Is maintenance therapy after first-line treatment of ovarian cancer cost-effective in the United States?BRCA variant when current olaparib pricing was reduced by half.In this economic evaluation of maintenance strategies after first-line ovarian cancer therapy, no maintenance regimen—including olaparib, olaparib-bevacizumab, bevacizumab, and niraparib—was cost-effective when using a willingness-to-pay threshold of $100 000 per progression-free life-year saved, even when stratified by molecular signatures. Olaparib monotherapy became cost-effective for patients with a Various frontline maintenance therapies for ovarian cancer may have clinical benefit but may not be considered cost-effective, even with reductions in drug pricing. BRCA Mutated Ovarian Cancer Following First Line Platinum Based Chemotherapy [December 2018]), PRIMA (A Study of Niraparib Maintenance Treatment in Patients With Advanced Ovarian Cancer Following Response on Front-Line Platinum-Based Chemotherapy [September 2019]), and PAOLA-1 —reporting positive efficacy results for maintenance regimens for women with primary, advanced epithelial ovarian cancer. The findings resulted in approval by the US Food and Drug Administration of the treatments studied as of May 2020. However, there are pressing economic considerations given the many eligible patients and substantial associated costs.There are large randomized clinical trials—SOLO-1  homologous recombination deficiency without a BRCA variant, or (3) homologous recombination proficiency.To evaluate the cost-effectiveness of maintenance strategies for patients with (1) a BRCA variant. Base case 2 assessed olaparib-bevacizumab, bevacizumab, and niraparib vs observation in a patient with homologous recombination deficiency without a BRCA variant. Base case 3 assessed olaparib-bevacizumab, bevacizumab, and niraparib vs observation in a patient with homologous recombination proficiency. The time horizon was 24 months. Costs were estimated from Medicare claims, wholesale acquisition prices, and published sources. Probabilistic sensitivity analyses with microsimulation were then conducted to account for uncertainty and assess model stability. One-way sensitivity analyses were also performed. The study was performed from January through June 2020.In this economic evaluation of the US health care sector using simulated patients with primary epithelial ovarian cancer, 3 decision trees were developed, one for each molecular signature. The maintenance strategies evaluated were olaparib (SOLO-1), olaparib-bevacizumab (PAOLA-1), bevacizumab (PAOLA-1), and niraparib (PRIMA). Base case 1 assessed olaparib, olaparib-bevacizumab, bevacizumab, and niraparib vs observation of a patient with a Incremental cost-effectiveness ratios (ICERs) in US dollars per progression-free life-year saved (PF-LYS).BRCA variant, olaparib was the most cost-effective . The third-party payer price per month of olaparib would need to be reduced from approximately $17 000 to $9000 to be considered cost-effective. Olaparib-bevacizumab was the most cost-effective in the case of a patient with homologous recombination deficiency without a BRCA variant , and bevacizumab was the most cost-effective in the case of patient with homologous recombination proficiency . Even at a price of $0 per month, niraparib could not be considered cost-effective as a maintenance strategy for patients with homologous recombination proficiency.Assuming a willingness-to-pay threshold of $100 000/PF-LYS, none of the drugs could be considered cost-effective compared with observation. In the case of a patient with a The findings of this study suggest that, at current costs, maintenance therapy for primary ovarian cancer is not cost-effective, regardless of molecular signature. For certain therapies, lowering the drug price alone may not make them cost-effective. BRCA variant, (2) homologous recombination deficiency without a BRCA variant, or (3) homologous recombination proficiency in the US health care sector using simulated patients with primary epithelial ovarian cancer.This economic evaluation evaluated the cost-effectiveness of maintenance strategies for patients with (1) a  BRCA variant after publication of the SOLO-1 (Olaparib Maintenance Monotherapy in Patients With BRCA Mutated Ovarian Cancer Following First Line Platinum Based Chemotherapy) trial in December 2018, which showed a substantial improvement in progression-free survival with olaparib compared with placebo.1 The success of olaparib in staving off recurrent disease is an important advance because approximately 70% of women with advanced ovarian cancer relapse within 3 years after diagnosis, despite the absence of residual disease after primary surgery and platinum-based chemotherapy.2 Recurrent ovarian cancer, in turn, is typically incurable and associated with a median survival of 2 years.3Olaparib, a poly–(adenosine diphosphate–ribose) polymerase (PARP) inhibitor, achieved regulatory approval for maintenance therapy for women with newly diagnosed advanced ovarian cancer who carry a BRCA and homologous recombination status.6 With the exception of the VELIA trial, which examined the efficacy of veliparib, the drugs studied  in the aforementioned randomized clinical trials are commercially available and, as of May 2020, have achieved regulatory approval through the US Food and Drug Administration (FDA). This leaves clinicians with several options for maintenance regimens for the approximately 22 000 women who have receive a diagnosis of advanced ovarian cancer in the US annually.7In the brief period since the publication of the SOLO-1 trial, there have been additional large randomized clinical trials—PRIMA (A Study of Niraparib Maintenance Treatment in Patients With Advanced Ovarian Cancer Following Response on Front-Line Platinum-Based Chemotherapy [September 2019]), VELIA , and PAOLA-1 —that have reported positive efficacy results for various maintenance regimens involving PARP inhibitors following first-line treatment of newly diagnosed ovarian cancer, stratified by BRCA variant, patients with homologous recombination deficiency without a BRCA variant, and patients with homologous recombination proficiency .Notwithstanding the clinical promise of the various strategies considered in these trials, economic evaluation is critical given the large number of newly eligible patients for the studied therapies in addition to the cost associated with treatments. Cost-effectiveness analyses could help assess whether the treatment benefit afforded is of justifiable cost. To our knowledge, there has not been a peer-reviewed cost-effectiveness analysis study published that compares the first-line maintenance regimens in these trials. The aim of our study was to evaluate the cost-effectiveness of the maintenance strategies outlined in the SOLO-1 (olaparib), PRIMA (niraparib), and PAOLA-1  trials for patients with a CHEERS) reporting guideline.8 It is deemed exempt from institutional review board review because publicly available information was used.This study was conducted from January through June 2020 in accordance with the Consolidated Health Economic Evaluation Reporting Standards  epithelial ovarian cancer who had already undergone cytoreductive surgery and had a complete or partial response to platinum-based chemotherapy was eligible for entrance into 1 of 3 models: one for patients with a  therapy . These m5  were assumed to have had 5 cycles of bevacizumab prior to entrance into the model. The time horizon was limited to 24 months given the absence of overall survival data from the trials. In addition, this time horizon approximated the mean follow-up period of the trials from which the treatment groups were derived. No discounting or drug discontinuation was accounted for given the limited time horizon.12 Imputing overall survival estimates in the absence of overall survival data results in a model with significant uncertainty because patients with ovarian cancer tend to have highly variable treatment courses after recurrence. Because quality-of-life end points were assessed differently among the trials, quality-adjusted life-years were not estimated. Kaplan-Meier estimates of progression-free survival from the randomized clinical trials  were calculated in US dollars per progression-free life-year saved (PF-LYS), as has been done in other economic evaluations of oncology drugs lacking overall survival data.13 The unit bevacizumab cost was estimated using the Centers for Medicare & Medicaid Services April 2020 Average Sales Price Drug Pricing Files.14 Administration (in the case of bevacizumab) and monitoring costs were obtained from the 2020 Medicare Physician Fee Schedule.15 Patients receiving a PARP inhibitor were assumed to require a complete blood count weekly for the first month, followed by a complete blood count monthly. It was assumed that, for these patients, office visits occurred monthly and a cancer antigen 125 test every 3 months. The cost of 15 comprehensive metabolic panels was added to the aforementioned PARP inhibitor costs for patients receiving combination olaparib-bevacizumab. For patients receiving bevacizumab alone, it was assumed that they had a complete blood count, a comprehensive metabolic panel, and an office visit (including a urine dipstick) with each infusion and a cancer antigen 125 test every 3 months. It was assumed that patients without a maintenance regimen had an office visit and cancer antigen 125 test every 3 months. Routine imaging was not incorporated into monitoring costs. Costs for treating adverse events that occurred in 20% or more of the respective study population and had previously been quantified16 were considered in the model. It was assumed that adverse events occurred independently and that the probability of those events remained constant over the 24-month time horizon. This assumption was made because adverse events were reported in the trials as a sum of each complication among participants throughout the total trial period. Germline and somatic genetic testing costs were not included because it was assumed that genetic testing was performed at the time of diagnosis, prior to entrance into our model. Detailed cost inputs used in the model are outlined in eTable 4 in the Costs were considered from a US health care perspective. Costs included those associated with drug acquisition, administration, monitoring, and adverse effects. The 2020 RED BOOK wholesale acquisition costs were used to estimate the prices of monthly supplies of olaparib and niraparib.Using TreeAge Pro 2019 R1, we performed 1-way deterministic sensitivity analyses on key model parameters in all 3 base cases to account for uncertainty. The key parameters varied and included drug and adverse event costs, progression-free survival advantage, and 24-month progression-free survival probability. These parameters were tested individually to determine the required threshold, if possible, at which the associated treatment regimen would become cost-effective using a WTP threshold of $100 000/PF-LYS. In addition, each variable was tested within realistic ranges , and the resulting ICERs were calculated.Probabilistic sensitivity analyses with microsimulation were performed for each base case within the following parameter distributions: olaparib, bevacizumab, and niraparib monthly price ±50%; olaparib, bevacizumab, and niraparib costs associated with adverse events ±50%; progression-free survival advantage compared with no maintenance for each possible treatment regimen ±10%; and 24-month progression-free survival probability for each possible treatment regimen ±10% .BRCA variant), the incremental PF-LYS compared with no maintenance was 2.23 for olaparib, 1.48 for olaparib-bevacizumab, 0.26 for bevacizumab, and 0.46 for niraparib. In base case 2 (homologous recombination deficient with a BRCA variant), the incremental PF-LYS compared with no maintenance was 0.86 for olaparib-bevacizumab, 0.18 for bevacizumab, and 0.46 for niraparib. In base case 3 (homologous recombination proficient), the incremental PF-LYS compared with no maintenance was 0.25 for olaparib-bevacizumab, 0.23 for bevacizumab, and 0.05 for niraparib. The resulting ICERs for each base case revealed that none of the treatment options were cost-effective at the prespecified WTP threshold. However, olaparib was the most cost-effective maintenance option in base case 1   , olapari/PF-LYS) , and bev/PF-LYS) .BRCA variant), olaparib-bevacizumab therapy remained the most cost-effective option in base case 2 homologous recombination deficient without a BRCA variant), and bevacizumab remained the most cost-effective option in base case 3 (homologous recombination proficient). When the inputs for base case 1 were concurrently varied, olaparib monotherapy yielded an ICER less than or equal to the WTP threshold in 10/1000 patients (1%) compared with no maintenance treatment. No treatment regimens in base case 2 or 3 yielded ICERs at or below the WTP threshold compared with no maintenance in the 1000 trials.On probabilistic sensitivity analyses with 1000 simulated patients, olaparib remained the most cost-effective option in base case 1 (BRCA variant) became cost-effective at the WTP threshold when the average wholesale acquisition price of olaparib was reduced 47% from $16 999 to approximately $8950 per month , no therapy could be considered cost-effective at the WTP threshold when individual variables were altered within plausible ranges , no therapy could be considered cost-effective at the WTP threshold when parameters were varied plausibly C. At a cFor all cases, alterations in the niraparib monthly drug price—from 50% ($9974) to 150% ($29 921) its current cost—varied the resulting ICERs most significantly. When the price of niraparib was altered within this range, the difference between the upper and lower limits of the ICER of niraparib compared with no treatment was $1 046 784/PF-LYS in base case 1, $1 049 845/PF-LYS in base case 2, and $10 638 427/PF-LYS in base case 3 . The ICEBRCA variant, which would become cost-effective if the current monthly pricing were reduced by half. However, not all therapies would become cost-effective even if the medication were free, as in the case of niraparib for patients with homologous recombination proficiency. Such findings provide a perspective from which to interpret the positive efficacy results of the SOLO-1, PAOLA-1, and PRIMA trials.Compared with observation, this study demonstrates that currently available frontline maintenance therapies for women with primary, advanced epithelial ovarian cancer are not cost-effective, regardless of molecular signature, in our cost-effectiveness model. One-way sensitivity analyses showed that price reductions would make some of these therapies cost-effective, as in the case of olaparib for women with a BRCA variant 17; olaparib combined with bevacizumab for patients with homologous recombination deficiency 18; and niraparib for patients regardless of molecular signature, including patients with homologous recombination proficiency .19 The approvals may lead to reflexive use of these treatments for frontline maintenance for all patients without the current cost being commensurate with the effectiveness. The potential financial toxicity that could result, combined with the lack of long-term follow-up and overall survival data from these studies, may have a cumulative net negative patient and societal impact.As a result of the progression-free survival advantage found with the various maintenance regimens in the SOLO-1, PAOLA-1, and PRIMA trials, the FDA has issued approvals for maintenance therapy in specific molecular subgroups of patients with ovarian cancer: olaparib for patients with a 21 However, this progression-free survival benefit was lost in long-term follow-up of the ICON7 cohort, and neither study ultimately showed an overall survival advantage except for specific populations with high-risk disease. Several economic evaluations prior to the publication of overall survival data also revealed that maintenance bevacizumab in the upfront setting had relatively low value.23 For example, a 2015 cost-utility analysis of the GOG 218 bevacizumab regimen for patients with ovarian cancer reported an ICER of $632 571/PF-LYS compared with no maintenance .22 With added quality-of-life data, the ICER increased to $792 380/quality-adjusted progression-free year. Taken in isolation, the progression-free survival advantage seen in the short-term follow-up reported initially in the GOG 218 and ICON7 trials would suggest that the standard of care for patients with newly diagnosed ovarian cancer should be adjuvant and maintenance bevacizumab therapy; however, the added cost and overall survival information described makes the role of maintenance bevacizumab in the upfront setting less certain, as noted by the American Society of Clinical Oncology Gynecologic Oncology Education Committee.24 The efficacy of frontline maintenance PARP inhibitor treatment should be viewed in a similar context, taking into account the known benefits, harms, and costs.For example, GOG 218  and ICON7  were 2 large phase 3 trials that demonstrated a progression-free survival advantage in short-term follow-up with frontline bevacizumab maintenance for patients with stage III or IV (GOG 218) and patients with stage I to IV (ICON7) ovarian cancer.BRCA variant has an ICER greater than the accepted $100 000/PF-LYS WTP threshold , but it could realistically become cost-effective with a reduction in olaparib pricing by 47%. The 3-year progression-free survival advantage seen in patients with a BRCA variantwho took maintenance olaparib in the SOLO-1 trial thus likely warrants clinical use in that population. Conversely, the use of niraparib in the homologous recombination proficiency population may be less certain. The ICER was substantially above the WTP threshold ($10 870 576/PF-LYS), and niraparib did not become cost-effective even when its price was reduced to $0 per month. The 3-month progression-free survival advantage in the homologous recombination proficient population with maintenance niraparib thus may not warrant the cost, especially in the absence of long-term and overall survival data.This does not imply that maintenance regimens be withheld from patients with ovarian cancer in the upfront setting simply because they are not cost-effective—rather, the effectiveness of maintenance therapy should be interpreted within the context of its expense. For example, olaparib maintenance therapy for patients with a BRCA variant, homologous recombination deficient, and homologous recombination proficient) were derived from subgroup analyses, which the trials were not powered to perform. The uncertainty in these values was accounted for in our probabilistic sensitivity analyses that varied parameters liberally. The stability of our findings from those analyses suggests that there is a low probability of misinterpreting the relative cost-effectiveness of the treatments studied.An inherent limitation of our analysis is that it relies on cross-trial comparison between 3 randomized clinical trials, which is necessary in the absence of a head-to-head randomized clinical trial comparing all maintenance regimens. Although the study populations of these trials had similar characteristics (eTable 2 in the BRCA variant could feasibly become cost-effective if its price were reduced by half. Other maintenance strategies, such as niraparib for patients with homologous recombination proficiency, do not have obvious pragmatic solutions like price reduction to make them sufficiently cost-effective and may require further investigation to allow for a more certain and complete interpretation of the efficacy results before use in clinical settings.Currently available frontline maintenance therapies for advanced, epithelial ovarian cancer cannot be considered cost-effective using a WTP threshold of $100 000/PF-LYS. Maintenance olaparib for patients with a


In selected patients with an acute myocardial infarction (AMI) complicated by Cardiogenic shock (CS), mechanical circulatory support with Impella may be beneficial, although conclusive evidence is still lacking. Nevertheless, it has been suggested that Impella initiation prior to primary PCI might improve survival.To investigate the effect pre-PCI versus immediate post-PCI Impella initiation on short term mortality.A prospective, single center, observational study, was performed including all patients with STEMI complicated by CS, treated with primary PCI and Impella. Thirty day mortality was compared between patients with Impella initiation pre-PCI and immediately post-PCI.A total of 88 patients were included. In the pre-PCI group (n = 21), admission heart rate was lower  and no IABP was implanted before Impella initiation, versus 17.9% in post-PCI group (n = 67), p = 0.04. Total 30-day all-cause mortality was 58%, and was lower in pre-PCI group, 47.6% versus 61.2% in the post-PCI group, however not statistically significant . Thirty-day cardiac mortality was significantly lower in the pre-PCI group, 19% versus 44.7% in the post-PCI group .Pre-PCI Impella initiation in AMICS patients was not associated with a statistically significant difference in 30-day all-cause mortality, compared to post-PCI Impella initiation. Cardiogenic shock (CS) occurs in 5–10% of patients with acute myocardial infarction (AMI) and is still associated with 30-day mortality of approximately 40–60% despite emergent revascularization of the culprit lesion , 8. GiveThe Impella , is a catheter-based microaxial flow pump placed across the aortic valve into the left ventricle (LV). It unloads the LV and increases the cardiac output and coronary blood flow , 11. It Therefore, it remains unknown whether early Impella initiation may improve survival in AMICS patients as compared to delayed initiation. We investigated the effect of Impella initiation immediately before versus immediately after primary PCI on 30-day mortality in a large prospective cohort of AMICS patients.Data for this study are from the prospective cohort of patients who received an Impella at the Amsterdam University Medical Center (AUMC), The Netherlands. Our center is a high volume tertiary referral hospital with on-site cardiac surgery. All patient hospitalized between June 2006 and December 2016 with STEMI complicated by CS, treated with primary PCI and MCS with percutaneous Impella 2.5 or CP or surgical Impella 5.0 , were included in this study. Patients who did not receive Impella support in the same session as the primary PCI procedure, were excluded in order to avoid bias from delayed Impella therapy.The Amsterdam University Medical Center Institutional Review Board approved the study and waived the requirement for informed consent in accordance with the Declaration of Helsinki. All data were fully anonymized.All AMICS patients were treated with primary PCI according to standard PCI protocol. Before primary PCI, all patients received intravenous aspirin (500mg) loading dose, a P2Y12 blocker (either 600 mg of Clopidogrel or 180 mg of Ticagrelor) loading dose orally or via an esophageal tube when intubated and intravenous unfractionated heparin (5000 IU). Adjunctive treatment with glycoprotein IIb/IIIa inhibitors was at the discretion of the treating interventional cardiologist. Also the timing of Impella support (before or immediately after primary PCI) was left at the discretion of the treating interventional cardiologist. Post-PCI all patients received lifelong aspirin 100mg once daily and a P2Y12 blocker for 12 months (either 75 mg of Clopidogrel once daily or 180 mg of Ticagrelor twice daily).Before 2012, only the Impella 2.5 and Impella 5.0 were available. After its introduction in 2012, the Impella CP became the first choice device in AMICS patients. Impella performance was set to a maximum level without console alarms (suction or position). Duration of Impella support was at discretion of the treating physicians. Upgrade to an Impella device with more hemodynamic support was considered when the device used was deemed to provide insufficient support. This was the case in patients who exhibited a combination of worsening hemodynamics and/or increased need for inotropes and vasopressors despite high Impella performance, together with an overall assessment of the patient and his/her neurological status. During Impella support, all patients were treated with unfractionated heparin in order to maintain an activated partial thromboplastin time (APTT) between 45 and 60 seconds.Weaning was not formally protocolized but was evaluated daily by the treating physician and typically started on signs of hemodynamic recovery, usually 12–24 hours after PCI, when inotropes and vasopressors were reduced. Weaning usually occurred in two steps: from maximum possible support (P7–8) to approximately half support (P4–5) , to low-level Impella support (P2–3) before device removal. Device removal was typically also two-staged. First the device was pulled back from the left ventricle into the descending aorta. The device was not switched off, but set to level P1 in order to prevent thrombus formation. After 45–60 minutes of heparin cessation depending of last activated clotting time (ACT) level, the device was removed, followed by approximately 30 minutes of femoral compression.CS was defined as a systolic blood pressure ≤ 90 mmHg for at least 30 minutes or the need for vasopressors to maintain a systolic blood pressure > 90 mmHg, clinical signs of pulmonary congestion and end-organ hypoperfusion  and compared with ANOVA corrected for multiple testing by Bonferroni. Skewed distributed variables are presented as median and compared with the Wilcoxon rank sum test. Categorical variables are presented as proportions and compared with Chi-square test.Age was dichotomized above and below the age of 75 years. Creatinine was dichotomized with the use of the clinical threshold for impaired renal function (>95 μmol/L for women and >110 for men). Hemoglobin was dichotomized using the clinical threshold for anemia (7.5 mmol/L for women and 8.5 mmol/L for man). Arterial pH, lactate, glucose and peak creatine-kinase (CK) MB were dichotomized according to the median value. Blood pressure at the time of Impella placement was dichotomized using the clinical threshold of 90 mmHg for systolic blood pressure and mean arterial pressure (MAP) of 60 mmHg. Cardiac arrest was categorized in: no cardiac arrest, return-off-spontaneous circulation (ROSC) time below 20 minutes and above 20 minutes.Kaplan Meier analyses were calculated and a log-rank test was used to compare the clinical outcomes between groups.A Cox proportional-hazards regression model was used to calculate both uni-variable and multi-variable adjusted hazard ratios, with calculation of 95% confidence intervals. Not all univariate significant variables were added to the model because of the limited number of patients and consequent loss of power of the model. A covariate was removed from the model if its significance level exceeded p = 0.10. Variables included in the multivariable analysis were age, sex, admission heart rate and IABP placement before Impella initiation. Analyses were performed with SPSS .A total of 88 patients were included in this study, with 21 patients (23.9%) in the pre-PCI and 67 patients (76.1%) in the post-PCI group. Baseline characteristics are summarized in Patients in the pre-PCI group had a lower heart rate at admission . IABP prior to Impella initiation was statistically different between the pre-PCI and post-PCI group, respectively 0 versus 12 patients . Six patients in the post-PCI group received IABP prior to primary PCI and prior to Impella initiation and 6 patients received IABP after primary PCI but prior to Impella initiation. Other baseline characteristics were not statistically different.Characteristics of the clinical course are summarized in There were no significant differences in the frequency of complications between the two groups . Two patThe overall all-cause 30-day mortality was 58.0%, with 47.6% in the pre-PCI group versus 61.2% in the post-PCI group , This prospective single-center observational study in AMICS patients evaluated the potential association between timing of Impella initiation and mortality. The key findings of our study were that 1) 30-day all-cause mortality was still very high (58%) despite successful primary PCI and mechanical circulatory support with Impella, 2) pre-PCI Impella initiation was not associated with a statistically significant difference in 30-day all-cause mortality, compared to post-PCI Impella initiation, 3) pre-PCI Impella initiation was associated with a clinically and statistically significant reduction in 30-day cardiac mortality compared to post-PCI Impella initiation.This study included a very high risk AMICS patient population with nearly 50% of patients admitted after an out-of-hospital cardiac arrest, which in itself is associated with poor survival , 24. ThiNeurological mortality did not differ significantly between the pre- and post-PCI group. This finding stresses out the necessity to be able to accurately predict which patients will recover from coma in the acute phase and which patients will not. Part of admitted patients after out-of-hospital cardiac arrest will not recover from coma, no matter the effort. Probably, (early) restoration of hemodynamics will not be beneficial in this subgroup of patients. However, till date it is impossible to accurately predict which patients will recover from coma after AMICS or cardiac arrest and which patients will not.Interestingly, in our analysis, cardiac mortality was significantly lower in the pre-PCI group. Till date, no clinical studies with hemodynamic support devices have extended the benefit of primary PCI in AMI or AMICS yet. Especially in CS it is postulated that stabilizing the systemic circulation with a hemodynamic support device could reduce mortality, as longer duration of CS, with subsequently the occurrence of multi-organ failure and systemic inflammatory response syndrome (SIRS) is associated with higher mortality , 27. EarWhile our study showed a significantly reduced 30 day cardiac mortality in the pre-PCI group, the 30 day all-cause mortality did not differ significantly. Our findings stress out the need for confirming data from an adequately powered RCT. The results of the DanGer Shock trial, which randomizes AMICS patients between Impella CP prior to PCI and current guideline driven therapy, are therefore eagerly awaited .There are several limitations that apply to this analysis. This analysis is a single center study with an observational design. The sample size is relatively small. Moreover, timing of Impella initiation was not dictated per protocol which may have led to selection bias. It remained unclear what the reason for pre-PCI Impella initiation was. Therefore, potential unmeasured confounding bias cannot be ruled out. We performed multivariable analysis, but this was limited due to the small sample size of our cohort. Finally, there are several factors that might have influenced the results, such as experience with the device, change of therapy over time, improvement of general therapy of AMICS patients over time, and change in patient selection over time. Given the abovementioned limitations, the findings of our study should be interpreted as hypothesis generating.Despite early revascularization and Impella support, 30-day mortality was still very high in patients with AMICS. Pre-PCI Impella initiation in AMICS patients was not associated with a statistically significant difference in 30-day all-cause mortality, compared to post-PCI Impella initiation. Future large randomized clinical trials will be needed to assess whether pre- or post- PCI Impella initiation increases survival in these patients with a priori high mortality.S1 Table(DOCX)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


Evidence from past pandemics suggests that fear, uncertainty, and loss of control during large-scale public health crises may lead to increased pandemic-related information seeking, particularly among persons predisposed to high anxiety. In such groups, a greater consumption of information pertaining to the COVID-19 pandemic may increase anxiety.In this study, we examine the association between online activity and Generalized Anxiety Disorder 7 (GAD-7) scores in the United States.We recruited participants for an online survey through advertisements on various platforms such as Google, Facebook, and Reddit. A total of 406 adult US participants with moderate to severe (≥10) GAD-7 scores met the inclusion criteria and completed the survey. Anxiety levels measured using the GAD-7 scale formed our primary outcome. Our key independent variables were average daily time spent online and average daily time spent online searching about COVID-19 within the past 14 days. We used as controls potential confounders of the relation between our key independent variables and GAD-7 scores, namely, sleep quality, the COVID-19 Fear Inventory scale, binge drinking, substance use, prescription drug abuse, and sociodemographic attributes.P=.002), controlling for all other covariates. The total time spent online was not statistically associated with GAD-7 scores.Linear multivariate regression analyses showed that GAD-7 scores were higher among those who spent >4 hours online (per day) searching for information about COVID-19 (coefficient 1.29, Results from this study indicate that limiting pandemic-related online information seeking may aid anxiety management in our study population. The COVID-19 pandemic has impacted multiple aspects of everyday life across the world. Social distancing measures mandated by state governments in the United States, including stay-at-home orders and closure of nonessential businesses, have preceded record-breaking unemployment rates and an unprecedented US $3 trillion relief and economic stimulus package from Congress .The convergence of social isolation, heightened ambient stress, and potential loss of resources including access to health care has elicited calls for research on correlates of mental health outcomes amid the current pandemic . UnderstThe initial stages of pandemics invariably correspond with widespread anxiety . ScholarResearch on the mental health impacts of the COVID-19 pandemic in China, which was the first country affected by this pandemic, finds a positive correlation between anxiety and exposure to news and information about COVID-19 online . In one Online studies are increasingly becoming a popular means of conducting health research during the COVID-19 pandemic -16. OnliThis study examines the relation between GAD-7 scores and time spent online searching for information about COVID-19 in a cross-section of 406 online survey participants with moderate to severe anxiety in the United States. To our knowledge, this is the first study to examine the relation between online activity pertaining to COVID-19 and GAD-7 scores in a US sample, and may help augment our understanding of the mental health consequences of the current pandemic.We recruited study participants through online advertisements on Facebook, Google ads, and online forums such as Reddit. Potential participants who clicked on the online ads were routed to a Qualtrics survey where they were screened for eligibility using the GAD-7 screening tool, which we modified in relation to COVID-19   to have The survey was conducted from March 15, 2020, to April 8, 2020. University of California, Irvine’s Institutional Review Board (IRB) deemed this study as IRB exempt. Our analytic sample comprised of 406 respondents who met the inclusion criteria and responded to all items on the survey.For the dependent variable, we measured anxiety levels using the GAD-7 scale . Scores The key independent variables included time spent online  and time spent online searching about COVID-19 . We converted time spent online searching about COVID-19 from categorical to binary (≤4 hours per day or >4 hours per day) for clarity of interpretation (very few participants reported spending <2 hours searching about COVID-19 per day).As described previously, pandemics correspond with a decline in quality of sleep, increased pandemic fear, and increased substance use ,8. TheseP<.05 were deemed statistically significant. All analyses were performed in Stata SE version 14.2 (StataCorp) [We used ordinary least squares multivariate regression analysis to examine the relation between GAD-7 scores and the independent, control variables. We specified robust standard errors to account for heteroskedasticity. Regression coefficients with ataCorp) . There wP=.002). This relation remained robust when using the 6-category  version of daily online activity searching for information about COVID-19 as well (results available upon request). The sleep scale scores varied inversely , and the COVID-19 Fear Inventory scale scores varied positively and significantly  with GAD-7 scores. Misuse or abuse of prescription drugs in the past 14 days was associated with higher GAD-7 scores . Participants with high school or GED, or higher education showed lower GAD-7 scores relative to those without high school education . Relative to non-Hispanic Whites, GAD-7 scores did not vary across non-Hispanic Blacks, Hispanics, Asians, and other races or ethnicities. We also observed no relation between GAD-7 scores and age, sex, alcohol use, and use of nonprescription drugs such as marijuana, cocaine, or heroin.We found that spending an average of 4 or more hours per day searching online about COVID-19 was associated with greater anxiety (measured using GAD-7 scores) in our cross-sectional sample of 406 US adults with moderate to severe anxiety. Relative to those who spent less than 4 hours on pandemic-related online searches, those who exceeded 4 hours of COVID-19–related online activity had GAD-7 scores that were 1.3 units higher. Our analyses controlled for individual sociodemographic attributes, time spent online overall, substance use, binge drinking, sleep quality, and the COVID-19 Fear Inventory. Our findings align with those from prior research and highlight the relation between online information seeking and worsened anxiety symptoms in the context of the COVID-19 pandemic ,10,11.Limitations include the cross-sectional nature of our study design that restricts causal inference and generalizability. We also note that, although GAD-7 scores may be used to assist with a psychiatric diagnosis of generalized anxiety disorder, this study uses them to approximate anxiety levels (over the past 2 weeks preceding the survey only) and not as a clinical diagnosis. Clinical diagnosis of generalized anxiety disorder, per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria, typically requires continued observation over a period of 6 months . For theWe encourage future research to examine whether (as indicated by our findings) relatively simple measures such as limiting exposure to COVID-19–related information may help in managing anxiety during pandemics. Our study may aid future research in examining the effect of misinformation during pandemics because persons exposed to a higher volume of COVID-19–related information may also, statistically speaking, be exposed to greater misinformation (owing to the sheer volume of exposure). People with high anxiety and high intolerance to uncertainty, when exposed to quack cures and misinformation, may be more likely to act on potentially fatal “preventive” measures ,22. Curaselect into greater pandemic-related information seeking online. In such cases, the propensity of persons with high anxiety to spend substantial amounts of time online may be used in targeted internet-based mental health service delivery. High frequency internet and social media users with pre-existing mental health conditions may serve as an accessible group for telepsychiatry, telemedicine, and social media–based interventions [It is plausible that persons with high anxiety ventions . Such inventions .In this cross-sectional study, we observed a positive relation between time spent online searching for information about COVID-19 and GAD-7 scores. Our analyses may assist in understanding correlates of mental health outcomes during the ongoing COVID-19 pandemic.


Rabies is a lethal zoonotic encephalomyelitis that causes an estimated 59,000 human deaths yearly worldwide. Although developing countries of Asia and Africa bear the heaviest burden, surveillance and disease detection in these countries is often hampered by the absence of local laboratories able to diagnose rabies and/or the difficulties of sample shipment from low-access areas to national reference laboratories. Filter papers offer a convenient cost-effective alternative for the sampling, shipment, and storage of biological materials for the diagnosis of many pathogens including rabies virus, yet the properties of diagnostic tests using this support have not been evaluated thoroughly. Sensitivity and specificity of molecular diagnosis of rabies infection using a reverse transcription followed by a hemi-nested polymerase chain reaction (RT-hn-PCR) either directly on brain tissue or using brain tissue dried on filter paper were assessed on 113 suspected field animal samples in comparison to the direct fluorescent antibody test (FAT) recommended by the World Health Organization as one of the reference tests for rabies diagnosis. Impact of the duration of the storage was also evaluated. The sensitivity and the specificity of RT-hn-PCR i) on brain tissue were 96.6% (95% CI: [88.1–99.6]) and 92.7% (95% CI: [82.4–98.0]) respectively and ii) on brain tissue dried on filter paper 100% (95% CI: [93.8–100.0]) and 90.9% (95% CI: [80.0–97.0]) respectively. No loss of sensitivity of RT-hn-PCR on samples of brain tissue dried on filter paper left 7 days at ambient temperature was detected indicating that this method would enable analyzing impregnated filter papers sent to the national reference laboratory at ambient temperature within a 1-week shipment time. It could therefore be an effective alternative to facilitate storage and shipment of samples from low-access areas to enhance and expand rabies surveillance. i.e. prevent them from further transmitting the virus to other people and animals). Yet, the reference diagnostic method for animal rabies requires brain samples to be collected post-mortem and shipped under temperature-controlled conditions. The shipping of such samples is complex in low-access areas, especially in low income countries, which are often those that bear the heaviest rabies burden. Filter papers offer a convenient alternative for biological sample shipment and storage. Here the efficiency of a molecular diagnostic method applied to brain tissue dried on filter paper is compared to one of the reference methods, the direct fluorescent antibody test. Our results show it has an excellent sensitivity (it does not miss any positive samples), even when filter papers are left 7 days at ambient temperature. These results let us foresee a cost-effective alternative facilitating shipment, storage and testing of samples from rabies suspected animals from low-access areas. This could considerably enhance and expand rabies surveillance in low-income countries, allowing a more comprehensive evaluation of rabies burden, and thus reinforcing arguments for allocating funds to rabies control policies.Dogs are responsible for 99% of human rabies deaths. Facilitating diagnostic of rabid dogs can help further identify i) people who were exposed to rabies in order to encourage them to seek post exposure prophylaxis and ii) other exposed animals to break the transmission chain ( Rabies is a lethal zoonotic encephalomyelitis caused by lyssaviruses affecting all mammals, including humans . It is ci.e. 2 intradermal injections of 0.1 mL at two sites (deltoids) on days 0, 3 and 7) ) and 92.7% (95% CI: [82.4–98.0]) respectively (Tables –99.6) anEight samples had discordant RT-hn-PCR-T and/or RT-hn-PCR-FP results compared to FAT and were subsequently tested by duplicating FAT, RT-hn-PCR-T and RT-hn-PCR-FP tests and, if discordant results persisted, by confirming them with MIT and RT-qPCR TaqMan L . Seven oRT-hn-PCR-FP enabled to detect rabies virus on the 58 true-positive filter papers stored at room temperature with the same level of 100% of sensitivity at day 7. At day 15, two samples out of 58 tested negative leading to 96.6% of sensitivity. At 24 months, all 67 samples tested were positive by RT-hn-PCR-FP.The ten samples collected in the field in Moramanga were all positive by FAT, RT-qPCR TaqMan L and RIDT  and a specificity of 100% (95% CI: [39.8–100])).The successful use of molecular diagnostic methods using brain tissue directly or brain tissue dried on filter paper or FTA cards, that are filter papers impregnated with patented chemicals designed to preserve nucleic acids, to detect different species of lyssavirus (including rabies virus) has been demonstrated by several studies , 34, 35.et al.  comparedOur study demonstrates that the sensitivity of our hemi-nested reverse transcriptase PCR on filter paper is extremely high  and that its specificity is also high . Compared to the sample size initially calculated, the number of true positive samples was sufficient to evaluate sensitivity with 80% power margin of error no greater than 0.05. Conversely, to reach the same power and to keep the same margin of error for specificity, 164 true negative samples should have been included.1 for logistic reasons (access to laboratory equipment and sample processing time (including drying time for FP)), and this delay could also have negatively impacted sensitivity. Moreover, these results were obtained in artificial conditions of important laboratory work load involving multiple series of PCRs carried out on an important number of samples, which can increase the risk of human error. In real-life conditions at the NRL of Madagascar, because samples of rabies-suspected animals are shipped with a low frequency, samples are processed one by one. Sometimes it is more difficult to recover RNA from brain tissue dried on filter paper than directly from brain tissue because there can be a decrease of the quantity of extracted RNA when using filter paper for molecular diagnosis: a loss of 1 log was shown for Newcastle disease virus [et al. did not show a loss in RNA when using FTA for rabies virus [It is noteworthy that these excellent sensitivity results were obtained using a majority (88.5%) of frozen samples given that the freezing-thawing step could have contributed to the degradation of the virus inducing a decrease of sensitivity. Furthermore, RT-hn-PCR could only be carried out on Dse virus  and of 0se virus . Converses virus . Althouges virus .Overall eight samples had discordant results. The results on duplicates for five of these samples  were concordant suggesting that human errors such as contamination or confusion between samples could have caused these discordant results. Indeed, for the four FAT negative samples , all duplicated tests were negative, suggesting that the discordant results could be due to a contamination during the first tests. For sample 3693–15, only one test was discordant, again suggesting a human error during this test. Furthermore, risk of human errors could have been amplified by heavy workload. Indeed, during this study, dozens of samples were processed simultaneously. For routine surveillance or when processing filter papers impregnated in the field, samples were processed consecutively. Confusion between samples rarely occurs when good laboratory practices are respected. As for any other technique, the application of the good laboratory practices and training on biosafety would be imperative if this technique were to be implemented for routine surveillance.For three samples , duplicated results remained discordant. Sample 3723–16 was positive by FAT , RT-hn-PCR-FP , MIT and RT-qPCR TaqMan L T but negative by RT-hn-PCR-T . All 5 PCR carried out at NRC-R were positive as well as Sanger sequencing genotyping , confirming that this sample was positive. Although we cannot rule out random errors, results of this rabies positive sample could suggest that RT-hn-PCR-T could be less sensitive for this sample than the other tests carried out or that PCR inhibitors or an inhibition due to overloading of nucleic acid after brain extraction occurred during the RT-hn-PCR-T (but not during RT-hn-PCR-FP nor during PCRs carried out at NRC-R). Sample 2555–15 was negative by FAT  and MIT but positive by hemi-nested PCR tests  and by RT-qPCR TaqMan L (FP and T). RT-qPCR TaqMan L results showed that the viral load was low (ct = 32 when using brain tissue and ct = 37.6 when using FP). Results obtained at NRC-R were also discordant: RT-hn-PCR N and RT-qPCR SyBR L and RT-qPCR TaqMan L were negative whereas RT-hn-PCR L was positive and RT-qPCR SyBR N was weakly positive. Sanger sequencing of the amplicons at NRC-R confirmed the Malagasy origin of the RABV. Based on these results, we can hypothesize that this sample was positive but with a low viral load. The latter could explain the discrepancies obtained with different techniques, reflecting their difference of sensitivity for this sample. According to his owner, this dog didn’t have any clinical symptoms when it was euthanized after having bitten someone. This information is compatible with the hypothesis that the animal was at an early stage of the infection, thus presenting a low viral load, which could have increased over time if it had not been euthanized. Sample 3656–15 was negative by FAT , RT-hn-PCR-T  and MIT but positive by RT-hn-PCR-FP  and RT-qPCR TaqMan L FP when tested at NRL laboratory . However, all other tests performed at the NRC-R were negative. This sample originated from a cat which was described by the veterinarian as having symptoms suggestive of a paralytic form of rabies. This sample could have originated from a rabid animal with a very low viral load that was not detected by FAT and MIT. FAT and MIT are highly sensitive and specific but they are not perfect. Sensitivity and specificity of FAT are considered to be between 96% and 99% , 32. Sevi.e. testing storage at higher temperatures). The use of RT-qPCR on FP could also be compared to RT-hn-PCR-FP as RT-qPCR is expected to be more sensitive and less prone to contamination.Although it was not the main objective, this study showed that viral RNA could be detected from filter papers stored for up to 2 years at room temperature. Sensitivity of the method was 100% on day 1 and day 7 but decreased to 96.7% on day 15 where 2 samples (out of 58 positive) turned negative. These 2 latter samples were frozen samples. It is noteworthy that one of these two samples already had weak signals when tested by FAT on day 0 and by RT-hn-PCR-FP on day 1. Conversely, after two years, all 67 samples stored at ambient temperature tested positive. Two studies have demonstrated the possibility of rabies RNA detection over longer storage periods (43 and 222 days) , 16. OurPreliminary results relative to samples from Moramanga showed it was possible to successfully i) carry out FP impregnation in the field, ii) ship impregnated FP to a central laboratory and iii) carry out molecular testing of these samples in the laboratory. Although Moramanga city in Moramanga district is not very far from Antananarivo city (approximately 110 km), villages in the district are poorly connected through dirt roads and paths and often involve walking to reach serviceable roads. These field results should be strengthened by collecting a greater number of samples and by asking different teams in multiple locations to test the process. The main practical drawback from this field experience was that the quantity of brain obtained using the straw method was small, limiting further testing of the samples. More brain samples should be collected on each animal to overcome this limit.Overall, the excellent sensitivity of RT-hn-PCR-FP demonstrated in our study shows the high potential for the use of filter paper in rabies surveillance, especially in low-income countries with poor road infrastructures, where shipping rabies suspected brain tissue specimens can be difficult. Excellent sensitivity is a compulsory requirement when test results of rabies suspected animals impact the post-exposure prophylaxis (PEP) continuation in humans since false negative results may lead to PEP interruption and death of the exposed person. Yet, given that molecular diagnostic capacities in Madagascar are extremely limited (the NRL is the only laboratory performing rabies molecular diagnosis in the country), and given the short (one-week)  and freeAlthough we have demonstrated the feasibility to impregnate filter papers with brain tissue in the field and to ship them to the laboratory for subsequent molecular diagnosis, several steps are necessary before considering expanding this method to the entire country. The first step to tackle concerns methods to access brain tissue of rabies suspected animals. In Madagascar, this is most frequently done by breaking the animal’s skull. Yet, because this method is hazardous, especially in the field, alternative tissue collection methods consisting in using a straw via the trans-orbital or trans-occipital route are recommended. Vaccination and training of the public health officers and field staff on these methods would also need to be implemented in Madagascar.Because Whatman type FP do not guarantee pathogen inactivation, the presence and infectiousness of infectious particles in brain tissue impregnated filter papers warrants further assessment. Indeed, 5 filter papers impregnated with infected brain tissue were tested by cell culture isolation (using Neuro-2A ATCC CCL-131 cell lines) 17 hours after drying and 3 of the 5 samples were still infectious. A more thorough study with a statistically supportive sample size should be set up to confirm these results and to assess the effect of storage duration on infectiousness of brain tissue impregnated on FP. Conversely, studies using FTA cards have shown that rabies virus , like otet al. [The excellent sensitivity and very high specificity of rabies RT-hn-PCR-FP compared to the FAT could be a cost-effective alternative for facilitating sample shipment and storage of rabies suspected animals from low-access areas to the NRL. This would greatly help enhance and expand surveillance coverage, in turn improving accuracy of reported data. Furthermore, FP and FTA cards also have the noteworthy advantage of enabling molecular characterization of rabies virus isolates  and estaet al. , togetheet al. . UnfortuHowever, the implementation of RT-hn-PCR-FP for surveillance activities will increase the lab costs (because RT-hn-PCR are more expensive than FAT tests). Another argument against this technique might be that if NRL only receive brain tissue impregnated FP instead of brain tissue samples, rabies viral strains will no longer be available to sustain virus repositories. Yet NRL need to have access to virus repositories for immunological, virology, vaccine and epidemiological studies. A compromise might be that i) in areas of low-access, from which there are currently no samples being shipped, the use of FP as sample support is implemented and ii) when samples are collected from more accessible areas, brain biopsies are collected ideally alongside to  impregnated FP.Other techniques, such as direct rapid immunohistochemistry test (dRIT) and RIDT, have been developed over the past decades to improve rabies diagnostic and surveillance. When brain tissue is available for testing, dRIT is an interesting alternative to FAT as, contrary to FAT, it does not require the acquisition of an expensive fluorescence microscope, and can thus facilitate the implementation of decentralized laboratories if appropriate supply and storage of reagents can be ensured . AlongsiApart from using FP (or FTA cards), another way to overcome problems due to sample storage and shipment in low-access areas is to use point of sample tests. RIDT such as Anigen have the strong advantage of being easy-to-use point of sample tests. However, they still need to be fully validated prior to use. They have good although not perfect sensitivity under laboratory conditions  when using the modified protocol (without the dilution step in PBS) . AlthougGiven its excellent sensitivity and very high specificity, the use of FP as a support for the molecular diagnostic of rabies infection seems to be an effective alternative to facilitate storage and shipment of samples from low-access areas to enhance and expand surveillance. The improvement of rabies surveillance, particularly in low-income countries, allows foreseeing a more comprehensive evaluation of rabies burden, which would in turn strengthen arguments for allocating funds to rabies control policies. These must go together with awareness-raising campaigns for the different actors involved in rabies surveillance, so that animal owners and bite victims know when to suspect rabies and how to prevent it, and health professionals know how to proceed to confirm rabies suspected cases.S1 Data(XLSX)Click here for additional data file.S2 Data(XLSX)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S3 Fig(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Multiple sexual partnerships increase the risk of transmission of HIV and can be exacerbated by substance abuse. However, the association between psychoactive substance use and multiple sexual partnerships among young people in informal settlements of low-income countries is not well known. This study established the prevalence of multiple sexual partnerships and associated factors among young psychoactive-substance-users in informal settlements in Kampala, Uganda.This was a cross-sectional study involving 744 young (aged 18–24 years), sexually active, psychoactive substance-users selected from 12 of the 57 informal settlements of Kampala City. The prevalence of multiple sexual partnerships and their differential distribution by socio-demographic strata was established. Modified Poisson regression models were run in Stata 14 software to generate prevalence rate ratios for the factors associated with multiple sexual partnerships.About 40.6%  had engaged in multiple sexual partnerships in the last 30 days. Engaging in multiple sexual partnerships in the last 30 days was positively associated with being female ; staying in the informal settlement for 6–10 years  and chewing khat in the last 30 days .Multiple sexual partnerships are highly prevalent among young psychoactive-substance-users, irrespective of the socio-demographic strata. Being female, having lived in the informal settlement for 6–10 years, and chewing khat were significantly associated with having multiple sexual partners in the last 30 days. In tackling this high-risk sexual behaviour, it is recommended that risk-reduction interventions are considered for the different socio-demographic strata identified in this study, i.e. females, those who have lived in the informal settlement for about 6–10 years, and those who chew khat. Globally, meeting the sexual and reproductive health needs of young people remains a public health challenge ,2. Thus,Young psychoactive-substance-users include individuals aged 10–24 years who use substances such as alcohol, khat, marijuana, heroin, and kuba. Such substances have the ability to impair the user’s cognition and decision making , therebyMultiple sexual partnerships or relationships, defined as having more than one sexual partner over a specified period of time, remain crucial in the transmission of Sexually Transmitted Infections (STIs) ,14. MultThe classification of multiple sexual partnerships as a high-risk sexual behaviour remains contentious . DiffereInformal settlements are unplanned residential areas mainly habituated by the urban poor, whose housing is often not in compliance with up-to-date planning and building regulations . These aGiven the behavioural and social vulnerability of young psychoactive-substance-users, focussing on multiple sexual partnerships provides a reliable indicator for surveillance of STIs in informal settlements ,5. This 2, and is Uganda’s main economic hub, generating 65% of the national GDP [This cross-sectional study was conducted in the informal settlements in Kampala, Uganda’s capital city, from June to July 2019. Kampala city has a population of over 1,507,080 people, among whom 27.5% are aged 15–24 years and 15.8% are aged 10–17 years. Kampala city occupies approximately 189 Kmonal GDP . Data weA minimum sample size of 770 respondents was determined using the Kish Leslie formula for cross-sectional studies . We consTwelve out of fifty-seven informal settlements were purposively selected from a list of informal settlements obtained from the Kampala Capital City Authority (KCCA) Department of Public Health Services and Environment . These informal settlements were purposively selected for geographical representativeness of the informal settlements in the entire city. Besides, the settlements also had the highest average house hold size. The informal settlements included Kinawataka, Luzira, Luzira-Kirombe, Kitintale, Nalukolongo, Wankulukuku-Kabowa, Kamwokya, Bwaise, Katanga, Katwe-Kinyoro, Namuwongo-Soweto and Kyebando. We used respondent-driven sampling (RDS), a form of chain-referral network sampling, to select respondents. This approach is recommended for hard-to-reach populations such as psychoactive substance users in informal settlements .In this study, the research assistants enrolled 4 psychoactive substance users  from each informal settlement as ‘seeds’ using contacts obtained in an earlier study . These sData were collected between June and July 2019 using a structured questionnaire. The questions used in the study tool were adopted from the Uganda Demographic Health Survey and the Global School-based Student Health Survey tools. These tools are arleady validated, and are used to collect information on high-risk sexual behaviours and alcohol consumption ,43. The Data collected included: socio-demographic characteristics such as age, educational status, marital status, average monthly income, duration of stay in the informal settlement, and history of use of a particular psychoactive substance, in addition to the number of sexual partners in the last 30 daysThe outcome of interest was engaging in multiple sexual partnerships in the last 30 days. Respondents were asked how many sexual relationships they had in the last 30 days. Those who reported more than one sexual relationship in the target period were considered to have engaged in multiple sexual partnerships , irrespeDescriptive statistics such as means and standard deviations were used to summarize continuous data while categorical data were expressed as frequencies and proportions. A chi-square test was performed to indicate statistically significant differences between the prevalence of multiple sexual characteristics across the sociodemographic strata and duration of use of each substance. The main outcome was dichotomized as “ever engaging in multiple sexual relationships in the last 30 days or not”. A “modified” Poisson regression analysis was applied to model the association between “ever engaging in multiple sexual partnerships in the last 30 days” and the independent variables. Simpler models consisting of the outcome and one predictor were initially run and variables with p-values less than 0.2 included in the multivariable model . PrevaleEthical approval was granted by Makerere University School of Public Health Higher Degrees and Research Ethics Committee (MakSPH HDREC). Administrative clearance to conduct this study was obtained from KCCA and the area local leaders. Informed written consent was sought from all respondents.There were 744 sexually active young psychoactive-substance-users with a mean age of 21.5 years (SD 2.17), representing a response rate of 96.6%. About 78% of the respondents were male, and 69.1% had never been married, while 85.3% were not living with their parents/guardians .Overall, 40.6% of the respondents had engaged in multiple sexual partnerships within the last 30 days prior to the interview. Half (50.0%) of the female respondents had engaged in multiple sexual partnerships. Sex  and the duration of stay in the informal settlements  were significantly associated with engaging in multiple sexual relationships in the last 30 days. Forty-two per cent of the adolescents aged 18–19 years, 45.5% with no formal education and 42.9% of those earning above UGX 500,000 (≈USD 138) per month were engaged in multiple sexual relationships .Engaging in multiple sexual partnerships in the last 30 days was statistically higher among those who drunk alcohol in the last 30 days (p = 0.007), and those who chewed khat (p = 0.025).The reasons young psychoactive-substance-users gave for engaging in multiple sexual relationships in the last 30 days were; sexual satisfaction (52.6%), pleasure (50.0%), peer pressure (26.8%) and earning money (24.8%). Of those who engaged in multiple sexual partnerships, 89% of the females and 1% of males did so because of money, 62.7% of males and 25.6% of females did so for sexual satisfaction, while 61.8% of males and 18.3% of females did so for pleasure. .Female psychoactive substance users had a 29% higher likelihood of engaging in multiple sexual relationships compared to males . Compared to respondents who had lived in informal settlements for ≤ 5 years, those who had stayed for 6–10 years had a 34% higher likelihood of engaging in multiple sexual relationships . Young psychoactive-substance-users who had chewed khat in the last 30 days had a 93% higher likelihood of engaging in multiple sexual partnerships compared to those who had not . At multivariable analysis, drinking alcohol, using marijuana, heroin, or kuba were not associated with engaging in multiple sexual partnerhsips. .This study among young psychoactive-substance-users, shows a high prevalence of multiple sexual partnerships in a short period of 30 days, indicating more recent sexual risk behaviour in this population. Young psychoactive-substance-users aged 18–19 years, females, those with no formal education, those living without any parent or guardian, and those earning above UGX 500,000 (≈ USD 138) reported a higher prevalence of multiple sexual partnerships compared to their counterparts. Sex, duration of staying in the informal settlement, and a history of chewing khat in the last 30 days were associated with multiple sexual partnerships, and are discussed in light of the existing literature here below.The high prevalence of multiple sexual partnerships is not surprising given the known impact of psychoactive substance use on high-risk sexual behaviours ,47. ThisImportantly, this study points out that psychoactive substance users opt to have multiple sexual partners to satisfy their sexual desires, for pleasure, satisfaction, and economic needs. Similar findings have also been reported among young people in Ethiopia . In our The prevalence of multiple sexual partnerships was higher among young people aged 18–19 years compared to those aged 20–24 years. This high proportion may be explained by the stages of development that adolescents (18–19 years) undergo as they transition into adulthood. These stages are often characterised by experimentation and exploration . As suchThis study also highlights the importance of staying with a parent or guardian as protective against sexual risk behaviours including multiple sexual partnerships. Young psychoactive-substance-users staying with parents may have restrictions on their sexual behaviours including who they interact with at risky periods at night and for how long. Independent Young psychoactive-substance-users may have a leeway to interact with several sexual partners at any time they wish and during periods of intoxication.From this study, it was evident that the prevalence of multiple sexual partnerships was higher among Young psychoactive-substance-users who earned more than UGX 500,000 000 (≈ USD 138) compared to those who earned less. Young psychoactive-substance-users, particulary males, earning a higher income have the financial power to sustain multiple relationships compared to those with lower financial power. These are also more likely to pay for sex compared to those with a low monthly income. These findings are in agreement with those of a study conducted in India which indicated that men of higher economic status were more likely to engage in multiple sexual partnerships compared to those of low economic status . It is aBased on our findings, chewing khat was associated with a higher prevalence of multiple sexual partnerships. The effect of khat on high-risk sexual behaviour and particularly engagement in multiple sexual partnerships may be explained by the alcohol myopia and expectancy theories ,56. The This is one of the few studies that have examined the prevalence and factors associated with multiple sexual partnerships among young psychoactive-substance-users in informal settlements in low-income countries. The study used a relatively large sample size, making the results more reliable. Besides, the study used a short recall period of 30 days, thus less prone to recall bias, and indicates more recent behaviour.This study was conducted among young psychoactive-substance-users in Kampala’s informal settlements. Therefore, these findings should not be generalised to all young people in Uganda. Therefore, there is a need to examine engagement in multiple sexual partnerships among young psychoactive-substance-users in affluent and formal settlements. The cross-sectional design limits causal linkages between psychoactive substances and engaging in multiple sexual partnerships.This study examined the prevalence and factors associated with multiple sexual partnerships among young psychoactive-substance-users in informal settlements in Kampala, Uganda. It was found that multiple sexual partnerships are highly prevalent across different socio-demographic strata. Being female, having lived in the informal settlement for 6–10 years and chewing khat were significantly associated with having multiple sexual partners in the last 30 days. These findings are indicative of the high risk of transmission of STIs including HIV among young psychoactive-substance-users. In tackling this high-risk sexual behaviour, it is recommended that risk-reduction interventions make special emphasis across the different socio-demographic strata identified in this study, i.e. females, those who have lived in the informal settlement for about 6–10 years, and those who chew khat.S1 File(XLS)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


These bacteria are capable of adapting to humans, leading to increased spread into the community and healthcare settings. Staphylococcus aureus (LA-MRSA) can acquire phage-encoded immune modulators, such as the immune evasion cluster (IEC), which protects bacteria from components of the human innate immune system, and the enzyme TarP, which protects against antibody-mediated immune recognition. We used whole-genome sequencing and epidemiologic investigations to study the effects of IEC- and tarP-harboring phages on household transmission of LA-MRSA in North Denmark Region during 2004–2011. We reviewed information about all patients throughout Denmark who experienced LA-MRSA infection during 2007–2018 to determine whether IEC is associated with increased spread into the general population. Horizontal acquisition of IEC in the human host was associated with increased household transmission of LA-MRSA and spillover into the community and healthcare settings, whereas we found no evidence to suggest that IEC-positive LA-MRSA isolates have become self-sustainable in the general population. By contrast, TarP did not seem to influence household transmission of LA-MRSA.Livestock-associated methicillin-resistant  In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.http://www.medscape.org/journal/eid; and (4) view/print certificate. All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 75% minimum passing score and complete the evaluation at Upon completion of this activity, participants will be able to:tarP-harboring phages on household transmission of LA-MRSA in the North Denmark Region during 2004–2011, according to whole-genome sequencing and epidemiologic investigationsDescribe the impact of IEC- and tarP-harboring phages in LA-MRSA in the North Denmark Region during 2004–2011 with spread in the general population, according to an analysis of all Danish patients who had an episode of LA-MRSA infection during 2007–2018Determine the association of IEC- and tarP-harboring phages on household transmission of LA-MRSA in the North Denmark Region during 2004–2011, and of their association with spread into the general populationIdentify clinical and public health implications of the effect of IEC- and Dana C. Dolan, BS, Copyeditor, Emerging Infectious Diseases. Disclosure: Dana C. Dolan, BS, has disclosed no relevant financial relationships.Laurie Barclay, MD, freelance writer and reviewer, Medscape, LLC. Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.Disclosures:Raphael N. Sieber, PhD; Tinna Urth, MPH; Andreas Petersen, PhD; Camilla Møller, MD, PhD; Lance B. Price, PhD; Robert L. Skov, MD; Anders Larsen, PhD; Marc Stegger, PhD;andJesper Larsen, PhD,have disclosed no relevant financial relationships. WARNING: Content in this section is NOT in the correct location. Check paragraph styling and re-export Staphylococcus aureus (LA-MRSA) clonal complex (CC) 398 is a major cause of zoonotic disease in Denmark and several other countries in Europe that have industrial pig production , on a 44-kb ΦSa3int prophage that is stably integrated into the hlb gene on the bacterial chromosome  . The National Committee on Health Research Ethics waived the need for approval and informed consent because data and biologic material were fully anonymized and collected in compliance with national legislation on statutory notification of MRSA in humans.2) is a semirural area in northwest Denmark that had a population of ≈580,000 persons and ≈3 million pigs in 2011 (http://www.statbank.dk). We identified the study population using surveillance data collected by the regional infection control staff in North Denmark Region; it included all patients colonized or infected with LA-MRSA CC398 during 2004–2011, as well as all their household contacts who tested negative during the same period. We interviewed all of these persons to obtain relevant information, including sex, age, livestock contact, residential address, and workplace, and assigned each to 1 of 3 categories: livestock-exposed persons (direct contact); household contacts of livestock-exposed persons (indirect contact); and persons not connected to livestock production (no contact). We defined livestock-exposed persons as primary cases in their households, and the index person as the primary case in households with no connection to livestock production.North Denmark Region  in North Denmark Region in 2014  Table 1.isolates .S. aureus identification and antimicrobial susceptibility testing and submit all confirmed MRSA isolates to the National Reference Laboratory for Antimicrobial Resistance at Statens Serum Institut , which collects patient information from general practitioners and assesses the spa type or the clonal complex and the presence or absence of the IEC element. The following data are collected for each case: sex, age, livestock contact, residential address, indication for testing (screening or infection), and hospitalization dates. Cases without direct or indirect livestock contact are defined as healthcare-onset (HO) if the culture is obtained >48 hours after admission; healthcare-associated community-onset (HACO) if the person has had contact with the healthcare setting within the preceding 12 months or the culture is obtained within the first 48 hours after admission; or community-onset (CO) if no other criteria are met. For this study, we retrieved the following information about all patients in Denmark who had an episode of LA-MRSA CC398 infection during January 2007–December 2018 : sex; age; direct, indirect, or no livestock contact; location of disease onset ; and presence or absence of the IEC element in the corresponding LA-MRSA CC398 isolate. We calculated the excess number of clinical cases due to increased spread of IEC-positive isolates into a given patient group of interest as the total number of cases in the patient group of interest multiplied by the difference between the proportion of IEC-positive isolates in the patient group of interest (the sink) and the patient group with direct contact to livestock (the source).MRSA has been notifiable in Denmark since November 2006. As part of the national MRSA surveillance program, local clinical microbiology departments perform https://www.graphpad.com). We reported prevalence differences between different groups as prevalence ratios (PRs) and 95% CIs. The significance level was set at α = 0.05.We used Fisher exact test to analyze categorical data and Student t test to analyze continuous data , 3 mink farm employees from 3 households and animal farms, 1 cattle farm employee, 1 turkey farm employee, 1 pig veterinarian, 3 lorry drivers transporting pigs from 3 households, 2 pig abattoir workers from 2 households, and 2 craftsmen working in pig stables from 2 households. Persons with indirect contact were from 2 households (a wife and a child of pig farm employees who were never tested), and those with no contact were from 8 households.tarP-harboring prophages  distance of 5.9 (range 0–18 SNPs) and were genotypically homogeneous with respect to presence of specific IEC-harboring and rophages  Figure. We identified IEC in 20 isolates, which clustered within a closely related clade  Figure. tarP gene in 45 isolates, which were more widely distributed across the phylogeny than the IEC-positive isolates . BLASTN searches (https://blast.ncbi.nlm.nih.gov/Blast.cgi) showed that the int gene in ΦUT1 was 100% identical to the int gene in the bovine S. aureus phage ΦDW2 (GenBank accession no. KJ140076). We found ΦtarP-Sa9int exclusively in pig isolates (n = 15), whereas the other tarP-harboring prophages were identified in 25 human isolates from 16 households and in 5 pig isolates.We identified the isolates  Figure. tarP was significantly less prevalent in human isolates  than in pig isolates  . The IEC element in the 3 pig isolates was genetically linked to tarP on ΦSa3int-V and ΦSa3int-VI  than in pig isolates , although the difference was not statistically significant . By contrast, a3int-VI  Figure.>2 persons reporting direct animal contact (n = 2) were excluded from both analyses. In addition, 1 household with a mixed population of IEC-positive and IEC-negative isolates was excluded from the corresponding analysis.Household transmission of LA-MRSA CC398 was based on detection of secondary cases of colonization or infection with isolates that were closely related and genotypically indistinguishable from the isolate of the primary case. Households consisting of 1 person (n = 26) and households with tarP were present in 32% (12/37) of the eligible households. We saw no differences in occurrence of secondary transmission between tarP-positive households  and tarP-negative households   or in the proportion of secondary cases between tarP-positive households  and tarP-negative households  . The average number of household contacts per household, excluding the primary case, did not differ significantly between IEC-positive  and IEC-negative households  or between tarP-positive  and tarP-negative households . These findings indicate that IEC, but not tarP, facilitates household transmission of LA-MRSA CC398.IEC-positive isolates were present in 14% (5/36) of the eligible households. Secondary transmission occurred more often in IEC-positive households  than in IEC-negative households , although the difference was not statistically significant . The proportion of secondary cases was significantly higher in IEC-positive households  than in IEC-negative households  . Isolates carrying We investigated whether IEC also plays a role during spread of LA-MRSA CC398 in the general population, on the assumption that persons with direct livestock contact serve as the source of transmission to their household contacts  and into the local community, through which the bacterium is transmitted into healthcare settings. The analysis included 1,545 isolates from patients in 4 groups: patients with direct livestock contact (n = 727); patients with indirect livestock contact (n = 256); patients with CO infection (n = 383); and patients with HO/HACO infection (n = 179). The results showed that the proportion of IEC-positive isolates increased along this hypothetical transmission chain, from 3.4% in patients with direct contact to livestock to 6.3%  in patients with indirect contact to livestock, 7.1%  in patients with CO infection, and 11%  in patients with HO/HACO infection . The excIf IEC-positive isolates become fixed  in the general population, we expect their proportion to increase over time in patients with CO and HO/HACO infections, compared with patients with direct contact to livestock. However, although the number of LA-MRSA CC398 infections increased in all 4 patient groups during 2007–2018 , panel AS. aureus in humans depends upon the bacterium’s ability to survive and multiply in newly colonized persons. For example, S. aureus must compete with other bacteria and avoid the innate and adaptive immune defenses of the skin and nasal environments. In this study, we have shown that acquisition of IEC, but not tarP, is associated with increased household transmission of LA-MRSA CC398 and excess spread into the community and healthcare settings. The findings should be interpreted with some caution because of the small number of households and cases analyzed, and more follow-up studies should be done to further evaluate the relative contribution of IEC and other risk factors, such as household size  located within the hlb gene, which interferes with phage integration and might explain why ΦSa3int phages often integrate into other genomic regions than the hlb gene in LA-MRSA CC398 through recombination between the phage attachment site (attP) and alternative attB sites, as demonstrated in our study and others  and earn continuing medical education (CME) credit, please go to http://www.medscape.org. If you are not registered on http://www.medscape.org, please click on the “Register” link on the right hand side of the website. You must be a registered user on CME@medscape.net. For technical assistance, contact CME@medscape.net. 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According to the whole-genome sequencing and epidemiologic study by Sieber and colleagues, which of the following statements about the impact of immune evasion cluster (IEC)- and tarP-harboring phages on household transmission of LA-MRSA in the North Denmark Region during 2004-2011 is correct?You are advising a public health department about the likelihood of livestock-associated methicillin-resistant tarP, but not IEC, facilitates household transmission of LA-MRSA CC398The proportion of secondary cases was significantly higher in IEC-negative than in IEC-positive householdsSecondary transmission occurred more often in IEC-positive than in IEC-negative households, but the difference was not statistically significant tarP-204–positive vs tarP-negative households had significantly greater secondary transmission and proportion of secondary casestarP-harboring phages in LA-MRSA in the North Denmark Region during 2004–2011 with spread in the general population is correct?According to the analysis by Sieber and colleagues of all Danish patients who had an episode of LA-MRSA infection during 2007–2018, which of the following statements about the association of IEC- and Horizontal acquisition of IEC in the human host was associated with increased household transmission of LA-MRSA CC398 and spillover into the community and healthcare settings The findings suggest that IEC-positive LA-MRSA isolates have become self-sustainable in the general populationProportion of IEC-positive isolates was highest in cases with direct livestock contact and lowest in cases with healthcare-onset (HO) or healthcare-associated community-onset (HACO) infectionThe prevalence ratio of IEC-positive isolates among patients with CO and HO/HACO infections increased over timetarP-harboring phages on household transmission of LA-MRSA in the North Denmark Region during 2004–2011, and of their association with spread into the general population, is correct?According to the genetic and epidemiologic study by Sieber and colleagues, which of the following statements about clinical and public health implications of the effect of IEC- and The findings suggest that all LA-MRSA CC398 isolates have the same ability to acquire ΦSa3int phagesAcquisition of IEC by LA-MRSA CC398 rarely occurs through transfer of ΦSa3int phages from human S aureus donors circulating in the respective householdsTarP-mediated protection against anti-wall teichoic acid (WTA) antibodies increased household transmission of LA-MRSA CC398Changing S aureus genome evolution and host adaptability mandate ongoing human-animal surveillance to detect evolutionary and epidemiologic changes that may affect public health