Decreases in Employer Referrals to First-Time Substance Use Treatment for Adults From 2004 to 2020

OBJECTIVE

The aim of the study is to examine trends of employer/employee assistance program referred admissions to outpatient substance use disorder (SUD) treatment in the United States.

METHODS

The publicly available Treatment Episode Data Set was used. Full-time employed adults with no history of SUD treatment referred to outpatient treatment by an employer/employee assistance program from 2004 to 2020 were included ( N = 36,142). Joinpoint regression examined admission trends.

RESULTS

Employer/employee assistance program referred admissions to outpatient treatment decreased annually by 6.4% from 2004 to 2020 ( P < 0.001). Joinpoint analyses identified 2 linear segments from 2004 to 2008 (increased but not significant) and from 2008 to 2020. From 2008 to 2020, an average annual percent decrease of 8.7% ( P < 0.001) was identified.

CONCLUSIONS

Findings from this repeated cross-sectional study suggest a missed opportunity for workplaces to serve as a potential SUD treatment access point.

Inpatient Hepatitis C Treatment Coordination and Initiation for Patients Who Inject Drugs

BACKGROUND

With hepatitis C (HCV) incidence rising due to injection drug use, people who inject drugs (PWID) are a priority population for direct-acting antivirals (DAA). However, significant barriers exist. At our institution, hospitalized PWID were screened for HCV but not effectively linked to care.

AIM

To improve retention in HCV care among hospitalized PWID.

SETTING

Quaternary academic center in the Southeast US from August 2021 through August 2022.

PARTICIPANTS

Hospitalized PWID with HCV.

PROGRAM DESCRIPTION

E-consultation-prompted care coordination and HCV treatment with outpatient telehealth.

PROGRAM EVALUATION

Care cascades were constructed to assess retention and HCV treatment, with the primary outcome defined as DAA completion or sustained virologic response after week 4. Of 28 patients, 11 started DAAs inpatient, 8 initiated outpatient, and 9 were lost to follow-up or transferred care. Overall, 82% were linked to care and 52% completed treatment. For inpatient initiators, 73% achieved the outcome. Of non-inpatient initiators, 71% were linked to care, 53% started treatment, and 36% achieved the outcome.

DISCUSSION

Inpatient HCV treatment coordination, including DAA initiation, and telehealth follow-up, was feasible and highly effective for hospitalized PWID. Future steps should address barriers to inpatient DAA treatment and expand this model to other similar patient populations.

Prevalence and risk factors for nerve injury following shoulder dislocation

BACKGROUND

The glenohumeral joint dislocation can be associated with major nerve injury. The reported prevalence and risk factors for major nerve injury are variable and this injury can have a severe and life-long impact on the patient. The objectives of this study were to analyse the prevalence of major nerve injury following shoulder dislocation and examine risk factors. Management and outcomes of nerve injury were explored.

METHODS

A 1 year retrospective cohort study of 243 consecutive adults who presented with a shoulder dislocation was performed. Data were collected on patient demographics, timings of investigations, treatment, follow-up, and nerve injury prevalence and management. The primary outcome measure was prevalence of nerve injury. Risk factors for this were analysed using appropriate tests with Stata SE15.1.

RESULTS

Of 243 patients with shoulder dislocation, 14 (6%) had neurological deficit. Primary dislocation (p = 0.004) and older age (p = 0.02) were significantly associated with major nerve injury. Sex, time to successful reduction and force of injury were not associated with major nerve injury in this cohort. Patients with nerve injury made functional recovery to varying degrees. Recurrent shoulder dislocation was common accounting for 133/243 (55%) attendances.

CONCLUSIONS

Shoulder dislocation requires careful assessment and timely management in the ED. A 6% rate of nerve injury following shoulder dislocation was at the lower border of reported rates (5-55%), and primary dislocation and older age were identified as risk factors for nerve injury. We emphasise the importance of referring patients with suspected major nerve injury to specialist services.

1244. Inpatient vs. outpatient initiation of Hepatitis C treatment among hospitalized patients who inject drugs: Lessons from a quality improvement project

Background

Hepatitis C (HCV) diagnoses are rising, driven by infections in people who inject drugs (PWID). PWID are identified as a target population for treatment, but access to care is a barrier. At our institution, Addiction Medicine (AM) and Infectious Diseases (ID) routinely screen hospitalized PWID for HCV. Our novel quality improvement project assessed feasibility of starting HCV care processes for PWID inpatient. This included: (1) inpatient e-consults, (2) inpatient treatment initiation with direct acting antivirals (DAAs) when possible, and (3) post-discharge telehealth care.

Methods

The project was implemented at an academic hospital in the Southeast in August 2021, with results observed through April 2022. Patients seen by AM consultants with detectable HCV RNA and interest in treatment were eligible. AM recommended ID e-consults focused on HCV care, which began care coordination, including inpatient treatment initiation in select cases (based primarily on length of stay) (Fig 1). The primary outcome was “likely cure,” defined as treatment completion or SVR-4 (chosen due to concerns for loss to follow up). Cascades of care were constructed including: (1) completed HCV e-consult; (2) linkage to care (defined as telehealth visit for those not initiating inpatient); (3) treatment initiation; and (4) likely cure. Figure 1:Workflow

Results

Twenty patients had detectable HCV RNA and all were interested in treatment. Enrolled patients had a mean age of 33 years; 9/20 (45%) were female; and 17/20 (85%) were White. Of 20 patients (Fig 2), 16 (80%) were linked to care with 13 (81%, 65% overall) started on HCV treatment, of which 9 were started inpatient. Likely cure was achieved for 7, and 6 were still on treatment at the time of this report (Fig 2). Likely cure has so far been achieved in 66% of inpatient initiators (6 of 9), compared with 18% of others (2 of 11) (Figs 3 and 4). 6 patients were lost to follow-up. None of those initiating DAAs inpatient were lost.

Conclusion

Inpatient initiation of HCV treatment for PWID was feasible for patients with prolonged hospitalizations and may be effective at facilitating HCV treatment and cure among a vulnerable population with substantial barriers to care. Future steps should address inpatient barriers to DAAs, and examine models of HCV telehealth.

Disclosures

Asher J. Schranz, MD, MPH, UnitedHealthCare: Honoraria.

Quickly identifying people at risk of opioid use disorder in emergency departments: trade-offs between a machine learning approach and a simple EHR flag strategy

OBJECTIVES

Emergency departments (EDs) are an important point of contact for people with opioid use disorder (OUD). Universal screening for OUD is costly and often infeasible. Evidence on effective, selective screening is needed. We assessed the feasibility of using a risk factor-based machine learning model to identify OUD quickly among patients presenting in EDs.

DESIGN/SETTINGS/PARTICIPANTS

In this cohort study, all ED visits between January 2016 and March 2018 for patients aged 12 years and older were identified from electronic health records (EHRs) data from a large university health system. First, logistic regression modelling was used to describe and elucidate the associations between patient demographic and clinical characteristics and diagnosis of OUD. Second, a Gradient Boosting Classifier was applied to develop a predictive model to identify patients at risk of OUD. The predictive performance of the Gradient Boosting algorithm was assessed using F1 scores and area under the curve (AUC).

OUTCOME

The primary outcome was the diagnosis of OUD.

RESULTS

Among 345 728 patient ED visits (mean (SD) patient age, 49.4 (21.0) years; 210 045 (60.8%) female), 1.16% had a diagnosis of OUD. Bivariate analyses indicated that history of OUD was the strongest predictor of current OUD (OR=13.4, CI: 11.8 to 15.1). When history of OUD was excluded in multivariate models, baseline use of medications for OUD (OR=3.4, CI: 2.9 to 4.0) and white race (OR=2.9, CI: 2.6 to 3.3) were the strongest predictors. The best Gradient Boosting model achieved an AUC of 0.71, accuracy of 0.96 but only 0.45 sensitivity.

CONCLUSIONS

Patients who present at the ED with OUD are high-need patients who are typically smokers with psychiatric, chronic pain and substance use disorders. A machine learning model did not improve predictive ability. A quick review of a patient's EHR for history of OUD is an efficient strategy to identify those who are currently at greatest risk of OUD.

174 An Audit on First Time Shoulder Dislocations: Are We Following BESS Guidelines?

Aim

Traumatic shoulder dislocations are the most common joint dislocation in the UK. They are often associated with concurrent injury to the joint and its stabilisers which can occasionally get missed. This can severely affect functional recovery and lead to chronic instability. Our aim was to assess adherence to the BESS guidelines for first time shoulder dislocations in a large acute general hospital.

Method

We conducted a retrospective review of all patients who attended the emergency department at Birmingham Heartlands Hospital between January and December 2019. A total of 20 patients were selected after verifying data received from the health informatics team. Patient notes, investigations and clinic letters were reviewed.

Results

The average age of our cohort was 50 with a male to female ratio of 13:7. The cohort was divided into three groups depending on their age i.e.,16–25, 25–40 and &gt;40. Although 85% were seen in a fracture clinic only 25% were seen by a consultant. It was noted that among all three groups only 40% of appropriate imaging was requested. In addition, only 50% were correctly referred to a shoulder surgeon or shoulder clinic to assess shoulder function, however most patients were seen by a physiotherapist.

Conclusions

We found a large number of concomitant injuries in those investigated for a first-time dislocation. We have therefore designed a pathway to ensure that all patients with a first-time shoulder dislocation are followed up in fracture clinic and appropriate investigations ordered in a timely manner.

Efficacy and tolerability of baclofen in a U.S. community population with alcohol use disorder: a dose-response, randomized, controlled trial

Identification of new medications for alcohol use disorder (AUD) is important for improving treatment options. Baclofen, a GABA_B agonist, has been identified as a potential pharmacotherapy for AUD. In a 16-week double-blind, randomized, placebo-controlled trial, we investigated 30 and 90 mg/day of baclofen compared to placebo and examined effects of dose, sex, and level of pretreatment drinking. One hundred and twenty participants with DSM-IV alcohol dependence (age 46.1 (sd = 10.1) years, 51.7% male) were randomized after exclusion for unstable medical/psychiatric illness and/or dependence on drugs other than nicotine. Seventy-three participants completed the trial. A main effect of baclofen was found [%HDD (F(2,112) = 4.16, p = 0.018, d = 0.51 95%CI (0.06-0.95), 13.6 fewer HDD) and %ABST (F(2,112) = 3.68, p = 0.028, d = 0.49 95%CI (0.04-0.93), 12.9 more abstinent days)] and was driven by the 90 mg/day dose. A sex × dose interaction effect was present for both %HDD (F(2,110) = 5.48, p = 0.005) and %ABST (F(2,110) = 3.19, p = 0.045). Men showed a marginally positive effect for 90 mg/day compared to PBO (%HDD t(110) = 1.88, p = 0.063, d = 0.36 95%CI (-0.09-0.80), 15.8 fewer HDD days; %ABST t(110) = 1.68 (p = 0.096, d = 0.32 95%CI (-0.12-0.76), 15.7 more ABST)) with no effect for 30 mg/day. Women showed a positive effect for 30 mg/day (%HDD, t(110) = 3.19, p = 0.002, d = 0.61 95%CI (0.16-1.05), 26.3 fewer HDD days; %ABST t(110) = 2.73, p = 0.007, d = 0.52 95%CI (0.07-0.96), 25.4 more ABST days) with marginal effects for 90 mg/day on %ABST (p = 0.06) with drop-outs/dose reduction from sedative side-effects of 59% in women at 90 mg/day compared to 5% for men. These findings support the hypothesis that baclofen has efficacy in AUD and suggest that dose and sex be further explored as potential moderators of baclofen response and tolerability.

Universal screening for substance use by Peer Support Specialists in the Emergency Department is a pathway to buprenorphine treatment

INTRODUCTION

Evidence suggests emergency department (ED)-initiated buprenorphine as efficacious in connecting ED patients to Medications for Opioid Use Disorder (MOUD) utilizing peer support specialists (PSS). However, there are no reports of implementation of ED-initiated buprenorphine in practice. Such information is crucial to support the adoption of ED-initiated buprenorphine.

METHODS

In this quality improvement pilot study, a PSS screened ED patients over age 18 with the Tobacco, Alcohol, Prescription medication, and other Substance use - 1 (TAPS-1). The PSS considered the patient a positive screen if the patient met the following criteria: risky weekly alcohol use, illicit drugs, or prescription drugs. For patients who screened positive, the PSS delivered a brief intervention and assessed interest in treatment. An ED clinician assessed patients who screened positive for heroin/opioid use and were interested in treatment for buprenorphine induction.

RESULTS

From January through June 2019, 1037 patients were screened for risky substance use, and, of these, 238 (23%) screened positive. The distribution of primary substance used was: 51% alcohol, 26% cannabis, 7.5% cocaine, 7.5% heroin, and 3.3% prescription opioids. Of the 23 patients who screened positive for heroin/opioid use and requested treatment, seven were admitted to the hospital. Of the remaining 16 patients, 14 patients wanted buprenorphine treatment, seven were provided buprenorphine in the ED, and four of these attended their intake appointments for community-based MOUD treatment.

CONCLUSION

ED-initiated buprenorphine facilitated by a PSS is feasible and requires coordination and planning. Approaches to ED-initiated buprenorphine that screen only for opioid use will miss many patients interested in substance use treatment.

Telemedicine works for treating substance use disorder: The STAR clinic experience during COVID-19

The coronavirus disease 2019 has exposed many opportunities for improvement in treatment for substance use disorders. Regulators can ensure higher quality treatment for addiction when acknowledging telemedicine as a necessary treatment option and amending regulations to allow for telehealth parity across the United States.

Impact of Powered Toothbrush Use and Interdental Cleaning on Oral Health

The long-term effectiveness of powered toothbrushes (PTBs) and interdental cleaning aids (IDAs) on a population level is unproven. We evaluated to what extent changes in PTB and IDA use may explain changes in periodontitis, caries, and tooth loss over the course of 17 y using data for adults (35 to 44 y) and seniors (65 to 74 y) from 3 independent cross-sectional surveys of the German Oral Health Studies (DMS). Oaxaca decomposition analyses assessed to what extent changes in mean probing depth (PD), number of caries-free surfaces, and number of teeth between 1) DMS III and DMS V and 2) DMS IV and DMS V could be explained by changes in PTB and IDA use. Between DMS III and V, PTB (adults: 33.5%; seniors: 28.5%) and IDA use (adults: 32.5%; seniors: 41.4%) increased along with an increase in mean PD, number of caries-free surfaces, and number of teeth. Among adults, IDA use contributed toward increased number of teeth between DMS III and V as well as DMS IV and V. In general, the estimates for adults were of lower magnitude. Among seniors between DMS III and V, PTB and IDA use explained a significant amount of explained change in the number of caries-free surfaces (1.72 and 5.80 out of 8.44, respectively) and the number of teeth (0.49 and 1.25 out of 2.19, respectively). Between DMS IV and V, PTB and IDA use contributed most of the explained change in caries-free surfaces (0.85 and 1.61 out of 2.72, respectively) and the number of teeth (0.25 and 0.46 out of 0.94, respectively) among seniors. In contrast to reported results from short-term clinical studies, in the long run, both PTB and IDA use contributed to increased number of caries-free healthy surfaces and teeth in both adults and seniors.

US database study: burden and healthcare resource utilization in adults with systemic endemic mycoses and aspergillosis

Aim: This study evaluated burden of illness in immunocompromised patients with systemic mycoses (SM) eligible for itraconazole treatment, specifically, histoplasmosis, blastomycosis and aspergillosis. Methods: A cross-sectional study used an electronic medical record network integrating information from 30 US hospitals, including >34 million patients, to evaluate burden and healthcare resource utilization over 6 months following initiation of antifungal therapy. Results: Symptomatic burden experienced by each of the otherwise healthy or age >65 or immunosuppressed cohorts receiving antifungal therapy for SM was comparable but significantly greater in cancer or HIV patients and transplant recipients. Across groups, there was substantially higher healthcare resource utilization in patients with SM versus matched controls without SM. Conclusion: The total impact of SM is particularly severe in high-risk or vulnerable populations.

Can We Predict Usage of Dental Services? An Analysis from Germany 2000 to 2015

OBJECTIVES

We aimed to predict the usage of dental services in Germany from 2000 to 2015 based on epidemiologic and demographic data, and to compare these predictions against claims within the statutory health insurance.

METHODS

Indicators for operative (number of coronally decayed or filled teeth, root surface caries lesions, and fillings), prosthetic (number of missing teeth), and periodontal treatment needs (number of teeth with probing pocket depths (PPDs) ≥ 4 mm) from nationally representative German Oral Health Studies (1997, 2005, 2014) were cross-sectionally interpolated across age and time, and combined with year- and age-specific population estimates. These, as well as the number of children eligible for individual preventive services (aged 6 to 17 y), were adjusted for age- and time-specific insurance status and services' utilization to yield predicted usage of operative, prosthetic, periodontal, and preventive services. Cumulative annual usage in these 4 services groups were compared against aggregations of a total of 24 claims positions from the statutory German health insurance.

RESULTS

Morbidity, utilization, and demography were highly dynamic across age groups and over time. Despite improvements of individual oral health, predicted usage of dental services did not decrease over time, but increased mainly due to usage shifts from younger (shrinking) to older (growing) age groups. Predicted usage of operative services increased between 2000 and 2015 (from 52 million to 56 million, +7.8%); predictions largely agreed with claimed services (root mean square error [RMSE] 1.9 million services, error range -4.6/+3.8%). Prosthetic services increased (from 2.4 million to 2.6 million, +11.9%), with near perfect agreement to claimed data [RMSE 0.1 million services, error range -8.3/+3.9%]). Periodontal services also increased (from 21 million to 27 million, +25.9%; RMSE 5.2 million services, error range +21.9/+36.5%), as did preventive services (from 22 million to 27 million, +20.4%; RMSE 3 million, error range -13.7/-4.7%).

CONCLUSION

Predicting dental services seems viable when accounting for the joint dynamics of morbidity, utilization, and demographics.

KNOWLEDGE TRANSFER STATEMENT

Based on epidemiologic and demographic data, predicting usage of certain dental services is viable when accounting for the dynamics of morbidity, utilization, and demographics.

Evaluation of the Prognostic Significance of TNM Staging Guidelines in Lung Carcinoid Tumors

INTRODUCTION

The TNM classification for lung cancer, originally designed for NSCLC, is applied to staging of bronchopulmonary carcinoid tumors. The validity of the eighth edition of the staging system for carcinoid tumors has not been assessed. In this study, we evaluated its prognostic accuracy by using data from a large national population-based cancer registry.

METHODS

Patients with typical and atypical bronchopulmonary carcinoids diagnosed between 2000 and 2013 were identified from the National Cancer Institute's Surveillance, Epidemiology and End Results registry. We used competing risks analysis to compare 10-year disease-specific survival (DSS) across stages.

RESULTS

Overall, 4645 patients with bronchopulmonary carcinoid tumors were identified. Worsening DSS with increasing TNM status and stage was demonstrated across both typical and atypical carcinoids, with overlaps between adjacent subcategories. The combined stages (I versus II, II versus III, and III versus IV) showed greater separation in DSS despite persistent overlaps between groups. For typical carcinoids, we found decreased DSS for stages II, III, and IV, with hazard ratios of 3.8 (95% confidence interval [CI]: 2.6-5.6), 4.3 (95% CI: 3.0-6.1), and 9.0 (95% CI: 6.1-13.1), respectively, compared with stage I.

CONCLUSION

The combined stage categories of the eighth edition of the TNM staging system provide useful information on outcomes for typical and atypical carcinoids. However, persistent overlaps in combined stage and subcategories of the staging system limit the usefulness of the TNM staging system, particularly in intermediate stages. These limitations suggest the need for future further study and refinement.

Bone marrow mesenchymal stem cells as nuclear donors improve viability and health of cloned horses

Introduction

Cell plasticity is crucial in cloning to allow an efficient nuclear reprogramming and healthy offspring. Hence, cells with high plasticity, such as multipotent mesenchymal stem cells (MSCs), may be a promising alternative for horse cloning. In this study, we evaluated the use of bone marrow-MSCs (BM-MSCs) as nuclear donors in horse cloning, and we compared the in vitro and in vivo embryo development with respect to fibroblasts.

Materials and methods

Zona-free nuclear transfer was performed using BM-MSCs (MSC group, n=3432) or adult fibroblasts (AF group, n=4527). Embryos produced by artificial insemination (AI) recovered by uterine flushing and transferred to recipient mares were used as controls (AI group).

Results

Blastocyst development was higher in the MSC group than in the AF group (18.1% vs 10.9%, respectively; p<0.05). However, pregnancy rates and delivery rates were similar in both cloning groups, although they were lower than in the AI group (pregnancy rates: 17.7% [41/232] for MSC, 12.5% [37/297] for AF and 80.7% [71/88] for AI; delivery rates: 56.8% [21/37], 41.5% [17/41] and 90.1% [64/71], respectively). Remarkably, the gestation length of the AF group was significantly longer than the control (361.7±10.9 vs 333.9±8.7 days), in contrast to the MSC group (340.6±8.89 days). Of the total deliveries, 95.2% (20/21) of the MSC-foals were viable, compared to 52.9% (9/17) of the AF-foals (p<0.05). In addition, the AF-foals had more physiological abnormalities at birth than the MSC-foals; 90.5% (19/21) of the MSC-delivered foals were completely normal and healthy, compared to 35.3% (6/17) in the AF group. The abnormalities included flexural or angular limb deformities, umbilical cord enlargement, placental alterations and signs of syndrome of neonatal maladjustment, which were treated in most cases.

Conclusion

In summary, we obtained 29 viable cloned foals and found that MSCs are suitable donor cells in horse cloning. Even more, these cells could be more efficiently reprogrammed compared to fibroblasts.

Functional Relationship and Gene Ontology Classification of Breast Cancer Biomarkers

Breast cancer is a complex disease that still imposes a significant healthcare burden on women worldwide. The etiology of breast cancer is not known but significant advances have been made in the area of early detection and treatment. The advent of advanced molecular biology techniques, mapping of the human genome and availability of high throughput genomic and proteomic strategies opens up new opportunities and will potentially lead to the discovery of novel biomarkers for early detection and prognostication of breast cancer. Currently, many biomarkers, particularly the hormonal and epidermal growth factor receptors, are being utilized for breast cancer prognosis. Unfortunately, none of the biomarkers in use have sufficient diagnostic, prognostic and/or predictive power across all categories and stages of breast cancer. It is recognized that more useful information can be generated if tumors are interrogated with multiple markers. But choosing the right combination of biomarkers is challenging, because 1) multiple pathways are involved, 2) up to 62 genes and their protein products are potentially involved in breast cancer-related mechanisms and 3) the more markers evaluated, the more the time and cost involved. This review summarizes the current literature on selected biomarkers for breast cancer, discusses the functional relationships, and groups the selected genes based on a Gene Ontology™ classification.

37 Healthy Foals Produced Using Bone Marrow-Mesenchymal Stem Cells as Nuclear Donors in Horse Cloning

Somatic cell nuclear transfer efficiency is based on the capacity of the donor cell to be reset and reprogrammed to an embryonic state. So, the less differentiated the donor cells are, the more easily they could be reprogrammed by a recipient cytoplasm. Failures on appropriate nuclear reprogramming frequently lead to abnormalities associated with the placenta, umbilical cord, birthweight, and limbs. In the present study, we evaluated the efficiency of bone marrow mesenchymal stem cells (BM-MSC) compared with adult fibroblasts (AF) as nuclear donors in horse cloning and evaluated both in vitro and in vivo development of the embryos generated. Moreover, we focused on comparing the health of the foals generated and on the presence of anatomical abnormalities in foals produced from the different treatments. Embryos produced by AI, recovered by uterine flushing, and transferred to recipient mares were used as controls. All variables were analysed by Fisher test (P < 0.05). The cloning procedure was performed according to Olivera et al. (2016 PLoS One 11, e0164049, 10.1371/journal.pone.0164049). Both cleavage and blastocyst rates were higher when MSC were used as nuclear donors (P < 0.05). Cleavage rates were 85.6% (3875/4527) v. 90.2% (3095/3432) and blastocyst rates were 10.9% (492/4527) and 18.1% (622/3432) for AF and MSC groups, respectively. In the AF group, 476 blastocysts were transferred to recipient mares (232 transfers), and in the MSC group, 594 blastocysts were transferred 297 transfers). In the AI control group, 88 embryos were transferred. Pregnancies were diagnosed by transrectal ultrasonography 15 days after embryo transfer in all the groups. Pregnancy rates were similar between both cloning groups (41/232, 17.7% and 37/297, 12.5%for AF and MSC, respectively), but higher in the AI group (71/88, 80.7%). However, significant differences were observed in the birth of viable offsprings among the cloning groups. Despite similar rates of foal delivery (AF, 17/41, 41.5%; MSC, 21/37, 56.7%), a higher proportion of viable foals were obtained from the MSC group (20/37, 54.1%) compared with the AF group (9/41, 22%; P < 0.05). Surprisingly, as in the AI group (63/63, 100%), all of the viable foals obtained using MSC (20/20, 100%) were considered normal and did not show abnormalities associated with cloning. In contrast, in the AF group, only 4/9 (44.4%) were considered normal foals. The defects present in the other 5 foals were related to flexural and angular limb deformities and umbilical cord malformations. These were corrected rapidly with standard treatments or, in the case of the umbilical cords, minor surgery. This study shows for the first time that BM-MSC can be used as nuclear donors in horse cloning and that the foals obtained are as healthy as those produced by AI, showing no abnormalities related to deficiencies in nuclear reprogramming.

30 Vitrification of Equine Embryos: Application in a Commercial Cloning Program

During a commercial horse cloning program, a critical point is the availability and maintenance of suitable recipient mares for a large quantity of embryo transfers. Usually, pregnancy rates and viable births off the breeding season decrease significantly, whereas the rate of in vitro embryo production remains constant. For this reason, an efficient vitrification system allows continuous embryo production throughout the year with the advantage of doing the transfers only during the breeding season. The vitrification technique evaluated in this study was the one described by Kuwayama et al. (2007 Theriogenology 67, 73-80). By using this method, we compared post-warming recovery efficiency, pregnancy rates, and viable foaling rates in 2 experimental groups: cloned blastocysts vitrified off-season and transferred in breeding season (VC, n = 337), and non-vitrified cloned blastocysts also transferred in breading season (no-VC, n = 516). To achieve this, equine oocytes were collected from slaughterhouse ovaries, matured, enucleated, and fused to a donor cell according to Olivera et al. (2016 PLoS One 11, e0164049, 10.1371/journal.pone.0164049). The reconstructed embryos (RE) were cultured in a well-of-the-well system by adding 3 RE per well for 7 to 8 days to reach the blastocyst stage, at which they were vitrified as mentioned above. During the breeding season, blastocysts were warmed and transferred in couples in a single cycling receptive mare. Pregnancies were confirmed by transrectal ultrasonography 15 days post-transfer. All variables were analysed by Fisher test (P < 0.05). The warming recovery rate was 91% (308/337) for cloned blastocysts. In addition, pregnancy and viable birth rates were similar for the VC and no-VC groups: 15.6% (24/154) v. 16.7% (43/258) for pregnancy rates, respectively, and 37.5% (9/24) v. 37.2% (16/43) for foaling rates, respectively. In summary, 9 viable cloned foals were obtained with off-season embryos warmed and transferred during the breeding season, showing that vitrification did not affect embryo quality. Hence, the proposed strategy provides the ability to maximize production efficiency of equine clones by generating a large number of pregnancies without stopping in vitro embryo production at any time of the year.

29 Co-Incubation of Equine Cloned Embryos with Sialic Acid: Effect on Pregnancy Rate

In vitro-produced equine embryos have certain morphological characteristics that differ from embryos produced in vivo. One of them is the absence or inadequate formation of the embryo capsule. This capsule is composed of mucin-like glycoproteins produced by the trophectoderm with high proportion of sialic acid, which confers anti-adhesive properties. This characteristic is necessary for the intrauterine embryo migration process to occur, which is vital and fundamental for pregnancy recognition. For this reason, inadequate formation of the glycoprotein capsule could result in a lower pregnancy rate. In this study, we aimed to evaluate the effect of cloned equine embryo co-incubation with sialic acid on blastocyst and pregnancy rates. To achieve this, equine oocytes obtained from slaughterhouse ovaries were matured in TCM-199 HEPES medium with 2% fetal bovine serum, 2% antibiotics, and 1 μg mL−1 FSH, incubated at 39°C for 24 h. Matured oocytes were denuded with pronase, enucleated, and fused to donor bone marrow mesenchymal cells according to Olivera et al. (2016 PLoS One 11, e0164049, 10.1371/journal.pone.0164049). Chemical activation was induced using 8.7 μM ionomycin for 4 min and embryos were incubated with 1 mM 6-DMAP and 5 mg mL−1 cycloheximide for 4 h. Afterwards embryos were cultured in microwells for 8 days in DMEM-F12 medium. On Day 6, cloned equine embryos were exposed to 5 μM sialic acid for 48 h (SA group). On Day 8, blastocysts were transferred to recipient mares 5 days post-ovulation and pregnancy was confirmed 15 days post-transfer by transrectal ultrasound. Embryo clones generated without sialic acid exposure were used as a control (C) group. Fisher test was used to analyse both blastocyst and pregnancy rates. Blastocyst rates were 14% (46/328) and 15% (62/413) and pregnancy rates were 30.4% (7/23) and 19.4% (6/31) for SA and C groups, respectively. No statistical differences were observed between groups for the analysed parameters, even though pregnancy rates tended to be higher in the SA group. This effect could be a consequence of higher concentrations of the glycoprotein involved in the formation of the embryo capsule.

Naloxone use among overdose prevention trainees in New York City: A longitudinal cohort study

BACKGROUND

Providing naloxone to laypersons who are likely to witness an opioid overdose is now a widespread public health response to the national opioid overdose epidemic. Estimating the proportion of individuals who use naloxone can define its potential impact to reduce overdose deaths at a population level. We determined the proportion of study participants who used naloxone within 12 months following training and factors associated with witnessing overdose and naloxone use.

METHODS

We conducted a prospective, observational study of individuals completing overdose prevention training (OPT) between June and September 2013. Participants were recruited from New York City's six largest overdose prevention programs, all operated by syringe exchange programs. Questionnaires were administered at four time points over 12 months. Main outcomes were witnessing or experiencing overdose, and naloxone administration.

RESULTS

Of 675 individuals completing OPT, 429 (64%) were approached and 351 (52%) were enrolled. Overall, 299 (85%) study participants completed at least one follow-up survey; 128 (36%) witnessed at least one overdose. Of 312 witnessed opioid overdoses, naloxone was administered in 241 events (77%); 188 (60%) by the OPT study participant. Eighty-six (25%) study participants administered naloxone at least once. Over one third of study participants (30, 35%) used naloxone 6 or more months after training.

CONCLUSIONS

Witnessing an overdose and naloxone use was common among this study cohort of OPT trainees. Training individuals at high risk for witnessing overdoses may reduce opioid overdose mortality at a population level if sufficient numbers of potential responders are equipped with naloxone.

Socio-Ecological Mechanisms Supporting High Densities of Aedes albopictus (Diptera: Culicidae) in Baltimore, MD

Social, ecological, and climatic factors interact creating a heterogeneous matrix that determines the spatiotemporal distribution of mosquitoes and human risks of exposure to the diseases they transmit. We explore linkages between the social and institutional processes behind residential abandonment, urban ecology, and the interactions of socio-ecological processes with abiotic drivers of mosquito production. Specifically, we test the relative roles of infrastructure degradation and vegetation for explaining the presence of Aedes albopictus Skuse 1894 to better predict spatial heterogeneity in mosquito exposure risk within urban environments. We further examine how precipitation interacts with these socially underpinned biophysical variables. We use a hierarchical statistical modeling approach to assess how environmental and climatic conditions over 3 years influence mosquito ecology across a socioeconomic gradient in Baltimore, MD. We show that decaying infrastructure and vegetation are important determinants of Ae. albopictus infestation. We demonstrate that both precipitation and vegetation influence mosquito production in ways that are mediated by the level of infrastructural decay on a given block. Mosquitoes were more common on blocks with greater abandonment, but when precipitation was low, mosquitoes were more likely to be found in higher-income neighborhoods with managed container habitat. Likewise, although increased vegetation was a negative predictor of mosquito infestation, more vegetation on blocks with high abandonment was associated with the largest mosquito populations. These findings indicate that fine spatial scale modeling of mosquito habitat within urban areas is needed to more accurately target vector control.

The impact of acid suppression medications and non-steroidal anti-inflammatory drugs on clinical and histologic features in celiac disease

INTRODUCTION

The prevalence of celiac disease (CD) in the US has increased in past decades, as has use of proton pump inhibitors (PPIs), histamine-2-receptor antagonists (H2RAs), aspirin (ASA) and nonsteroidal anti-inflammatory drugs (NSAIDs). We aimed to measure the association between medication use and distribution of villous flattening (VF) among newly diagnosed CD patients.

METHODS

We performed a cross-sectional study of adult patients with newly-diagnosed CD at two institutions. We collected data on regular use of these medications, clinical presentation, CD serologic status, and distribution of VF. We compared current ASA/NSAID users to non-users, and current PPI/H2RA users to non-users, with regard to these clinical characteristics.

RESULTS

Of 148 patients with newly-diagnosed CD, current users of ASA/NSAIDs were older than non-users (47 vs 39 years, p=0.003) and users of PPI/H2RAs were older than non-users (48 vs 39 years, p=0.004). PPI/H2RA users comprised 12% of seropositive patients, compared to 55% of seronegative patients (p<0.01). Patient gender and distribution of villous flattening in the bulb and distal duodenum did not differ by PPI/H2RA or ASA/NSAID use.

CONCLUSIONS

PPI/H2RA use was associated with seronegative CD. Given the effect of these medications on gastric milieu, the impact of these drugs on presentation and course of CD deserves further investigation.

Antibody-dependent and antibody-independent uptake of HBsAg across human leucocyte subsets is similar between individuals with chronic hepatitis B virus infection and healthy donors

Maintaining detectable levels of antibodies to hepatitis B surface antigen (HBsAg) in serum after HBsAg sero-conversion is the key clinical endpoint indicative of recovery from infection with hepatitis B virus (HBV). As HBV-infected hepatocytes secrete HBsAg subviral particles in vast excess over HBV virions, detectable hepatitis B surface antibody (anti-HBs) titres imply complete elimination of HBV virions as well as HBsAg particles. Although intrahepatic phagocytes, for example Kupffer cells, are thought to mediate clearance of HBsAg via antibody (Ab)-dependent and Ab-independent mechanisms, the relative contributions of circulating phagocytic cell types to HBsAg elimination are poorly characterized. Understanding the role of various immune cell subsets in the clearance of HBsAg is important because Ab-dependent or Ab-independent phagocytic HBsAg uptake may modulate presentation of HBsAg-derived epitopes to antigen-specific T cells and hence plays a critical role in adaptive immunity against HBV. This study aims to characterize phagocytic leucocyte subsets capable of internalizing HBsAg immune complexes (HBsAg:IC) or un-complexed HBsAg particles in whole blood directly ex vivo. The data show that uptake of HBsAg:IC occurs most prominently in monocytes, B cells, dendritic cells and in neutrophils. In contrast, B cells, and to a lesser degree also monocytes, seem to be effective phagocytes for un-complexed HBsAg. Importantly, a similar pattern of phagocytic HBsAg uptake was observed in blood from chronic hepatitis B (CHB) patients compared to healthy controls, suggesting that phagocytosis-related cellular functions are not altered in the context of CHB.

First Report of Catharanthus mosaic virus in Mandevilla in the United States

Mandevilla (Apocynaceae) is an ornamental tropical vine popular for its bright and attractive flowers. During 2012 to 2013, 12 Mandevilla sp. samples from Minnesota and Florida nurseries were submitted for analysis at the University of Minnesota Plant Disease Clinic. Plants showed mosaic symptoms, leaf deformation, premature leaf senescence, and vine dieback. Filamentous virus particles with modal lengths 700 to 900 nm were observed by transmission electron microscopy (TEM) in partially purified preparations from symptomatic leaves. Partially purified virions were obtained using 30% sucrose cushion centrifuged at 109,000 g_max for 2 h at 10°C (5). No other virus particles were observed in these samples, nor were any observed in non-symptomatic samples. One sample was submitted as potted plant (Mandevilla 'Sunmandeho' Sun Parasol Giant White) and was kept under greenhouse conditions for subsequent analyses. Total RNA (Qiagen) was extracted from this sample, and Potyvirus was detected using the universal primers Poty S (5'-GGN AAY AAY AGY GGN CAR CC-3') and PV1 (5'-20(T)V-3') (1) by reverse transcription (RT)-PCR (3). The amplified product was the expected ~1.7-kb, corresponding to the partial nuclear inclusion body gene, the coat protein (CP) gene, and the 3' end untranslated region. The RT-PCR amplicon was cloned (NEB) and sequenced, and the 1,720-bp consensus sequence was deposited in GenBank (Accession No. KM243928). NCBI BLAST analysis at the nucleotide level revealed highest identity (83%) with an isolate of Catharanthus mosaic virus (CatMV) from Brazil (Accession No. DQ365928). Pairwise analysis of the predicted 256 amino acid CP revealed 91% identity with the CatMV Brazilian isolate (ABI94824) and 68% or less identity with other potyviruses. Two potyviruses are usually considered the same species if their CP amino acid sequences are greater than 80% identical (2). Serological analysis of the infected sample Mandevilla 'Sunmandeho' Sun Parasol Giant White using a CatMV specific antiserum (4) resulted in positive indirect ELISA reactions. CatMV has been previously reported in periwinkle (Catharanthus roseus) in Brazil (4). Based on the analyses by TEM, RT-PCR, nucleotide and amino acid sequence identities, and serological reactivity, we identify this virus as a U.S. Mandevilla isolate of CatMV. To our knowledge, this is the first report of Catharanthus mosaic virus both in the United States and in Mandevilla. References: (1) J. Chen et al. Arch Virol. 146:757, 2001. (2) A. Gibbs and K. Ohshima. Ann. Rev. Phytopathol. 48:205, 2010. (3) R. L. Jordan et al. Acta Hortic. 901:159, 2011. (4) S. C. Maciell et al. Sci. Agric. Piracicaba, Brazil. 68:687, 2011. (5) D. Mollov et al. Arch Virol. 158:1917, 2013.