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The significance of the left atrial appendage has been well known for a half century. Surgeons used a number of left atrial appendage closure techniques to reduce the risk of stroke without increasing the chance of bleeding from fragile left atrial appendage. Removal and oversewing are simple and effective. Current procedures, however, have the disadvantage of 30% to 40% residual appendage. Here, we discuss our innovative lasso technique using a Cor-Knot device for left atrial appendage closure in 50 consecutive patients between January 2018 and January 2019 who underwent mitral valve surgery. This technique ensured complete closure, with no new cerebrovascular events during the 2-year follow-up.

Aim: To develop a method for the quantitation of effector functionless mouse surrogate IgG1 drug molecules in mouse matrices. Materials & methods: A panel of antibodies that bound specifically to N297G mutation-containing mouse IgG molecules was generated in rats. The panel was screened to identify an antibody that could be used as both the capture and detection reagent in an electrochemiluminescent immunoassay. Results & conclusion: The quantitative assay developed with the N297G-specific antibody passed acceptance criteria across multiple IgG1 fragment crystallizable (Fc)-containing protein formats and provides accurate quantitation of the total levels of mouse surrogate protein Fc present in in vivo mouse serum samples. These results are useful in understanding drug integrity and the development of precise pharmacokinetic/pharmacodynamic relationships.

OBJECTIVE. A scoping review assessed access to medications for opioid use disorder (MOUD) and treatment outcomes among adolescents (12 to 17 years) and young adults (18 to 25 years). METHODS. Studies addressing adolescent and young adult opioid use disorder (OUD) and treatment with MOUD on patient outcomes (e.g., retention in care) were included. Randomized trials and controlled observational studies were prioritized. Investigators extracted key information, summarized findings, noted methodological weaknesses and tabled the details. RESULTS. The search identified four randomized trials (N=241), one systematic review with 52 studies (total N = 125,994) and five retrospective analyses of health insurance claims. The trials reported buprenorphine and extended-release naltrexone reduced opioid use. Return to use was observed when pharmacotherapy ceased. A systematic review concluded that adolescents and young adults had lower retention in care than older adults. The observational studies found that adolescents were unlikely to receive MOUD. There was some evidence that non-Hispanic Black adolescents and young adults were less likely than non-Hispanic whites to receive MOUD. CONCLUSIONS. MOUD therapies reduce opioid use among adolescent and young adults but few receive MOUD. MOUD services for adolescents and young adults should be developed and tested. Randomized clinical trials are necessary to develop appropriate clinical guidelines for using MOUD with adolescents and young adults.

Introduction National reports suggest that Hispanic patients may underutilize influenza and pneumococcal vaccination, although studies sometimes conflict on this point. A clearer picture of adult immunization utilization in older Hispanic patients is necessary to ensure equity in adult vaccinations. Methods Using electronic health records from 648 community health centers (CHCs) across 21 states, we compared English-preferring Hispanic patients, Spanish-preferring Hispanic patients, and Non-Hispanic White (NHW) adults aged ≥50 years across five outcomes between 2012-2017: (1) Odds of ever receiving pneumococcal vaccination after age 65, (2) Odds of ever receiving ≥2 pneumococcal vaccinations for those ≥65, (3) odds of vaccination between the ages of 50 and 64 for those with diabetes or heart disease, (4) odds of influenza vaccine, and (5) annual rate of influenza vaccination. Results Of our total study sample (N = 143,869), 85,562 were age 50-64 during the entire study period, and 65,977 were ≥65 at some point during the study period. In patients aged 50-64, Spanish-preferring Hispanic patients were more likely to have ever had an influenza vaccination (covariate-adjusted odds ratio [aOR] = 1.33, 95% CI = 1.29-1.37), had higher rates of annual influenza vaccination (covariate-adjusted rate ratio [aRR] = 1.41, 95% CI = 1.38-1.44), and higher odds of pneumococcal vaccination (aOR = 1.87, 95% CI = 1.76-1.98) than NHW patients. These findings were similar in Spanish-preferring Hispanic patients ≥65. English-preferring Hispanics ≥65 were less likely than NHW patients to ever have an influenza vaccination (aOR = 0.91, 95% CI = 0.85-0.98) and to have ever received at least one (aOR = 0.92, 95% CI = 0.86-0.99) or two (aOR = 0.86, 95% CI = 0.77-0.95) pneumococcal vaccine doses. Conclusions In a multistate CHC network, Spanish-preferring Hispanic patients were more likely to receive influenza and pneumococcal vaccinations than NHW patients; older English-preferring Hispanic patients were often less likely than NHW patients to receive these vaccinations. In vaccine initiatives, English-preferring Hispanic patients may be at higher risk of vaccination inequity.

The authors conducted a scoping review to survey the evidence landscape for studies that assessed outcomes of treating patients with opioid use disorder with methadone in office-based settings.Ovid MEDLINE and the Cochrane Database of Systematic Reviews were searched, and reference lists were reviewed to identify additional studies. Studies were eligible if they focused on methadone treatment in office-based settings conducted in the United States or other highly developed countries and reported outcomes (e.g., retention in care). Randomized trials and controlled observational studies were prioritized; uncontrolled and descriptive studies were included when stronger evidence was unavailable. One investigator abstracted key information, and a second verified data. A scoping review approach broadly surveyed the evidence, and therefore study quality was not rated formally.Eighteen studies of patients treated with office-based methadone were identified, including six trials, eight observational studies, and four additional articles discussing use of pharmacies to dispense methadone. Studies on office-based methadone treatment, including primary care-based dispensing, were limited but consistently found that stable methadone patients valued office-based care and remained in care with low rates of drug use; outcomes were similar compared with stable patients in regular care. Office-based methadone treatment was associated with higher treatment satisfaction and quality of life. Limitations included underpowered comparisons and small samples.Limited research suggests that office-based methadone treatment and pharmacy dispensing could enhance access to methadone treatment for patients with opioid use disorder without adversely affecting patient outcomes and, potentially, inform modifications to federal regulations. Research should assess the feasibility of office-based care for less stable patients.

The COVID-19 pandemic presents challenges in participant recruitment strategies for clinical research involving people with opioid use disorders recently engaged in treatment. We describe challenges to participant recruitment in a trial comparing virtual buprenorphine treatment platform to office-based buprenorphine treatment.The parent study was a cohort trial of telehealth delivered buprenorphine treatment compared to office-based buprenorphine treatment, however, due to the pandemic potential participant recruitment for both arms became virtual. Between 9/27/2021 and 7/11/2022, telephone, email, flyers, and word-of-mouth were used to recruit study participants from each treatment setting. Recruitment tracking documents recorded the primary outcomes: number of outreach attempts and most effective contact methods.Treatment settings provided contact information for 1485 potential study participants. Information was incorrect or disconnected for 282 (19%) individuals, 695 (47%) did not respond to outreach, and 508 (34%) responded to outreach. Of these responders, 369 were interested in study participation, 259 completed the online informed consent and screening assessment, and 148 met eligibility criteria and enrolled in the study. A total of 3804 virtual outreach attempts across 1485 potential participants were made, resulting in an average of 2.7 attempts per contact and a mean of 25.7 attempts per enrolled participant (n = 148).Conducting research during the COVID-19 pandemic required shifting from in-person to virtual recruitment strategies to contact and engage potential study participants. Virtual recruitment for this population during a pandemic appears to be less efficient and hindered efforts to meet recruitment goals.

Study Design Participatory design. Objectives Activity-based therapies (ABT) have physical and psychosocial benefits for individuals with spinal cord injury (SCI). A Canadian ABT summit was held to: (1) identify methods used in stroke rehabilitation that may be appropriate for SCI; (2) understand the current state of ABT activities in Canada; and (3) identify priorities for ABT research and care for the next five years. Setting Stakeholder-engaged meeting at a tertiary rehabilitation hospital. Methods Thirty-nine stakeholders, including individuals with SCI, frontline clinicians, healthcare administrators, researchers, funders and health policy experts, attended. Two participants were note-takers. Priority identification occurred through input from stakeholder groups, followed by individual voting. Conventional content analysis was used to synthesize the information in the meeting notes. Results The strengths of ABT in stroke rehabilitation included clear and clinically feasible definitions, measurements and interventions, and recognized requirements for implementation (e.g. behavior change, partnerships). Knowledge gaps concerning ABT activities in Canada were identified for acute and community settings, non-traumatic populations, and the interventions, equipment and standardized measures (i.e. upper limb, activity levels) used. Five priorities for ABT across the continuum of care were identified: (1) Identify current ABT activities; (2) Create a network to facilitate dialog; (3) Track engagement in ABT activities; (4) Develop and implement best practice recommendations; and (5) Study optimal timing, methods, and dose of ABT. Working groups were formed to address priorities 1–3. Conclusions The priorities will guide SCI research and care activities in Canada over the next five years. Sponsorship Praxis Spinal Cord Institute.

Overdoses continue to increase in the US, but the contribution of methamphetamine use is understudied in rural communities.To estimate the prevalence of methamphetamine use and its correlates among people who use drugs (PWUD) in rural US communities and to determine whether methamphetamine use is associated with increased nonfatal overdoses.From January 2018 through March 2020, the National Rural Opioid Initiative conducted cross-sectional surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin). Participants included rural PWUD who reported any past-30-day injection drug use or noninjection opioid use to get high. A modified chain-referral sampling strategy identified seeds who referred others using drugs. Data analysis was performed from May 2021 to January 2022.Use of methamphetamine alone, opioids alone, or both.Unweighted and weighted prevalence of methamphetamine use, any past-180-day nonfatal overdose, and number of lifetime nonfatal overdoses.Among the 3048 participants, 1737 (57%) were male, 2576 (85%) were White, and 225 (7.4%) were American Indian; the mean (SD) age was 36 (10) years. Most participants (1878 of 2970 participants with any opioid or methamphetamine use [63%]) reported co-use of methamphetamine and opioids, followed by opioids alone (702 participants [24%]), and methamphetamine alone (390 participants [13%]). The estimated unweighted prevalence of methamphetamine use was 80% (95% CI, 64%-90%), and the estimated weighted prevalence was 79% (95% CI, 57%-91%). Nonfatal overdose was greatest in people using both methamphetamine and opioids (395 of 2854 participants with nonmissing overdose data [22%]) vs opioids alone (99 participants [14%]) or methamphetamine alone (23 participants [6%]). Co-use of methamphetamine and opioids was associated with greater nonfatal overdose compared with opioid use alone (adjusted odds ratio, 1.45; 95% CI, 1.08-1.94; P = .01) and methamphetamine use alone (adjusted odds ratio, 3.26; 95% CI, 2.06-5.14; P .001). Those with co-use had a mean (SD) of 2.4 (4.2) (median [IQR], 1 [0-3]) lifetime overdoses compared with 1.7 (3.5) (median [IQR], 0 [0-2]) among those using opioids alone (adjusted rate ratio, 1.20; 95% CI, 1.01-1.43; P = .04), and 1.1 (2.9) (median [IQR], 0 [0-1]) among those using methamphetamine alone (adjusted rate ratio, 1.81; 95% CI, 1.45-2.27; P .001). Participants with co-use most often reported having tried and failed to access substance use treatment: 827 participants (44%) for both, 117 participants (30%) for methamphetamine alone, and 252 participants (36%) for opioids alone (χ22 = 33.8; P .001). Only 66 participants (17%) using methamphetamine alone had naloxone.These findings suggest that harm reduction and substance use disorder treatment interventions must address both methamphetamine and opioids to decrease overdose in rural communities.

Objective To identify and critically evaluate the economic evaluations examining the cost‐effectiveness of hydrophilic‐coated vs uncoated catheters for individuals with spinal cord injury. Methods We searched MEDLINE, the Excerpta Medica database (EMBASE), Cochrane Database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Emcare for studies in English and French. There were no restrictions to the year of publication. Our search strategy included the following key terms: “spinal cord injury,” “catheterization,” and “cost analysis.” Results The search identified 371 studies, of which eight studies met the inclusion criteria. Five studies observed hydrophilic‐coated catheters to be cost‐effective compared to uncoated catheters. Two studies found hydrophilic‐coated catheters to be not cost‐effective compared to uncoated catheters and one study estimated that hydrophilic‐coated catheters reduced the long‐term health‐care costs compared to uncoated catheters. Conclusion The cost‐effectiveness of hydrophilic‐coated catheters was dependent on the comparator used, the consideration of long‐term effects, and the unit cost of treatment. Further studies are needed to explore the short‐term and long‐term effects of hydrophilic‐coated catheter use on urinary tract infections and clarify the impact of hydrophilic‐coated catheter use on long‐term renal function. Overall, our critical evaluation of the literature suggests that the evidence is pointing toward hydrophilic‐coated catheters being cost‐effective, particularly when a societal perspective is applied.

BACKGROUND: A large proportion of individuals who use heroin report initiating opioid use with prescription opioids. However, patterns of prescription opioid use preceding heroin-related overdose have not been described. OBJECTIVE: To describe prescription opioid use in the year preceding heroin overdose. DESIGN: Case-control study comparing prescription opioid use with a heroin-involved overdose, non-heroin-involved opioid overdose, and non-overdose controls from 2015 to 2017. PARTICIPANTS: Oregon Medicaid beneficiaries with linked administrative claims, vital statistics, and prescription drug monitoring program data. MAIN MEASURES: Opioid, benzodiazepine, and other central nervous system depressant prescriptions preceding overdose; among individuals with one or more opioid prescription, we assessed morphine milligram equivalents per day, overlapping prescriptions, prescriptions from multiple prescribers, long-term use, and discontinuation of long-term use. KEY RESULTS: We identified 1458 heroin-involved overdoses (191 fatal) and 2050 non-heroin-involved opioid overdoses (266 fatal). In the 365 days prior to their overdose, 45% of individuals with a heroin-involved overdose received at least one prescribed opioid compared with 78% of individuals who experienced a non-heroin-involved opioid overdose (p

Objectives Although medications for opioid use disorder (MOUD) save lives, treatment retention remains challenging. Identification of interventions to improve MOUD retention is of interest to policymakers and researchers. On behalf of the Agency for Healthcare Research and Quality, we conducted a rapid evidence review on interventions to improve MOUD retention. Methods We searched MEDLINE and the Cochrane Library from February 2009 through August 2019 for systematic reviews and randomized trials of care settings, services, logistical support, contingency management, health information technology (IT), extended-release (XR) formulations, and psychosocial interventions that assessed retention at least 3 months. Results Two systematic reviews and 39 primary studies were included; most did not focus on retention as the primary outcome. Initiating MOUD in soon-to-be-released incarcerated people improved retention following release. Contingency management may improve retention using antagonist but not agonist MOUD. Retention with interventions integrating medical, psychiatric, social services, or IT did not differ from in-person treatment-as-usual approaches. Retention was comparable with XR- compared to daily buprenorphine formulations and conflicting with XR-naltrexone monthly injection compared to daily buprenorphine. Most psychosocial interventions did not improve retention. Discussion Consistent but sparse evidence supports criminal justice prerelease MOUD initiation, and contingency management interventions for antagonist MOUD. Integrating MOUD with medical, psychiatric, social services, delivering through IT, or administering via XR-MOUD formulations did not worsen retention. Fewer than half of the studies we identified focused on retention as a primary outcome. Studies used different measures of retention, making it difficult to compare effectiveness. Additional inquiry into the causes of low retention would inform future interventions.Registration: PROSPERO: CRD42019134739.

Study design Multicenter, randomized, double-blind, placebo controlled, clinical trial. Objective The objective of this paper is to evaluate the effectiveness of cannabinoids and an anti-inflammatory diet, alone and in combination, for the management of neuropathic pain (NP) after spinal cord injury (SCI). Setting Two Canadian SCI rehabilitation centers. Methods A sample of 144 individuals with SCI will receive either an anti-inflammatory diet, cannabinoids or a placebo for 6 weeks. Following this, a combined effect of these treatments will be evaluated for a further 6 weeks. The primary outcome measure will be the change in NP as assessed by the numeric rating scale (NRS). Secondary outcomes will include changes in inflammation, mood, sleep, spasticity, cost-effectiveness, and function. Conclusion This study will assess the efficacy of an anti-inflammatory diet and cannabinoids (individually and in combination) for the treatment of NP following SCI. Results may reveal a cost-effective, side-effect free intervention strategy which could be utilized for the long-term management of NP following SCI.

In India, many people living with HIV (PLHIV) do not successfully initiate antiretroviral therapy (ART) after diagnosis. We conducted a clinic-based qualitative study at the Y.R. Gaitonde Centre for AIDS Research in Chennai, Tamil Nadu to explore factors that influence ART non-initiation. We interviewed 22 men and 15 women; median age was 42 (IQR, 36–48) and median CD4+ was 395 (IQR, 227–601). Participants were distrustful of HIV care freely available at nearby government facilities. Faced with the perceived need to access the private sector and therefore pay for medications and transportation costs, non-initiators with high CD4+ counts often decided to postpone ART until they experienced symptoms whereas non-initiators with low CD4+ counts often started ART but defaulted quickly after experiencing financial stressors or side effects. Improving perceptions of quality of care in the public sector, encouraging safe serostatus disclosure to facilitate stronger social support, and alleviating economic hardship may be important in encouraging ART initiation in India.

OBJECTIVE To undertake a cost-utility analysis comparing virtual illusion (VI) and transcranial direct current stimulation (tDCS) combination therapy, tDCS alone and standard pharmacological care in Ontario, Canada from a societal perspective over a three-month time horizon. DESIGN Cost-utility analysis using Markov model methods. SETTING Community setting in Ontario, Canada. PARTICIPANTS Individuals with spinal cord injury and neuropathic pain (NP) resistant to pharmacological therapy. INTERVENTIONS Virtual illusion and transcranial direct current stimulation, transcranial direct current stimulation alone and standard pharmacological therapy. OUTCOME MEASURES Incremental costs, quality adjusted life years (QALY) and incremental cost effectiveness ratio. RESULTS The incremental cost effectiveness ratio of VI and tDCS therapy cost is $3,396 per QALY (2020 Canadian dollars) when compared to standard care. The incremental cost per QALY of tDCS therapy alone is $33,167. VI and tDCS therapy had lower incremental costs (-$519) and higher incremental QALYs (0.026) compared to tDCS alone. From a public healthcare payer perspective, there is a 74% probability that VI and tDCS therapy and 54% probability that tDCS alone would be cost effective at a $50,000 per QALY willingness-to-pay threshold. Our findings remained relatively robust in various scenario analyses. CONCLUSION Our findings suggest that at three-months after therapy, VI and tDCS combination therapy may be more cost effective than tDCS therapy alone. Based on conventional health technology funding thresholds, VI and tDCS combination therapy merits consideration for the treatment of NP in adults with spinal cord injuries.

Background One in 5 people in Canada have a disability affecting daily activities, and, for rural patients, accessing lifelong physiatry care to improve function and manage symptoms requires complex and expensive travel. We compared the costs of new outreach physiatry clinics with those of conventional urban clinics in Manitoba. Methods Six outreach clinics were held from January 2018 to September 2019 in the remote communities of St. Theresa Point and Churchill, Manitoba. A general physiatry population was seen in these clinics, including patients with musculoskeletal and neurologic conditions seen in consultation and follow-up. We performed a societal cost-minimization analysis comparing outreach clinic costs to estimated costs of standard care at conventional outpatient clinics in Winnipeg. Outcomes of interest included direct costs to government health services and patients, and indirect opportunity cost of travel time. We calculated total costs, average cost per clinic visit and incremental costs for outreach clinics compared to conventional urban clinics. Costs were inflated to 2020 Canadian dollars. Results Thirty-one patients (48 visits) were seen at the outreach clinics. The total cost of providing outreach clinics, $33 136, was 21% of the estimated cost of standard care, $158 344. When only direct costs were included, outreach clinics cost an estimated 24% of conventional care costs. The average unit cost per outreach visit was $690, compared to $3299 per conventional visit, for an incremental cost of -$2609 per outreach visit. Interpretation An outreach physiatry visit in Manitoba cost an estimated 21% of a conventional urban outpatient visit, or 24% when only direct costs were included, with costs savings largely related to travel. Outreach physiatry care in this model provides substantial cost savings for the public health care system as the primary payer, and can reduce the travel cost burden for patients who do not have public travel funding.

Background Residential treatment is a common approach for treating opioid use disorder (OUD), however, few studies have directly compared it to outpatient treatment. The objective of this study was to compare OUD outcomes among individuals receiving residential and outpatient treatment. Methods A retrospective cohort study used linked data from a state Medicaid program, vital statistics, and the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episodes Dataset (TEDS) to compare OUD-related health outcomes among individuals treated in a residential or outpatient setting between 2014 and 2017. Multivariable Cox proportional hazards and logistic regression models examined the association between treatment setting and outcomes (i.e., opioid overdose, non-overdose opioid-related and all-cause emergency department (ED) visits, hospital admissions, and treatment retention) controlling for patient characteristics, co-morbidities, and use of medications for opioid use disorders (MOUD). Interaction models evaluated how MOUD use modified associations between treatment setting and outcomes. Results Of 3293 individuals treated for OUD, 957 (29%) received treatment in a residential facility. MOUD use was higher among those treated as an outpatient (43%) compared to residential (19%). The risk of opioid overdose (aHR 1.39; 95% CI 0.73–2.64) or an opioid-related emergency department encounter or admission (aHR 1.02; 95% CI 0.80–1.29) did not differ between treatment settings. Independent of setting, MOUD use was associated with a significant reduction in overdose risk (aHR 0.45; 95% CI 0.23–0.89). Residential care was associated with greater odds of retention at 6-months (aOR 1.71; 95% CI 1.32–2.21) but not 1-year. Residential treatment was only associated with improved retention for individuals not receiving MOUD (6-month aOR 2.05; 95% CI 1.56–2.71) with no benefit observed in those who received MOUD (aOR 0.75; 95% CI 0.46–1.29; interaction p = 0.001). Conclusions Relative to outpatient treatment, residential treatment was not associated with reductions in opioid overdose or opioid-related ED encounters/hospitalizations. Regardless of setting, MOUD use was associated with a significant reduction in opioid overdose risk.

There are three common foot strike techniques in runners. Whether these techniques generate different sounds at the point of impact with the ground may influence lower limb kinetics. No previous studies have determined whether such relationships exist.To determine foot-ground impact sound characteristics and to compare the impact sound characteristics across foot strike techniques and the relationships between impact sound characteristics and vertical loading rates.Cross-sectional study Setting: Gait analysis laboratory Patients or Other Participants: Thirty runners (50% female, age=23.5±4.0 yrs, mass=58.1±8.2kg, height=1.67±0.1m) completed overground running trials with rearfoot strike (RFS), midfoot strike (MFS) and forefoot strike (FFS) techniques in a gait analysis laboratory.Impact sound was measured by a shotgun microphone and the peak sound amplitude, median frequency and sound duration were analysed. Separate linear regression, clustering participants repeated measures were used to compare the sound parameters across foot strike techniques. Kinetic data was collected from a force plate and the vertical loading rates were calculated. Pearson's correlation was used to determine relationship between sound characteristic and kinetics.Landing with a MFS or FFS resulted in greater peak sound amplitude (ps0.001) and shorter sound duration (ps0.001) than RFS. MFS exhibited the highest median frequency among the three foot strike patterns, followed by FFS (ps0.001). We did not find a significant relationship between vertical loading rates and any impact sound parameters (ps0.115).The results suggest that impact sound characteristics may be used to differentiate foot strike patterns in runners. However, this did not relate to lower limb kinetics. Therefore, clinicians should not solely rely on impact sound to infer impact loading.

PURPOSE High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients’ needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work. METHODS We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 “usual care” members. We conducted a thematic analysis, using an inductive approach, at a semantic level. RESULTS Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient–health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients’ individual situations. Participants’ definitions of success focused more on improving patient engagement than reducing utilization or cost. CONCLUSION FQHC staff working with HNHC patients perceive mismatch between the health care system and patients’ clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.

Context: Spinal cord injury (SCI) presents numerous physiological, psychosocial, and environmental complexities resulting in significant healthcare system resource demands. Objective: To describe the current health system surveillance mechanisms in Ontario, Canada and highlight gaps in health surveillance among adults with SCI across their lifespan. Methods: A review of administrative data sources capturing SCI-specific information took place via internet searching and networking among SCI rehabilitation and health services experts with emphasis on functionality, health service utilization, and quality of life data. Results: The review identified a distinct paucity of data elements specific to the health surveillance needs of individuals with SCI living in the community. The gaps identified are: (1) a lack of data usability; (2) inadequate linkage between available datasets; (3) inadequate/infrequent reporting of outcomes; (4) a lack of relevant content/patient-reported outcomes; and, (5) failure to incorporate additional data sources (e.g. Insurance datasets). Conclusion: Currently, SCI-specific health data is disproportionately weighted towards the first 3-6 months post injury with detailed data regarding pre-hospital care, acute management and rehabilitation, but little existing infrastructure supporting community-based health surveillance. Given this reality, the bolstering of meaningful community health surveillance of this population across the lifespan is needed. Addressing the identified gaps in health surveillance must inform the creation of a comprehensive community health dataset incorporating patient-reported outcome measures and enabling linkage with existing administrative and/or clinical databases. A future harmonized data surveillance strategy would, in turn, positively impact function, health services, resource utilization and health-related quality of life surveillance.

Electronic Patient Reported Outcomes (PROs), which consist of questionnaires administered directly to patients via handheld device or computer, allow for the routine and systematic capture of sensitive domains as well as longitudinal data on functional status, symptom severity, and physical and psychological well-being. There have been few examples of PROs in HIV care in low- and middle-income countries (LMICs) and none in India. We conducted a study to assess the feasibility and acceptability of PROs at the Y.R. Gaitonde Centre for AIDS Research and Education in Chennai, Tamil Nadu. We adapted an adherence and psychosocial questionnaire into an electronic PRO format and administered it to a convenience sample of 50 participants. Almost all participants indicated that the PRO questionnaire was easy to complete and understand (96%). The percentage who needed any staff help was 83% among illiterate participants but only 13% among literate participants (p

BACKGROUND: Currently, there are no accepted FDA-approved pharmacotherapies for cocaine use disorder, though numerous medications have been tested in clinical trials. We conducted a systematic review and meta-analysis to better understand the effectiveness of pharmacotherapy for cocaine use disorder. METHODS: We searched multiple data sources (MEDLINE, PsycINFO, and Cochrane Library) through November 2017 for systematic reviews and randomized controlled trials (RCTs) of pharmacological interventions in adults with cocaine use disorder. When possible, we combined the findings of trials with comparable interventions and outcome measures in random-effects meta-analyses. We assessed the risk of bias of individual trials and the strength of evidence for each outcome using standardized criteria. Outcomes included continuous abstinence (3+ consecutive weeks); cocaine use; harms; and study retention. For relapse prevention studies (participants abstinent at baseline), we examined lapse (first cocaine positive or missing UDS) and relapse (two consecutive cocaine positive or missed UDS′). RESULTS: Sixty-six different drugs or drug combinations were studied in seven systematic reviews and 48 RCTs that met inclusion criteria. Antidepressants were the most widely studied drug class (38 RCTs) but appear to have no effect on cocaine use or treatment retention. Increased abstinence was found with bupropion (2 RCTs: RR 1.63, 95% CI 1.02 to 2.59), topiramate (2 RCTs: RR 2.56, 95% CI 1.39 to 4.73), and psychostimulants (14 RCTs: RR 1.36, 95% CI 1.05 to 1.77), though the strength of evidence for these findings was low. We found moderate strength of evidence that antipsychotics improved treatment retention (8 RCTs: RR 1.33, 95% CI 1.03 to 1.75). DISCUSSION: Most of the pharmacotherapies studied were not effective for treating cocaine use disorder. Bupropion, psychostimulants, and topiramate may improve abstinence, and antipsychotics may improve retention. Contingency management and behavioral interventions along with pharmacotherapy should continue to be explored. SR REGISTRATION: Prospero CRD42018085667 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05074-8) contains supplementary material, which is available to authorized users.

Background Early readmission amongst older safety-net hospitalized adults is costly. Interventions to prevent early readmission have had mixed success. The role of perceived social support is unclear. We examined the association of perceived social support in 30-day readmission or death in older adults admitted to a safety-net hospital. Methods This is an observational cohort study derived from the Support From Hospital to Home for Elders (SHHE) trial. Participants were community-dwelling English, Spanish and Chinese speaking older adults admitted to medicine wards at an urban safety-net hospital in San Francisco. We assessed perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We defined high social support as the highest quartile of MSPSS. We ascertained 30-day readmission and mortality based on a combination of participant self-report, hospital and death records. We used multiple/multivariable logistic regression to adjust for patient demographics, health status, and health behaviors. We tested for whether race/ethnicity modified the effect high social support had on 30-day readmission or death by including a race-social support interaction term. Results Participants (n = 674) had mean age of 66.2 (SD 9.0), with 18.8% White, 24.8% Black, 31.9% Asian, and 19.3% Latino. The 30-day readmission or death rate was 15.0%. Those with high social support had half the odds of readmission or death than those with low social support (OR = 0.47, 95% CI 0.26–0.88). Interaction analyses revealed race modified this association; higher social support was protective against readmission or death among minorities (AOR = 0.35, 95% CI 0.16–0.76) but increased likelihood of readmission or death among Whites (AOR = 3.7, 95% CI 1.07–12.9). Conclusion In older safety-net patients nearing discharge, high perceived social support may protect against 30-day readmission or death among minorities. Assessing patients’ social support may aid targeting of transitional care resources and intervention design. How perceived social support functions across racial/ethnic groups in health outcomes warrants further study. Trial registration NIH trials registry number ClinicalTrials.gov: NCT01221532.

Background Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. Methods/design Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have Discussion The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858

Background Intravenous (IV) vancomycin is used in the treatment of severe infection in neonates. However, its efficacy is compromised by elevated risks of acute kidney injury. The risk is even higher among neonates admitted to the neonatal intensive care unit (NICU), in whom the pharmacokinetics of vancomycin vary widely. Therapeutic drug monitoring is an integral part of vancomycin treatment to balance efficacy against toxicity. It involves individual dose adjustments based on the observed serum vancomycin concentration (VCs). However, the existing trough-based approach shows poor evidence for clinical benefits. The updated clinical practice guideline recommends population pharmacokinetic (popPK) model–based approaches, targeting area under curve, preferably through the Bayesian approach. Since Bayesian methods cannot be performed manually and require specialized computer programs, there is a need to provide clinicians with a user-friendly interface to facilitate accurate personalized dosing recommendations for vancomycin in critically ill neonates. Objective We used medical data from electronic health records (EHRs) to develop a popPK model and subsequently build a web-based interface to perform model-based individual dose optimization of IV vancomycin for NICU patients in local medical institutions. Methods Medical data of subjects prescribed IV vancomycin in the NICUs of Prince of Wales Hospital and Queen Elizabeth Hospital in Hong Kong were extracted from EHRs, namely the Clinical Information System, In-Patient Medication Order Entry, and electronic Patient Record. Patient demographics, such as body weight and postmenstrual age (PMA), serum creatinine (SCr), vancomycin administration records, and VCs were collected. The popPK model employed a 2-compartment infusion model. Various covariate models were tested against body weight, PMA, and SCr, and were evaluated for the best goodness of fit. A previously published web-based dosing interface was adapted to develop the interface in this study. Results The final data set included EHR data extracted from 207 subjects, with a total of 689 VCs measurements. The final model chosen explained 82% of the variability in vancomycin clearance. All parameter estimates were within the bootstrapping CIs. Predictive plots, residual plots, and visual predictive checks demonstrated good model predictability. Model approximations showed that the model-based Bayesian approach consistently promoted a probability of target attainment (PTA) above 75% for all subjects, while only half of the subjects could achieve a PTA over 50% with the trough-based approach. The dosing interface was developed with the capability to optimize individual doses with the model-based empirical or Bayesian approach. Conclusions Using EHRs, a satisfactory popPK model was verified and adopted to develop a web-based individual dose optimization interface. The interface is expected to improve treatment outcomes of IV vancomycin for severe infections among critically ill neonates. This study provides the foundation for a cohort study to demonstrate the utility of the new approach compared with previous dosing methods.

Purpose Recent research has outlined the increasing incidence of acute kidney injury (AKI) and its effect on morbidity/mortality. There is evidence that current rates are significantly under-reported nationally, with uncertainty about pre-operative factors that might influence AKI reduction and the impact on other healthcare outcomes such as mortality and later Chronic Kidney Disease (CKD) development. We set out to help address these current deficiencies in the literature. Methods A retrospective cohort study was undertaken using data collected from patients undergoing elective primary lower limb arthroplasty within our institution from 01/10/16–31/09/17 with a 2-year follow-up. Results 53/782 (6.8%) patients had an AKI during the study time period. This was associated with a longer inpatient stay (p p = 0.134), 30-day readmission (p = 1.00) or later CKD development (p = 0.63). Independent predictors of AKI were as follows: Diabetes (OR 2.49; 95%CI 1.15–5.38; p = 0.021), CKD (OR 4.59; 95%CI 2.37–8.92; p p = 0.002). Conclusions AKI in those undergoing hip and knee arthroplasty remains under-reported at a national level. AKI development was associated with an increased length of stay, but not long-term healthcare outcomes. This may be due to the mechanism of AKI development or the low absolute numbers of AKI suffered. We have identified three pre-operative factors (Diabetes, CKD & Male Sex) that were independently predictive of AKI. Targeted interventions may reduce the risk of AKI after lower limb arthroplasty.

Introduction: Federally qualified health centers (FQHC) provide care to over 28 million people in the United States, primarily serving people with low incomes who are underinsured or not insured. FQHC patients have different patterns of illness than non-FQHC populations, which may require tailored interventions to support at the population level. Model based segmentation methods can identify patterns of need but may generate spurious results without clinical context. Here, we used stakeholder feedback combined with machine learning methods to identify subgroups of patients seen by a large FQHC in an urban setting. Methods: We used electronic health record and administrative hospital utilization data to identify subgroups of patients seen at the FQHC in 2017 using latent class analysis (LCA). We designed an activity to gather feedback from physicians, social service staff, and administrators during model design. We trained a final model using a feed-forward neural network.Results: Using data from 5,985 primary care patients, we identified four candidate LCA models—with 26, 27, 28, and 29 classes—and integrated inter-professional feedback to develop a final model with 19 clinically meaningful classes. Three classes had greater medical complexity and older age, 15 classes were separated primarily by behavioral health diagnoses, and a final class had low complexity.Conclusions: Populations served by FQHCs are clinically heterogenous with varying levels of complexity. Use of LCA can provide insights into patterns among FQHC patients, which can be used to inform the development of interventions tailored to the needs of specific classes.

SARS-CoV-2 in an Immunocompromised Host This letter describes an immunocompromised patient who had persistent infection with SARS-CoV-2 over a period of months, despite several courses of remdesivi...