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These NCCN Guidelines for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. All patients experience some level of distress associated with a cancer diagnosis and the effects of the disease and its treatment regardless of the stage of disease. Clinically significant levels of distress occur in a subset of patients, and identification and treatment of distress are of utmost importance. The NCCN Distress Management Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights describe updates to the NCCN Distress Thermometer (DT) and Problem List, and to the treatment algorithms for patients with trauma- and stressor-related disorders.

Therapeutics to reduce intracranial pressure are an unmet need. Preclinical data have demonstrated a novel strategy to lower intracranial pressure using glucagon-like peptide-1 (GLP-1) receptor signalling. Here, we translate these findings into patients by conducting a randomized, placebo-controlled, double-blind trial to assess the effect of exenatide, a GLP-1 receptor agonist, on intracranial pressure in idiopathic intracranial hypertension. Telemetric intracranial pressure catheters enabled long-term intracranial pressure monitoring. The trial enrolled adult women with active idiopathic intracranial hypertension (intracranial pressure >25 cmCSF and papilloedema) who receive subcutaneous exenatide or placebo. The three primary outcome measures were intracranial pressure at 2.5 h, 24 h and 12 weeks and alpha set a priori at less than 0.1. Among the 16 women recruited, 15 completed the study (mean age 28 ± 9, body mass index 38.1 ± 6.2 kg/m2, intracranial pressure 30.6 ± 5.1 cmCSF). Exenatide significantly and meaningfully lowered intracranial pressure at 2.5 h −5.7 ± 2.9 cmCSF (P = 0.048); 24 h −6.4 ± 2.9 cmCSF (P = 0.030); and 12 weeks −5.6 ± 3.0 cmCSF (P = 0.058). No serious safety signals were noted. These data provide confidence to proceed to a phase 3 trial in idiopathic intracranial hypertension and highlight the potential to utilize GLP-1 receptor agonist in other conditions characterized by raised intracranial pressure.

To derive and initially validate a brief bedside clinical decision support tool that identifies emergency department patients at high risk of substantial, persistent posttraumatic stress symptoms after a motor vehicle collision.Derivation (n=1,282, 19 ED sites) and validation (n=282, 11 separate ED sites) data were obtained from adults prospectively enrolled in the Advancing Understanding of RecOvery afteR traumA study who were discharged from the ED after motor vehicle collision-related trauma. The primary outcome was substantial posttraumatic stress symptoms at 3 months (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 ≥38). Logistic regression derivation models were evaluated for discriminative ability using the area under the curve and the accuracy of predicted risk probabilities (Brier score). Candidate posttraumatic stress predictors assessed in these models (n=265) spanned a range of sociodemographic, baseline health, peritraumatic, and mechanistic domains. The final model selection was based on performance and ease of administration.Significant 3-month posttraumatic stress symptoms were common in the derivation (27%) and validation (26%) cohort. The area under the curve and Brier score of the final 8-question tool were 0.82 and 0.14 in the derivation cohort and 0.76 and 0.17 in the validation cohort.This simple 8-question tool demonstrates promise to risk-stratify individuals with substantial posttraumatic stress symptoms who are discharged to home after a motor vehicle collision. Both external validation of this instrument, and work to further develop more accurate tools, are needed. Such tools might benefit public health by enabling the conduct of preventive intervention trials and assisting the growing number of EDs that provide services to trauma survivors aimed at promoting psychological recovery.

Family caregivers frequently use health and social services to support their caregiving. In evaluating care-giving interventions, however, researchers rarely examine the influences of such concurrent services on intervention effectiveness. In this Part 2 secondary analysis of data from the Oregon Health & Science University/Kaiser Permanente Northwest Region Family Care Study, we examined the moderating influences of concurrent services on intervention effectiveness. The Family Care Study was a randomized controlled trial to evaluate the preparedness, skill, enrichment, and predictability (PREP) intervention with caregivers of frail older adults referred for skilled home health. Compared with control caregivers receiving usual home health care ( n = 103), PREP intervention caregivers ( n = 104) reported greater improvements in family care (effect size, d = 0.58). We conducted follow-up analyses to determine whether PREP was differentially effective depending on whether dyads received concurrent Social Health Maintenance Organization (SHMO) services, concurrent hospice services, or neither. In the 55% of dyads not receiving SHMO or hospice, we found that PREP's effects were large compared to usual care ( d = 1.16, p < 0.001). PREP's effects were not significant for dyads receiving concurrent SHMO or hospice services. Results highlight the strong benefits of hospice for control dyads, but reveal difficulties in evaluating intervention effectiveness when dyads receive concurrent services. [ Research in Gerontological Nursing, 16 (2), 71–83.]

There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.

We assessed the frequency of emergency department (ED) HIV and hepatitis C (HCV) screening in a high-risk cohort of ED patients with untreated opioid use disorder (OUD).This analysis used data from a prospective, observational study of English-speaking adults with untreated OUD enrolled from April 2017 to December 2018 in 4 urban, academic EDs. Two cohorts were defined for this analysis by self-reported negative/unknown status for HIV (cohort 1) and HCV (cohort 2). Sites featured structured screening programs throughout the entire enrollment period for HIV and during at least part of the enrollment period for HCV. We calculated the proportion tested for HIV and HCV during the study enrollment ED visit.Among 394 evaluated ED patients, 328 of 394 (83.2%) were not tested for HIV or HCV and 244 of 393 (62.1%) lacked a usual medical care provider. In cohort 1, 375 reported negative or unknown HIV status; 59/375 (15.7%) overall and 33/218 (15.1%) of those reporting recent injection drug use were tested for HIV. In cohort 2, 231 reported negative of unknown HCV status; 22/231 (9.5%) overall and 9/98 (9.2%) of those reporting recent injection drug use were tested for HCV. The proportion tested by the ED ranged from 3% to 25% for HIV and 4% to 32% for HCV across study sites.Emergency department HIV and HCV screening remains infrequent among patients with untreated OUD, including those who inject drugs, even in EDs committed to screening. Targeted HIV/HCV screening should be considered as an adjunct strategy until the ideal of universal screening is more fully achieved.

Background and Objective Care partners of people living with dementia require support to knowledgeably navigate decision making about how and when to use monitoring technologies for care purposes. We conducted a pilot study of a novel self-administered intervention, “Let’s Talk Tech,” for people living with mild dementia and their care partners. This paper presents preliminary efficacy findings of this intervention designed to educate and facilitate dyadic communication about a range of technologies used in dementia care and to document the preferences of the person living with dementia. It is the first-of-its-kind decision-making and planning tool with a specific focus on technology use. Research Design and Methods We used a 1-group pretest–post-test design and paired t tests to assess change over 2 time periods in measures of technology comprehension, care partner knowledge of the participant living with mild Alzheimer’s disease’s (AD) preferences, care partner preparedness to make decisions about technology use, and mutual understanding. Thematic analysis was conducted on postintervention interview transcripts to elucidate mechanisms and experiences with Let’s Talk Tech. Results Twenty-nine mild AD dementia care dyads who live together completed the study. There was statistically significant improvement with medium and large effect sizes on outcome measures of care partners’ understanding of each technology, care partners’ perceptions of the person living with dementia’s understanding of each technology, knowledge of the person living with dementia’s preferences, decision-making preparedness, and care partners’ feelings of mutual understanding. Participants reported that it helped them have important and meaningful conversations about using technology. Discussion and Implications Let’s Talk Tech demonstrated promising preliminary efficacy on targeted measures that can lead to informed, shared decision making about technologies used in dementia care. Future studies should assess efficacy with larger samples and more diverse sample populations in terms of race, ethnicity, and dementia type.

Objectives: Emergency departments (EDs) could play an important role in the COVID-19 pandemic response by reaching patients who would otherwise not seek vaccination in the community. Prior to expanding COVID-19 vaccination to the acute care setting, we assessed ED patients’ COVID-19 vaccine status, perspectives, and hypothetical receptivity to ED-based vaccination. Methods: From January 11 through March 31, 2021, we conducted a multisite (Albany Medical Center, Boston Medical Center, Buffalo General Hospital, University of Cincinnati Medical Center, and Upstate Medical Center), cross-sectional survey of ED patients, with embedded randomization for participants to receive 1 of 4 vignette vaccination messages (simple opt-in message, recommendation by the hospital, community-oriented message, and acknowledgment of vaccine hesitancy). Main outcomes included COVID-19 vaccination status, prior intention to be vaccinated, and receptivity to randomized hypothetical vignette messages. Results: Of 610 participants, 122 (20.0%) were vaccinated, 234 (38.4%) had prior intent to be vaccinated, 111 (18.2%) were unsure as to prior intent, and 143 (23.4%) had no prior intent to be vaccinated. Vaccine hesitancy (participants who were vaccine unsure or did not intend to receive the vaccine) was associated with the following: age Conclusions: EDs have appropriate patient populations to initiate COVID-19 vaccination programs as a supplement to community efforts. A simple opt-in approach may offer the best messaging to reach vaccine-hesitant ED patients.

The United States has the highest perinatal morbidity and mortality (MM) rates among all high-resource countries in the world. Birth settings (birth center, home, or hospital) influence clinical outcomes, experience of care, and health care costs. Increasing use of low-intervention birth settings can reduce perinatal MM. This integrative review evaluated factors influencing birth setting decision making among women and birthing people in the United States.A search strategy was implemented within the CINAHL, PubMed, PsycInfo, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the review, and the Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate methodological quality and appraisal of the evidence. The Whittemore and Knafl integrative review framework informed the extraction and analysis of the data and generation of findings.We identified 23 articles that met inclusion criteria. Four analytical themes were generated that described factors that influence birth setting decision making in the United States: "Birth Setting Safety vs. Risk," "Influence of Media, Family, and Friends on Birth Setting Awareness," "Presence or Absence of Choice and Control," and "Access to Options."Supporting women and birthing people to make informed decisions by providing information about birth setting options and variations in models of care by birth setting is a critical patient-centered strategy to ensure equitable access to low-intervention birth settings. Policies that expand affordable health insurance to cover midwifery care in all birth settings are needed to enable people to make informed choices about birth location that align with their values, individual pregnancy characteristics, and preferences.

A cancer diagnosis carries a significant economic burden. Yet little is known about perceived financial security on the health of couples with a partner diagnosed with cancer.The current study explored perceived financial security in young-midlife couples.The study included 49 couples (aged 27-58 years) 1 to 3 years after diagnosis. Multilevel modeling was used to examine the association of perceived financial security on physical and mental health of couples controlling for interdependent data; hierarchical linear regression was used to examine perceived financial security on survivor symptoms and partner care strain.Mean age of survivors was 43.5 (±9.0) years. Most survivors were female (69%) and 2.2 (±0.6) years after diagnosis. Lower levels of perceived financial security were significantly associated with poorer physical (P.001) and mental (P.05) health status for survivors, controlling for age, sex, education, and years since diagnosis; there were no significant associations with partner health status. Lower levels of perceived financial security were significantly associated with higher survivor pain severity (P.001), pain interference (P.001), and fatigue (P.01); there was no significant association with partner care strain.Financial security plays a role on the physical and mental health of couples after diagnosis.Screening for financial hardship at diagnosis and posttreatment can identify couples at high risk and in need of additional resources and counseling. Greater assessment and reporting of financial security in studies of families surviving cancer are needed to understand the impact on health outcomes.

The “entrepreneurial ecosystem” has become the dominant metaphor in theories explaining how location-specific forces influence entrepreneurship. Despite the progress made by scholars studying entrepreneurial ecosystems, in this essay we contend that the ecosystem metaphor has created an implicit tendency in entrepreneurship theory to emphasize macro-, ecosystem-level dynamics rather than the causal and mediating mechanisms linking entrepreneurs and their local ecosystems. To accompany the macro-dynamics focus in entrepreneurial ecosystem theory, we call for a micro-foundations approach that emphasizes the bidirectional connections between entrepreneurs’ strategizing and organizing activities and their ecosystems. We offer an agenda of theory development opportunities at the intersection of strategic organization and entrepreneurial ecosystems.

Background There are more than 1 million hospital admissions and 3 million emergency visits for heart failure in the USA annually. Although spouse/partners make substantial contributions to the management of heart failure and experience poor health and high levels of care strain, they are rarely the focus of heart failure interventions. This protocol describes a pilot randomized controlled trial that tests the feasibility, acceptability, and preliminary change in outcomes of a seven-session couple-based intervention called Taking Care of Us© (TCU). The TCU© intervention is grounded in the theory of dyadic illness management and was developed to promote collaborative illness management and better physical and mental health of adults with heart failure and their partners. Methods A two-arm randomized controlled trial will be conducted. Eligible adults with heart failure and their co-residing spouse/partner will be recruited from a clinical site in the USA and community/social media outreach and randomized to either the TCU© intervention or to a control condition (SUPPORT©) that offers education around heart failure management. The target sample is 60 couples (30 per arm). TCU© couples will receive seven sessions over 2 months via Zoom; SUPPORT© couples will receive three sessions over 2 months via Zoom. All participants will complete self-report measures at baseline (T1), post-treatment (T2), and 3 months post-treatment (T3). Acceptability and feasibility of the intervention will be examined using both closed-ended and open-ended questions as well as enrollment, retention, completion, and satisfaction metrics. Preliminary exploration of change in outcomes of TCU© on dyadic health, dyadic appraisal, and collaborative management will also be conducted. Discussion Theoretically driven, evidence-based dyadic interventions are needed to optimize the health of both members of the couple living with heart failure. Results from this study will provide important information about recruitment and retention and benefits and drawbacks of the TCU© program to directly inform any needed refinements of the program and decision to move to a main trial. Trial registration ClinicalTrials.gov (NCT04737759) registered on 27 January 2021.

Objective Emergency departments (EDs) are highly valued settings for HIV screening. Most large-volume ED HIV screening programs have attenuated operational barriers by screening only ED patients who already have a blood sample available for other clinical reasons. Our objective was to estimate the proportion of HIV positive patients who are missed when an ED excludes patients for whom HIV screening would be the only indication to obtain a blood sample. Methods This cross-sectional analysis used existing electronic records of patients seen between 2017 and 2019 by an urban, academic ED and its HIV screening program, which includes patients regardless of whether they receive other ED blood testing. The primary outcome was the proportion of patients tested by the screening program who were newly diagnosed with HIV (Sample 1) for whom HIV screening would be the only indication for venipuncture. We secondarily 1) estimate the proportion of ED patients who received venipuncture using a representative sample of consecutively approached participants which prospectively recorded whether patients had blood obtained or intravenous catheter placement during usual ED care (Sample 2) and 2) report patient characteristics including HIV risk factors for those with and without ED venipuncture for both groups. Results Of 41 persons newly diagnosed with HIV by the ED screening program (Sample 1), 13 (31.7%, 95%CI 18.6–48.2) did not undergo venipuncture for any reason other than their HIV test. The proportion of ED visits without a venipuncture (Sample 2) was 44.2% (95% CI 41.9–46.6). Patient characteristics were similar for both groups. Conclusions Screening only those patients with a blood sample already available or easily obtainable due to usual ED care, misses many opportunities for earlier HIV diagnosis. Innovation in research, policy, and practice is needed to overcome still unaddressed barriers to ED HIV screening when HIV screening is the only indication for collection of a biological sample.

Background Multiple lumbar punctures have historically been a strategy to relieve headaches associated with idiopathic intracranial hypertension despite limited clinical evidence of long-term efficacy. Lumbar puncture is typically a straightforward procedure with minimal complications reported, however, serious complications can occur. Lumbar-puncture-related spinal hematomas are rare but can lead to irreversible paralysis. Case presentation We report a case of a 28-year-old Caucasian woman who was treated with multiple lumbar punctures to manage headache, thought to be attributed to idiopathic intracranial hypertension. The patient developed a lumbosacral epidural hematoma following a lumbar puncture, which led to incomplete cauda equina syndrome. Multiple lumbar punctures had been the long-term management for the patient’s chronic headaches associated with her diagnosis of idiopathic intracranial hypertension. She had no risks of an underlying coagulopathy. Following a lumbar puncture, she re-presented with lower back pain and bilateral paresthesia. Over the subsequent 48 hours, this progressed to urinary incontinence and saddle paresthesia. Imaging revealed an epidural hematoma, which was conservatively managed. She continued to report saddle paresthesia and urinary incontinence 7 months following the lumbar puncture. Between 1974 to 2022, our literature search found 41 case reports detailing lumbar-puncture-related spinal hematomas. It is an established but rare complication of lumbar puncture and there are limited studies looking at the incidence of its occurrence. Whilst coagulopathy has been found to be a risk factor, it is unclear if the gauge of the needle is relevant. Case evidence suggests there may be no significant difference in outcomes between surgical and conservative management of spinal hematomas. This case highlights that lumbar punctures can be invasive, with potentially serious complications. A lumbar puncture should therefore only be performed when clinically justified. Conclusions This case highlights a rare complication of lumbar puncture and emphasizes the importance of a risk–benefit discussion for each procedure. Spinal hematoma following lumbar puncture is a rare complication but with potentially devastating consequences. Within the setting of idiopathic intracranial hypertension, the evidence base for the long-term benefit of headache relief by repeat lumbar puncture is low.

Purpose Due to stay-at-home orders during COVID-19, we transitioned supervised, group, in-person resistance training interventions in two clinical trials in cancer survivors to live, online delivery using video-conferencing technology. We describe the feasibility, preliminary efficacy, and safety of live online group training and compare to in-person training. Methods Adherence (% sessions attended), retention (% participants completing intervention), and safety (# adverse events) data of resistance training groups from two randomized controlled trials in cancer survivors that participated before or during the COVID-19 pandemic were collated. Participants were post-treatment breast cancer survivors and their spouses (n = 62) and prostate cancer survivors (n = 32) (age range: 38-82 years). During COVID-19, delivery of supervised, group resistance exercise sessions was delivered live online via video-conference. Preliminary evidence for training efficacy was assessed by chair stand performance over the 6-month intervention. Results Feasibility of online resistance training was better than in-person for both studies (adherence: 86% vs 82% and 91% vs. 81% and retention 95% vs. 80% and 92% vs. 84% for online and in-person classes). Improvements in chair stand time were similar in prostate cancer and spouse groups that trained online vs. in-person, except for breast cancer survivors who improved more with in-person training (7% vs. 14% for online vs. in-person). Safety was similar between formats (12 vs. 11 adverse events for online vs. in-person). Conclusion Supervised, in-person group resistance training can be feasibly adapted for live, online delivery and could help broaden approaches to exercise delivery in cancer survivors, including older adults. Trial registration The studies described in this commentary were registered on ClinicalTrials.gov on August 3, 2018 (NCT03630354) and on October 30, 2018 (NCT03741335).

We evaluated children's cardiometabolic health (CMH) risk indicators and adverse childhood experiences (ACEs) stratified by family structure type (grandparent-headed, two-parent headed, and single-parent headed households). Separately, we assessed whether family structure type and number of ACEs were independently associated with the CMH risk indicators.Utilizing data from the 2017-2018 National Survey of Children's Health, we evaluated five CMH risk indicators (obesity, physical activity, secondhand smoke exposure, sleep, and sports participation). We used multivariable logistic regressions to assess the association of CMH risk indicators with family structure type and ACEs. We controlled for sex, age, race/ethnicity, health insurance, household poverty level, and overall health status.Among children aged 10-17 years (n = 24,885), we found the number of ACEs differed by family structure type (P 0.001) and was independently associated with obesity, secondhand smoke exposure, sleep, and sports participation. Adjusting for all covariates except ACEs, family structure type was significantly associated with children's CMH risk; but after controlling for ACEs that association was attenuated - except for sleep (less adequate sleep in grandparent-headed households) and exposure to secondhand smoke (less exposure in single-parent headed households).ACEs were highest among children living in grandparent-headed households and independently associated with a majority of the CMH risk indicators. Findings suggest that children living in grandparent-headed households may be at elevated risk for poor CMH, potentially due to higher risk for ACEs.It is recommended to consider ACEs and family structure type when assessing CMH risk in children.

OBJECTIVE: Major negative life events, such as trauma exposure, can play a key role in igniting or exacerbating psychopathology. However, few disorders are diagnosed with respect to precipitating events, and the role of these events in the unfolding of new psychopathology is not well understood. The authors conducted a multisite transdiagnostic longitudinal study of trauma exposure and related mental health outcomes to identify neurobiological predictors of risk, resilience, and different symptom presentations. METHODS: A total of 146 participants (discovery cohort: N = 69; internal replication cohort: N = 77) were recruited from emergency departments within 72 hours of a trauma and followed for the next 6 months with a survey, MRI, and physiological assessments. RESULTS: Task-based functional MRI 2 weeks after a motor vehicle collision identified four clusters of individuals based on profiles of neural activity reflecting threat reactivity, reward reactivity, and inhibitory engagement. Three clusters were replicated in an independent sample with a variety of trauma types. The clusters showed different longitudinal patterns of posttrauma symptoms. CONCLUSIONS: These findings provide a novel characterization of heterogeneous stress responses shortly after trauma exposure, identifying potential neuroimaging-based biotypes of trauma resilience and psychopathology.

The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, “nurses influence ED pain management” and “adjustments in ED pain management”, and an overarching message that “pain management depends on the care team.” By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.

Objective Pre-exposure prophylaxis (PrEP) is a highly effective but underutilized method of HIV prevention. Emergency departments (EDs) have access to at-risk populations meeting CDC eligibility criteria for PrEP. Characterizing this population could help motivate, develop, and implement ED interventions to promote PrEP uptake. Methods This cross-sectional study explored the proportion of patients from an urban, academic ED who met CDC 2017 PrEP eligibility criteria using three existing datasets that mimic patient selection strategies for HIV screening: 1) study of consecutively approached ED patients from 2008 to 2009 (analogous to non-targeted screening), 2) patients of the ED's HIV screening program in 2017 (analogous to risk-targeted screening), and 3) electronic health record (EHR) diagnostic codes in 2017 (analogous to EHR selected screening). The primary outcome was the proportion eligible for PrEP referral. Secondary outcomes included proportion by risk group: men who have sex with men (MSM), heterosexual men and women (HMW), and persons who inject drugs (PWID). Results The proportion eligible for PrEP was: 568/1970 (28.8%, 95% CI: 26.9–30.9) for consecutively approached patients, 552/3884 (14%, 95% CI: 13–15) for risk-targeted patients, and 605/66287 (0.9%, 95% CI: 0.8–1.0) for EHR diagnoses of all patients. For the two datasets with behavioral risk information, the proportion eligible was: MSM 1–2%, HMW 12–28%, and PWID 1–4%. Conclusions A large subgroup of this ED population was eligible for PrEP referral. EDs are a compelling setting for development and implementation of HIV prevention interventions to assist in national efforts to expand PrEP.

Expanding the global protected area network is critical for addressing biodiversity declines and the climate crisis. However, how climate change will affect ecosystem representation within the protected area network remains unclear. Here we use spatial climate analogs to examine potential climate-driven shifts in terrestrial ecoregions and biomes under a +2 °C warming scenario and associated implications for achieving 30% area-based protection targets. We find that roughly half of land area will experience climate conditions that correspond with different ecoregions and nearly a quarter will experience climates from a different biome. Of the area projected to remain climatically stable, 46% is currently intact (low human modification). The area required to achieve protection targets in 87% of ecoregions exceeds the area that is intact, not protected, and projected to remain climatically stable within those ecoregions. Therefore, we propose that prioritization schemes will need to explicitly consider climate-driven changes in patterns of biodiversity. Preservation of biodiversity by expanding protected areas is complicated by expected climate change that could dissociate ecoregion or biome from climate conditions in over half of land area, according to analyses of spatial climate analogs

Acinetobacter baumannii is a Gram-negative opportunistic pathogen that causes nosocomial infections, especially among immunocompromised individuals. The rise of multidrug resistant strains of A. baumannii has limited the use of standard antibiotics, highlighting a need for new drugs that exploit novel mechanisms of pathogenicity. Disrupting iron acquisition by inhibiting the biosynthesis of iron-chelating molecules (siderophores) secreted by the pathogen is a potential strategy for developing new antibiotics. Here we investigated FbsI, an N-hydroxylating monooxygenase involved in the biosynthesis of fimsbactin A, the major siderophore produced by A. baumannii. FbsI was characterized using steady-state and transient-state kinetics, spectroscopy, X-ray crystallography, and small-angle X-ray scattering. FbsI was found to catalyze the N-hydroxylation of the aliphatic diamines putrescine and cadaverine. Maximum coupling of the reductive and oxidative half-reactions occurs with putrescine, suggesting it is the preferred (in vivo) substrate. FbsI uses both NADPH and NADH as the reducing cofactor with a slight preference for NADPH. The crystal structure of FbsI complexed with NADP+was determined at 2.2 Å resolution. The structure exhibits the protein fold characteristic of Class B flavin-dependent monooxygenases. FbsI is most similar in 3D structure to the cadaverine N-hydroxylases DesB and DfoA. Small-angle X-ray scattering shows that FbsI forms a tetramer in solution like the N-hydroxylating monooxygenases of the SidA/IucD/PvdA family. A model of putrescine docked into the active site provides insight into substrate recognition. A mechanism for the catalytic cycle is proposed where dehydration of the C4a-hydroxyflavin intermediate is partially rate-limiting, and the hydroxylated putrescine product is released before NADP+ Accepted version

IntroductionOpioid-involved overdose deaths continue to surge in many communities, despite numerous evidence-based practices (EBPs) that exist to prevent them. The HEALing Communities Study (HCS) was launched to develop and test an intervention (ie, Communities That HEAL (CTH)) that supports communities in expanding uptake of EBPs to reduce opioid-involved overdose deaths. This paper describes a protocol for a process foundational to the CTH intervention through which community coalitions select strategies to implement EBPs locally.Methods and analysisThe CTH is being implemented in 67 communities (randomised to receive the intervention) in four states in partnership with coalitions (one per community). Coalitions must select at least five strategies, including one to implement each of the following EBPs: (a) overdose education and naloxone distribution; expanded (b) access to medications for opioid use disorder (MOUD), (c) linkage to MOUD, (d) retention in MOUD and (e) safer opioid prescribing/dispensing. Facilitated by decision aid tools, the community action planning process includes (1) data-driven goal setting, (2) discussion and prioritisation of EBP strategies, (3) selection of EBP strategies and (4) identification of next steps. Following review of epidemiologic data and information on existing local services, coalitions set goals and discuss, score and/or rank EBP strategies based on feasibility, appropriateness within the community context and potential impact on reducing opioid-involved overdose deaths with a focus on three key sectors (healthcare, behavioural health and criminal justice) and high-risk/vulnerable populations. Coalitions then select EBP strategies through consensus or majority vote and, subsequently, suggest or choose agencies with which to partner for implementation.Ethics and disseminationThe HCS protocol was approved by a central Institutional Review Board (Advarra). Results of the action planning process will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders.Trial registration numberNCT04111939.

The authors quantified the impact of the use of telehealth services on patient-level clinical outcomes among children with complex behavioral and emotional needs in Idaho during the COVID-19 pandemic by comparing data collected in 2020 with data for the same months in 2019.Longitudinal statewide data of Child and Adolescent Needs and Strengths (CANS) assessments were extracted from Idaho's mental and behavioral health system. Prepandemic assessments were matched to midpandemic assessments. A linear mixed-effect model was used to explore four child-level outcomes: psychosocial strengths-building rate, rate of need resolution within a life-functioning domain, rate of need resolution within a behavior-emotional domain, and rate of need resolution within a high-risk behaviors domain.The number of new patients admitted to Idaho's state-funded mental and behavioral health program decreased almost twofold from April-December 2019 to April-December 2020 (N=4,458 vs. 2,794). For most children with complex needs, the use of telehealth was as effective in terms of strengths building and needs resolution as in-person services; for children whose caregivers had issues with access to transportation, availability of telehealth services improved outcomes for the children.The COVID-19 pandemic in 2020 was associated with a dramatic drop in the number of children served by Idaho's mental health program. Telehealth may effectively bridge mental health service delivery while patients and providers work toward the resolution of transportation issues or may serve as a more acceptable permanent format of service delivery for some populations.

Background: There are more than 1 million hospital admissions and 3 million emergency visits for heart failure in the U.S. annually. Although spouse/partners make substantial contributions to the management of heart failure and experience poor health and high levels of care strain, they are rarely the focus of heart failure interventions. This protocol describes a pilot randomized controlled trial that tests the feasibility, acceptability, and preliminary efficacy of a seven-session couple-based intervention called Taking Care of Us (TCU). The TCU intervention is grounded in the Theory of Dyadic Illness Management and was developed to promote collaborative illness management and better physical and mental health of adults with heart failure and their partners.Methods: A two-arm randomized controlled trial will be conducted. Eligible adults with heart failure and their co-residing spouse/partner will be recruited from a clinical site in the USA and community/social media outreach and randomized to either the TCU intervention or to a control condition (SUPPORT) that offers education around heart failure management. The target sample is 72 couples (36 per arm). TCU couples will receive seven sessions over two months via Zoom; SUPPORT couples will receive three sessions over two months via Zoom. All participants will complete self-report measures at baseline (T1), post-treatment (T2), and 3 months post-treatment (T3). Acceptability and feasibility of the intervention will be examined using both closed-ended and open-ended questions as well as enrollment and retention metrics. Preliminary efficacy of TCU on dyadic health, dyadic appraisal, and collaborative management will be examined using standardized measures.Discussion: Theoretically-driven, evidence-based dyadic interventions are needed to optimize the health of both members of the couple living with heart failure. Results from this study will provide important information about recruitment and retention and benefits and drawbacks of the TCU program to directly inform a large-scale grant application to test the impact of the TCU program in a fully powered sample.Trial registration: ClinicalTrials.gov (NCT04737759) registered on 27 January 2021.

PurposeThe purpose of this paper is to argue that defining, measuring and developing skills are crucial to successful entrepreneurship and that being able to do so can help to build strong rural entrepreneurial ecosystems.Design/methodology/approachThe literature on entrepreneurship success and entrepreneurial skills is reviewed, and this knowledge is used to create and describe the Entrepreneurship Skill-building Framework (ESBF), which provides a scaffold for thinking about the identification, measurement and development of essential entrepreneurship skills. The same literature is used to develop a tool for effectuating the ESBF, called the Readiness Inventory for Successful Entrepreneurship (RISE), which assesses entrepreneurship skills using the communimetrics theory of measurement.FindingsBoth the ESBF and the RISE are detailed, and they are applied to the successful development and maintenance of rural entrepreneurial ecosystems, with an example from practice. Specific implications for rural entrepreneurship-focused economic development are also discussed.Originality/valueThe ESBF represents a new way of framing entrepreneurship skills and their development. The RISE is a skills assessment tool that is clinical, not predictive, utilizing an innovative theory of measurement. Together, they offer a fresh approach to thinking about the purpose and effective implementation of entrepreneurial ecosystems.

Nationally, opioid overdose remains strikingly persistent among people experiencing homelessness and housing instability. Limited information is available about the characteristics of this phenomenon in economically disadvantaged communities of color. This study sought to evaluate the association between key contextual factors and experiencing a non-fatal opioid overdose among people who use heroin in Washington Heights, New York City. We conducted a cross-sectional survey (N = 101) among participants seeking harm reduction services who reported heroin use in the last three months. Binary logistic regression models examined the association between key social and structural factors and the likelihood of ever experiencing a non-fatal opioid overdose and recently experiencing a non-fatal opioid overdose. The majority of the sample reported housing instability and lived in poverty; almost 42% were homeless. After adjustment, participants who injected heroin were more likely to have ever experienced a non-fatal opioid overdose. Also, younger participants who reported hunger in the last six months were more likely to have experienced a non-fatal opioid overdose in the last three months. Findings suggest the role of structural vulnerability in shaping overdose risk among the participants. Overdose prevention strategies should consider factors of the social and economic environment to mitigate barriers to accessing health and social services within the context of the current opioid crisis.

As dyadic health science enters a golden age, important conceptual, theoretical, and technical challenges remain. This forum review brings together perspectives on the burgeoning dyadic literature from several subdisciplines within aging research. We first define key concepts and terms so that interested researchers can navigate the complex and various ways in which dyadic health research is conducted. We discuss exciting scientific advances and close by identifying crucial challenges and considerations that coincide with important future directions for the field.

Background Reproductive and sexual health (RSH) concerns are common and distressing for young adults diagnosed with breast and gynecologic cancer and their partners. This study evaluates the efficacy of a virtual couple-based intervention called Opening the Conversation (OC). The OC intervention is grounded in theory and evidence-based practice and was adapted to improve coping and communication specifically in relation to RSH concerns after cancer. Methods This Phase III trial is conducted in a fully remote setting and enrolls young adult couples (current age 18–44 years) with a history of breast or gynecologic cancer (stage 1–4, diagnosed under age 40) within the past 6 months to 5 years. Eligible dyads are recruited from across the USA. The target sample size is 100 couples. Dyads are randomly assigned to receive either the 5-session OC intervention or a 4-session active control intervention (Side by Side). The primary outcomes are change in reproductive distress and sexual distress. Secondary outcomes include communication about reproductive concerns, communication about sexual concerns, depressive symptoms, sexual function, relationship quality, relationship intimacy, sexual satisfaction, self-efficacy to communicate about sex and intimacy, and quality of life. An exploratory aim examines whether dyadic coping and communication quality mediate intervention effects on survivors’ and partners’ reproductive distress or sexual distress. Self-report outcome measures are assessed for both groups at baseline (T1), 2 weeks post-treatment (T2), and 3 months post-treatment (T3). Discussion Despite the importance of RSH for quality of life for young adult cancer survivors and their partners, evidence-based interventions that help couples navigate RSH concerns are lacking. This randomized controlled trial will determine the efficacy of a novel couple-based intervention to reduce distress related to RSH concerns for younger couples after breast or gynecologic cancer, in comparison to an active control intervention. Trial registration ClinicalTrials.gov NCT04806724. Registered on Mar 19, 2021.

ObjectiveTo develop and test predictive models of admissions to a psychiatric residential treatment facility (PRTF) in transitional age youth using routinely collected health insurance claims and enrollment data.Data SourcesWe used outpatient service and pharmaceutical claims from Medicaid beneficiaries aged 6-to 21-years old in Kentucky for the years 2010-2017.Study DesignWe assessed over 1,250 predictors (derived from Medicaid claims data) prior to the first PRTF admission. An ensemble machine learning (ML) algorithm based on logistic regression models fitted to a random subsample of the original data was used to predict pathways to the first PRTF admission. Discrimination performance of the ML ensemble was evaluated by comparing predictions to actual outcomes and calculating area under the curve (AUC), accuracy, sensitivity, and specificity. Additionally, a multivariate logistic regression model was fit to investigate the contribution of the continuity of mental health care after the initial PRTF admission on the risk of readmission.Data Collection/Extraction MethodsWe identified N = 519,011 unique children and youth with at least one outpatient service or pharmaceutical claim during our study period (January 1, 2010 through December 31, 2017).Principal FindingsFewer than 0.5% of children and youth in Kentucky had an episode of PRTF admission. Despite a very low prevalence of PRTF admission, classification accuracy of the ML ensemble for identifying PRTF youth achieved over 90% accuracy (AUC = 0.96). Factors associated with the initial PRTF admission were having been prescribed anti-psychotic and anti-manic medications, and receiving outpatient psychiatric care. Within six months after the initial PRTF discharge, there was a surprising drop in service utilization with a large proportion of youth not appearing to receive any follow-up care.ConclusionsDespite the fact that admission into a PRTF was a relatively rare event, our findings suggest that it is a predictable event among youth with identified mental health conditions who are receiving care in the community.What is known on this topicAfter psychiatric hospitalization, PRTF treatment is the most expensive and restrictive intervention available to serve children and youth.Previous research examining predictors of PRTF entry using Medicaid reimbursement data showed that clinical factors were strong predictors of hospitalization.What this study addsWe provide a comprehensive analysis of the factors beyond clinical diagnoses that lead to PRTF entry.We also seek to identify whether any specific patterns of service and/or pharmacy claims utilization are associated with reducing the likelihood of readmission.

Among married couples living with breast and prostate cancer, positive perceptions of relationship quality by both survivors and their spouses were associated with lower inflammation or insulin resistance in their partner. Our data support evidence that health within couples is both interdependent and transactional and suggests that one member's perception of the relationship is associated with biologic changes in one's partner, leading to better physical health of the couple. These findings may provide a biologic underpinning to observations of an inverse relationship between relational satisfaction and overall mortality and underscore the need for a dyadic approach to health.Couples' health and health behaviors are intertwined, where the health of one partner can influence the health of the other but the biologic underpinnings are not known. We examined the associations between relational health and markers of inflammation and insulin resistance in couples coping with breast or prostate cancer.Participants (90 cancer survivor-spouse dyads) completed self-report measures of relational health including Dyadic Adjustment Scale-7 (relationship quality), Dyadic Coping Inventory (communication), and shared physical activity, as well as Community Health Activities Model Program for Seniors (individual physical activity). Inflammation (C-reactive protein (CRP)) and homeostasis model assessment of insulin resistance (HOMA-IR) were measured in serum samples. Structural equation modeling including demographic and clinical covariate controls was used to estimate separate actor and partner effects of relationship quality, communication, and physical activity on CRP and HOMA-IR.Participants were aged 63.1 ± 10.4 years with an average relationship duration of 30.0 ± 1.1 years. Higher survivor perceived relationship quality was associated with lower spouse CRP (b = - 0.07; 95%CI: - 0.13, - 0.01), whereas higher spouse perceived relationship quality was associated with lower survivor HOMA-IR (b = - 0.07; 95%CI: - 0.13, - 0.03). There were no other significant actor or partner effects observed.Among cancer survivor-spouse dyads, how one member of the couple perceives the quality of the relationship impacts disease biomarkers in the other, providing preliminary evidence for biological linkage between relational health and chronic disease risk.Relationship quality may positively influence biomarkers of inflammation and insulin resistance in couples coping with breast and prostate cancer. Dyadic approaches to optimize survivorship health may be warranted.ClinicalTrials.gov NCT03630354, 08/14/2018; Open Science Framework ( https://bit.ly/3S4rUtJ ).

ObjectiveThe objective of this study was to examine associations between level of depressive symptoms in older adult spouse/partner couples and their physical health and social factors (social activity and number of close friends).MethodsUsing data from 116 community-dwelling couples (age 76.2 ± 8.5), we simultaneously analyzed associations between depressive symptoms (Geriatric Depression Scale, range 0–11) and dyadic physical health, engagement in social activities, and connectedness with close friends.ResultsGreater engagement in social activities was associated with fewer depressive symptoms in men, whereas more close friendships were associated with fewer depressive symptoms in women, controlling for partner effects, age, education, and cognitive function, with good model fit. Additionally, more disparate physical health within the couple (latent incongruence score) was associated with greater depressive symptoms in men.DiscussionLess social activity and fewer close friends were associated with depressive symptoms in older adult couples, but may be distinctly influential depending on gender and in the context of the older adult couple's physical health.

To assess the level of chronic obstructive pulmonary disease (COPD)-related knowledge within patient and informal caregiver dyads, and to identify factors influencing the knowledge level considering the interdependence within the dyads.Patients with COPD and their informal caregivers present poor disease knowledge and different characteristics are associated with their level of knowledge. Disease knowledge and related characteristics have been assessed separately in patients and informal caregivers, without considering possible influence within the dyads.Cross-sectional study.A convenience sample of dyads was recruited in outpatient and inpatient settings in Central and South Italy. The Bristol COPD Knowledge Questionnaire was used to measure disease knowledge. Sociodemographic, clinical and caregiving characteristics, self-efficacy and depression were measured in patients and caregivers. Multilevel modelling was used to analyse COPD knowledge at the level of the dyad to control for interdependency between patients and informal caregivers. The STROBE guidelines for cross-sectional studies were followed for study reporting.We recruited 133 dyads. The total level of correct knowledge shared by dyads was 32.89%. Dyads presented higher levels of correct knowledge about disease symptoms, smoking cessation and vaccination, and lower about COPD treatment. Younger patients with greater self-efficacy, who attended pulmonary rehabilitation and were cared for by a spouse/partner with low levels of depression, and informal caregivers who were patients' spouse/partner were more likely to have higher levels of disease-related knowledge.Our study advances dyadic research in COPD. Future studies should investigate the effects of shared knowledge and incongruent knowledge (where one member knows more than the other) on patient self-care and caregiver contribution to patient self-care.Our study shows what knowledge nurses should provide in educational programmes directed at patients and caregivers, and which dyads have greater knowledge deficits, to whom offer targeted educational interventions.

This article analyses the improvement of cotton-spinning technologies in the years after the great inventions of Hargreaves, Arkwright, and Crompton. While these ‘macro-inventions’ have attracted considerable historical attention, our understanding of the major changes in types and sizes of spinning machines used in the UK between the 1780s and the onset of state-collected factory statistics in the 1830s is still largely based on the experience of high-profile firms or specific technologies and regions. A new dataset of 1,465 machinery advertisements published in newspapers in England, Scotland, and Ireland between 1780 and 1835 allows us to examine the temporal and spatial dimensions of the market for cotton-spinning machinery, the timings of transitions between different spinning machines, and increases in machine size. The article demonstrates the importance of post-invention technical improvements in the cotton industry, showing that the productivity increases associated with the initial transition from hand to machine spinning have been overstated and that larger gains were made in the ‘micro-invention’ phase, when spinning machines became larger and faster, and required fewer workers to operate them.

Introduction The study objective was to assess tobacco screening and cessation counseling practices of pediatric emergency department (PED) and urgent care (UC) nurses and physicians, and factors associated with these practices. Secondarily, we assessed factors associated with performing tobacco smoke exposure reduction and tobacco cessation counseling. Methods We conducted a cross-sectional survey of 30 PED/UC nurses and physicians working at one large, urban, Midwestern children's hospital. Measures included current practices of performing the 5 As of tobacco counseling (Ask, Advise, Assess, Assist, Arrange), and attitude and practice factors that may influence practices. Results Overall, 90.0% of participants had not received recent tobacco counseling training, 73.3% were unaware of the 5 As, and 63.3% did not have a standardized, routine screening system to identify patients exposed to secondhand smoke. The majority of participants reported that they: asked about patients' secondhand smoke exposure status (70.0%) and parents' tobacco use status (53.3%), and advised parental smokers to not smoke around their child (70.0%) and to quit smoking (50%). One in five participants reported they assessed smokers' interest in quitting smoking, and 16.7% talked with smokers about cessation techniques and tactics; of these, 10% referred/enrolled smokers to the Tobacco Quitline or cessation program, and 6.7% made a quit plan or recommended nicotine replacement therapy medication. Conclusions Key findings identified are the need for professional tobacco counseling training, standardizing efforts during visits, and emphasizing pediatric patients' potential health benefits. This information will be used for developing a PED/ UC-based parental tobacco cessation and child tobacco smoke exposure reduction intervention.

Surveys, questionnaires, and assessments are the only approved means for measuring outcomes, yet there is a paucity of evidence that these tools can perform well as outcomes measures. A major barrier to utilizing these tools as measures of improvement in care is an inability to recognize when the responses are incomplete, inaccurate, or insincere. In this study, we propose a hybrid unsupervised-supervised approach to identify inauthentic assessments via anomalous response patterns. The study utilized 60-question behavioral assessment from a clinical population served by a county-operated public children’s behavioral health services (n = 42,945). A novel hybrid unsupervised-supervised approach was developed to identify inauthentic assessment records from highly dimensional assessment data without the need for a priori record labels, which would otherwise require countless hours of record review by highly trained clinical staff. A neural network trained with 75% of the labeled data recognized anomalous response patterns in the test data with 84.5% sensitivity and 97.3% specificity. The model identified 26% of records as potentially inauthentic based on anomalous response patterns. For mental health and behavioral health, this novel method could flag a relatively small proportion of the records for clinical review while allowing records with probable authenticity to bypass review processes, saving time and creating efficiency in care. This method is also a potential tool for improving service quality through the identification of circumstances that have been overlooked but could otherwise be addressed during care. For decades, assessment data has been collected by policy and ignored by practice due to limitations of utility. With the right approaches, we could uncover the patterns of what works for whom that are currently hidden in our existing assessments.

ImportanceEmergency department (ED)–initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.ObjectiveTo evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy.Design, Setting, and ParticipantsThis multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022.ExposureA 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback.Main Outcomes and MeasuresThe primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed.ResultsA total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P Conclusions and RelevanceIn this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine.Trial RegistrationClinicalTrials.gov Identifier: NCT03023930

Introduction Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician. Methods This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone. Results Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1–33.8). Naloxone provision occurred for 33.6% (95% CI 30.5–36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0–19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4–30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011–0.33]) for naloxone provision compared to those only referred to outpatient treatment. Conclusion A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment “bundle” as a conceptual model for care of ED patients with suspected OUD.

Chronic pain and prescription opioid use are prevalent among patients with end-stage kidney disease treated with hemodialysis. Vulnerabilities to complications from opioid use are high in this patient population, as shown in many recent, well-conducted, patient-oriented studies. Such studies have highlighted the need for a balanced approach to pain management in hemodialysis patients that includes careful assessment of the risks and benefits of opioid prescriptions in this population. In this article, we review the available literature and experience regarding opioid prescriptions among hemodialysis patients, discuss clinical implications, and outline ongoing research.

Multiple lumbar punctures have historically been a strategy to relieve headaches associated with idiopathic intracranial hypertension despite limited clinical evidence of long-term efficacy. Lumbar puncture is typically a straightforward procedure with minimal complications reported, however, serious complications can occur. Lumbar-puncture-related spinal hematomas are rare but can lead to irreversible paralysis.We report a case of a 28-year-old Caucasian woman who was treated with multiple lumbar punctures to manage headache, thought to be attributed to idiopathic intracranial hypertension. The patient developed a lumbosacral epidural hematoma following a lumbar puncture, which led to incomplete cauda equina syndrome. Multiple lumbar punctures had been the long-term management for the patient's chronic headaches associated with her diagnosis of idiopathic intracranial hypertension. She had no risks of an underlying coagulopathy. Following a lumbar puncture, she re-presented with lower back pain and bilateral paresthesia. Over the subsequent 48 hours, this progressed to urinary incontinence and saddle paresthesia. Imaging revealed an epidural hematoma, which was conservatively managed. She continued to report saddle paresthesia and urinary incontinence 7 months following the lumbar puncture. Between 1974 to 2022, our literature search found 41 case reports detailing lumbar-puncture-related spinal hematomas. It is an established but rare complication of lumbar puncture and there are limited studies looking at the incidence of its occurrence. Whilst coagulopathy has been found to be a risk factor, it is unclear if the gauge of the needle is relevant. Case evidence suggests there may be no significant difference in outcomes between surgical and conservative management of spinal hematomas. This case highlights that lumbar punctures can be invasive, with potentially serious complications. A lumbar puncture should therefore only be performed when clinically justified.This case highlights a rare complication of lumbar puncture and emphasizes the importance of a risk-benefit discussion for each procedure. Spinal hematoma following lumbar puncture is a rare complication but with potentially devastating consequences. Within the setting of idiopathic intracranial hypertension, the evidence base for the long-term benefit of headache relief by repeat lumbar puncture is low.