Treatment Demonstration Project Research Articles

Grndad and Disease Modifying Therapy (DMT): Shifts in Dmt Are Seen at the Adolescent/Young Adult Transition in Sickle Cell Disease in a Multi-Site Prospective Registry

The ability to characterize the modern person living with SCD in the US has been limited by the lack of a well-curated longitudinal registry. The Globin Research Network for Data and Discovery ( GRNDaD) registry aims to overcome this challenge by collecting data from the now 53 IRB-approved centers across the US in collaboration with the National Alliance of Sickle Cell Centers (NASCC) and the HRSA-funded Sickle Cell Disease Treatment Demonstration Project Grant. Here, we describe the use of disease-modifying therapy in (actively consented) adults and children with Hgb SS/ SB 0 thalassemia (SCA) from 37 sites. Methods: Each site consents subjects and enters extensive baseline data including SCD complications and labs, subjects also complete patient-reported outcomes (PROs)-both at baseline and annually. Each subject is expected to have an annual follow-up where data is extracted from the Electronic Health Record (EHR). All data is stored in REDCap and, for this abstract, data were extracted into R on all active subjects (data entry in the last two years) who have complete minimum data collected. Median values were compared using Mann-Whitney U tests. Disease-modifying therapy (DMT) in this study comprises hydroxyurea (HU), chronic red blood cell (RBC) transfusions, crizanlizumab, L-glutamine, and voxelotor. Results: There are 2501 active patients in GRNDaD. Twenty-six percent of subjects are pediatric </= 18 years of age, 55.5% are female and 66.7% have HgbSS or HgbSB 0 thalassemia (SCA). Here, we report data on people with SCA only, whose minimum data were complete (n=1272). Table 1 shows DMT by age. 187 (21%) adults and 31 (8.5%) children were not on DMT. Figure 2 is a box plot of the absolute neutrophil count (ANC) comparing adults and children who are and are not taking HU. Adults on HU had significantly lower ANCs than those not on HU (median = 4.4 (IQR: 3.07, 6.3) v 6.6 (IQR:4.07, 8.14), p<0.001) (Figure). Similar findings were observed for children ( median = 3.5 (IQR:2.5, 5.7) Vs 8.1 (5.8, 12.8) , p =0.04) Both children and adults on HU had higher MCVs than those not on HU (median for peds: 91.5 (IQR: 85.1, 98.75) v 86 (IQR: 83.3, 86.1), p=0.05, median for adults: 96.5 (IQR: 89, 107) v 90 (IQR: 86.1, 95.1), p<0.001). We compared hemoglobin for those on and off HU, and on and off voxelotor, excluding patients on chronic transfusion therapy. There was a statistically significant difference in hemoglobin when comparing on or off of HU (median 8.9 g/dl (IQR 7.95, 9.9) v 8.2 g/dl (IQR: 7.2, 9.7, p =0.047)). There were no statistically significant differences in hemoglobin when comparing subjects on or off of voxelotor (median = 8.4 g/dl (IQR: 7.5, 9.6) vs 7.9 (IQR: 7.4, 9.8), p =0.57). In the adults, there were statistically significantly more males than females on HU, but there were no differences seen in the pediatric cohort. Examining DMT by age group, chronic RBC transfusion use doubled from the 11-17 age group to the 18-29-year age group (12% to 25%) and HU use decreased (83%-59%) over this same period. Limitations: This cohort may over-represent those on DMT as those enrolled in GRNDaD were more likely to have clinic visits. Discussion: GRNDaD has doubled the number of sites consenting subjects and entering data over the last year. The number is expected to increase again in the next 12 months, as an additional 15 sites are already IRB-approved with a goal to include all SCD centers in NASCC. This cross-sectional description of the current population of people living with SCD and treated in NASCC-recognized SCD centers in the US shows that the majority of those with SCA are receiving DMT. There is a noticeable decrease in HU use during the transition period with an increase in the use of chronic transfusion therapy. Newer DMT has had limited uptake in this cohort. The next steps will be to provide longitudinal data on this population and examine associations of DMT and important clinical outcomes including PROs.

Successful quality improvement project to increase hydroxyurea prescriptions for children with sickle cell anaemia

Hydroxyurea (HU) is an effective but underused disease-modifying therapy for patients with sickle cell anaemia (SCA). EMBRACE SCD, a sickle cell disease treatment demonstration project, aimed to improve access to...

Investigation and Analysis on Rural Domestic Sewage Discharge in Key Watersheds

In order to grasp the latest changes in the quality and quantity of domestic sewage in the Taihu Lake Basin and Chaohu Lake Basin, and to scientifically guide the construction of rural sewage treatment demonstration projects, two typical villages were selected from Taihu Lake Basin and Chaohu Lake Basin respectively for fieldwork continuous monitoring of sewage water quality and quantity. The results show that the typical rural per capita daily drainage in the plain area of the Taihu Lake Basin in summer is 89.4 L·cap−1·d−1, which is significantly higher than that in the typical rural area of the Chaohu Lake Basin (56.5 L·cap−1·d−1). The amount of sewage hourly discharge fluctuated distinctly, and the coefficient of variation of sewage discharge in the two villages ranged from 2.4 to 6.1, showing obvious characteristics of “morning and evening peaks” or “morning, noon and evening peaks”. In addition, the rural sewage water quality in the two places shows the same pattern, and the pollutant concentration of sewage from different sources is significantly different. It was found that the toilet-flush sewage in Wangjiatang village provided 84.42% of TN and 92.94% of NH4 +-N in the total domestic sewage, while toilet-flush sewage in Qianying village provided 74.31% of TN and 84.56% of NH4 +-N in the total domestic. Therefore, when constructing a sewage treatment demonstration project, the ideological principles of sewage classification and treatment from the source should be considered.

The Association Between Social Support, Violence, and Social Service Needs Among a Select Sample of Urban Adults in Baltimore City.

Experiencing violence has been associated with negative health outcomes. The objectives of this study were to determine whether experiencing violence is associated increased support service needs and suboptimal general health indicators. In addition, we explore the relationship between these and perceived social support among a select sample of urban predominantly male adults in Baltimore City. A cross-sectional survey was conducted among 187 adults being seen in one of seven urban partner agencies participating in a parent HIV prevention and treatment demonstration project. Associations were examined using a multivariable logistic regression model, adjusting for the clinic site at which the client was being seen as well as age and gender identity. There was a significant amount of violence experienced by this population; 131 (72%) reported having seen someone be physically assaulted, and 89 (49%) had been physically assaulted without a weapon. Direct victimization from violence was associated with a threefold increased odds of needing housing and mental health/substance use services. Exposure to violence was associated with a threefold increase in needing housing and mental health/substance use services, and with sub-optimal health status. Perceived social support was associated with 30% decreased reports of experiencing violence. In conclusion, our select sample of urban adults report having experienced high rates of violence, and this is associated with increased support service needs as well as suboptimal perceived health status. Incorporating care for the effects of experiencing violence as well as social service needs are important in optimizing the health of urban populations.

Bayonne, NJ Combined Sewer Overflow Treatment Demonstration Project: Disinfection Results

Bayonne, NJ Combined Sewer Overflow Treatment Demonstration Project: Disinfection Results

Using Project Echo Telementoring to Improve Sickle Cell Disease Care in the Midwest

Sickle Treatment and Outcomes Research in the Midwest (STORM) is a regional sickle cell network, funded by the Health Resources and Services Administration Treatment Demonstration Project (HRSA U1EMC27863), established to improve outcomes for individuals with sickle cell disease (SCD) living in Indiana, Illinois, Michigan, Minnesota, Ohio and Wisconsin. The STORM network is led by pediatric and adult hematologists who coordinate network activities in each state, along with a Regional Coordinating Center that organizes efforts throughout the Midwest. The goal of the STORM network is to increase the number of pediatric and adult primary care providers (PCP) who are knowledgeable about the management and treatment of SCD, and who are willing to prescribe and manage hydroxyurea therapy as a means to improve medical care for the approximately 15,000 individuals living with SCD in the Midwest. One PCP engagement strategy that has been implemented to increase provider knowledge in the region is replication of the Project ECHOTM (Extension for Community Healthcare Outcomes) telementoring model. Project ECHO was developed by the University of New Mexico to utilize low-cost, high-impact video technology to link expert inter-disciplinary specialist teams with primary care providers to improve management of chronic diseases. This guided practice telementoring model delivers complex specialty medical care to underserved areas, reduces health disparities, and increases workforce capacity. Project ECHO's methodology is based on 1) using telehealth technology to build healthcare resources where they are scarce; 2) sharing best practices to reduce variation in clinical care; 3) utilizing practice-based learning to develop specialty expertise among providers; and 4) monitoring and evaluating provider outcomes. Project ECHO has demonstrated improved healthcare outcomes in Hepatitis C and several other chronic diseases, and is now being piloted by STORM to test its feasibility and applicability for SCD by using a regional approach with CME accreditation. STORM network site physician leads in each state are recruiting multi-disciplinary primary care teams to participate as "spokes" in monthly SCD TeleECHO clinics. The "hub" led by the STORM Regional Coordinating Center, located at Cincinnati Children's Hospital Medical Center, coordinates implementation and evaluation of the telementoring clinics, delivered through monthly teaching sessions. STORM TeleECHO participants log onto an internet-based virtual meeting site, using a webcam to interact during the session. STORM TeleECHO clinics include brief didactic presentations from nationally-recognized SCD content experts with topics and curriculum based on the National Heart Lung and Blood Institute Evidence-Based Management of Sickle Cell Disease guidelines released in 2014. TeleECHO teaching clinics also include 1-2 de-identified, HIPAA protected case discussions (pediatric and adult) presented by providers who would like medical and psychosocial feedback on management of challenging clinical scenarios. Providers participating in the STORM TeleECHO complete an initial survey assessing knowledge and comfort levels, practice behaviors (including hydroxyurea prescribing practices) and clinic demographics. Satisfaction surveys are sent to participants after each session as part of the CME-credit evaluation. Follow-up surveys at 6 months and 1 year will assess satisfaction, knowledge, comfort level and changes in practice. STORM's TeleECHO was launched in March 2016. Preliminary data indicate an interest in STORM TeleECHO teaching sessions by both pediatric and adult providers across the Midwest region. Future efforts will expand the network to more PCPs in the region, while improving the applicability and utility of STORM TeleECHO in SCD through provider assessment. DisclosuresWare:Global Blood Therapeutics: Consultancy; Biomedomics: Research Funding; Bristol Myers Squibb: Research Funding; Addmedica: Research Funding; Nova Laboratories: Consultancy; Bayer Pharmaceuticals: Consultancy.

Bayonne, NJ Combined Sewer Overflow Treatment Demonstration Project: Preliminary Disinfection Results

Bayonne, NJ Combined Sewer Overflow Treatment Demonstration Project: Preliminary Disinfection Results

English

Like many large abandoned mining areas, the Tri-State Mining District of the central US is plagued by numerous environmental problems, including contaminated soils, tailings, waste rock, and water, with subsequent detrimental impacts to human and ecological health. In one of the major basins of the district, the Tar Creek watershed, impacts to surface waters were once deemed to be due to irreversible man-made damages, resulting in minimal effort to address environmental risk from these legacy mine waters over the past 30 years. However, recent watershed-scale environmental monitoring studies, along with completion and evaluation of a full-scale passive treatment demonstration project, indicate that this may no longer be the case. Evaluation of artesian discharges indicates significant evolution of mine pool water quality (e.g., decreased metal concentrations, increased pH and alkalinity) since first flush. In-stream water quality, although still not meeting designated beneficial uses, has also changed. Substantial surface water degradation due to waste rock and tailings runoff and leachate is still problematic, but large-scale land reclamation (including wholesale removal and underground injection) is ongoing. Conceptual designs for watershed-scale passive treatment implementation have been developed and indicate that both artesian mine discharges and remaining runoff/leachate waters may be treatable in a cost-effective and sustainable manner. Recent voluntary relocation efforts, resulting in the dissolution of historic mining communities, provide opportunities for watershed-scale remediation and restoration. However, long-term operation and maintenance obligations for the proposed passive systems, incorporating the cultural and social needs of Native American tribes, requires sustained commitment of technical and financial resources. Promising initial results, coupled with results from other ongoing remediation efforts, warrant further exploration and reevaluation of previous administrative decisions.

Overview of the Field Test of Innovative On-Site Wastewater Treatment Systems during the La Pine National Demonstration Project

This paper presents an overview of the field test results of the La Pine National Decentralized Wastewater Treatment Demonstration Project (La Pine Project). The main objective of the field test was to identify innovative on-site wastewater treatment systems that reduce the amount of nitrogen discharged to groundwater. The aquifer underlying the La Pine subbasin of the upper Deschutes River Watershed is shallow and unconfined and provides the drinking water source for the region’s population. The project also evaluated septic tank and sand filter performance in order to provide baseline information on the impacts of conventional systems on the aquifer. The performance of nitrogen reducing treatment technologies are compared to septic tank and sand filter performance, the State of Oregon’s residential waste strength definition, and La Pine Project performance criteria. The study found that several systems can effectively reduce typical water quality parameters (5-day biochemical oxygen demand, total suspen...

Providing Culturally Specific Substance Abuse Services in Refugee and Immigrant Communities: Lessons from a Cambodian Treatment and Demonstration Project

ABSTRACT Several agencies interested in serving Cambodian immigrants established a substance abuse treatment demonstration project which included culturally specific elements such as co-therapy done by a bilingual, bicultural Cambodian worker and a mainstream American social worker; formation of an advisory committee with Cambodian members; home visiting and family involvement; emphasis on traditional cultural values as motivators; integration of Buddhist philosophy; and use of acupuncture for detoxification. In spite of careful planning and several program accomplishments, the program initially received few client referrals. A fact-finding process revealed several barriers, including stigmatization of substance abuse and few Cambodian providers with substance abuse training. Case vignettes and organizational and clinical recommendations are provided for community leaders and advisory groups working with other low-incidence refugee and immigrant populations.

EPA selects technologies for arsenic treatment project

The Environmental Protection Agency (EPA) has commenced the second stage of its National Arsenic Treatment Demonstration Project that ultimately aims to deliver better drinking water to US households. This is a short news story only. Visit www.filtsep.com for the latest filtration industry news.

Cocaine users with antisocial personality improve HIV risk behaviors as much as those without antisocial personality

Previous work has documented that antisocial personality disorder (APD) is associated with increased rates of HIV risk behaviors and with worse substance abuse treatment outcomes. The question addressed by this paper is whether cocaine users with APD respond to an HIV risk-reduction intervention as well as cocaine users without the disorder. The study subjects were 333 cocaine users followed up at 18 months as part of a NIDA-funded treatment demonstration project. The total sample improved across a wide range of HIV risk behaviors. Improving significantly ( P<0.05) from baseline to the 18-month follow-up were several drug-related behaviors: cocaine use; current cocaine dependence; use of drugs other than cocaine drug injection; injection equipment sharing; and use of syringes that were not cleaned. Several sex-related HIV risk behaviors also improved significantly: having multiple sex partners; being intoxicated during sex; giving drugs for sex; receiving money for sex; and receiving drugs for sex. When the sample was stratified by APD status, very similar improvement was seen in respondents with and without APD. To examine further the relationship of APD to change in HIV risk behaviors, separate logistic regression models of improving and worsening HIV risk behaviors were tested. What the authors found was no association of APD with improvement in HIV risk behaviors but a significant association of APD with worsening HIV risk behaviors. It appears that cocaine users with APD improve their HIV risk behaviors just as much as those without APD but may be at higher HIV risk for the development of such behaviors.

Patterns and Predictors of Cocaine and Crack Use by Clients in Standard and Enhanced Methadone Maintenance Treatment

This paper reports on the patterns of cocaine use among subjects (N = 427) admitted to a methadone maintenance treatment demonstration project designed to reduce risk for HIV. Assessments were conducted at intake and at approximately 18–24 months after treatment admission. Self-reported data on cocaine use was compared with results of urinalysis tests at both intake and follow-up; 29 subjects who falsely reported no use were recoded as users. Over one-third used some form of cocaine at both intake and follow-up, while approximately 30% abstained at both points. Approximately 20% ceased as well as initiated cocaine use between intake and follow-up. Use of powder cocaine, either alone or combined with heroin in “speedballs,” decreased at follow-up, whereas crack use increased. Discriminant function analyses were performed to determine the predictors of the different patterns of cocaine use by type. Receipt of enhanced methadone treatment compared with standard methadone treatment, treatment duration, or average duration of counselor contact appeared unrelated to cocaine use. Cocaine use at follow-up was associated with polydrug and alcohol use, illegal activity, a negative emotional state, and sex work. Crack users were more likely to be African American than nonusers; continuous users of powder cocaine were more likely to also be using heroin than were nonusers: and continuous speedball users were more likely to be women sex workers with high levels of depression. This analysis demonstrated that cessation or continuation of cocaine use after entry into methadone maintenance treatment is not uniform across different types of cocaine.

Users of free treatment slots at a community-based methadone maintenance clinic

At a community-based methadone clinic in Seattle, WA, 360 opiate-addicted individuals were enrolled in a treatment demonstration project. The treatment slots were free to clients and, unlike other funded treatment slots, did not require proof of eligibility based on documentation of indigence. The clients were compared with 70 clients enrolled in a research project begun 2 years earlier in which the sample was drawn from a population using normal funding sources at the same program. Subjects in the later demonstration project were older and had fewer years of education. A higher percentage of the demonstration project subjects were African American. These differences indicate that introduction of free treatment opened opportunities to individuals who have difficulty accessing treatment under normal circumstances. Subjects in the treatment demonstration project were more likely to have obtained needles from legal sources and used bleach to clean needles. These findings probably reflect the impact of needle exchange and outreach programs, established in the year prior to the demonstration project.