678. Title: Treatment Outcomes with Carbapenems vs. Non-Carbapenem Beta-Lactams in Infections with Carbapenem-Discordant Enterobacter cloacae Complex

Background

Carbapenem-discordant Enterobacter cloacae complex (CDECC) isolates are defined as ertapenem non-susceptible and meropenem susceptible drug phenotype. The optimal treatment of these infections is unknown. In 2021, the Infectious Diseases Society of America released guidance recommending extended infusion meropenem as the preferred treatment option. Newer agents, including ceftazidime-avibactam, may be effective but comparative data is lacking. Evaluation of treatment outcomes for use in infections with CDECC is necessary to establish optimal therapy.

Methods

This single center, retrospective, cohort study was conducted at The University of Kansas Hospital from January 2016 to June 2021. Individuals at least 18 years of age with non-urinary culture positive for CDECC that were treated with either meropenem (MEM) or a non-carbapenem beta-lactam (NCBL) were included. Individuals with polymicrobial infections, infections from a urinary source, or death within 72 hours of admission were excluded. The primary outcome was clinical failure, which was a composite endpoint. Secondary outcomes included individual components of the primary outcome.

Results

There were 29 unique episodes of monomicrobial, carbapenem-discordant Enterobacter cloacae complex infections during the study period. The primary outcome was met in 6 patients receiving a NCBL and 6 patients receiving MEM, respectively (67% vs. 30%, p=0.11). A total of 8 patients died within 30 days, 4 in the MEM group and 4 in the NCBL group (20% vs. 44%, p = 0.21). Univariate logistic regression analysis demonstrated a significant increase in need to modify antibiotic therapy in the NCBL group (OR 15.2, 95% CI, 1.37-168; p=0.02), with a trend towards increased risk for in-hospital 30-day mortality (OR, 3.2; 95% CI, 0.58-17.72; p = 0.18).

Conclusion

There was no difference in clinical failure rates between the MEM and NCBL treatment groups. However, treatment with NCBLs was associated with a trend towards increased in-hospital mortality and need for antibiotic modifications due to clinical decompensation. Larger studies are needed to assess treatment outcomes in carbapenem-discordant Enterobacter cloacae complex infections to define optimal antibiotic therapy.

Disclosures

All Authors: No reported disclosures.

Implementation and evaluation of a two-eyed seeing approach using traditional healing and seeking safety in an indigenous residential treatment program in Northern Ontario

Indigenous clients in need of residential care for substance use disorders (SUD) often present with the diagnosis of substance use disorder (SUD) combined with intergenerational trauma (IGT) or both. SUD is exceedingly prevalent amongst Indigenous peoples due to the health impacts of colonisation, residential school trauma, and IGT on this population’s health. We evaluated the effectiveness of a Two-Eyed Seeing approach in a four-week harm reduction residential treatment programme for clients with a history of SUD and IGT. This treatment approach blended Indigenous Healing practices with Seeking Safety based on Dr. Teresa Marsh’s research work known as Indigenous Healing and Seeking Safety (IHSS). The data presented in this study was drawn from a larger trial. This qualitative study was undertaken in collaboration with the Benbowopka Treatment Centre in Blind River, Northern Ontario, Canada. Patient characteristic data were collected from records for 157 patients who had enrolled in the study from April 2018 to February 2020. Data was collected from the Client Quality Assurance Survey tool. We used the qualitative thematic analysis method to analyse participants’ descriptive feedback about the study. Four themes were identified: (1) Motivation to attend treatment; (2) Understanding Benbowopka’s treatment programme and needs to be met; (3) Satisfaction with all interventions; and (4) Moving forward. We utilised a conceptualised descriptive framework for the four core themes depicted in the medicine wheel. This qualitative study affirmed that cultural elements and the SS Western model were highly valued by all participants. The impact of the harm reduction approach, coupled with traditional healing methods, further enhanced the outcome. This study was registered with clinicaltrials.gov (identifier number NCT0464574).

Community trial evaluating the integration of Indigenous healing practices and a harm reduction approach with principles of seeking safety in an Indigenous residential treatment program in northern Ontario

Objective

Our primary objective was to evaluate how the Indigenous Healing and Seeking Safety (IHSS) model impacted residential addiction treatment program completion rates. Our secondary objective was to evaluate health service use 6 months before and 6 months after residential treatment for clients who attended the program before and after implementing IHSS.

Methods

We observed clients of the Benbowopka Residential Treatment before IHSS implementation (from April 2013 to March 31, 2016) and after IHSS implementation (from January 1, 2018 – March 31, 2020). The program data were linked to health administration data, including the Ontario Health Insurance Plan (OHIP) physician billing, the Registered Persons Database (RPDB), the National Ambulatory Care Reporting System (NACRS), and the Discharge Abstract Database (DAD). Chi-square tests were used to compare patient characteristics in the no-IHSS and IHSS groups. We used logistic regression to estimate the association between IHSS and treatment completion. We used generalized estimating equation (GEE) regression model to evaluate health service use (including primary care visits, ED visits overall and for substance use, hospitalizations and mental health visits), Results: There were 266 patients in the no-IHSS group and 136 in the IHSS group. After adjusting for individual characteristics, we observed that IHSS was associated with increased program completion rates (odds ratio = 1.95, 95% CI 1.02-3.70). There was no significant association between IHSS patients’ health service use at time one or time two. Primary care visits time 1: aOR 0.55, 95%CI 0.72-1.13, time 2: aOR 1.13, 95%CI 0.79-1.23; ED visits overall time 1: aOR 0.91, 95%CI 0.67-1.23, time 2: aOR 1.06, 95%CI 0.75-1.50; ED visits for substance use time 1: aOR 0.81, 95%CI 0.47-1.39, time 2: aOR 0.79, 95%CI 0.37-1.54; Hospitalizations time 1: aOR 0.78, 95%CI 0.41-1.47, time 2: aOR 0.76, 95%CI 0.32-1.80; Mental health visits time 1: aOR 0.66, 95%CI 0.46-0.96, time 2: aOR 0.92 95%CI 0.7-1.40.

Conclusions

Our results indicate that IHSS positively influenced program completion but had no significant effect on health service use.

Trial registration

This study was registered with clinicaltrials.gov (identifier number NCT04604574). First registration 10/27/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08406-3.

American College of Rheumatology/Association of Rheumatology Professionals (ACR/ARP) 2021 Annual Meeting (November 5-9, 2021 - Virtual Meeting)

ACR Convergence is the annual meeting of the American College of Rheumatology (ACR). This year, ACR Convergence was to be held in San Francisco, California, but due to the COVID-19 crisis and subsequent travel restrictions, it was changed to a virtual meeting format. The meeting comprised several days of live sessions and on-demand virtual content including posters and prerecorded presentations.

Association between social deprivation status, age of presentation, and survival following ST-segment elevation myocardial infarction

Introduction

Many factors influence age of presentation with and survival following ST-segment myocardial infarction (STEMI). These include age, mode of, and time-delay to emergency treatment, diabetes and smoking. We sought to assess whether overall social deprivation status is associated with age of presentation and mortality following STEMI patients treated with primary PCI.

Methods

All patients treated emergently for STEMI in a large Northern Irish tertiary hospital from 2013 – 2017 were reviewed. Social deprivation is determined as a composite score relating to income, crime etc, and assigned to small geographical regions by the Northern Ireland Statistics and Research Agency. Deprivation score was assigned to patients based on their postcode. The database was ranked by social deprivation score and divided in to quintiles. The most (Grp 1) and least (Grp 5) deprived quintiles were compared. Mortality was determined from a national electronic health record.

Results

1,192 patients were included in the analysis. Mean follow up was 52.5 months (SD 15.6), minimum follow up was 35.6 months. There was no difference in gender: 70.1% male in Grp 1 vs 75.2% male in Grp 5 (p=0.68); no difference in ECG to balloon time: mean 89.9mins (95% CI 84.9–94.9) Grp 1 vs 90.5mins (95% CI 86.2–94.9) Grp 5 (p=0.86). The more deprived group was younger: mean age 60.6 (95% CI 59.5–61.6) vs 65.2 (95% CI 64.2–66.3) (p<0.000). Crude survival measured by Log-rank test was the same between the groups (p=0.52). Following Cox-regression adjustment for age, survival was longer in the least deprived group (p=0.042).

Conclusion

Social deprivation is associated with both a younger age of presentation with, and a higher mortality following STEMI. This is important variable is often overlooked in medical literature and should be further studied.

Funding Acknowledgement

Type of funding sources: None.

Postoperative Use of Ketorolac Improves Pain Management and Decreases Narcotic Use Following Primary Cleft Palate Surgery

OBJECTIVE

To study the efficacy and safety profile of ketorolac in cleft palate surgery.

DESIGN

Retrospective analysis of patients who underwent primary cleft palate surgery and received either postoperative ketorolac or opioids.

SETTING

Tertiary care children's hospital.

PATIENTS, PARTICIPANTS

Eighty-nine patients enrolled who were all younger than 36 months of age, not dependent on a gastrostomy tube, with no history of bleeding disorders, and had undergone their primary cleft palate procedure by one specific surgeon between January 2010 and June 2019.

INTERVENTIONS

n/a.

MAIN OUTCOME MEASURE

Morphine equivalent dose (MED), Face, Legs, Activity, Cry, Consolability (FLACC) score, length of stay (LOS), total oral intake (mL), total oral intake/LOS, and postoperative adverse events between ketorolac and no ketorolac groups.

RESULTS

MED, FLACC score, and LOS were significantly lower in the ketorolac group compared to the no ketorolac group. One patient in the ketorolac group had a bleeding event.

CONCLUSIONS

Use of ketorolac significantly decreased narcotic usage and pain scores as reported by the FLACC score. Moreover, postoperative bleeding was rare in both ketorolac and no ketorolac groups.

Longitudinal typing of molecular HIV clusters in a statewide epidemic

BACKGROUND

HIV molecular epidemiology is increasingly integrated into public health prevention. We conducted cluster typing to enhance characterization of a densely sampled statewide epidemic towards informing public health.

METHODS

We identified HIV clusters, categorized them into types, and evaluated their dynamics between 2004 and 2019 in Rhode Island. We grouped sequences by diagnosis year, assessed cluster changes between paired phylogenies, t0 and t1, representing adjacent years and categorized clusters as stable (cluster in t0 phylogeny = cluster in t1 phylogeny) or unstable (cluster in t0 ≠ cluster in t1). Unstable clusters were further categorized as emerging (t1 phylogeny only) or growing (larger in t1 phylogeny). We determined proportions of each cluster type, of individuals in each cluster type, and of newly diagnosed individuals in each cluster type, and assessed trends over time.

RESULTS

A total of 1727 individuals with available HIV-1 subtype B pol sequences were diagnosed in Rhode Island by 2019. Over time, stable clusters and individuals in them dominated the epidemic, increasing over time, with reciprocally decreasing unstable clusters and individuals in them. Conversely, proportions of newly diagnosed individuals in unstable clusters significantly increased. Within unstable clusters, proportions of emerging clusters and of individuals in them declined; whereas proportions of newly diagnosed individuals in growing clusters significantly increased over time.

CONCLUSION

Distinct molecular cluster types were identified in the Rhode Island epidemic. Cluster dynamics demonstrated increasing stable and decreasing unstable clusters driven by growing, rather than emerging clusters, suggesting consistent in-state transmission networks. Cluster typing could inform public health beyond conventional approaches and direct interventions.

micro-RNA-486-5p protects against kidney ischemic injury and modifies the apoptotic transcriptome in proximal tubules

Acute kidney injury (AKI) carries high morbidity and mortality, and effective treatments are lacking. Preclinical models support involvement of micro-RNAs (miRs) in AKI pathogenesis, although effects on the kidney transcriptome are unclear. We previously showed that injection of cord blood endothelial colony forming cell-derived exosomes, enriched in miR-486-5p, prevented ischemic AKI in mice. To further define this, we studied direct effects of miR-486-5p in mice with kidney ischemia-reperfusion injury. RNA-Seq was used to compare the impact of miR-486-5p and exosomes on the transcriptome of proximal tubules and kidney endothelial cells 24 hours after ischemia-reperfusion. In mice with AKI, injection of miR-486-5p mimic increased its levels in proximal tubules and endothelial cells, and improved plasma creatinine, histological injury, neutrophil infiltration, and apoptosis. Additionally, miR-486-5p inhibited expression of its target phosphatase and tensin homolog, and activated protein kinase B. In proximal tubules, miR-486-5p or exosomes reduced expression of genes associated with ischemic injury and the tumor necrosis factor (TNF) pathway, and altered distinct apoptotic genes. In endothelial cells, genes associated with metabolic processes were altered by miR-486-5p or exosomes, although TNF pathway genes were not affected. Thus, our results suggest that miR-486-5p may have therapeutic potential in AKI.

Pharmacists' nonprescription syringe dispensing perceptions and behaviors: A three-state descriptive analysis

BACKGROUND

One approach to increasing the reach of syringe programs in rural areas could be through provision of syringes at community pharmacies. This study evaluated relationships between state-specific syringe policies, pharmacy, and pharmacist characteristics and pharmacists' nonprescription syringe dispensing behaviors in a 3- state Appalachian region at high risk for HIV and HCV transmission.

METHODS

We conducted a telephone census of community pharmacies in the Appalachian counties of North Carolina, Tennessee, and Virginia from April-June 2018. Behaviors studied included having ever sold syringes without a prescription, quantity of individuals to whom nonprescription syringes were dispensed in the past 30 days, having ever denied a request for nonprescription syringes, and past 30-day denial of nonprescription syringe requests. Behavioral intention and perceptions of legality were elicited.

RESULTS

A response rate of 52.3 % was achieved (N = 391). North Carolina pharmacists reported increased past 30-day dispensing, less denial of nonprescription syringe requests, and decreased justification for syringe dispensing (proof of medical need) as compared to Tennessee and Virginia pharmacists. Behavioral intention to dispense did not vary by state but did vary by political affiliation. Perceptions of syringe dispensing legality in NC were significantly different from those in TN and VA.

CONCLUSIONS

Significant differences in pharmacists' perceptions and behaviors were noted across state lines with North Carolina pharmacists reporting more engagement in syringe dispensing as compared to pharmacists in Tennessee and Virginia. Policy allowing pharmacists to dispense syringes to people who inject drugs appears to foster some but not all pharmacist engagement in this harm reduction intervention.

A study protocol for a quasi-experimental community trial evaluating the integration of indigenous healing practices and a harm reduction approach with principles of seeking safety in an indigenous residential treatment program in Northern Ontario

Background

Indigenous communities in Canada face significant challenges with intergenerational trauma, which manifests in substance use disorders. There is consensus that connecting treatment approaches to culture, land, community, and spiritual practices is a pathway to healing trauma and substance use disorders for Indigenous peoples. Indigenous residential addiction treatment programs have been established as the primary intervention to provide healing for Indigenous peoples with substance use disorders and intergenerational trauma. However, there is limited evidence demonstrating the effectiveness of these programs. In collaboration with the Benbowopka Treatment Centre, this paper describes a study protocol which aims to evaluate the effectiveness of blending Indigenous Healing Practices and Seeking Safety for the treatment of Indigenous patients with intergenerational trauma and substance use disorders.

Methods

We will conduct a pre/post Quasi Experimental Community trial, to compare historical treatment outcomes for patients following the implementation of Indigenous Healing and Seeking Safety. We will conduct quantitative and qualitative analyses to understand the differences before and after the intervention is implemented. The pre- Indigenous Healing and Seeking Safety intervention study window will span from 2013 to 2016; n = 343, and the post-Indigenous Healing and Seeking Safety intervention study window from 2018 to 2020; n > 300. All participants will be enrolled in the Benbowopka residential treatment for the first time during the study periods. All data will be anonymized at the time of data entry. Propensity matching will be undertaken for patient characteristics, including sex/gender, age, and substance use type.

Results and conclusions

The study findings could be used to inform intergenerational trauma and substance use disorders residential treatment programming for Indigenous communities across Canada. Our work will contribute to the field of community-based intergenerational trauma and substance use disorders programming by addressing objectives that consider: (a) the patient perspective, (b) the program perspective, and (c) the community perspective. The study findings may validate an innovative approach for evaluating the effectiveness of residential addiction treatment and particularly the effective and appropriate care for Indigenous patients with intergenerational trauma and substance use disorders.

Empirical comparison of analytical approaches for identifying molecular HIV-1 clusters

Public health interventions guided by clustering of HIV-1 molecular sequences may be impacted by choices of analytical approaches. We identified commonly-used clustering analytical approaches, applied them to 1886 HIV-1 Rhode Island sequences from 2004-2018, and compared concordance in identifying molecular HIV-1 clusters within and between approaches. We used strict (topological support ≥ 0.95; distance 0.015 substitutions/site) and relaxed (topological support 0.80-0.95; distance 0.030-0.045 substitutions/site) thresholds to reflect different epidemiological scenarios. We found that clustering differed by method and threshold and depended more on distance than topological support thresholds. Clustering concordance analyses demonstrated some differences across analytical approaches, with RAxML having the highest (91%) mean summary percent concordance when strict thresholds were applied, and three (RAxML-, FastTree regular bootstrap- and IQ-Tree regular bootstrap-based) analytical approaches having the highest (86%) mean summary percent concordance when relaxed thresholds were applied. We conclude that different analytical approaches can yield diverse HIV-1 clustering outcomes and may need to be differentially used in diverse public health scenarios. Recognizing the variability and limitations of commonly-used methods in cluster identification is important for guiding clustering-triggered interventions to disrupt new transmissions and end the HIV epidemic.

Novel Use of Biphasic Cuirass Ventilation During Definitive Radiation Therapy: A Technical Report

The use of biphasic cuirass ventilator supported radiation therapy has never been documented. We present the first technical report here. A 57-year-old man with obstructive sleep apnea presented with a T0N1M0 right sided, human papillomavirus related head and neck cancer diagnosed on excisional lymph node biopsy. On further workup, the cancer was found to have originated in the right tonsil and was staged as T1N1. The patient started definitive treatment with concurrent chemo-radiation therapy, but after 5 treatments was no longer able to lay in a supine position for treatment. Diagnostic imaging workup eventually revealed an idiopathic right sided hemi-diaphragm eventration. After consultation with cardiology, pulmonology, and head and neck surgery, recommendation was made for tracheostomy to tolerate supine radiotherapy position, but the patient refused. Instead, computed tomography simulation for radiotherapy replanning was performed using a combination of biphasic cuirass ventilation, home continuous positive airway pressure and oxygen. The patient then tolerated definitive treatment to a dose of 69.96 Gray in 33 fractions with concurrent chemotherapy and experienced no unexpected side effects. Although complex, daily treatment setup was consistent. Daily onboard imaging was precise and accurate. The patient continues to follow up with radiation oncology, medical oncology, and pulmonology. This is the first use of biphasic cuirass ventilator supported radiotherapy reported in the scientific literature. Although daily treatment setup is complex, its use could be considered in patients unable to tolerate radiation therapy treatment positioning as an alternative to tracheostomy.

Pharmacologic Therapies for Aortic Stiffness in End-Stage Renal Disease: A Systematic Review and Meta-Analysis

Background:

Increased carotid-femoral pulse wave velocity (cf-PWV), a surrogate of increased aortic stiffness, is a risk factor for cardiovascular events and all-cause mortality in end-stage renal disease (ESRD). To minimize the deleterious effects of an increased aortic stiffness in ESRD patients, several interventions have been developed and cf-PWV has been used to monitor responses.

Objective:

The aim of this study was to determine the effects of pharmacologic interventions that target aortic stiffness on cf-PWV and systolic blood pressure (SBP) in adults with ESRD.

Study design:

This study implements a systematic review and meta-analysis.

Data sources:

MEDLINE, EMBASE, Cochrane Central, Health Technology Assessment, and EBM databases were searched.

Study eligibility, participants, and interventions:

Randomized and non-randomized studies involving adults (>18 years) with ESRD of any duration, receiving or not renal replacement therapy (hemodialysis, peritoneal dialysis) and exposed to a pharmacologic intervention whose effects were assessed by cf-PWV.

Methods:

Study screening, selection, data extraction, and quality assessments were performed by 2 independent reviewers. Narrative synthesis and quantitative data analysis summarized the review.

Results:

We included 1027 ESRD participants from 13 randomized and 5 non-randomized studies. Most pharmacologic interventions targeted bone mineral metabolism disorder or hypertension. Treatment with vitamin D analogues or cinacalcet did not decrease cf-PWV or SBP over placebo or matched controls (P > .05). Calcium-channel blockers (CCB) decreased cf-PWV and SBP compared with placebo or standard care (P < .05). Renin-angiotensin system inhibitors did not show any advantage over placebo in decreasing cf-PWV (P > .05).

Limitations:

Quality of evidence ranged from very low to moderate. Overall evidence was limited by the low number of studies, small sample sizes, and methodological inconsistencies.

Conclusions:

Pharmacologic interventions targeting aortic stiffness in ESRD have mixed effects on reducing cf-PWV, with some strategies suggesting potential benefit. The quality of evidence, however, is insufficient to draw definitive conclusions on their use to slow progression of aortic stiffness in ESRD. Further well-designed studies are needed to confirm these associations and their impact on cardiovascular outcomes in ESRD.

Registered in PROSPERO (CRD42016033463)

THE OLDER POPULATION LIVING WITH AND PROVIDING CARE TO GRANDCHILDREN, BY NATIVITY: 2013-2017

The rapid growth of the older population in the United States combined with changing living arrangements, marital status, and employment, increases the importance of multi-generational ties for the well-being of families. The U.S. Census Bureau’s earlier reports on grandparents living with grandchildren mostly focused on the background characteristics of all grandparents without classifying them by nativity. This study expands on the research by presenting data for both native- and foreign-born grandparents aged 60 and older who live with and provide care to their grandchildren under 18. Data for this study come from the 2013-2017 American Community Survey 5-year estimates. Among native-born grandparents living with grandchildren, the majority were females, aged 60-69, White alone, non-Hispanic or Latino, married, high school graduate or higher, had no disability, lived in a household that was owned, uninsured, not in labor force, and not in poverty. The foreign-born grandparents were similar in most characteristics except for race component and educational attainment. Key findings include: • Among total older population, 14.3 percent of the foreign-born lived with grandchildren, compared with 4.1 percent of the native-born. • Among co-resident grandparents, the native-born (36 percent) were more likely to be caregivers, compared with the foreign-born (14 percent). • The proportions of co-resident grandparents widely vary by race and Hispanic origin. • Among grandparent caregivers, over 50 percent had been responsible for grandchildren for 5 years or more, while 14 percent for less than a year. • Both native- and foreign-born grandparents show declining patterns of care-giving by age.

A Systematic Review and Meta-analysis of Nonpharmacologic-based Interventions for Aortic Stiffness in End-Stage Renal Disease

Introduction

Increased carotid-femoral pulse wave velocity (cf-PWV) in end-stage renal disease (ESRD) indicates enhanced aortic stiffness and mortality risk. We conducted a systematic review and meta-analysis of nonpharmacologic interventions in adults with ESRD to determine their effects on cf-PWV, systolic blood pressure (SBP), and intervention-associated adverse events.

Methods

MEDLINE, EMBASE, and EBM databases were searched. Study screening, selection, data collection, and methodological quality assessments were performed by 2 independent reviewers. Pooled-effect estimates from mean differences and 95% confidence intervals (CIs) were calculated using random effect models.

Results

A total of 2166 subjects with ESRD from 33 studies (17 randomized; 16 nonrandomized) were included. Four intervention-comparator pairs were meta-analyzed. Quality of evidence ranged from very low to moderate. Kidney transplantation decreased cf-PWV (−0.70 m/s; CI: –1.3 to −0.11; P = 0.02) and SBP (−8.3 mm Hg; CI: −13.2 to −3.3; P < 0.001) over pretransplantation. In randomized trials, control of fluid overload by bio-impedance reduced cf-PWV (−1.90 m/s; CI: −3.3 to −0.5); P = 0.02) and SBP (−4.3 mm Hg; CI: −7.7 to −0.93); P = 0.01) compared with clinical assessment alone. Cross-sectional studies also demonstrated significantly lower cf-PWV and SBP in normovolemia compared with hypervolemia (P ≤ 0.01). Low calcium dialysate decreased cf-PWV (−1.70 m/s; CI: −2.4 to −1.0; P < 0.00001) without affecting SBP (−1.6 mm Hg; CI: −8.9 to 5.8; P = 0.61). Intradialytic exercise compared with no exercise reduced cf-PWV (−1.13 m/s; CI: −2.2 to −0.03; P = 0.04), but not SBP (+0.5 mm Hg; CI: −9.5 to 10.4); P = 0.93).

Conclusions

Several nonpharmacologic interventions effectively decrease aortic stiffness in ESRD. The impact of these interventions on cardiovascular outcomes and mortality risk reduction in ESRD requires further study.

Attitudes of psychiatrists to evidence-based guidelines

Aims and Method

We aimed to survey clinicians' attitudes on using evidence-based guidelines. A postal questionnaire based on a previous survey of general practitioners was sent to 105 psychiatrists working within Avon and Western Wiltshire Mental Health Partnership NHS Trust.

Results

There was a 91% response rate. Respondents were generally in favour of clinical guidelines, with scores indicating a positive attitude to guidelines in 13 of the 18 statements. The majority felt that guidelines were effective in improving patient care, could be used flexibly to suit individual patients and did not impinge on their clinical judgement.

Clinical Implications

Psychiatrists welcomed the increasing use of guidelines. Further research is needed to determine whether this will translate into actual use and improved outcomes for patients.

Effect of implementation of a preconception counselling resource for women with diabetes: A population based study

AIM

To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators.

METHODS

A preconception counselling DVD was distributed to women by diabetes care teams and general practices. Subsequently, in a prospective population-based study, pregnancy planning indicators were evaluated. The post-DVD cohort (n=135), including a viewed-DVD subgroup (n=58), were compared with an historical cohort (pre-DVD, n=114). Primary outcome was HbA1c at first diabetes-antenatal visit. Secondary outcomes included preconception folic acid consumption, planned pregnancy and HbA1c recorded in the 6 months preconception.

RESULTS

Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8mmol/mol]; p=0.12), although not statistically significant. 53% and 20% of women with type 1 and 2 diabetes, respectively, viewed the DVD. The viewed-DVD subgroup were significantly more likely to have lower first visit HbA1c: 6.9% vs. 7.8% [52.1 vs. 61.8mmol/mol], P<0.001; planned pregnancy (88% vs. 59%, P<0.001); taken folic acid preconception (81% vs. 43%, P=0.001); and had HbA1c recorded preconception (88% vs. 53%, P<0.001) than the pre-DVD cohort.

CONCLUSIONS

Implementation of a preconception counselling resource was associated with improved pregnancy planning indicators. Women with type 2 diabetes are difficult to reach. Greater awareness within primary care of the importance of preconception counselling among this population is needed.

High Risk Aortic Valve Replacement - The Challenges of Multiple Treatment Strategies with an Evolving Technology

OBJECTIVES

Deciding on the optimal treatment strategy for high risk aortic valve replacement is challenging. Transcatheter Aortic Valve implantation (TAVI) has been available in our centre as an alternative treatment modality for patients since 2008. We present our early experience of TAVI and SAVR (surgical Aortic Valve Replacement) in high risk patients who required SAVR because TAVI could not be performed.

METHODS

The database for Surgical aortic valve and Transcatheter aortic valve replacement referrals was interrogated to identify relevant patients.

RESULTS

Survival to hospital discharge was 95.5% in the forty five patients who had SAVR when TAVI was deemed technically unsuitable. One year survival was 86%.

CONCLUSION

Defining who is appropriate for TAVI or high risk SAVR is challenging and multidisciplinary team discussion has never been more prudent in this field of evolving technology with ever decreasing risks of surgery. The introduction of TAVI at our institution has seen a rise in our surgical caseload by approximately by 25%. Overall, the option of aortic valve intervention is being offered to more patients in general which is a substantial benefit in the treatment of aortic valve disease.

Quantifying consumer portion control practices. A cross-sectional study

The use of portion control practices has rarely been quantified. The present study aimed to: (1) explore which portion control practices are actually used by the general population and their association with cognitive restraint, demographic background and general health interest (GHI), and (2) examine how the usage of portion control practices predicts the estimated consumption of an energy dense food (i.e. pizza). Twenty-two portion control practices were rated in terms of their frequency of use from 'never' to 'very often' by a representative sample of 1012 consumers from the island of Ireland. Three factors were extracted and named: measurement-strategy scale, eating-strategy scale, and purchasing-strategy scale. The eating-strategy scale score was the highest, while the measurement-strategy scale carried the lowest frequency score. For each strategy scale score, the strongest predictor was GHI, followed by gender. Having higher GHI and being female were independently associated with more frequent portion control. Both the eating-strategy scale score and the purchasing-strategy scale score were negatively associated with pizza portion size consumption estimates. In conclusion, while this study demonstrates that the reported use of portion control practices is low, the findings provide preliminary evidence for their validity. Further studies are needed to explore how portion control practices are used in different kinds of portion size decisions and what their contribution is to the intake of food over an extended period of time.

Multiple knockout mouse models reveal lincRNAs are required for life and brain development

Many studies are uncovering functional roles for long noncoding RNAs (lncRNAs), yet few have been tested for in vivo relevance through genetic ablation in animal models. To investigate the functional relevance of lncRNAs in various physiological conditions, we have developed a collection of 18 lncRNA knockout strains in which the locus is maintained transcriptionally active. Initial characterization revealed peri- and postnatal lethal phenotypes in three mutant strains (Fendrr, Peril, and Mdgt), the latter two exhibiting incomplete penetrance and growth defects in survivors. We also report growth defects for two additional mutant strains (linc–Brn1b and linc–Pint). Further analysis revealed defects in lung, gastrointestinal tract, and heart in Fendrr^−/− neonates, whereas linc–Brn1b^−/− mutants displayed distinct abnormalities in the generation of upper layer II–IV neurons in the neocortex. This study demonstrates that lncRNAs play critical roles in vivo and provides a framework and impetus for future larger-scale functional investigation into the roles of lncRNA molecules.

DOI:http://dx.doi.org/10.7554/eLife.01749.001

The mammalian genome is comprised of DNA sequences that contain the templates for proteins, and other DNA sequences that do not code for proteins. The coding DNA sequences are transcribed to make messenger RNA molecules, which are then translated to make proteins. Researchers have known for many years that some of the noncoding DNA sequences are also transcribed to make other types of RNA molecules, such as transfer and ribosomal RNA. However, the true breadth and diversity of the roles played by these other RNA molecules have only recently begun to be fully appreciated.

Mammalian genomes contain thousands of noncoding DNA sequences that are transcribed. Recent in vitro studies suggest that the resulting long noncoding RNA molecules can act as regulators of transcription, translation, and cell cycle. In vitro studies also suggest that these long noncoding RNA molecules may play a role in mammalian development and disease. Yet few in vivo studies have been performed to support or confirm such hypotheses.

Now Sauvageau et al. have developed several lines of knockout mice to investigate a subset of noncoding RNA molecules known as long intergenic noncoding RNAs (lincRNAs). These experiments reveal that lincRNAs have a strong influence on the overall viability of mice, and also on a number of developmental processes, including the development of lungs and the cerebral cortex.

Given that the vast majority of the human genome is transcribed, the mouse models developed by Sauvageau et al. represent an important step in determining the physiological relevance, on a genetic level, of the noncoding portion of the genome in vivo.

DOI:http://dx.doi.org/10.7554/eLife.01749.002

Does a diet high or low in fat influence the oxidation potential of VLDL, LDL and HDL subfractions?

BACKGROUND AND AIMS

High-fat diets have become increasingly popular for weight-loss, but their effect on the oxidation potential of lipoprotein subfractions has not been studied. Therefore, this study compared the effects of high-fat vs. low-fat weight reduction diets on this parameter.

METHODS AND RESULTS

Very-low, low- and high-density lipoprotein (VLDL, LDL & HDL) subfractions were isolated by rapid ultracentrifugation from 24-overweight/obese subjects randomised to a high- or low-fat diet. The lipoprotein subfractions were assessed for oxidation potential by measuring conjugated diene (CD) production and time at half maximum. We found a significant between-group difference in oxidation potential. Specifically, a high-fat diet led to increased CD production in VLDL(A-D) and HDL(2&3), and a prolongation of time at half maximum. Within-group differences found that CDs increased in VLDL(A&D), LDL(I-III) and HDL(2&3) in the high-fat group and fell in VLDL(A-C) and HDL(2&3) and increased in LDL(I&II), in the low-fat group. Furthermore, following both diets all lipoprotein subfractions, except LDL(II) in the low-fat group, were protected against oxidation.

CONCLUSION

These results demonstrate that at first glance, a high-fat diet may be indicative of having heart-protective properties. However, this may be erroneous, as although the time for oxidation to occur was prolonged, once this occurred these lipoproteins had the potential to produce significantly more oxidised substrate. Conversely, a low-fat diet may be considered anti-atherogenic, as these subfractions were protected against oxidation and mainly contained fewer oxidised substrate. Thus, increased fat intake may, by increasing the oxidation product within lipoprotein subfractions, increase cardiovascular disease.

Evaluation of a DVD for women with diabetes: impact on knowledge and attitudes to preconception care

AIMS

To determine if an educational DVD increases knowledge and changes attitudes of women with diabetes towards preconception care.

METHODS

Ninety-seven women with diabetes (Type 1, n = 89; Type 2, n = 8), aged 18-40 years, completed a pre-DVD and post-DVD intervention study by postal questionnaire. Beliefs and attitudes associated with preventing an unplanned pregnancy and seeking preconception care were assessed using a validated questionnaire; scales included benefits, barriers, personal attitudes and self-efficacy. Knowledge of pregnancy planning and pregnancy-related risks were assessed by a 22-item questionnaire.

RESULTS

After viewing the DVD there was significant positive change in women's perceived benefits of, and their personal attitudes to, receiving preconception care and using contraception: change in score post-DVD viewing 0.7 (95% confidence interval 0.3, 1.2), P = 0.003, and 0.8 (0.3, 1.2), P = 0.001, respectively. The DVD significantly improved self-efficacy, that is, self-confidence to use contraception for prevention of an unplanned pregnancy and to access preconception care [3.3 (1.9, 4.7), P < 0.001], and significantly reduced perceived barriers to preconception care [-0.7 (-1.2, -0.2), P = 0.01]. Knowledge of pregnancy planning and pregnancy-related risks increased significantly after viewing the DVD: mean increase was 37.6 ± 20.0%, P < 0.001, and 16.9 ± 21.2%, P < 0.001, respectively.

CONCLUSIONS

This study demonstrates the effectiveness of a DVD in increasing knowledge and enhancing attitudes of women with diabetes to preconception care. This DVD could be used as a prepregnancy counselling resource to prepare women with diabetes for pregnancy.

An exploration of knowledge and attitudes related to pre-pregnancy care in women with diabetes

AIMS

Pre-pregnancy care optimizes pregnancy outcome in women with pre-gestational diabetes, yet most women enter pregnancy unprepared. We sought to determine knowledge and attitudes of women with Type 1 and Type 2 diabetes of childbearing age towards pre-pregnancy care.

METHODS

Twenty-four women (18 with Type 1 diabetes and six with Type 2 diabetes) aged 17-40 years took part in one of four focus group sessions: young nulliparous women with Type 1 diabetes (Group A), older nulliparous women with Type 1 diabetes (Group B), parous women with Type 1 diabetes (Group C) and women with Type 2 diabetes of mixed parity (Group D).

RESULTS

Content analysis of transcribed focus groups revealed that, while women were well informed about the need to plan pregnancy, awareness of the rationale for planning was only evident in parous women or those who had actively sought pre-pregnancy advice. Within each group, there was uncertainty about what pre-pregnancy advice entailed. Despite many women reporting positive healthcare experiences, frequently cited barriers to discussing issues around family planning included unsupportive staff, busy clinics and perceived social stereotypes held by health professionals.

CONCLUSIONS

Knowledge and attitudes reported in this study highlight the need for women with diabetes, regardless of age, marital status or type of diabetes, to receive guidance about planning pregnancy in a motivating, positive and supportive manner. The important patient viewpoints expressed in this study may help health professionals determine how best to encourage women to avail of pre-pregnancy care.

A comparison of the sampling efficiencies of a range of atmosphere samplers when collecting polymeric diphenylmethane di-isocyanate (MDI) aerosols

Polymeric diphenylmethane di-isocyanate (PMDI) is a precursor or an intermediate in the manufacture of pure MDI and is used in many industrial applications. Potential health effects of diisocyanates are generally considered to include irritation and respiratory sensitization, dictating the need for low occupational hygiene standards and robust hygiene monitoring methods. A wide range of methods has been developed or adopted for this purpose but questions concerning their ability to accurately sample MDI aerosols in the occupational environment have often been raised. In order to provide such information, studies have been conducted to compare several MDI sampling systems: the Institute of Occupational Medicine (IOM) 25-mm open-faced inhalable dust sampler; the 13-mm Millipore Swinnex Cassette sampler; the 37-mm open-face Millipore cassette; the midget-impinger, the glass tube containing glass wool, and two direct reading paper tape monitors. The program was comprised of two phases, the first being a preliminary comparison of the collection efficiencies of the IOM, 13 mm and midget-impinger at a range of orientations to air flow, aerosol particle sizes, and sampling flow rates, using inert polyethylene glycol aerosols. The second phase compared all samplers operating according to each manufacturer's recommendations and sampling PMDI aerosols at a range of particle sizes and concentrations. All studies were conducted in a wind tunnel. All filter methods performed well in atmospheres containing small particles except impingers that required a filter backup. In general, the variability of all the samplers was high for larger particle size ranges. Direct reading monitors showed low efficiencies.

CAM evaluation: what are the research questions?

Much effort is being directed towards the evaluation of CAM therapies. Yet evaluation is often encouraged before truly considering the research questions which need to be asked. Research questions like 'Does this CAM therapy work?' must be clearly distinguished from 'Does this particular CAM treatment work?' and the latter question needs to be replaced by even more specific ones like 'Does it work when administered by therapist X?' and 'Is therapist X effective?'. Suggestions for the study of the therapeutic process and the evaluation of therapist effectiveness are presented.

Beating heart coronary artery bypass grafting. A theatre nurse's perspective

Coronary artery bypass graft (CABG) surgery has been going through a time warp. The development of cardiopulmonary bypass (CPB), together with continuing advances in equipment and refinement of techniques, introduced a high level of safety for CABG operations. Recently, however, with pharmacological and technological advances, surgeons have been able to 'go back in time' and undertake complex CABG surgery without CPB.

Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

OBJECTIVES

To determine whether postal prompts to patients who have survived an acute coronary event and to their general practitioners improve secondary prevention of coronary heart disease.

DESIGN

Randomised controlled trial.

SETTING

52 general practices in east London, 44 of which had received facilitation of local guidelines for coronary heart disease.

PARTICIPANTS

328 patients admitted to hospital for myocardial infarction or unstable angina.

INTERVENTIONS

Postal prompts sent 2 weeks and 3 months after discharge from hospital. The prompts contained recommendations for lowering the risk of another coronary event, including changes to lifestyle, drug treatment, and making an appointment to discuss these issues with the general practitioner or practice nurse.

MAIN OUTCOME MEASURES

Proportion of patients in whom serum cholesterol concentrations were measured; proportion of patients prescribed beta blockers (6 months after discharge); and proportion of patients prescribed cholesterol lowering drugs (1 year after discharge).

RESULTS

Prescribing of beta bockers (odds ratio 1.7, 95% confidence interval 0.8 to 3.0, P>0.05) and cholesterol lowering drugs (1.7, 0. 8 to 3.4, P>0.05) did not differ between intervention and control groups. A higher proportion of patients in the intervention group (64%) than in the control group (38%) had their serum cholesterol concentrations measured (2.9, 1.5 to 5.5, P<0.001). Secondary outcomes were significantly improved for consultations for coronary heart disease, the recording of risk factors, and advice given. There were no significant differences in patients' self reported changes to lifestyle or to the belief that it is possible to modify the risk of another coronary event.

CONCLUSIONS

Postal prompts to patients who had had acute coronary events and to their general practitioners in a locality where guidelines for coronary heart disease had been disseminated did not improve prescribing of effective drugs for secondary prevention or self reported changes to lifestyle. The prompts did increase consultation rates related to coronary heart disease and the recording of risk factors in the practices. Effective secondary prevention of coronary heart disease requires more than postal prompts and the dissemination of guidelines.

Why do we continue to take unnecessary smears?

A questionnaire survey of all general practices and family planning doctors in Manchester Health Authority was undertaken to determine why many more smears are taken in primary care than are scheduled by the screening programme. An 82% response rate was obtained. The indications for additional smear tests most frequently cited by responders were postcoital (88%), postmenopausal (84%), or intermenstrual bleeding (55%); genital warts (87%); and multiple sexual partners (52%). Forty-six per cent think that a woman should have a repeat test within one year of her first ever test. We discuss why these are not valid indications for additional smear tests.

Exon and intron variants in the human tryptophan 2,3-dioxygenase gene: potential association with Tourette syndrome, substance abuse and other disorders

Defects in serotonin metabolism, and abnormalities in both blood serotonin and tryptophan levels, have been reported in many psychiatric disorders. Tryptophan 2,3-dioxygenase (TDO2) is the rate limiting enzyme for the breakdown of tryptophan to N-formyl kenurenine. Functional variants of this gene could account for the observed simultaneous increases or decreases of both serotonin and tryptophan in various disorders. We have identified four different polymorphisms of the human TDO2 gene. Association studies show a significant association of one or more of these polymorphisms and Tourette syndrome (TS), attention deficit hyperactivity disorder (ADHD) and drug dependence. The intron 6G-->T variant was significantly associated with platelet serotonin levels. Only the association with TS was significant with a Bonferroni correction (p = 0.005). Our purpose here is not to claim these associations are proven, but rather to report preliminary results and show that easily testable polymorphisms are available. We hope to encourage additional research into the potential role the TDO2 gene in these and other psychiatric disorders.

Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London

OBJECTIVE

To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training, inner city general practices.

DESIGN

Randomised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions.

SUBJECTS

24 inner city, non-training general practices.

SETTING

East London.

MAIN OUTCOME MEASURES

Recording of key variables in patient records (asthma: peak flow rate, review of inhaler technique, review of asthma symptoms, prophylaxis, occupation, and smoking habit; diabetes: blood glucose concentration, glycaemic control, funduscopy, feet examination, weight, and smoking habit); size of practice disease registers; prescribing in asthma; and use of structured consultation "prompts."

RESULTS

In practices receiving diabetes guidelines, significant improvements in recording were seen for all seven diabetes variables. Both groups of practices showed improved recording of review of inhaler technique, smoking habit, and review of asthma symptoms. In practices receiving asthma guidelines, further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma. Sizes of disease registers were unchanged. The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma.

CONCLUSIONS

Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city, non-training practices. The use of simple prompts may enhance this improvement.

Home visitation services for at-risk pregnant and postpartum women: a randomized trial

A randomized trial tested the psychosocial efficacy of a home visitation model for women at risk of out-of-home placement of their newborns. After an average of ten months of exposure, the experimental group reported significantly increased social support, greater access to services, and decreased psychological distress. Implications of the findings for interventions with at-risk families are discussed.

Psychosocial characteristics of pregnant women with and without a history of substance abuse

This study was undertaken to identify the psychosocial characteristics and service needs of pregnant women with substance abuse histories. Two hundred and twenty-five pregnant women defined as having high-risk pregnancies for psychosocial reasons were interviewed using a structured questionnaire when they presented for prenatal care at a large urban clinic. Women who admitted to problems with substance abuse were compared to those who denied a history of substance abuse. Women with an admitted history of substance abuse were significantly older, had more children, were more likely to live on their own or in an institutional setting, and more frequently reported that they currently smoked cigarettes. In addition, women with substance abuse problems delayed prenatal care an average of one month longer. Other differences between the two groups, as well as the implications of the findings for social work practice in health care settings, are discussed.

Clinical experience with penicillin skin testing in a large inner-city STD clinic

OBJECTIVE

To establish (1) the prevalence of positive penicillin skin tests among outpatients with well-defined but variable history of penicillin allergy and (2) the reproducibility, safety, and negative predictive value of skin testing with benzylpenicilloyl polylysine (PPL) and a minor-determinant mixture (MDM).

DESIGN

Serial consenting outpatients with current indications for penicillin therapy were skin-tested in duplicate with PPL and MDM. Subjects with negative skin tests (93% of those positive by history and 95% of those negative by history) received therapeutic courses of benzylpenicillin (81%) or ampicillin (19%). Negative predictive value of skin testing was established by 72-hour follow-up for adverse reactions to drug.

SETTING/PATIENTS

A total of 5063 consecutive, qualifying outpatients in a Baltimore, Md, sexually transmitted disease (STD) clinic. The study group was young (73% between 20 and 40 years old), 66% male, and 90% black; 25% had history of atopy. Follow-up was 94% complete.

RESULTS

Positive skin tests were observed in 7.1% of 776 individuals with previous history of penicillin allergy and in 1.7% of 4287 subjects negative by history (P << .001). Previous history of anaphylaxis or urticaria was associated with significantly higher rates of positive skin tests of 17.3% and 12.4%, respectively (P<<.001). Only 4% with history of exanthem had positive skin tests (P = .03). The coefficient of variation for duplicate skin tests was 11%. Time intervals since last penicillin treatment did not influence the rate of positive skin tests. Adverse reactions to skin tests occurred in 13 (1.2% of patients positive by history; 9.4% of those with positive skin tests). A mild anaphylactic reaction occurred in one individual whose preliminary scratch testing was inadvertently omitted; systemic pruritus or urticaria occurred in 11 subjects; one had a large local reaction. After penicillin administration to individuals with negative skin tests, acute allergic reactions occurred in 0.5% of subjects negative by history compared with 2.9% of subjects positive by history (chi 2 = 33.3; P = .0001). Reactions were generally mild and self-limited; only two cases of mild anaphylactic reaction occurred, both in patients with history of severe IgE-mediated reaction.

CONCLUSIONS

Skin testing with both major and minor penicillin determinants is safe using current recommendations, and both reagents are necessary for maximizing the identification of sensitized subjects. Routine penicillin skin testing can facilitate the safe use of penicillin in 90% of individuals with a previous history of penicillin allergy.

Evolution of the human immunodeficiency virus epidemic among patients attending sexually transmitted disease clinics: a decade of experience

Since human immunodeficiency virus (HIV) is predominantly sexually transmitted, serologic surveys for HIV infection in sexually transmitted disease (STD) clinics provide sentinel observations regarding HIV epidemiology. Over the past decade, 17,207 systematically collected sera from patients attending Baltimore STD clinics were analyzed. From 1979 through 1989, HIV seroprevalence rose from 0.23% to 5.35%, increasing significantly in both men and women (P less than .001). Due to a marked increase in HIV infection among women during the mid-1980s, the male-to-female ratio of HIV infection declined from 16:1 in 1979-1982 to 1.0 in 1988-1989. HIV seroprevalence increased significantly (P less than .001) in all age groups, with the greatest increase among teenagers, rising from 0.18% in 1979-1983 to 2.1% in 1987-1989 (P less than .001). Although HIV seroprevalence was higher among whites than blacks during the early 1980s, it increased in blacks subsequently (P less than .001), eventually resulting in a greater rate among black than white clinic patients (P less than .01). These data reflect the evolution of the HIV epidemic in US inner cities. HIV prevalence has increased greater than 20-fold, with recent increases being most marked among women, teenagers, and blacks. Additional resources will undoubtedly be required to support further intensive behavioral and educational programs targeted at adolescents and inner-city minorities.