Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study.

BACKGROUND: Neonatal Opioid Withdrawal Syndrome (NOWS) is a significant public health issue and while millions of neonates are affected each year, an optimal pharmacologic weaning protocol has yet to be demonstrated. In this study, we compare hospital length of stay (LOS) and length of treatment (LOT) for treatment of neonatal opioid withdrawal (NOWS) with morphine versus methadone. METHODS: This was a single-site, open-label, randomized controlled pilot study conducted from October 2016-September 2018. Infants were eligible if their primary in-utero drug exposure was heroin, oral opioids, or methadone and they were born at greater than or equal to 34 weeks gestation. Infants were excluded for serious medical comorbidities and primary in-utero exposure to buprenorphine. RESULTS: Sixty-one infants were enrolled; 30 were randomized to methadone treatment, and 31 to morphine treatment. Overall 46% of infants required treatment for NOWS. LOS and LOT for infants treated with morphine was 17.9 days and 14.7 days respectively, compared to 16.1 days and 12.8 days for babies treated with methadone (p = 0.5, p = 0.54). Infants treated with morphine received lower total morphine equivalents than those treated with methadone (9.7 vs. 33, p < 0.01). Three treated infants in the methadone group required transfer to the Neonatal Intensive Care Unit, versus no infants in the morphine group. CONCLUSIONS: Infants treated with morphine versus methadone had no significant differences in LOS or LOT in this pilot study. Infants treated with methadone received up to 3 times the opioid based on morphine equivalents as infants treated with morphine and had more transfers to the NICU for over sedation. CLINICAL TRIAL REGISTRATION: Morphine Versus Methadone for Opiate Exposed Infants With Neonatal Abstinence Syndrome NCT02851303 , initiated 01/08/2016.

Breastfeeding Education in Family Medicine Residencies: A 2019 CERA Program Directors Survey.

BACKGROUND AND OBJECTIVES: Breastfeeding counseling is an integral skill for all family physicians, regardless of whether they ultimately practice maternal child health (MCH). Evidence on time spent in breastfeeding education and resident competence is lacking. This study aimed to identify program characteristics associated with an increase the amount of breastfeeding education and program directors' (PDs) perceived competence of residents' breastfeeding counseling skills. METHODS: A national survey of family medicine PDs including breastfeeding questions was conducted as part of the 2019 CERA survey. We specifically sought to identify variables that correlate with increased breastfeeding education time and perceived competence. RESULTS: Family medicine programs with greatest breastfeeding education time and perceived resident competence included lactation consultants, had more MCH visits in resident continuity clinic, more graduates that practice MCH, and included competency evaluations by faculty. There was more volume of breastfeeding education in programs with group prenatal care and an academic affiliation. There was greater perceived competence among programs with more hours of breastfeeding training overall. CONCLUSIONS: This study defines associations with curricular targets for improved breastfeeding counseling competence among family medicine residents. Inclusion of lactation consultants, regular faculty observation of counseling skills, and group prenatal care may be gradually introduced in programs to strengthen resident education and skills in breastfeeding counseling. The body of evidence in this field remains lacking, and further research is needed to characterize curricular interventions that increase resident competence in this important skill.

Group Prenatal Care for Women Receiving Medication-Assisted Treatment for Opioid Use Disorder in Pregnancy: An Interprofessional Approach.

Opioid use disorder among pregnant women is common and rapidly increasing nationwide. Group prenatal care is an innovative alternative to individual care for pregnant women and has been shown to improve women's and health care providers' satisfaction and adherence to care. We describe a novel group prenatal care program colocated in an opioid treatment program that integrates prenatal care, substance use disorder counseling, and medication-assisted treatment. Our interprofessional model draws on the unique contributions of physicians, midwives, nurses, and mental health professionals to address the complex needs of pregnant women with opioid use disorder. Participants reported increased trust and engagement with health care providers and peers, improved prenatal care and birth experience, and increased resilience for relapse prevention. Group prenatal care is an accepted and promising model for women with opioid use disorder in pregnancy and has the potential to improve outcomes for women and newborns.

Patient-centered Care to Address Barriers for Pregnant Women with Opioid Dependence.

Pregnant women affected by substance use often encounter barriers to treatment, including housing insecurity, poverty, mental health issues, social stigma, and access to health care. Providers may lack the resources needed to provide quality care. Clinicians offering prenatal care to women with substance use disorder are encouraged to support family-centered, multidisciplinary care to women and their infants, focusing on harm reduction. Collaboration between providers of maternity care, substance abuse treatment, case management, family primary care, and pediatric developmental care can improve outcomes during pregnancy and through the early years of parenting.

Teaching maternity care in family medicine residencies: what factors predict graduate continuation of obstetrics? A 2013 CERA program directors study.

BACKGROUND AND OBJECTIVES: Maternity care is an essential component of family medicine, yet the number of residency graduates providing this care continues to decline. Residency programs have struggled to identify strategies to increase continuation of obstetric practice among graduates. Leaders in family medicine obstetrics previously proposed a tiered model of training to ensure adequate volume for those desiring to continue maternity care upon graduation. However, whether this approach will be successful is unknown. This study aimed to identify program characteristics and teaching methods that may influence residents to continue obstetrics practice upon graduation. METHODS: A nationwide survey of family medicine residency program directors (PDs) was conducted as part of the 2013 CERA survey to characterize teaching in maternity care and identify program-level predictors of graduate continuation of obstetrics (OB). RESULTS: Family medicine programs, which were community-based, university-affiliated programs in the Midwest and West, contributed more trainees who continued to provide OB care upon graduation. Trainees at these programs received greater supervision by family medicine faculty preceptors on labor and delivery, reported at least 80 deliveries by graduates during residency, and experienced greater autonomy in decision-making during OB rotations. CONCLUSIONS: This study supports a targeted approach to teaching maternity care in family medicine residency programs. Prioritizing continuity delivery experiences and fostering resident independence are strategies toward promoting increased provision of obstetric care by family medicine graduates. Further research is needed to evaluate the impact of tiered or track systems in practice.

Newborn well-child visits in the home setting: a pilot study in a family medicine residency.

BACKGROUND: The purpose of our study was to pilot a home visit program targeting neonates conducted by family medicine residents. While the literature shows that home visit programs are successful at preventing adverse outcomes for young children, such as improving parenting practices and promoting breastfeeding, no data exist about newborn home visits conducted by resident physicians. METHODS: Residents conducted newborn home visits precepted by a family medicine faculty member from June 2012--May 2013. Subjects were recruited from the residency continuity practice and randomized to receive two home visits (which replaced two office visits) or routine office-based newborn care. All participants were surveyed using the validated WHOQOL-BREF quality of life scale and a patient satisfaction instrument. Metrics were also obtained from the electronic medical record. Mothers and resident physicians completed an open-ended questionnaire about their experience. RESULTS: All patients, whether receiving office-based or home-based care, rated their care highly. Significant differences were seen in usage of acute care in the first 6 months of life, and mothers in the home visit group trended toward initiating breastfeeding at a higher rate. The home visit group ranked their quality of life higher across all domains when compared to the control group, approaching statistical significance in two domains. Residents providing home visits reported increased connectedness to patients and improved confidence in anticipatory guidance delivery. CONCLUSIONS: Home visits are valuable for families with newborns, in terms of minimizing acute care service usage, breastfeeding promotion, and perhaps increasing maternal perceptions of well-being. A home visit program has the potential to enhance resident education and the doctor-patient relationship.

Neonatal opioid withdrawal syndrome.

Neonatal opioid withdrawal syndrome is common due to the current opioid addiction epidemic. Infants born to women covertly abusing prescription opioids may not be identified as at risk until withdrawal signs present. Buprenorphine is a newer treatment for maternal opioid addiction and appears to result in a milder withdrawal syndrome than methadone. Initial treatment is with nonpharmacological measures including decreasing stimuli, however pharmacological treatment is commonly required. Opioid monotherapy is preferred, with phenobarbital or clonidine uncommonly needed as adjunctive therapy. Rooming-in and breastfeeding may decease the severity of withdrawal. Limited evidence is available regarding long-term effects of perinatal opioid exposure.

Molecular mechanism of type I collagen homotrimer resistance to mammalian collagenases.

Type I collagen cleavage is crucial for tissue remodeling, but its homotrimeric isoform is resistant to all collagenases. The homotrimers occur in fetal tissues, fibrosis, and cancer, where their collagenase resistance may play an important physiological role. To understand the mechanism of this resistance, we studied interactions of alpha1(I)(3) homotrimers and normal alpha1(I)(2)alpha2(I) heterotrimers with fibroblast collagenase (MMP-1). Similar MMP-1 binding to the two isoforms and similar cleavage efficiency of unwound alpha1(I) and alpha2(I) chains suggested increased stability and less efficient unwinding of the homotrimer triple helix at the collagenase cleavage site. The unwinding, necessary for placing individual chains inside the catalytic cleft of the enzyme, was the rate-limiting cleavage step for both collagen isoforms. Comparative analysis of the homo- and heterotrimer cleavage kinetics revealed that MMP-1 binding promotes stochastic helix unwinding, resolving the controversy between different models of collagenase action.