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Background: Lack of access to buprenorphine to treat Opioid Use Disorder is profound in rural areas where over half of small and remote rural counties have no buprenorphine prescriber. To increase prescribing, an online, Medication of Opioid Use Disorder (MOUD) Extensions for Community Healthcare Outcomes (ECHO) was developed that addressed known barriers to the startup and expansion of treatment. The objective of the present study was to determine the relationship between participating in MOUD ECHO sessions and prescribing of buprenorphine for OUD in rural primary care.Methods: Using non-random, rolling-recruitment from Feb 2018 to October of 2021, all rural primary care clinics in New Mexico were contacted via phone call and fax to recruit providers (Physicians, Nurse Practitioners, and Physician Assistants) who had no or limited buprenorphine experience to enroll in this study. Participation in the MOUD ECHO was tracked across the 12 week series. Start-up and expansion of buprenorphine treatment was measured every 3 months for up to 2 years using 5 implementation benchmarks spanning training completion, obtaining licensure, prescribing and adding patients. Using a dose-response intention to treat type analysis, associations between number of sessions and benchmark achievement were analyzed using logistic regression.Results: Eighty providers were enrolled, mostly female (66%) white (82%), non-Hispanic (82%), and mostly nurse practitioners (51%) or MDs (38%). Achievement of prescribing benchmarks at 6 months was significantly increased by attendance at MOUD ECHO sessions including obtaining training and licensure Odds Ratio (OR = 1.24; P= .001); starting to prescribe (OR = 1.31; P= .004), and adding patients (OR = 1.14; P= .025).Conclusions: This study provides compelling evidence that MOUD ECHO participation may significantly increase the number of providers implementing this treatment and adding patients onto their panels. The dose-response approach helps address current gaps in ECHO research that call for more rigorous examination of the ECHO model’s impact on provider practice improvements.

The objective of this retrospective study was to evaluate the impact of the RELiZORB immobilized lipase cartridge with overnight enteral nutrition (EN) on body mass index (BMI) or weight-for-length percentile, stool quality, and gastrointestinal (GI) symptoms in children with cystic fibrosis (CF) and pancreatic insufficiency. Frequency of diarrhea, steatorrhea, and malodorous stools significantly decreased at final visit compared with baseline (P= .008, P= .004, P= .031, respectively). Improved BMI or weight-for-length percentile was observed in 10 out of 16 participants; however, the change was not significant. RELiZORB use decreased frequency of most GI symptoms in pediatric patients with CF on EN.

AbstractBackground:Buprenorphine combined with psychosocial support is the standard of care for treatment of opioid use disorder (OUD) in office-based primary care settings. However, uptake of this treatment has been slow due to a number of addressable barriers including providers’ lack of training, staffing concerns, stigma and the need for ongoing support and consultation. This study examined acceptability and feasibility of an online Extensions for Community Healthcare Outcomes (ECHO) model intervention developed to support rural primary care clinics to expand treatment and is part of a larger study tracking the impact of participation in this ECHO on expansion of MOUD in rural primary care. Methods:We developed a comprehensive, 12-week online education and mentorship intervention using ECHO aimed at supporting the entire primary care clinic to start or expand treatment using MOUD, psychosocial treatments and recovery supports. We tracked participation and collected feedback using qualitative interviews and post-session questionnaires. Results:Sixty-seven primary care staff across 27 rural clinics in New Mexico participated in the study including 32 prescribers and 35 clinic support staff. Average participation was 4/12 sessions. Post-session questionnaires showed positive feedback, including that 95% or more respondents agreed or strongly agreed that the sessions were relevant and improved their confidence. Qualitative interview themes included strong endorsement of the ECHO curriculum. Clinical duties were the most common barrier to attending sessions. Conclusions:Engagement of 27 clinics, the range of staff and providers who participated, and positive feedback gathered through survey and qualitative interviews provide evidence of feasibility and acceptability of MOUD ECHO to support expansion of this treatment. However, barriers to participation present an important threat to feasibility. Understanding feasibility and acceptability is an important component of research on the impact of ECHO to expand MOUD treatment.

Background Buprenorphine combined with psychosocial support is the standard of care for treatment of opioid use disorder (OUD) in office-based primary care settings. However, uptake of this treatment has been slow due to a number of addressable barriers including providers’ lack of training, staffing concerns, stigma and the need for ongoing support and consultation. This study examined acceptability and feasibility of an online Extensions for Community Healthcare Outcomes (ECHO) model intervention developed to support rural primary care clinics to expand treatment and is part of a larger study tracking the impact of participation in this ECHO on expansion of MOUD in rural primary care.Methods We developed a comprehensive, 12-week online education and mentorship intervention using ECHO aimed at supporting the entire primary care clinic to start or expand treatment using MOUD, psychosocial treatments and recovery supports. We tracked participation and collected feedback using qualitative interviews and post-session questionnaires.Results Sixty-seven primary care staff across 27 rural clinics in New Mexico participated in the study including 32 prescribers and 35 clinic support staff. Average participation was 4/12 sessions. Post-session questionnaires showed positive feedback, including that 95% or more respondents agreed or strongly agreed that the sessions were relevant and improved their confidence. Qualitative interview themes included strong endorsement of the ECHO curriculum. Clinical duties were the most common barrier to attending sessions.Conclusions Engagement of 27 clinics, the range of staff and providers who participated, and positive feedback gathered through survey and qualitative interviews provide evidence of feasibility and acceptability of MOUD ECHO to support expansion of this treatment. However, barriers to participation present an important threat to feasibility. Understanding feasibility and acceptability is an important component of research on the impact of ECHO to expand MOUD treatment.

Delirium in hospitalized patients often goes undetected. Cerebral state monitors, which measure limited-channel electroencephalography, have shown potential for improving delirium detection.

Objective: National pathology guidelines recommend full pathologic analysis for all adult tonsillectomy specimens. We evaluated the available data on occult malignancy in adult tonsillectomy for benign indication, and created a screening system to reduce the risk of missed malignancies if routine histopathologic examination were to be discontinued.Study design: Retrospective chart review and systematic review of the literature.Setting: Tertiary care academic hospital and multi-hospital private healthcare system.Subjects and methods: A systematic literature review identified case series of adult tonsillectomy. Retrospective chart review at our institutions from 2000 to 2016 produced an additional case series. The pooled rate of occult malignancy was determined, and re-analyzed using criteria based on preoperative risk factors designed to identify patients requiring full pathologic analysis. The predicted effects of prospective application of the proposed criteria were calculated. Pooled occult malignancy prevalence was estimated.Results: Literature review and our own case series yielded 12,094 total cases. Occult malignancy prevalence in the combined data was 0.033%, representing four occult malignancies. Three out of the four would have been selected for full pathology preoperatively with use of the proposed criteria. Statistical analysis indicates that the predicted frequency of occult malignancy incidence in cases negative for the criteria is 0.01%, or 1/10,000.Conclusion: Application of the proposed criteria to adults undergoing tonsillectomy for benign indication identifies a subset of patients with an estimated incidence of occult malignancy similar to that reported for pediatric tonsillectomy, and potentially may permit safe elimination of pathologic analysis of their tonsil specimens.Level of Evidence: Pooled analysis of case series from the literature and a single institution, level 4.

AbstractAim:To determine the false-positive rate of pulse oximetry screening at moderate altitude, presumed to be elevated compared with sea level values and assess change in false-positive rate with time.Methods:We retrospectively analysed 3548 infants in the newborn nursery in Albuquerque, New Mexico, (elevation 5400 ft) from July 2012 to October 2013. Universal pulse oximetry screening guidelines were employed after 24 hours of life but before discharge. Newborn babies between 36 and 36 6/7 weeks of gestation, weighing >2 kg and babies >37 weeks weighing >1.7 kg were included in the study. Log-binomial regression was used to assess change in the probability of false positives over time.Results:Of the 3548 patients analysed, there was one true positive with a posteriorly-malaligned ventricular septal defect and an interrupted aortic arch. Of the 93 false positives, the mean pre- and post-ductal saturations were lower, 92 and 90%, respectively. The false-positive rate before April 2013 was 3.5% and after April 2013, decreased to 1.5%. There was a significant decrease in false-positive rate (p = 0.003, slope coefficient = −0.082, standard error of coefficient = 0.023) with the relative risk of a false positive decreasing at 0.92 (95% CI 0.88–0.97) per month.Conclusion:This is the first study in Albuquerque, New Mexico, reporting a high false-positive rate of 1.5% at moderate altitude at the end of the study in comparison to the false-positive rate of 0.035% at sea level. Implementation of the nationally recommended universal pulse oximetry screening was associated with a high false-positive rate in the initial period, thought to be from the combination of both learning curve and altitude. After the initial decline, it remained steadily elevated above sea level, indicating the dominant effect of moderate altitude.

Delirium in hospitalized patients often goes undetected. Cerebral state monitors, which measure limited-channel electroencephalography, have shown potential for improving delirium detection.

IMPORTANCE: Little is known about the long-term yield of high-grade cervical intraepithelial neoplasia (CIN) and the influence on biopsy and treatment rates of human papillomavirus (HPV) triage of cytology showing atypical squamous cells of undetermined significance (hereafter ASC-US cytology). OBJECTIVE: To examine 5-year outcomes after ASC-US cytology with vs without HPV testing. DESIGN, SETTING, AND PARTICIPANTS: In this observational study, all cervical cytology and HPV testing reports from January 1, 2007, to December 31, 2012, were obtained for women throughout New Mexico and linked to pathology reports. The dates of the analysis were May 4, 2015, to January 13, 2017. MAIN OUTCOMES AND MEASURES: Influence of HPV testing on disease yield, time to histologically confirmed disease, and biopsy or loop electrosurgical excision procedure rates. RESULTS: A total of 457 317 women (mean [SD] age, 39.8 [12.5] years) with a screening test were recorded between 2008 and 2012, and 20 677 (4.5%) of the first cytology results per woman were reported as ASC-US. CIN grade 3 or more severe (CIN3+) lesions were detected in 2.49% of women with HPV testing vs 2.15% of women without HPV testing (P = .23). Time to CIN3+ detection was much shorter in those with HPV testing vs those without testing (median, 103 vs 393 days; P < .001). CIN grade 1 was detected in 11.6% of women with HPV testing vs 6.6% without testing (relative risk, 1.76; 95% CI, 1.56-2.00; P < .001). Loop electrosurgical excision procedure rates within 5 years were 20.0% higher in those who underwent HPV testing, resulting in more CIN2+ and CIN3+ detection. CONCLUSIONS AND RELEVANCE: Human papillomavirus testing led to faster and more complete diagnosis of cervical disease, but 55.8% more biopsies and 20.0% more loop electrosurgical excision procedures were performed. In those tested, virtually all high-grade disease occurred in the 43.1% of women who were HPV positive, allowing clinical resources to be focused on women who need them most. These data provide essential information for cervical screening guidelines and public health policy.

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Protein quality control (proteostasis) depends on constant protein degradation and resynthesis, and is essential for proper homeostasis in systems from single cells to whole organisms. Cells possess several mechanisms and processes to maintain proteostasis. At one end of the spectrum, the heat shock proteins modulate protein folding and repair. At the other end, the proteasome and autophagy as well as other lysosome-dependent systems, function in the degradation of dysfunctional proteins. In this review, we examine how these systems interact to maintain proteostasis. Both the direct cellular data on heat shock control over autophagy and the time course of exercise-associated changes in humans support the model that heat shock response and autophagy are tightly linked. Studying the links between exercise stress and molecular control of proteostasis provides evidence that the heat shock response and autophagy coordinate and undergo sequential activation and downregulation, and that this is essential for proper proteostasis in eukaryotic systems.

Significant international differences abound in the adherence of hemodialysis (HD) patients to prescribed treatments. Unfortunately, factors influencing adherence within the United States (US) are not well understood. This study explores the hypothesis that race/ethnicity, geographic region and clinic size are associated with differences in the frequency of missed/shortened treatments. A retrospective analysis on all prevalent chronic HD patients treated at Dialysis Clinics Inc. facilities between January 2007 and June 2008. Logistic regression models were computed in which the outcome measures were the odds for missing or shortening treatments. The cohort consisted of 15,340 HD patients of whom 48 % were non-Hispanic whites (NHW), 41 % African Americans (AA), 6 % Hispanics, 2 % Native Americans, 2 % Asians, and 1 % unknown. Patients were older in the Northeast than in the South (p < 0.001) or West (p = 0.0052). The frequency of missed and shortened treatments was lower in the Northeast than other regions, p < 0.0001. Hospitalization rates were lower in the West than the Northeast (p < 0.01) but mortality rates were similar across all regions. The odds ratio and 95 % confidence interval for missed [1.31 (1.14–1.52)] and shortened treatments [1.86 (1.73–2.0)] were greater in clinics with >100 patients than in those with <50 patients. Compared to NHW, the frequencies of missed and shortened treatments were higher in AA, Hispanics and Native Americans (p < 0.001) but lower among Asians (p < 0.001). The frequency of missed and shortened HD varies significantly by race/ethnicity, geographic region and clinic size. The relationship of clinic size to missed/shortened treatments may warrant consideration when planning new HD facilities.

Proliferation rates in diffuse large B-cell lymphoma have been associated with conflicting outcomes in the literature, more often with high proliferation associated with poor prognosis. In most studies, the proliferation rate was estimated by a pathologist using an immunohistochemical stain for the monoclonal antibody Ki-67. We hypothesized that a quantitative image analysis algorithm would give a more accurate estimate of the proliferation rate, leading to better associations with survival. In all, 84 cases of diffuse large B-cell lymphoma were selected according to the World Health Organization criteria. Ki-67 percentage positivity estimated by the pathologist was recorded from the original report. The same slides were then scanned using an Aperio ImageScope, and Ki-67 percentage positivity was calculated using a computer-based quantitative immunohistochemistry nuclear algorithm. In addition, chart review was performed and survival time was recorded. The Ki-67 percentage estimated by the pathologist from the original report versus quantitative image analysis was significantly correlated (P<0.001), but pathologist Ki-67 percentages were significantly higher than quantitative image analysis (P=0.021). There was less agreement at lower Ki-67 percentages. Comparison of Ki-67 percentage positivity versus survival did not show significant association either with pathologist estimate or quantitative image analysis. However, although not significant, there was a trend of worse survival at higher proliferation rates detected by the pathologist but not by quantitative image analysis. Interestingly, our data suggest that the Ki-67 percentage positivity as assessed by the pathologist may be more closely associated with survival outcome than that identified by quantitative image analysis. This may indicate that pathologists are better at selecting appropriate areas of the slide. More cases are needed to assess whether this finding would be statistically significant. Due to the good correlation between pathologist estimate and quantitative image analysis, there is no substantial benefit to using quantitative image analysis at this point of time.

Proliferation rates in diffuse large B-cell lymphoma have been associated with conflicting outcomes in the literature, more often with high proliferation associated with poor prognosis. In most studies, the proliferation rate was estimated by a pathologist using an immunohistochemical stain for the monoclonal antibody Ki-67. We hypothesized that a quantitative image analysis algorithm would give a more accurate estimate of the proliferation rate, leading to better associations with survival. In all, 84 cases of diffuse large B-cell lymphoma were selected according to the World Health Organization criteria. Ki-67 percentage positivity estimated by the pathologist was recorded from the original report. The same slides were then scanned using an Aperio ImageScope, and Ki-67 percentage positivity was calculated using a computer-based quantitative immunohistochemistry nuclear algorithm. In addition, chart review was performed and survival time was recorded. The Ki-67 percentage estimated by the pathologist from the original report versusquantitative image analysis was significantly correlated (P<0.001), but pathologist Ki-67 percentages were significantly higher than quantitative image analysis (P=0.021). There was less agreement at lower Ki-67 percentages. Comparison of Ki-67 percentage positivity versussurvival did not show significant association either with pathologist estimate or quantitative image analysis. However, although not significant, there was a trend of worse survival at higher proliferation rates detected by the pathologist but not by quantitative image analysis. Interestingly, our data suggest that the Ki-67 percentage positivity as assessed by the pathologist may be more closely associated with survival outcome than that identified by quantitative image analysis. This may indicate that pathologists are better at selecting appropriate areas of the slide. More cases are needed to assess whether this finding would be statistically significant. Due to the good correlation between pathologist estimate and quantitative image analysis, there is no substantial benefit to using quantitative image analysis at this point of time.

Soil moisture integrates and drives ecohydrological processes in dryland ecosystems. However, despite the central importance of soil moisture, relevant field studies have not holistically assessed key inter‐related aspects of ecohydrological spatiotemporal variation: the threshold‐like manner in which soil texture controls the frequency at which soil water is readily available for plants, assessment of horizontal heterogeneity associated with vegetation patches in addition to vertical heterogeneity associated with depth, seasonal variation associated with precipitation type (snow vs rain) and inter‐annual variation spanning notably wet and dry periods. We measured soil water content by neutron probe in a semiarid piñon‐juniper woodland (Pinus edulisand Juniperus monosperma) in northern New Mexico, USA, over 15 years and evaluated an ecohydrological metric–plant‐available water, estimated as the percentage of time that soil water content was sufficiently wet to be generally available to plants. The frequency of plant‐available water varied significantly across all variables assessed: precipitation amount (across years or seasons), precipitation type, vertically with soil depth and horizontally with vegetation patch type (canopy patches beneath trees, intercanopy patches between trees and edges between the two patch types). Notably, in many cases, horizontal heterogeneity in plant‐available water associated with vegetation patch was as substantial as vertical heterogeneity associated with depth, yet such horizontal heterogeneity is not included in most ecological or hydrological models. Our results highlight spatiotemporal variation in the frequency of plant‐available water that is substantial, often overlooked, and may need to be explicitly considered for predicting dryland vegetation responses to land use and climate change. Copyright © 2009 John Wiley & Sons, Ltd.

We quantified the availability and utilization of habitat types by eight small-bodied cyprinid fish species, including the federally threatened Pecos bluntnose shiner Notropis simus pecosensis, in the Pecos River, New Mexico. The Pecos River is a medium-sized, sand-bed river with a highly variable hydrograph and some reaches characterized by historic and recent periods of flow intermittency. Fish habitat was described in four reaches at flows of 0.05–2.29 m3/s by means of a simultaneous, coordinated program of channel topographic surveys, mesohabitat mapping, fish sampling, and measurement of microhabitat and chemical parameters. We determined that fish habitat in this sand-bed river was effectively described at the mesohabitat scale. Furthermore, mesohabitats were visually distinguishable and separable by means of hydraulic and geomorphic parameters and the relationship between flow and depth, velocity, and velocity : depth ratios. The eight cyprinid species in the Pecos River primarily used four mesohabitat types that were consistently available at the full range of flows examined, including perpendicular and parallel plunges, backwaters, and slackwaters. In winter, five species (red shiner Cyprinella lutrensis, plains killifish Fundulus zebrinus, plains minnow Hybognathus placitus, Arkansas River shiner N. girardi, and sand shiner N. stramineus) shifted to backwaters, where water temperatures were relatively warmer than those of the main channel. Runs, flats, and riffles were generally the most available mesohabitat types, but their availability changed with flow; only four species (red shiner, plains killifish, speckled chub Macrhybopsis aestivalis, and sand shiner) selected these types, and they did so infrequently in summer. The Pecos bluntnose shiner was a habitat specialist that selected primarily rare plunge pools at sandbar faces, whereas species such as the red shiner were habitat generalists that used a variety of mesohabitat types. We found that a range of base flows sustained the preferred habitats of the eight cyprinid species and that no single flow maximized this preferred habitat because of a scaling effect of flow on sand bedforms.

We investigated the interacting effects of a nonpathogenic immunological challenge and exposure to lead shot early in the development of nestling western bluebirds (Sialia mexicana). Nestlings were randomly assigned to each of six treatments of an incomplete block design with two antigen treatments, Newcastle disease virus (NDV) or sheep red blood cells (SRBC), and four lead shot treatments (no shot, one shot – 0.05 g, 2 shots – 0.1 g, or three shots – 0.15 g). Survival functions did not differ between the lead treatment groups, and there were no effects of lead treatments on weight, growth rates, fluctuating asymmetry (FA), or antibody response. NDV- and SRBC-treated birds survived better than control birds which may be due to an adjuvant-activation of the entire immune system. However, FA was greater in individuals in the NDV and SRBC treatment groups, suggesting a tradeoff between growth and immunocompetence. Cell-mediated response to phytohemagglutinin of the high-lead treatment groups was significantly less than other groups. Hematocrit increased with age and weight, and was not affected by lead or antigen. While in this study the shape of the growth curve, FA, cell-mediated immunity, and behavior were affected by the higher dose of lead shot, actual lead concentrations in blood are needed to verify this process. Antigenic stress was documented in nestling developmental stability and there were no measured effect of both the lead shot and immunological challenge in combination.

Different combinations of species characteristics like dietary strategies and foraging tactics define unique pathways for material cycling and energy flow in ecosystems. I used multivariate cluster analysis on a species attribute matrix to identify groups of species with similar vulnerabilities of exposure to contaminants. The clusters of species may also have similar functions in ecosystems, because they use similar resources in similar ways. Cluster analyses produced hierarchical dendrograms of species relationships that were difficult to characterize with simple labels like herbivore or insectivore. Regardless of whether multivariate analyses are used for aggregating species into exposure guilds, the species attribute matrix is a concise statement of assumptions about how species function in ecosystems. By using species characteristics to aggregate and define assessments, it is hoped that assessment endpoints will be ecologically relevant.

Different combinations of species characteristics like dietary strategies and foraging tactics define unique pathways for material cycling and energy flow in ecosystems. I used multivariate cluster analysis on a species attribute matrix to identify groups of species with similar vulnerabilities of exposure to contaminants. The clusters of species may also have similar functions in ecosystems, because they use similar resources in similar ways. Cluster analyses produced hierarchical dendrograms of species relationships that were difficult to characterize with simple labels like herbivore or insectivore. Regardless of whether multivariate analyses are used for aggregating species into exposure guilds, the species attribute matrix is a concise statement of assumptions about how species function in ecosystems. By using species characteristics to aggregate and define assessments, it is hoped that assessment endpoints will be ecologically relevant.

Carbaryl (1-naphthyl methylcarbamate) and malathion (diethyl mercaptosuccinate, S-ester with O, O-dimethyl phosphorodithioate) are insecticides used to control grasshopper infestations on rangeland. Insecticides used to control grasshopper infestations pose a hazard to aquatic organisms because although no-spray buffer zones are observed around aquatic habitats, pesticide may be deposited by drift or mobilized from upland areas by runoff. A number of processes may affect the fate of carbaryl and malathion in the aquatic environment, but no method is available for estimating degradation over the range of conditions that occur in the field. We used results of published studies in meta-analyses to estimate degradation models that predict half-life of carbaryl and malathion in freshwater over temperature and pH ranges relevant to western grasshopper-management programs. Estimated degradation models were:In (half-life carbaryl) = 24.3 - 2.36(pH) - 0.0788(t)and In (half-life malathion) = 5.98 + 2.84(pH) - 0.326(pH2) - 0.202(t) + 0.00135(t2)where half-life has units of hours, and temperature (t) has units °C. Both models accounted for a significant amount of total variation (P<0.0001) and had r2>0.97. Accuracy of these degradation models was evaluated by comparing predicted degradation of carbaryl and malathion to field and laboratory data. We suggest that use of these degradation models be restricted to conditions where water has 7 ≤. pH ≤. 10 for carbaryl, and 7 ≤ pH ≤ 8.2 for malathion.

The Health Sciences Reasoning Test (HSRT) is a validated instrument to assess critical-thinking skills. The objective of this study was to determine if HSRT results improved in second-year student pharmacists after exposure to an explicit curriculum designed to develop critical-thinking skills.