 min, which is comparable to the average transport time for FTEs formed in the subsolar region to the high-latitude magnetopause. Future simulations shall revisit reconnection-driven island evolution processes with improved spatial resolutions.

Assessment of the Impact of Pharmacist-led Transitions of Care Services in a Primary Health Center

Background: The impact of pharmacist-led transition of care services with collaborative drug therapy management has shown to improve patients' outcomes and decrease health costs. Compelling statistics show higher readmission rates for under-insured patients compared with insured patients at primary health care clinics. Methods: This is a single center, prospective, cohort study designed to examine team-based collaborative drug therapy management and its effect on therapeutic outcomes of under-insured patients with target chronic diseases managed in a primary health center. Targeted chronic diseases included dyslipidemia, diabetes, hypertension, anticoagulation disorders, chronic obstructive pulmonary disease, and heart failure. The primary outcome measures included percentage of time in therapeutic international normalized ratio (INR) and percentage of patients at targeted goals of blood pressure, lipids, and hemoglobin A1c (HbA1c). Secondary outcomes included reduced emergency department visits, number of patient encounters, hospital readmissions within 30 days of discharge, and disease exacerbation rates. Results: Patients were at INR goal 58% of the time compared with 52% at baseline (P = .66). There was a 9% improvement in mean HbA1c in the intervention group when compared with baseline (9.6% vs 10.9%, P = .03). With pharmacist intervention, 73.8% of the patients had their blood pressure at goal compared with 50% at baseline (P = .14). A limited number of patients were readmitted for different reasons, including uncontrolled disease states. Conclusions: The pharmacist-physician collaborative drug therapy management led to improved blood pressure control, average HbA1c, and time in therapeutic INR range. A decrease in health care utilization was also identified.

MMS observations of electron scale magnetic cavity embedded in proton scale magnetic cavity

Magnetic cavities (sometimes referred to as magnetic holes) at electron kinetic scale are thought to be one of the extremely small intermittent structures formed in magnetized turbulent plasmas, where the turbulence energy cascaded down to electron scale may finally be dissipated and consequently energize the electrons. However, the geometry and formation of these structures remain not definitively resolved. Here we discuss an electron scale magnetic cavity embedded in a proton scale magnetic cavity observed by the MMS spacecraft in the magnetosheath. By applying an innovative particle sounding technique, we directly depict the boundary of the electron scale magnetic cavity and uncover the geometry. We find that this structure is nearly circular with a radius of 10.0 km and its formation is due to the diamagnetic current. Investigation of the electron scale structure is only recently made possible by the high spatial and temporal resolution provided by MMS observations.

Population Size Estimation of Venue-Based Female Sex Workers in Ho Chi Minh City, Vietnam: Capture-Recapture Exercise

Background

There is limited population size estimation of female sex workers (FSWs) in Ho Chi Minh City (HCMC)—the largest city in Vietnam. Only 1 population size estimation among venue-based female sex workers (VFSWs) was conducted in 2012 in HCMC. Appropriate estimates of the sizes of key populations are critical for resource allocation to prevent HIV infection.

Objective

The aim of this study was to estimate the population size of the VFSWs from December 2016 to January 2017 in HCMC, Vietnam.

Methods

A multistage capture-recapture study was conducted in HCMC. The capture procedures included selection of districts using stratified probability proportion to size, mapping to identify venues, approaching all VFSWs to screen their eligibility, and then distribution of a unique object (a small pink makeup bag) to all eligible VFSWs in all identified venues. The recapture exercise included equal probability random selection of a sample of venues from the initial mapping and then approaching FSWs in those venues to determine the number and proportion of women who received the unique object. The proportion and associated confidence bounds, calculated using sampling weights and accounting for study design, were then divided by the number of objects distributed to calculate the number of VFSWs in the selected districts. This was then multiplied by the inverse of the proportion of districts selected to calculate the number of VFSWs in HCMC as a whole.

Results

Out of 24 districts, 6 were selected for the study. Mapping identified 573 venues across which 2317 unique objects were distributed in the first capture. During the recapture round, 103 venues were selected and 645 VFSWs were approached and interviewed. Of those, 570 VFSWs reported receiving the unique object during the capture round. Total estimated VFSWs in the 6 selected districts were 2616 (95% CI 2445-3014), accounting for the fact that only 25% (6/24) of total districts were selected gives an overall estimate of 10,465 (95% CI 9782-12,055) VFSWs in HCMC.

Conclusions

The capture-recapture exercise provided an estimated number of VFSWs in HCMC. However, for planning HIV prevention and care service needs among all FSWs, studies are needed to assess the number of sex workers who are not venue-based, including those who use social media platforms to sell services.

Quantifying the Effect of Non-Larmor Motion of Electrons on the Pressure Tensor

In space plasma, various effects of magnetic reconnection and turbulence cause the electron motion to significantly deviate from their Larmor orbits. Collectively these orbits affect the electron velocity distribution function and lead to the appearance of the "non-gyrotropic" elements in the pressure tensor. Quantification of this effect has important applications in space and laboratory plasma, one of which is tracing the electron diffusion region (EDR) of magnetic reconnection in space observations. Three different measures of agyrotropy of pressure tensor have previously been proposed, namely, A∅ _e , D_ng and Q. The multitude of contradictory measures has caused confusion within the community. We revisit the problem by considering the basic properties an agyrotropy measure should have. We show that A∅ _e , D_ng and Q are all defined based on the sum of the principle minors (i.e. the rotation invariant I ₂) of the pressure tensor. We discuss in detail the problems of I ₂-based measures and explain why they may produce ambiguous and biased results. We introduce a new measure AG constructed based on the determinant of the pressure tensor (i.e. the rotation invariant I ₃) which does not suffer from the problems of I ₂-based measures. We compare AG with other measures in 2 and 3-dimension particle-in-cell magnetic reconnection simulations, and show that AG can effectively trace the EDR of reconnection in both Harris and force-free current sheets. On the other hand, A∅ _e does not show prominent peaks in the EDR and part of the separatrix in the force-free reconnection simulations, demonstrating that A∅ _e does not measure all the non-gyrotropic effects in this case, and is not suitable for studying magnetic reconnection in more general situations other than Harris sheet reconnection.

Structure, force balance, and topology of Earth's magnetopause

The magnetopause deflects the solar wind plasma and confines Earth's magnetic field. We combine measurements made by the four spacecraft of the Magnetospheric Multiscale mission to demonstrate how the plasma and magnetic forces at the boundary affect the interaction between the shocked solar wind and Earth's magnetosphere. We compare these forces with the plasma pressure and examine the electron distribution function. We find that the magnetopause has sublayers with thickness comparable to the ion scale. Small pockets of low magnetic field strength, small radius of curvature, and high electric current mark the electron diffusion region. The flow of electrons, parallel and antiparallel to the magnetic field, reveals a complex topology with the creation of magnetic ropes at the boundary.

Global observations of magnetospheric high-m poloidal waves during the 22 June 2015 magnetic storm

We report global observations of high-m poloidal waves during the recovery phase of the 22 June 2015 magnetic storm from a constellation of widely spaced satellites of five missions including Magnetospheric Multiscale (MMS), Van Allen Probes, Time History of Events and Macroscale Interactions during Substorm (THEMIS), Cluster, and Geostationary Operational Environmental Satellites (GOES). The combined observations demonstrate the global spatial extent of storm time poloidal waves. MMS observations confirm high azimuthal wave numbers (m ~ 100). Mode identification indicates the waves are associated with the second harmonic of field line resonances. The wave frequencies exhibit a decreasing trend as L increases, distinguishing them from the single-frequency global poloidal modes normally observed during quiet times. Detailed examination of the instantaneous frequency reveals discrete spatial structures with step-like frequency changes along L. Each discrete L shell has a steady wave frequency and spans about 1 R_E , suggesting that there exist a discrete number of drift-bounce resonance regions across L shells during storm times.

The political and scientific challenges in evaluating compulsory drug treatment centers in Southeast Asia

Background

In Vietnam, like many countries in Southeast Asia, the commonly used approach of center-based compulsory drug treatment (CCT) has been criticized on human rights ground. Meanwhile, community-based voluntary methadone maintenance treatment (MMT) has been implemented for nearly a decade with promising results. Reform-minded leaders have been seeking empirical evidence of the costs and effectiveness associated with these two main treatment modalities. Conducting evaluations of these treatments, especially where randomization is not ethical, presents challenges. The aim of this paper is to discuss political challenges and methodological issues when conducting cost-effectiveness studies within the context of a non-democratic Southeast Asian country.

Methods

A retrospective analysis of the political and scientific challenges that were experienced in the study design, sample size determination, government approval and ethics approvals, participant recruitment, data collection, and determination of sources, and quantification of cost and effectiveness data was undertaken. As a consequence of the non-randomized design, analysis of patient characteristics for both treatment types was undertaken to identify the magnitude of baseline group differences. Concordance between self-reported heroin use and urine drug testing was undertaken to determine the reliability of self-report data in a politically challenging environment.

Results

We demonstrate that conducting research around compulsory treatment in a non-democratic society is feasible, yet it is politically challenging and requires navigation between science and politics. We also demonstrate that engagement with the government decision makers in the research conception, implementation, and dissemination of the results increases the likelihood of research evidence being considered for change in a contentious drug policy area.

Conclusions

Local empirical evidence on the comparative cost-effectiveness of CCT and MMT in a Southeast Asian setting is critical to consideration of more holistic, humane, and effective drug-dependence treatment approaches, but the garnering of such evidence is very challenging.

Cost-effectiveness of center-based compulsory rehabilitation compared to community-based voluntary methadone maintenance treatment in Hai Phong City, Vietnam

INTRODUCTION

In Vietnam, two dominant approaches for heroin treatment are center-based compulsory rehabilitation (CCT), funded by the Vietnamese government and community-based voluntary methadone maintenance treatment (MMT), funded primarily by international donors. Recent reduction in international funding requires more efficient allocation of government funding for public health programs. A cost-effectiveness analysis comparing two approaches provides a useful source of evidence to inform the government about funding reallocation.

METHODS

The study was a combined retrospective and prospective, non-randomized cohort comparison over three years of CCT and MMT in Vietnam, conducted between 2012 and 2014, involving 208 CCT participants and 384 MMT participants with heroin dependence. The primary end-point was drug-free days over three years. Total costs, including both program and participant personal costs were measured and cost-effectiveness compared. Mixed effects regression analyses were used to analyze effectiveness data and non-parametric bootstrapping method was used to compare cost-effectiveness.

RESULTS

Over three years, MMT costed on average VND85.73 million (US$4108) less than CCT (95% CI: -VND76.88 million, -VND94.59 million). On average, a MMT participant had 344.20 more drug-free days compared to a CCT participant (p<0.001). The incremental cost-effectiveness ratio for MMT was -VND0.25 million (US$11.99) (95% CI: -VND0.34 million, -VND0.19 million) per drug-free day suggesting MMT is the more cost effective alternative.

CONCLUSIONS

Compared to CCT, MMT is both less expensive and more effective in achieving drug-free days. If the government of Vietnam invests in MMT instead of CCT, it is potentially a cost-saving strategy for reducing illicit drug use among heroin dependent individuals.

A comparative study of dipolarization fronts at MMS and Cluster

We present a statistical study of dipolarization fronts (DFs), using magnetic field data from MMS and Cluster, at radial distances below 12 R_E and 20 R_E , respectively. Assuming that the DFs have a semicircular cross section and are propelled by the magnetic tension force, we used multispacecraft observations to determine the DF velocities. About three quarters of the DFs propagate earthward and about one quarter tailward. Generally, MMS is in a more dipolar magnetic field region and observes larger-amplitude DFs than Cluster. The major findings obtained in this study are as follows: (1) At MMS ∼57 % of the DFs move faster than 150 km/s, while at Cluster only ∼35 %, indicating a variable flux transport rate inside the flow-braking region. (2) Larger DF velocities correspond to higher B_z  values directly ahead of the DFs. We interpret this as a snow plow-like phenomenon, resulting from a higher magnetic flux pileup ahead of DFs with higher velocities.

Transient, small-scale field-aligned currents in the plasma sheet boundary layer during storm time substorms

We report on field-aligned current observations by the four Magnetospheric Multiscale (MMS) spacecraft near the plasma sheet boundary layer (PSBL) during two major substorms on 23 June 2015. Small-scale field-aligned currents were found embedded in fluctuating PSBL flux tubes near the separatrix region. We resolve, for the first time, short-lived earthward (downward) intense field-aligned current sheets with thicknesses of a few tens of kilometers, which are well below the ion scale, on flux tubes moving equatorward/earthward during outward plasma sheet expansion. They coincide with upward field-aligned electron beams with energies of a few hundred eV. These electrons are most likely due to acceleration associated with a reconnection jet or high-energy ion beam-produced disturbances. The observations highlight coupling of multiscale processes in PSBL as a consequence of magnetotail reconnection.

Delivering a sustainable trauma management training programme tailored for low-resource settings in East, Central and Southern African countries using a cascading course model

BACKGROUND

Injuries cause five million deaths and 279 Disability Adjusted Life Years (DALYS) each year worldwide. The COSECSA Oxford Orthopaedic Link (COOL) is a multi-country partnership programme that has delivered training in trauma management to nine sub-Saharan countries across a wide-cadre of health-workers using a model of "primary" courses delivered by UK instructors, followed by "cascading" courses led by local faculty. This study examines the impact on knowledge and clinical confidence among health-workers, and compares the performance of "cascading" and "primary" courses delivered in low-resource settings.

METHODS

Data was collated from 1030 candidates (119 Clinical Officers, 540 Doctors, 260 Nurses and 111 Medical Students) trained over 28 courses (9 "primary" and 19 "cascading" courses) in nine sub-Saharan countries between 2012 and 2013. Knowledge and clinical confidence of candidates were assessed using pre- and post-course MCQs and confidence matrix rating of clinical scenarios. Changes were measured in relation to co-variants of gender, job roles and primary versus cascading courses. Multivariate regression modelling and cost analysis was performed to examine the impact of primary versus cascading courses on candidates' performance.

FINDINGS

There was a significant improvement in knowledge (58% to 77%, p<0.05) and clinical confidence (68% to 90%, p<0.05) post-course. "Non-doctors" demonstrated a greater improvement in knowledge (22%) and confidence (24%) following the course (p<0.05). The degree of improvement of MCQ scores differed significantly, with the cascading courses (21%) outperforming primary courses (15%) (p<0.002). This is further supported by multivariate regression modelling where cascading courses are a strong predictor for improvement in MCQ scores (Coef=4.83, p<0.05).

INTERPRETATION

Trauma management training of health-workers plays a pivotal role in tackling the ever-growing trauma burden in Africa. Our study suggests cascading PTC courses may be an effective model in delivering trauma training in low-resource settings, however further studies are required to determine its efficacy in improving clinical competence and retention of knowledge and skills in the long term.

A large-scale view of Space Technology 5 magnetometer response to solar wind drivers

In this data report we discuss reprocessing of the Space Technology 5 (ST5) magnetometer database for inclusion in NASA's Coordinated Data Analysis Web (CDAWeb) virtual observatory. The mission consisted of three spacecraft flying in elliptical orbits, from 27 March to 27 June 2006. Reprocessing includes (1) transforming the data into the Modified Apex Coordinate System for projection to a common reference altitude of 110 km, (2) correcting gain jumps, and (3) validating the results. We display the averaged magnetic perturbations as a keogram, which allows direct comparison of the full-mission data with the solar wind values and geomagnetic indices. With the data referenced to a common altitude, we find the following: (1) Magnetic perturbations that track the passage of corotating interaction regions and high-speed solar wind; (2) unexpectedly strong dayside perturbations during a solstice magnetospheric sawtooth oscillation interval characterized by a radial interplanetary magnetic field (IMF) component that may have enhanced the accompanying modest southward IMF; and (3) intervals of reduced magnetic perturbations or "calms," associated with periods of slow solar wind, interspersed among variable-length episodic enhancements. These calms are most evident when the IMF is northward or projects with a northward component onto the geomagnetic dipole. The reprocessed ST5 data are in very good agreement with magnetic perturbations from the Defense Meteorological Satellite Program (DMSP) spacecraft, which we also map to 110 km. We briefly discuss the methods used to remap the ST5 data and the means of validating the results against DMSP. Our methods form the basis for future intermission comparisons of space-based magnetometer data.

Injection and sexual risk practices among young heroin users in Hanoi, Vietnam

Epidemiological data in Vietnam shows high HIV prevalence rates among injection drug users, especially in urban centres. However, there are limited data on specific practices used to prepare and inject drugs or on sexual practices among Vietnamese injectors. A street-based cross-sectional interview was conducted with 862 heroin injectors in Hanoi, Vietnam, to collect such data. Variability was seen in both injection and sexual risk, with 12.9% of current injectors reporting at least one unsafe method of drug sharing and 57.1% reporting unsafe sex in the past 30 days. These risks were strongly associated with those who engaged in unsafe injection significantly more likely to engage in unsafe sex (69.4% vs. 55.3%) and those engaging in unsafe sex significantly more likely to engage in unsafe injection (15.7% vs. 9.2%). These findings highlight the overlap of injection and sexual risk practices among Vietnamese heroin users and suggest the need for strong, broadly targeted HIV prevention activities among this population.

Small molecule inhibitors of the LEDGF site of human immunodeficiency virus integrase identified by fragment screening and structure based design

A fragment-based screen against human immunodeficiency virus type 1 (HIV) integrase led to a number of compounds that bound to the lens epithelium derived growth factor (LEDGF) binding site of the integrase catalytic core domain. We determined the crystallographic structures of complexes of the HIV integrase catalytic core domain for 10 of these compounds and quantitated the binding by surface plasmon resonance. We demonstrate that the compounds inhibit the interaction of LEDGF with HIV integrase in a proximity AlphaScreen assay, an assay for the LEDGF enhancement of HIV integrase strand transfer and in a cell based assay. The compounds identified represent a potential framework for the development of a new series of HIV integrase inhibitors that do not bind to the catalytic site of the enzyme.

Paediatric umbilical cord blood transplantation

Umbilical cord blood is being used increasingly as a source of haematopoietic stem cells for transplantation because of rapid availability, and the unavailability of a HLA matched adult donor for some patients. This study reports the characteristics and outcomes of 15 patients who have undergone umbilical cord blood transplantation (UCBT) in Ireland between 1998 and 2009. The median total nucleated cell and CD34+ doses post-processing were 6.5 x 107cells/kg and 1.8 x 105 cells/kg, respectively. Median neutrophil recovery time was 30 days (range, 14-44). Median platelet recovery time was 46.5 days (range, 35-148). 33.3% of patients developed acute cutaneous graft-versus-host disease (GVHD) grade I-II. Three patients died of transplant-related toxicity and two died of leukaemic relapse. We conclude that, with a satisfactory stem cell dose, UCBT offers a high chance of engraftment with acceptable toxicity, and should be regarded as a favourable option in selected patients when satisfactory bone marrow or peripheral blood stem cell donors are not available.

Structural basis for a new mechanism of inhibition of HIV-1 integrase identified by fragment screening and structure-based design

BACKGROUND

HIV-1 integrase is a clinically validated therapeutic target for the treatment of HIV-1 infection, with one approved therapeutic currently on the market. This enzyme represents an attractive target for the development of new inhibitors to HIV-1 that are effective against the current resistance mutations.

METHODS

A fragment-based screening method employing surface plasmon resonance and NMR was initially used to detect interactions between integrase and fragments. The binding sites of the fragments were elucidated by crystallography and the structural information used to design and synthesize improved ligands.

RESULTS

The location of binding of fragments to the catalytic core of integrase was found to be in a previously undescribed binding site, adjacent to the mobile loop. Enzyme assays confirmed that formation of enzyme-fragment complexes inhibits the catalytic activity of integrase and the structural data was utilized to further develop these fragments into more potent novel enzyme inhibitors.

CONCLUSIONS

We have defined a new site in integrase as a valid region for the structure-based design of allosteric integrase inhibitors. Using a structure-based design process we have improved the activity of the initial fragments 45-fold.

Design of a series of bicyclic HIV-1 integrase inhibitors. Part 2: azoles: effective metal chelators

Synthesis of a diverse set of azoles and their utilizations as an amide isostere in the design of HIV integrase inhibitors is described. The Letter identified thiazole, oxazole, and imidazole as the most promising heterocycles. Initial SAR studies indicated that these novel series of integrase inhibitors are amenable to lead optimization. Several compounds with low nanomolar inhibitory potency are reported.

Clinical application of surface mode on three-dimensional ultrasonography: a preliminary study

To investigate the methology and evaluate the clinical value of surface mode on three-dimensional ultrasonography (3DUS) in static anatomical structures, 62 patients with various diseases were studied. The equipment used here was Voluson 530D 3DUS imaging system and 3D volume transducer with frequency being 3.0-5.0 MHz. The 3DUS rendering method was surface mode. The results showed that: 1) Surface mode of 3DUS could demonstrate clearly the anatomical characteristics of the region-of-interest (ROI) and the inner wall of lesions or organs that contained fluid. The anatomic details, such as location, size, shape, and number of the ROI, could be visualized intuitively; 2) The outer anatomic features (e.g. contour, edge, configuration, etc.) of some organs or lesions surrounded by fluid could be displayed clearly. It could be concluded that surface mode on 3DUS could provide more diagnostic information than two-dimensional ultrasonography (2DUS) in some cases and could served as a beneficial supplement to 2DUS in clinical practice.

Reliability and reproducibility of a Chinese-language visual function assessment

OBJECTIVE

The purpose of the study was to validate a Chinese-language visual function assessment within the context of a routine cataract surgery practice and to assess the contribution of the method of questionnaire administration.

DESIGN

The visual function assessment (VFA) was translated into Chinese. Two groups of study subjects were recruited: Chinese who did not speak English and Chinese conversant in English. Consecutive preoperative cataract patients of Chinese ancestry presenting to an urban ophthalmology practice were recruited. The questionnaire was administered in person or by telephone interview. Pre-operative visual acuity was recorded. Visual function scores were analyzed to assess reliability and correlation with visual acuity.

RESULTS

Among the 186 potential study subjects, 155 patients completed the study The Chinese-language visual function assessment had good internal consistency (Cronbach alpha = 0.97, inter-item correlations = 0.43 to 0.96) . Reliability (with regard to the English version) and test-retest reproducibility of the Chinese questionnaire were strong with intraclass correlation coefficients greater than 0.60. The method of administration contributed to the measures of reliability and reproducibility.

CONCLUSION

These results show that a Chinese-language version of the VFA questionnaire is reliable and valid. In industrialized countries with large Chinese-speaking populations and newly developed countries of East and Southeast Asia, the visual function assessment may be helpful in assisting routine clinical patient evaluation and cross-cultural outcome assessment programmes. Our findings also suggest that self-administered visual function assessments may be more reliable and valid than interview-generated assessments.

Epidural analgesia use as a marker for physician approach to birth: implications for maternal and newborn outcomes

BACKGROUND

Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver's belief system and his or her behavior. The study objective was to determine if a family physician's overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes.

METHODS

Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low-risk women attended by 96 family physicians within an 18-month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians' mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay.

RESULTS

Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0-30 percent (15 physicians, 263 births); medium, 31-50 percent (55 physicians, 1323 births); and high, 51-100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2%) and oxytocin augmentation (12.2 vs 29.8%), sustained fewer malpositions (occiput posterior or transverse) (23.2 vs 34.2%), had fewer cesarean sections (14.0 vs 24.4%), less obstetric consultation (47.9 vs 63.8%), and fewer newborn special care admissions (7.2 vs 12.8%).

CONCLUSIONS

In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity.

The study of ovarian artery hemodynamics in patients with infertility by color Doppler energy

Seventy-four cases of infertility were examined to study the hemodynamics of the bilateral ovarian arteries at 21st day during the corpus luteum phase by color Doppler energy(CDE) and color Doppler flow imaging (CDFI). All the patients were verified by laparoscopy, fallopian tube patency examination and ovarian function test. Twenty-two healthy women served as controls. The results showed that the difference of resistance index(RI) and pulsatility index (PI) of bilateral ovarian arteries between the infertility and the normal controls had statistical significance (P < 0.01), and the PI showed negative correlation with the thickness of endometrium (left side: r = 0.724, P < 0.01; right side: r = 0.756, P < 0.01). The results also showed that CDE was more sensitive than CDFI in displaying the ovarian arteries. It could be concluded that the elevated resistance of ovarian artery during the corpus luteum phase was one of the important factors that resulted in infertility.

[Construction of plasmids expressing hepatitis E virus antigen fragments and their combinations]

OBJECTIVE

Several different regions of the HEV antigen were expressed in Escherichia coli and their immunological characteristics were simply evaluated.

METHODS

Three coding sequences of immunodominant antigenic regions in structural protein of the hepatitis E virus (ORF2.1: 6287-6403nt, ORF2.2: 6743-7126nt, ORF3: full length of ORF3) were amplified by RT-PCR from the fecal supernatants of macaques experimentally infected with HEV. These three fragments were inserted into the pThioHisC expression vector separately or fused in line by (Gly)n short arms. After identified by DNA sequence analysis, these six recombinant plasmids were transformed into Escherichia coli, and immunology characteristics of expressed antigen fragments were evaluated by Western blotting.

RESULTS

All six genes were successfully expressed in Escherichia coli. Western blotting assay showed that the recombinant proteins specifically reacted with the serum antibody from hepatitis E patient in various degrees.

CONCLUSION

Artificial antigen based on strung epitopes provides a promising strategy for detection and prevention of HEV infection.

Identification of 6 new mutations in the iduronate sulfatase gene. Mutation in brief no. 233. Online

Mucopolysaccharidosis type II (Hunter syndrome) is an X-linked lysosomal storage disorder caused by a deficiency of the enzyme iduronate-2-sulfatase. We sequenced genomic DNA and RT-PCR products in the iduronate sulfatase (IDS) gene in 6 unrelated patients with Hunter syndrome to assess genotype/phenotype relationships and offer carrier testing where required. Six novel mutations were identified: four missense mutations, one four-base pair deletion (596-599delAACA) and a cryptic splice site mutation. Three of the missense mutations were significant amino acid substitutions (S143F, S491F, E341K) of which the latter two involve amino acids conserved amongst sulfatase enzymes. The patients identified with these mutations all had a severe clinical phenotype. One missense mutation with a minimal amino acid substitution (H342Y), in a non-conserved region of the gene, was associated with a mild clinical phenotype. We identified a novel cryptic splice site (IVS5+934G>A) with some normal (wild type) mRNA processing. We predict that the normal mRNA product confered some residual functional enzyme, resulting in a mild phenotype associated with the absence of overt central nervous system disease.

Examination for sexual assault: is the documentation of physical injury associated with the laying of charges? A retrospective cohort study

BACKGROUND

Few studies have examined whether there is an association between individual medical findings and legal outcome in cases of sexual assault. This study was undertaken to determine the relation between the extent of documented physical injury and a positive legal outcome in cases of sexual assault and to determine other factors associated with the laying of charges in such cases.

METHODS

In this retrospective cohort study, the authors reviewed the charts and medicolegal reports for all cases of sexual assault that were handled by the BC Women's Sexual Assault Service in 1992 for which a police report had been filed. Information on patients' characteristics, the nature of the assault and the extent of injury was extracted from these records. A system for scoring clinical injury was developed by 4 of the physicians at the Sexual Assault Service, and a clinical injury score was assigned for each case by one physician. The relation between the outcome (in terms of whether charges were laid) and the circumstances of the case was examined by logistic regression.

RESULTS

A total of 95 cases with complete medical records and information about legal outcome were identified during the 1992 calendar year. After adjustment for income level and the patient's knowledge of the assailant (either as an acquaintance or as his or her partner), the odds ratio (OR) for charge-laying in a sexual assault case with documented moderate to severe injury was 3.33 (95% confidence interval [CI] 1.06-10.42). Socioeconomic status above the group median (defined as annual income greater than $21,893) (OR 3.26, 95% CI 1.09-9.71) and knowledge of the assailant (OR 4.58, 95% CI 1.52-13.79) were also associated with charge-laying. Presence of genital injury per se, age of the patient and detection of sperm by microscopy at the time of examination were not associated with the laying of charges.

INTERPRETATION

The results of this study show that the extent of documented injury is associated with the laying of charges in cases of sexual assault. However, many questions remain about the effectiveness of the medical component of gathering such evidence.