Improving Outcomes of Pediatric Lupus Care Delivery With Provider Goal-Setting Activities and Multidisciplinary Care Models.

OBJECTIVE: The present study was undertaken to evaluate high-quality care delivery in the context of provider goal-setting activities and a multidisciplinary care model using an electronic health record (EHR)-enabled pediatric lupus registry. We then determined associations between care quality and prednisone use among youth with systemic lupus erythematosus (SLE). METHODS: We implemented standardized EHR documentation tools to autopopulate a SLE registry. We compared pediatric Lupus Care Index (pLCI) performance (range 0.0-1.0; 1.0 representing perfect metric adherence) and timely follow-up 1) before versus during provider goal-setting activities and population management, and 2) in a multidisciplinary lupus nephritis versus rheumatology clinic. We estimated associations between pLCI and subsequent prednisone use adjusted for time, current medication, disease activity, clinical features, and social determinants of health. RESULTS: We analyzed 830 visits by 110 patients (median 7 visits per patient [interquartile range 4-10]) over 3.5 years. The provider-directed activity was associated with improved pLCI performance (adjusted ß 0.05 [95% confidence interval (95% CI) 0.01, 0.09]; mean 0.74 versus 0.69). Patients with nephritis in multidisciplinary clinic had higher pLCI scores (adjusted ß 0.06 [95% CI 0.02, 0.10]) and likelihood of timely follow-up than those in rheumatology (adjusted relative risk [RR] 1.27 [95% CI 1.02, 1.57]). A pLCI score of ≥0.50 was associated with 0.72-fold lower adjusted risk of subsequent prednisone use (95% CI 0.53, 0.93). Minoritized race, public insurance, and living in areas with greater social vulnerability were not associated with reduced care quality or follow-up, but public insurance was associated with higher risk of prednisone use. CONCLUSION: Greater attention to quality metrics is associated with better outcomes in childhood SLE. Multidisciplinary care models with population management may additionally facilitate equitable care delivery.

Draft Genome Sequence of the Yeast Ogataea degrootiae Strain UCD465, Isolated from Soil in Ireland.

Ogataea degrootiae is an ascomycete yeast that was first isolated in the Netherlands in 2017. It is a member of the Pichiaceae clade. Here, we present the genome sequence of O. degrootiae UCD465, which was isolated from soil in Ireland. This genome is 14.6 Mb and haploid.

Predictors of change in global psychiatric functioning at an inpatient adolescent psychiatric unit: A decade of experience.

BACKGROUND: Psychiatric inpatient treatment for children is sometimes beneficial, but predictors of who benefits, and in what circumstances, are largely unknown. This study aimed to identify personal and environmental factors that influence outcome in an adolescent unit that accepts both emergency and planned admissions. METHODS: Routine standardised intake and outcome measures were analysed for the period 2009-2018. Potential predictors assessed included the Children's Global Assessment Scale (CGAS), engagement with treatment, behavioural attitudes and peer relationships on the unit. FINDINGS: One hundred and twelve admissions were tracked. Mean age of admission was 16 years, and 71% were female. A total of 61% had higher (better) CGAS scores on discharge than on admission; 34% of inpatients fully engaged with their treatment. Median admission duration was 118 days for males and 196 days for females. Admission lengths were much shorter for ethnic minority patients, but group sizes were small. Longer admissions led to greater improvement. Poor outcomes were associated with failure to engage with treatment and a deterioration in peer relationships. INTERPRETATION: Compliance with treatment and female gender were both significant predictors of positive change during admission. The establishment of good and supportive peer relationships during the admission was also a potent indicator of benefit.

The legacy of Malcolm Beverley Segal (1937-2019) on the science and fields concerned with choroid plexus and cerebrospinal fluid physiology.

This article highlights the scientific achievements, professional career, and personal interactions of Malcolm B. Segal who passed away in July this year. Born in 1937 in Goodmayes, Essex, UK, Segal rose to the Chairman position in the Division of Physiology at United Medical and Dental School of Guy's and St. Thomas' Hospitals, retiring in 2006 after his long professional career in biomedical science. Being trained in Hugh Davson's laboratory, Segal became one of the pioneers in research on cerebrospinal fluid physiology and the choroid plexus. During the course of his career, Segal himself trained a number of young scientists and collaborated with many colleagues around the world, making long-lasting friendships along the way. In addition to his professional accomplishments as a researcher and educator, Segal was an avid sailor and wine connoisseur, and enjoyed teaching classes on navigation and wine tasting.

Clinician education, advice and SMS/text reminders improve test of reinfection rates following diagnosis of Chlamydia trachomatis or Neisseria gonorrhoeae: before and after study in primary care.

BACKGROUND: Evidence-based guidelines for the management of Chlamydia trachomatis and Neisseria gonorrhoeae recommend testing for reinfection 3-6 months following treatment, but retesting rates are typically low. METHODS: Participants included six primary care clinics taking part in a pilot study of strategies designed to improve partner notification, follow-up and testing for reinfection. Rates of retesting between 6 weeks and 6 months of a positive chlamydia or gonorrhoea diagnosis were compared across two time periods: (1) a historical control period (no systematic approach to retesting) and (2) during an intervention period involving clinician education, patient advice about reinfection risk reduction and retesting, and short messaging service/text reminders sent 2-3 months post-treatment inviting return for retesting. Retesting was calculated for demographic subgroups (reported with 95% CI). RESULTS: Overall 25.4% (61 of 240, 95% CI 20.0 to 31.4) were retested during the control period and 47.9% (116 of 242, 95% CI 43.2 to 55.1) during the intervention period. Retesting rates increased across most demographic groups, with at least twofold increases observed for men, those aged 20-29 years old, and Maori and Pasifika ethnic groups. No significant difference was observed in repeat positivity rates for the two time periods, 18% (11 of 61) retested positive during the control and 16.4% (19 of 116) during the intervention period (p>0.05). CONCLUSIONS: Clinician and patient information about retesting and a more systematic approach to follow-up resulted in significant increases in proportions tested for reinfection within 6 months. These simple strategies could readily be implemented into primary healthcare settings to address low rates of retesting for bacterial sexually transmitted infections. TRIAL REGISTRATION NUMBER: ACTRN12616000837426.

Addressing Gaps in the Management of Chlamydia trachomatis and Neisseria gonorrhoeae in Primary Care: Lessons Learned in a Pilot Intervention Study.

BACKGROUND: We aimed to test the acceptability and utility of strategies designed to facilitate the delivery of clinical best practice for patients diagnosed with chlamydia or gonorrhea in primary care. METHODS: A nonrandomized pilot intervention study with a historic control period was run over 9 months in six primary health care clinics (2 youth services, 3 low-fee clinics, and 1 student health service) in Wellington, New Zealand. "Study nurses" in participating clinics oversaw the implementation of strategies designed to facilitate partner notification and follow-up for patients diagnosed with chlamydia or gonorrhea. Clinics chose which of 2 approaches they wished to trial-either managing all study processes themselves or drawing on the assistance of an external specialist sexual health advisor. Outcome measures included acceptability and utility of study processes ascertained via structured interviews with study nurses and collection of clinical data. RESULTS: Outcomes for 287 patients seen during the intervention were compared with 240 historic controls. Participant views on study processes were positive overall, and all clinics intended to continue all or most of the study processes implemented. During the intervention, substantial improvements were observed in documented patient management (sexual history, partner notification, and outcomes, P < 0.05). Increases were observed in percentages of patients reached for follow-up (74% vs. 26% at baseline, P < 0.05) and partners reported to have been notified (79% vs. 23%, P < 0.05). CONCLUSIONS: Nurse-led strategies implemented were deemed acceptable and appeared to facilitate delivery of best practice care for patients diagnosed with bacterial sexually transmitted infections in participating primary care practices.

Partner notification and retesting for Chlamydia trachomatis and Neisseria gonorrhoeae: a case-note review in New Zealand primary care.

INTRODUCTION Bacterial sexually transmitted infections (STIs) contribute to a significant burden of ill-health despite being easy to diagnose and treat. STI management guidelines provide clinicians with evidence-based guidance on best-practice case management. AIM To determine the extent of adherence to STI management guidelines for partner notification, follow up and testing for reinfection following diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae. METHODS Retrospective review of electronic patient records for individuals diagnosed with chlamydia or gonorrhoea in eight primary care clinics in Wellington, New Zealand. At each clinic, 40 clinical records were reviewed (320 in total). Outcome measures were: overall numbers (%) of cases with documented evidence of reason for testing, sexual history, treatment, advice, partner notification and follow up. Partner notification outcomes were: n (%) with evidence of partner notification discussion and n (%) with partners advised, tested and treated. Proportions retested between 6 weeks and 6 months and n (%) positive on retesting were also determined. RESULTS Presenting features and treatment were generally well documented. Recent sexual history including number of partners was documented for half of cases reviewed (159/320). Partner notification discussion was documented for 74% (237/320) of cases, but only 24.4% (78/320) had documentation on numbers of partners notified and 17% (54/320) on numbers of partners treated. Testing for reinfection between 6 weeks and 6 months occurred for 24.7% (79/320), of whom 19% (15/79) re-tested positive. CONCLUSIONS This research suggests there are gaps in important aspects of patient care following bacterial STI diagnosis - a factor that may be perpetuating our high rates of infection. A more systematic approach will be needed to ensure people diagnosed with an STI receive the full cycle of care in line with best practice guidelines.

Healthcare-seeking behaviour of people with sexually transmitted infection symptoms attending a Sexual Health Clinic in New Zealand.

AIMS: Untreated sexually transmitted infections (STIs) can lead to serious health complications and may be transmitted to uninfected individuals. Therefore, the early detection and subsequent management of STIs is crucial to control efforts. Time to presentation for STI symptoms and risk of transmission in this period has not been assessed in New Zealand to date. METHODS: All new clients presenting to an urban sexual health clinic (SHC) were invited to complete a questionnaire, which included demographic information, sexual health history, and details about the clinic visit. RESULTS: Of 331 people approached, 243 (73.4%) agreed to complete the questionnaire. Four incomplete questionnaires were excluded, leaving 239 participants (47.3% female and 52.7% male, 43.8% under the age of 25). The most common reason for seeking healthcare was experiencing symptoms (39.4%) and 41.7% of people with symptoms waited more than seven days to seek healthcare. Around a third (30.6%) of people with symptoms had sex after they first thought they may need to seek healthcare. Infrequent condom use was reported more often by people who had sex with existing partners (84.6%) than by people who had sex with new partners (10.0%). CONCLUSIONS: This is the first study to quantify healthcare-seeking behaviour for STI in New Zealand. Delayed healthcare-seeking (defined as waiting more than seven days) was common and almost a third of people reported engaging in sex while symptomatic. Enabling prompt healthcare-seeking is crucial to minimise transmission risk. Structural barriers such as the financial cost of STI tests must be removed and education around symptom recognition and healthcare system navigation should be provided.

Specialist services for management of individuals identifying as transgender in New Zealand.

AIMS: In light of the rising number of referrals to secondary level services of people who identify as transgender, and the Human Rights Commission concerns regarding the care of this group in New Zealand, we felt it was timely to determine the availability of services for people who identify as transgender and whether there are variations in management protocols. METHODS: We contacted 100 physicians involved in providing a secondary level service to care for people who identify as transgender, and asked them to complete a questionnaire about the services available in their region. This questionnaire consisted of two parts, a 'general questionnaire', which focussed on the consultants' understanding of services available locally, and a 'clinical questionnaire', which presented hypothetical clinical case histories and asked respondents to indicate how they would manage the case. RESULTS: Sixty-two of the physicians responded. Of these, 18 (45% of the 40 physicians that answered the question) believed they could access a psychological or psychiatric opinion in the public sector for a patient who identifies as transgender, whereas 28 (82% of the 34 that answered the question) knew of access in the private sector. There was a conflict of opinion on the availability of psychological and surgical services in several DHBs where there was more than one clinician responding. This may reflect the case experience of individual clinicians. There was restricted access to common surgical procedures in the public sector, and about half of respondents did not know if techniques were available locally. CONCLUSIONS: Our results support the development of specialist care services in tertiary centres in addition to the secondary services already available in New Zealand for people who identify as transgender. Development of multidisciplinary management and improved access to psychological support services for individual cases is required.

Enhanced surveillance of infectious syphilis in New Zealand sexual health clinics.

Following a rise in cases of infectious syphilis in New Zealand, national enhanced surveillance at sexual health clinics was initiated. All public sexual health clinics reported monthly on the number of cases seen, and completed a coded questionnaire on each case. Monthly reports to routine surveillance were compared and discrepancies reconciled. During 2011, 72 cases of infectious syphilis were reported. The majority (83%) were among men who have sex with men who were mainly infected in New Zealand and had an ethnic profile similar to all New Zealanders. Most heterosexual infections occurred overseas, among people of non-European non-Maori ethnicity. About half the cases had symptoms on presentation. Overall, 18% of men who have sex with men were HIV positive. Resurgent syphilis in New Zealand disproportionally affects men who have sex with men, amongst whom HIV is prevalent. Men who have sex with men should be aware of the risks and symptoms of syphilis and encouraged to have regular sexual health checks including serology testing. Control of syphilis should be included in the strategy to check HIV spread. Syphilis serology should continue to be part of routine immigration and antenatal screening, and where clinically indicated. Enhanced surveillance was easily initiated for an uncommon condition seen at sexual health clinics, and provided valuable information.

Sexual health and the Rugby World Cup 2011: a cross-sectional study of sexual health clinics in New Zealand.

BACKGROUND: We aimed to describe the characteristics of sexual health clinic (SHC) attendance and sexually transmissible infection (STI) diagnoses during the Rugby World Cup (RWC) in New Zealand in 2011. METHODS: SHC attendance and STI diagnoses around the time of the RWC were compared with the 5 preceding years. A cross-sectional survey conducted at SHCs in four New Zealand cities collected information from attendees having RWC-related sex. RESULTS: Although there was no statistically significant increase in clinic attendance or STI diagnoses during the RWC compared with previous years, in these four cities, 151 individuals of 2079 attending SHCs for a new concern reported RWC-related sex. The most frequently diagnosed STIs were chlamydial infection (Chlamydia trachomatis), genital warts and genital herpes. Most attendees (74%) who had RWC-related sex had consumed three or more alcoholic drinks; 22% had used a condom. Seven percent of women reported nonconsensual sex. RWC-related sex was associated with an increased risk of STI diagnoses in men: gonorrhoea (Neisseria gonorrhoeae): relative risk (RR)=4.9 (95% confidence interval (CI): 2.1-11.4); nonspecific urethritis: RR=2.8 (95% CI: 1.3-5.9); chlamydial infection: RR=1.8 (95% CI: 1.1-2.9). Using a condom was associated with a reduced risk (RR=0.3, 95% CI: 0.1-0.9) of diagnosis with any STI among those having RWC-related sex. CONCLUSIONS: These findings highlight issues that are amenable to prevention. The continued promotion of condoms as well as a reduction in the promotion and availability of alcohol at such events may reduce sexual health risks as well as other harm.

Drug injectors and dealers in Odessa, Ukraine.

This article reports on the results observed in a series of focus groups and in-depth interviews with injection drug users (IDUs) and drug dealers in Odessa, Ukraine. Ukraine has the highest rate of HIV infection in Eastern as well as Western Europe, and Odessa ranks among the cities in that country with the highest seroprevalence. The epidemic is largely concentrated among IDUs, although heterosexual transmission is increasing. The purpose of this study was to further understand the context in which HIV-related risk behaviors occur in order to recommend intervention strategies that might reduce the rate of new infections. The drug users who participated in the research were impoverished and severely addicted. Findings revealed that there were two sources for drugs in Odessa: either from gypsies in preloaded syringes, or from drug dealers also in a liquid form. The most common drug injected was liquid poppy straw, a weak opiate known as "hemia." Results showed widespread victimization of drug users by police officials, leading to increased risk-taking to avoid arrest or harassment. Needle/syringe sharing was common and users rarely had time to disinfect their works. The most common product used to clean was urine, believed to be an antiseptic. When asked to recommend prevention strategies to reduce the rising rate of HIV, the most common response by the users and dealers was to legalize drugs. The drug and HIV epidemics in Odessa, as well as all of Ukraine, call for urgent public health measures to impact and improve the health of its citizens.