Rooming-in for Infants at Risk for Neonatal Abstinence Syndrome: Outcomes 5 Years following Its Introduction as the Standard of Care at One Hospital.

OBJECTIVE: The practice of rooming-in for opioid-dependent infants was introduced as the standard of care at our hospital following a pilot study which demonstrated that such infants had shorter lengths of stay and were less likely to require pharmacological treatment. We sought to determine whether these benefits have continued, and whether outcomes support continuing to use rooming-in as standard care. STUDY DESIGN: Opioid-dependent infants delivered at 36 weeks gestation or later between January 1, 2015, and December 31, 2019, were eligible for rooming-in. Charts were reviewed and data were extracted regarding maternal and infant conditions, whether neonatal pharmacological treatment was required, and total length of hospital stay. Outcomes were compared with two historical groups reported in a previous pilot study: 24 healthy near-term opioid-dependent newborns who were admitted directly to the neonatal intensive care unit (NICU) prior to the introduction of rooming-in (May 1, 2012-May 31, 2013), and 20 similar opioid-dependent infants who were the first to room-in at our hospital (September 1, 2013-September 30, 2014). RESULTS: Only 3.5% of 57 infants who roomed-in during the 5-year study period required pharmacological treatment, compared with 15% who roomed-in during the first year of the program's introduction and 83.3% who had been admitted directly to the NICU. The median length of stay remained 5 days for infants rooming-in, compared with 24 days for opioid-dependent infants in the cohort admitted to the NICU. CONCLUSION: Early observations of the benefits of rooming-in on neonatal outcomes were sustained. Infants allowed to room-in were significantly less likely to require initiation of pharmacotherapy and a prolonged hospital stay than similar infants prior to the implementation of rooming-in as standard care. A large proportion of the infants who might have benefited from rooming-in required admission to the NICU for reasons other than neonatal abstinence syndrome (NAS). KEY POINTS: · Benefits of rooming-in for near-term opioid-dependent infants were sustained or increased.. · Rooming-in is sustainable as standard care for these newborns.. · Many infants required admission to NICU for reasons other than NAS..

Need for women-centered treatment for substance use disorders: results from focus group discussions.

BACKGROUND: There are few women-centered treatment programs for substance use disorder. We therefore undertook an exploratory study to better understand the treatment experience, barriers, and facilitators of mothers with substance use disorder. METHODS: We conducted two focus groups with a total of ten women with a history of substance use disorder in Kingston (Canada). Women were recruited from a community program for mothers with substance use disorder. The focus groups were recorded, and the resulting data were transcribed, coded, and thematically analyzed. Barriers, facilitators and treatment needs were identified. RESULTS: The mean age of the participants was 31.1 years, 30% were currently using substances, and 60% had a child in their care. A key concern for women regarding substance use treatment was the welfare of their child(ren). Agencies charged with child protection were a barrier to treatment because women feared disclosing substance use would result in loss of child custody. In contrast, when agencies stipulated that women must attend treatment to retain custody, they facilitated treatment engagement. Other barriers to treatment included identifying treatment programs and completing admission requirements, wait times, counselor ability to address woman-centered issues, fear, safety, and stigma. Women's personal motivation for treatment was a facilitator. Suggestions to improve treatment programs included to allow children to accompany their mothers, involvement of peer support, and women-only programs. CONCLUSIONS: This small but novel study provides important data to inform treatment programming for mothers with substance use disorders.

Infants Born to Opioid-Dependent Women in Ontario, 2002-2014.

BACKGROUND: There is a paucity of data characterizing mother-infant pairs with prenatal opioid dependence in Canada. We therefore conducted a study of relevant births in Ontario from 2002 to 2014. METHODS: We used data from the Institute for Clinical Evaluative Sciences, the linked databases of coded population-based Ontario health services records. Differences in characteristics of opioid-dependent mother-neonate pairs and infant hospital costs by year were assessed using linear regression, and we calculated rates of preterm birth, low birth weight, birth defects, mortality, and neonatal abstinence syndrome. RESULTS: The number of infants born to opioid-dependent women in Ontario rose from 46 in 2002 to almost 800 in 2014. Methadone was most frequently used for prenatal opioid dependence; there was little buprenorphine or buprenorphine + naloxone use. Rates of preterm birth and low birth weight were high. The proportion of neonates with neonatal abstinence syndrome (58%) was stable over the study period. The mean length of neonatal hospital stay was 13.96 days. Infant hospital costs increased from $724 774 in 2003 to $10 539 988 in 2013, and the mean cost per infant grew from $9928 to $12 917. Birth defect prevalence was 75.84/1000 live births (95% CI 68.12/1000 to 84.10/1000). The stillbirth rate was 11.39/1000 births (95% CI 8.47/1000 to 14.99/1000), and the infant mortality rate was 12.21/1000 live births (95% CI 9.16/1000 to 15.95/1000). CONCLUSION: We observed a 16-fold increase in the number of mother-infant pairs affected by opioid dependence in Ontario over the past decade. Adverse birth outcome rates were high. Expanded services for opioid-dependent women and their children are needed.

Structural and Biochemical Analysis of Protein-Protein Interactions Between the Acyl-Carrier Protein and Product Template Domain.

In fungal non-reducing polyketide synthases (NR-PKS) the acyl-carrier protein (ACP) carries the growing polyketide intermediate through iterative rounds of elongation, cyclization and product release. This process occurs through a controlled, yet enigmatic coordination of the ACP with its partner enzymes. The transient nature of ACP interactions with these catalytic domains imposes a major obstacle for investigation of the influence of protein-protein interactions on polyketide product outcome. To further our understanding about how the ACP interacts with the product template (PT) domain that catalyzes polyketide cyclization, we developed the first mechanism-based crosslinkers for NR-PKSs. Through in vitro assays, in silico docking and bioinformatics, ACP residues involved in ACP-PT recognition were identified. We used this information to improve ACP compatibility with non-cognate PT domains, which resulted in the first gain-of-function ACP with improved interactions with its partner enzymes. This advance will aid in future combinatorial biosynthesis of new polyketides.

Molecular Characterization of the Cercosporin Biosynthetic Pathway in the Fungal Plant Pathogen Cercospora nicotianae.

Perylenequinones are a class of photoactivated polyketide mycotoxins produced by fungal plant pathogens that notably produce reactive oxygen species with visible light. The best-studied perylenequinone is cercosporin-a product of the Cercospora species. While the cercosporin biosynthetic gene cluster has been described in the tobacco pathogen Cercospora nicotianae, little is known of the metabolite's biosynthesis. Furthermore, in vitro investigations of the polyketide synthase central to cercosporin biosynthesis identified the naphthopyrone nor-toralactone as its direct product-an observation in conflict with published biosynthetic proposals. Here, we present an alternative biosynthetic pathway to cercosporin based on metabolites characterized from a series of biosynthetic gene knockouts. We show that nor-toralactone is the key polyketide intermediate and the substrate for the unusual didomain protein CTB3. We demonstrate the unique oxidative cleavage activity of the CTB3 monooxygenase domain in vitro. These data advance our understanding of perylenequinone biosynthesis and expand the biochemical repertoire of flavin-dependent monooxygenases.

Rooming-in for Infants at Risk of Neonatal Abstinence Syndrome.

OBJECTIVE: To examine the impact of a rooming-in program for infants at risk of neonatal abstinence syndrome (NAS) on the need for pharmacologic treatment and length of hospitalization. STUDY DESIGN: Our hospital implemented a rooming-in program for newborns at risk of NAS in June 2013. Previously, standard care was to admit these infants to the neonatal intensive care unit. Charts were reviewed to abstract data on at-risk infants born in the 13-month periods prior and subsequent to implementation of rooming-in (n = 24 and n = 20, respectively) and the groups were compared with the outcomes of interest. RESULT: Rooming-in was associated with a reduced need for pharmacologic treatment and shorter length of stay. CONCLUSION: These findings add to an emerging body of evidence on the health care resource utilization benefits associated with rooming-in for infants at risk of NAS. Future studies should evaluate a broader range of outcomes for this model of care.

Rooming-in care for infants of opioid-dependent mothers: Implementation and evaluation at a tertiary care hospital.

PROBLEM ADDRESSED: Infants born to opioid-dependent women are admitted to intensive care units for management of neonatal abstinence syndrome (NAS), serious morbidity, and prevention of mortality; however, the disadvantages of this approach include infants experiencing more severe NAS and exhibiting a greater need for pharmacotherapy owing to the interference with mother-infant bonding. OBJECTIVE OF PROGRAM: To implement a rooming-in program to support close uninterrupted contact between opioid-dependent women and their infants in order to decrease the severity of NAS scores, lessen the need for pharmacotherapy, and shorten hospital stays. PROGRAM DESCRIPTION: Opioid-dependent pregnant women were assessed antenatally by a multidisciplinary team and provided with education and support. Psychosocial issues were addressed in collaboration with a community program developed to support addicted mothers. The mother-infant dyad was admitted postpartum to a private room and attended by nurses trained in Finnegan scoring. Infants remained with their mothers unless persistently elevated scores made transfer to neonatal intensive care units necessary for initiation of pharmacotherapy. CONCLUSION: With the rooming-in program, the proportion of infants requiring pharmacotherapy decreased from 83.3% to 14.3% (P < .001) and the average length of stay decreased from 25 days to 8 days (P < .001). The rooming-in experience was rated favourably by participating mothers.

Systematic domain swaps of iterative, nonreducing polyketide synthases provide a mechanistic understanding and rationale for catalytic reprogramming.

Iterative, nonreducing polyketide synthases (NR-PKSs) are multidomain enzymes responsible for the construction of the core architecture of aromatic polyketide natural products in fungi. Engineering these enzymes for the production of non-native metabolites has been a long-standing goal. We conducted a systematic survey of in vitro "domain swapped" NR-PKSs using an enzyme deconstruction approach. The NR-PKSs were dissected into mono- to multidomain fragments and recombined as noncognate pairs in vitro, reconstituting enzymatic activity. The enzymes used in this study produce aromatic polyketides that are representative of the four main chemical features set by the individual NR-PKS: starter unit selection, chain-length control, cyclization register control, and product release mechanism. We found that boundary conditions limit successful chemistry, which are dependent on a set of underlying enzymatic mechanisms. Crucial for successful redirection of catalysis, the rate of productive chemistry must outpace the rate of spontaneous derailment and thioesterase-mediated editing. Additionally, all of the domains in a noncognate system must interact efficiently if chemical redirection is to proceed. These observations refine and further substantiate current understanding of the mechanisms governing NR-PKS catalysis.

Treatment of chronic hepatitis C infection among current and former injection drug users within a multidisciplinary treatment model at a community health centre.

The aim of the present prospective observational study was to assess uptake and success of hepatitis C virus (HCV) treatment among a group of former and current injection drug users with chronic HCV infection at the Street Health Centre in Kingston, Ontario. The Street Health Centre offers hepatitis C education, assessment and treatment within a multidisciplinary, integrated and collaborative treatment model of care delivered by primary care professionals. The study enrolled a convenience sample of 34 patients. Seventy per cent of study patients had no postsecondary education, 85% were unemployed and one-third were unstably housed. A majority of study patients self-reported mental health problems. Of the 14 patients who initiated antiviral treatment in the study period, eight (57%) achieved sustained virological response. Regardless of virological outcome, patients who initiated treatment showed positive trends toward increased social and psychiatric stability, and decreases in high-risk behaviours. These results suggest that not only is successful treatment of chronic HCV infection in current and former injection drug users with concurrent psychiatric disorders possible, but the benefits of such treatment delivered in a community-based, multidisciplinary, primary care model may extend beyond narrowly defined virological outcomes.

Analysis of the cercosporin polyketide synthase CTB1 reveals a new fungal thioesterase function.

The polyketide synthase CTB1 is demonstrated to catalyze pyrone formation thereby expanding the known biosynthetic repertoire of thioesterase domains in iterative, non-reducing polyketide synthases.

Structure and function of an iterative polyketide synthase thioesterase domain catalyzing Claisen cyclization in aflatoxin biosynthesis.

Polyketide natural products possess diverse architectures and biological functions and share a subset of biosynthetic steps with fatty acid synthesis. The final transformation catalyzed by both polyketide synthases (PKSs) and fatty acid synthases is most often carried out by a thioesterase (TE). The synthetic versatility of TE domains in fungal nonreducing, iterative PKSs (NR-PKSs) has been shown to extend to Claisen cyclase (CLC) chemistry by catalyzing C-C ring closure reactions as opposed to thioester hydrolysis or O-C/N-C macrocyclization observed in previously reported TE structures. Catalysis of C-C bond formation as a product release mechanism dramatically expands the synthetic potential of PKSs, but how this activity was acquired has remained a mystery. We report the biochemical and structural analyses of the TE/CLC domain in polyketide synthase A, the multidomain PKS central to the biosynthesis of aflatoxin B(1), a potent environmental carcinogen. Mutagenesis experiments confirm the predicted identity of the catalytic triad and its role in catalyzing the final Claisen-type cyclization to the aflatoxin precursor, norsolorinic acid anthrone. The 1.7 A crystal structure displays an alpha/beta-hydrolase fold in the catalytic closed form with a distinct hydrophobic substrate-binding chamber. We propose that a key rotation of the substrate side chain coupled to a protein conformational change from the open to closed form spatially governs substrate positioning and C-C cyclization. The biochemical studies, the 1.7 A crystal structure of the TE/CLC domain, and intermediate modeling afford the first mechanistic insights into this widely distributed C-C bond-forming class of TEs.

Quantitative PCR analysis of diepoxybutane and epihalohydrin damage to nuclear versus mitochondrial DNA.

The bifunctional alkylating agents diepoxybutane (DEB) and epichlorohydrin (ECH) are linked to the elevated incidence of certain cancers among workers in the synthetic polymer industry. Both compounds form interstrand cross-links within duplex DNA, an activity suggested to contribute to their cytotoxicity. To assess the DNA targeting of these compounds in vivo, we assayed for damage within chicken erythro-progenitor cells at three different sites: one within mitochondrial DNA, one within expressed nuclear DNA, and one within unexpressed nuclear DNA. We determined the degree of damage at each site via a quantitative polymerase chain reaction, which compares amplification of control, untreated DNA to that from cells exposed to the agent in question. We found that ECH and the related compound epibromohydrin preferentially target nuclear DNA relative to mitochondrial DNA, whereas DEB reacts similarly with the two genomes. Decreased reactivity of the mitochondrial genome could contribute to the reduced apoptotic potential of ECH relative to DEB. Additionally, formation of lesions by all agents occurred at comparable levels for unexpressed and expressed nuclear loci, suggesting that alkylation is unaffected by the degree of chromatin condensation.