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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.

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.

People with type 2 diabetes mellitus (T2DM) are at increased risk of mild cognitive impairment and dementia. Systemic inflammation has been proposed as a common risk factor. This study aimed to summarize the clinical data pertaining to peripheral blood inflammatory markers. We identified original peer-reviewed articles reporting blood inflammatory marker concentrations in groups of people with a T2DM diagnosis who have cognitive impairment (CI; including mild cognitive impairment, Alzheimer’s disease, vascular cognitive impairment) vs. normal cognition (NC). Between-group standardized mean differences (SMD) were summarized in random effects meta-analyses. From 2108 records, data were combined quantitatively from 40 studies. Concentrations of interleukin-6 (IL-6; NCI/NNC=934/3154, SMD 0.74 95% confidence interval [0.07, 1.42], Z5=2.15, p=0.03; I2=98.08%), C-reactive protein (CRP; NCI/NNC=1610/4363, SMD 0.80 [0.50, 1.11], Z14=5.25, p

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.

Background: Methadone and buprenorphine are effective medications for opioid use disorder (MOUD) that are highly regulated in the United States. The on-going opioid crisis, and more recently COVID-19, has prompted reconsideration of these restrictions in order to sustain and improve treatment access, with renewed interest in telemedicine. We reviewed the evidence on use of telemedicine interventions and applicability to MOUD policy changes in the post-COVID-19 treatment landscape. Methods: Ovid MEDLINE and the Cochrane Database of Systematic Reviews databases were searched from inception to April 2021 and reference lists were reviewed to identify additional studies. Studies were eligible if they examined telemedicine interventions and reported outcomes (e.g. treatment initiation, retention in care). Randomized trials and controlled observational studies were prioritized; other studies were included when stronger evidence was unavailable. One investigator abstracted key information and a second investigator verified data. We described the results qualitatively. Results: We identified nine studies: three controlled trials (two randomized), and six observational studies. Three studies evaluated patients treated with methadone and six studies with buprenorphine, including one study of pregnant women with OUD. All studies showed telemedicine approaches associated with similar outcomes (treatment retention, positive urine toxicology) compared to treatment as usual. Trials were limited by small samples sizes, lack of reporting harms, and most were conducted prior to the COVID-19 pandemic; observational studies were limited by failure to control for confounding. Conclusions: Limited evidence suggests that telemedicine may enhance access to MOUD with similar effectiveness compared with face-to-face treatment. Few studies have been published since COVID-19, and it is unclear the potential impact of these interventions on the existing racial/ethnic disparities in treatment. The COVID-19 pandemic and need for social distancing led to temporary policy changes for prescribing of MOUD that could inform additional research in this area to support comprehensive policy reforms.

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.

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.

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.

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.

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

Aims Addiction to methamphetamine/amphetamine (MA/A) is a major public health problem. Currently there are no pharmacotherapies for MA/A use disorder that have been approved for use by the US Food and Drug Administration or the European Medicines Agency. We reviewed the effectiveness of pharmacotherapy for MA/A use disorder to assess the quality, publication bias and overall strength of the evidence. Methods Systematic review and meta-analysis. We searched multiple data sources (MEDLINE, PsycINFO and Cochrane Library) to April 2019 for systematic reviews (SRs) and randomized controlled trials (RCTs). Included studies recruited adults who had MA/A use disorder; sample sizes ranged from 19 to 229 participants. Outcomes of interest were abstinence, defined as 3 or more consecutive weeks with negative urine drug screens (UDS); overall use, analyzed as the proportion of MA/A negative UDS specimens; and treatment retention. One SR of pharmacotherapies for MA/A use disorder and 17 additional RCTs met our inclusion criteria encompassing 17 different drugs (antidepressants, antipsychotics, psychostimulants, anticonvulsants and opioid antagonists). We combined the findings of trials with comparable interventions and outcome measures in random-effects meta-analyses. We assessed quality, publication bias and the strength of evidence for each outcome using standardized criteria. Results There was low-strength evidence from two RCTs that methylphenidate may reduce MA/A use: 6.5 versus 2.8% MA/A-negative UDS in one study (n = 34, P = 0.008) and 23 versus 16% in another study (n = 54, P = 0.047). Antidepressants as a class had no statistically significant effect on abstinence or retention on the basis of moderate strength evidence. Studies of anticonvulsants, antipsychotics (aripiprazole), opioid antagonists (naltrexone), varenicline and atomoxetine provided either low-strength or insufficient evidence of no effect on the outcomes of interest. Many of the studies had high or unclear risk of bias. Conclusions On the basis of low- to moderate-strength evidence, most medications evaluated for methamphetamine/amphetamine use disorder have not shown a statistically significant benefit. However, there is low-strength evidence that methylphenidate may reduce use.

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

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.

Background Opioid treatment programs (OTPs) may provide interim methadone services – up to 120 days of methadone dosing without counseling. Regulatory requirements limit use of interim methadone services. We summarized the evidence on interim methadone and other strategies to minimize wait lists in OTPs. Methods A scoping review selected studies of interim methadone and strategies that facilitated access to methadone. Randomized trials and controlled observational studies were prioritized; if evidence was lacking, lesser quality evidence was included. Results Six studies examined interim methadone and three studies examined alternatives: low threshold services, an open access policy, and a medication first policy. The studies included four randomized clinical trials of interim methadone (with three follow-up reports and five secondary analyses), one prospective cohort of interim methadone, one retrospective cohort of interim methadone, one randomized trial of low threshold services and two pre-post assessments of changes in program or state policies. The clinical trials and observational cohorts reported reductions in heroin use during interim methadone and participants were more likely to enter OTPs than those on wait lists. Retention rates in interim methadone were similar to patients in active treatment. Studies testing strategies to facilitate access to methadone were effective without interim methadone’s restrictions. Conclusion Interim methadone appears to be effective and safe compared to wait list controls and provided similar outcomes to standard services. Interim methadone could increase access to OTPs. More research is needed on the alternative approaches to facilitate access to medication with comparisons to wait list controls and assessment of patient outcomes.

Chimeric antigen receptor T cell (CAR-T) therapy holds great promise for preventing and treating deadly diseases such as cancer. However, it remains challenging to transfect and engineer primary immune cells for clinical cell manufacturing. Conventional tools using viral vectors and bulk electroporation suffer from low efficiency while posing risks like viral transgene integration and excessive biological perturbations. Emerging techniques using microfluidics, nanoparticles, and high-aspect-ratio nanostructures can overcome these challenges, and on top of that, provide universal and high-throughput cargo delivery. Herein, the strengths and limitations of traditional and emerging materials for immune cell transfection, and commercial development of these tools, are discussed. To enhance the characterization of transfection techniques and uptake by the clinical community, a list of in vitro and in vivo assays to perform, along with relevant protocols, is recommended. The overall aim, herein, is to motivate the development of novel materials to meet rising demand in transfection for clinical CAR-T cell manufacturing.

IntroductionGlaucoma is a progressive, chronic condition that can have a significant impact on a patient’s health-related quality of life (HRQoL). Validated, disease-specific HRQoL tools such as the Health Utility for Glaucoma (HUG-5) tool and the Glaucoma Quality of Life Questionnaire (GlauQoL-17) can be used to monitor a patient’s quality of life. However, the utility of these tools in outpatient clinic practice is not well established. The primary objective of this study is to characterise the feasibility of administering periodic HRQoL questionnaires in glaucoma using a semi-automated workflow.Methods and analysisThis study will be a single-centre, unblinded, randomised, parallel-group study with an exploratory data analysis framework. We aim to determine the feasibility of administering the HUG-5 in an outpatient clinic using a semi-automated workflow and determine patient engagement through email and telephone contact methods. We will also be investigating the association of the HUG-5 and GlauQoL-17 with patient visual field testing and visual acuity. Mean differences between groups will be tested with analysis of variance to determine if the frequency of calls affects burden, satisfaction and perceived value of information.Ethics and disseminationThis study has been approved by the Hamilton Integrated Research Ethics board (ID: 13046) and will be conducted within Canadian Tri-Council Statement policy. Personal information of the study’s participants will be anonymised with identification codes and data will be kept on an encrypted server. Results of this study will be disseminated through peer-reviewed journals, conferences and internal meetings.

CONTEXT:Transition from the pediatric to the adult health care system is a complex process that should include medical, psychosocial, educational, recreational, and vocational considerations.OBJECTIVE:In this systematic review, we aim to synthesize the evidence on transitional care interventions (TCIs) to improve the quality of life (QoL) for adolescents and young adults with childhood-onset disabilities, including neurodevelopmental disorders.DATA SOURCES:Four electronic databases (Medline, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature) were searched.STUDY SELECTION:In the included studies, researchers examined TCIs for adolescents and young adults (12–24 years of age) with childhood-onset disabilities. Studies were experimental, quasi-experimental, and observational studies published in the last 26 years.DATA EXTRACTION:Two reviewers independently completed study screening, data extraction, and risk-of-bias assessment.RESULTS:Fifty-two studies were included. Five studies reported on QoL, but statistically significant improvements were noted in only 1 of these studies. Significant improvements were also found in secondary outcomes including disability-related knowledge and transitional readiness. TCIs targeted patients, families and/or caregivers, and health care providers and exhibited great heterogeneity in their characteristics and components.LIMITATIONS:Inconsistent reporting on interventions between studies hindered synthesis of the relationships between specific intervention characteristics and outcomes.CONCLUSIONS:Although there is limited evidence on the impact of TCIs on the QoL for youth with childhood-onset disabilities, there is indication that they can be effective in improving patient and provider outcomes. The initiation of transition-focused care at an early age may contribute to improved long-term health outcomes in this population.

Background In India, which has the world's third-largest HIV epidemic, the extent to which levels of HIV-related stigma have changed during an era of ART scale-up is unknown. Methods We analyzed data from the 2005-06 and 2015-16 National Family Health Surveys (NFHS) to estimate trends in two stigma domains among people in the general population: desires for social distance from people living with HIV (ie, unwillingness to interact) and fear of serostatus disclosure in the case of a hypothetical HIV infection. We fitted multivariable linear probability models to the data with year of NFHS as the explanatory variable and alternately specifying fear of disclosure or desires for social distance as the dependent variable. Analyses were stratified by sex, state, and high vs low HIV prevalence states. Results We included data on 172 795 women and 159 194 men. Desires for social distance declined in 2015-16 compared with 2005-06 (38% in 2015-16 vs 43% in 2005-06; adjusted b = -0.046; 95% confidence interval (CI = -0.049 to -0.043; P

Continuous delivery of oxygen therapy has been observed to improve healing for individuals with an advanced diabetic foot ulcer (DFU). However, this intervention requires the purchasing of an oxygen delivery device and moist dressings. It is unknown whether this upfront financial investment represents good value for money. Thus the aim of this project is to evaluate the cost‐effectiveness of treating advanced DFU using continuous delivery of oxygen compared with negative pressure wound therapy from the perspective of the public health care payer in Ontario, Canada. A microsimulation model was constructed with inputs from peer‐reviewed journal publications and publicly available reports. The 5‐year costs and quality‐adjusted life‐years were compared between treatment and comparator. Sensitivity analyses were conducted to evaluate the robustness of results. The model predicted that continuous delivery of oxygen would cost $4800 less compared with negative pressure wound therapy and increased quality‐adjusted life years by 0.025. Lower cost and improved outcomes were observed in most scenario analyses. The results of this economic evaluation suggest that CDO therapy may reduce health care economic burden with a modest increase in quality of life outcomes. Health care decision‐makers should consider the inclusion of CDO for the treatment of DFU.

Background Multiple overlapping stents (Full metal jacket, FMJ) from percutaneous coronary artery intervention (PCI) renders coronary artery bypass modus operandi unmanageable. We report our surgical revascularisation in patients with failed full metal jacket of left anterior descending coronary artery (FMJ-LAD). Methods We reviewed 22 patients who presented with FMJ-LAD From 2006 to 2019. Extensive endarterectomy involving almost the whole length of the left anterior descending (LAD) was performed, the arteriotomy patched up with a saphenous vein. All reconstructed LADs were grafted with the left internal mammary artery. We compared the group to propensity-matched patients with single proximal LAD lesions requiring coronary artery bypass graft (CABG). Results The mean age was 54±3.5 years. Twenty-one (21) patients (95%) were in angina class III or IV despite maximum medical therapy. Fourteen (14) patients (63.6%) presented with MI within 1 month. All patients had a preoperative positive test for ischaemia. Cross-clamp and bypass times were significantly shorter (25.5±7 mins and 65±5 mins, versus 52±3 mins and 77.2±4 mins) in the CABG group compared to FMJ-LAD group, the mean hospital stay of 6±1.5 days was not different between the groups. Postoperative electrocardiograms showed non-specific changes in 75% (n=16) with no enzyme rise. Early postoperative angiography was performed in 10 patients because of the new electrocardiograph (ECG) changes; all FMJ-LAD patients had an angiogram at 1 year, two late angiograms (2 and 3 years postoperatively), and one computed tomography (CT)-angiogram for readmission with angina. All patients in the FMJ-LAD group had 12 months follow-up angiogram or cardiac CT scan. All the endarterectomies' LADs were patent. There was no mortality within the 30 days. Patients' follow-up time was between 1–13 years. Conclusions Open stent endarterectomy is a valuable alternative option for patients with “full metal jacket” diseased LAD that is not graftable using standard techniques with acceptable midterm results.

The objectives of this study were to describe home care utilization and costs in community-dwelling individuals 2 years post-spinal cord injury (SCI) in Ontario, Canada. This retrospective incident cohort study uses administrative health care data to identify individuals with traumatic SCI (tSCI). Time to service delivery and frequency of service delivery and costs were calculated. A total of 798 individuals with tSCI comprised the cohort. In the first 2 years, personal support/homemaking was the most utilized service. Median cumulative home care 2 years post-discharge was $7,200 ($1,240-35,410 25-75% interquartile range). This study highlights the importance of home care to individuals with SCI.

Background Australian clinical guidelines recommend further investigation in females with postmenopausal bleeding (PMB) and endometrial thickness (ET) of ≥4 mm on transvaginal ultrasound (TVUS). However, the literature indicates that an ET of ≥3 mm as an upper limit is a more sensitive predictor of endometrial malignancy (EM) in females with PMB. Aims To assess whether Australian guidelines for PMB with an upper limit of 4 mm ET on ultrasound investigation, is sensitive enough for malignancy detection. Material and methods A retrospective study was performed on tissue results in PMB presentations to the Gold Coast Hospital and Health Service between 2011 and 2015. Results Twenty point nine percent of women with PMB had a malignancy. With an upper limit of 4 mm in ET on ultrasound, malignancy was present in 22% of participants. [Correction added on 10 July 2020, after first online publication: percentage of women with PMB that had a malignancy has been amended to twenty point nine percent.] CONCLUSIONS: A limit of 3 mm for ET in PMB, along with office endometrial biopsy, should be considered to ensure timely diagnoses.

Co-occurring heroin and methamphetamine use is a growing public health problem. This study assessed the characteristics of Medicaid patients admitted to substance use disorder (SUD) treatment programs for heroin and methamphetamine use compared with patients admitted for heroin only.The study identified patients who entered treatment for heroin and methamphetamine and those admitted for heroin only between 2014 and 2017 from the Oregon Treatment Episode Data Set linked with Medicaid enrollment, and medical and pharmacy claims. We used a cross-sectional design to compare demographics, type of treatment, and substance use characteristics between the two groups. We used logistic regression models to assess differences in the odds of opioid-related and all-cause adverse events.Among the 3802 study sample, 2004 (53%) were admitted for both heroin and methamphetamine use. The heroin and methamphetamine group were more likely to be younger, female, White or American Indian/Alaska Native; and had more comorbidities than patients admitted for heroin only. Patients admitted for heroin and methamphetamine treatment were less likely to receive any medication for opioid use disorder (MOUD) (56% vs 75%, p 0.001) and received fewer days of MOUD treatment (mean 188 vs. 265 days, p 0.001) compared to the heroin only group. The heroin and methamphetamine group were more likely to receive buprenorphine (28.1% vs 24.2%) and less likely to receive methadone (39.9% vs 62.5%). The heroin and methamphetamine group began use at a younger age, used and injected more frequently than those admitted for heroin only. Patients treated for heroin and methamphetamine had 17% lower odds of OUD-related adverse events (aOR 0.83; 95% CI 0.70-0.99) and 52% higher odds of all-cause adverse events (aOR 1.52; 95% CI 1.14-2.03) relative to the heroin only group.Patients admitted for both heroin and methamphetamine reported greater addiction severity (more frequent use, earlier onset of use, and injection use), yet less commonly received MOUD compared to those who were admitted for heroin only. These findings indicate substantial missed opportunities for MOUD treatment even among people who successfully engage with the SUD treatment system.

Objective: To determine the publicly funded health care system lifetime cost-of-illness of spinal cord injury (SCI) from the perspective of the Ontario Ministry of Health and Long-term Care. Methods: Individuals hospitalized for their first SCI between the years 2005 and 2011 were identified and their health care costs were calculated using Ontario administrative health care data. From this information, lifetime costs were estimated using phase-based costing methods. The spinal cord injured cohort was matched to a non-spinal cord injured using propensity score matching. Net costs were determined by calculating the difference in costs between the two matched groups. Net costs were also presented for subgroups stratified by demographic characteristics. Results: A total of 1,716 individuals with SCI were identified and matched in our study. The net lifetime cost of SCI was $336,000 per person. Much of the costs were observed in the first year post-SCI. The lifetime cost of SCI for individuals with a concurrent pressure ulcer at the initial hospitalization rises to $479,600. Costs were also higher for individuals with cervical or thoracic injury or requiring inpatient rehabilitation. Conclusions: Spinal cord injury is a substantial burden to the health care system. Our results are limited to the direct health care costs from the publicly funded health care payer perspective. Further analysis with a broader perspective is needed to understand the full economic impact of this catastrophic condition.

Background: Reaching World Health Organization hepatitis C (HCV) elimination targets requires diagnosis and treatment of people who use drugs (PWUD) with direct acting antivirals (DAAs). PWUD experience challenges engaging in HCV treatment, including needing multiple provider and laboratory appointments. Women, minoritized racial communities, and homeless individuals are less likely to complete treatment. Methods: We implemented a streamlined opt-out HCV screening and linkage-to-care program in two healthcare for the homeless clinics and a medically supported withdrawal center. Front-line staff initiated a single-order reflex laboratory bundle combining screening, confirmation, and pre-treatment laboratory evaluation from a single blood draw. Multinomial logistic regression models identified characteristics influencing movement through each stage of the HCV treatment cascade. Multiple logistic regression models identified patient characteristics associated with HCV care cascade progression and Cox proportional hazards models assessed time to initiation of DAAs. Results: Of 11,035 clients engaged in services between May 2017 and March 2020, 3,607 (32.7%) were screened. Of those screened, 1,020 (28.3%) were HCV PCR positive. Of those with detectable RNA, 712 (69.8%) initiated treatment and 670 (94.1%) completed treatment. Of those initiating treatment, 407 (57.2%) achieved SVR12. There were eight treatment failures and six reinfections. In the unadjusted model, the bundle intervention was associated with increased care cascade progression, and in the survival analysis, decreased time to initiation; these differences were attenuated in the adjusted model. Women were less likely to complete treatment and SVR12 labs than men. Homelessness increased likelihood of screening and diagnosis but was negatively associated with completing SVR12 labs. Presence of opioid and stimulant use disorder diagnoses predicted increased care cascade progression. Conclusions: The laboratory bundle and referral pathways improved treatment initiation, time to initiation, and movement across the cascade. Despite overall population improvements, women and homeless individuals experienced important gaps across the HCV care cascade.

Background The Drug Enforcement Administration (DEA) approved the first mobile medication unit (i.e., a van to administer methadone) in 1988 and approved units on an ad hoc basis until issuing a moratorium in 2007 citing concerns about safety and diversion. In February 2020, the DEA released a notice of proposed rulemaking to permit a resumption of mobile medication units. The Biden Administration plans to release the final rule in 2021. Because a preliminary scan suggested limited evidence, a scoping review examined the research related to methadone vans to identify and assess the extent of mobile methadone research and inform the development and implementation of new mobile services. Methods A scoping review, supplemented with key informant interviews, identified and described the most relevant evidence. Ovid MEDLINE and the Cochrane Database of Systematic Reviews databases were searched from inception to July 2020. Results Informant interviews provided perspective on the need for and the use of mobile medication units, the history of methadone vans, and benefits and problems associated with the units. The scoping review found limited evidence: three cohort analyses (one prospective) and one before and after analysis (four studies) of individuals using mobile medication services. Mobile services were associated with enhanced retention in care (relative to patients in fixed site programs) and mobile units appeared to facilitate access for underserved populations with opioid use disorders. Discussion The key informants addressed the history of methadone vans, the potential use to serve rural communities and correctional facilities and the benefits and problems associated with mobile services. The scoping review found evidence that mobile services increase methadone access among underserved populations and may enhance retention in care. The DEA's proposed regulatory modification creates opportunities to further evaluate the implementation and the effects of mobile medication units.

Objective: To systematically review the published academic literature on the cost of chronic ulcers. Methods: A literature search was conducted in MEDLINE, EMBASE, HealthSTAR, Econlit and CINAHL up to 12 May 2016 to identify potential studies for review. Cost search terms were based on validated algorithms. Clinical search terms were based on recent Cochrane reviews of interventions for chronic ulcers. Titles and abstracts were screened by two reviewers to determine eligibility for full text review. Study characteristics were summarised. The quality of reporting was evaluated using a modified cost-of-illness checklist. Mean costs were adjusted and inflated to 2015 $US and presented for different durations and perspectives. Results: Of 2267 studies identified, 36 were eligible and included in the systematic review. Most studies presented results from the health-care public payer or hospital perspective. Many studies included hospital costs in the analysis and only reported total costs without presenting condition-specific attributable costs. The mean cost of chronic ulcers ranged from $1000 per year for patient out of pocket costs to $30,000 per episode from the health-care public payer perspective. Mean one year cost from a health-care public payer perspective was $44,200 for diabetic foot ulcer (DFU), $15,400 for pressure ulcer (PU) and $11,000 for leg ulcer (LU). Conclusions: There was large variability in study methods, perspectives, cost components and jurisdictions, making interpretation of costs difficult. Nevertheless, it appears that the cost for the treatment of chronic ulcers is substantial and greater attention needs to be made for preventive measures.

BACKGROUND: Electronic patient-portals offer the potential to enhance patient-physician communication and health outcomes but differential use may create or worsen disparities. While prior studies identified patient characteristics associated with patient-portal use, the role of physician factors is less known. We investigated differences in overall and patterns of portal use for patients with resident and attending primary care providers (PCPs). METHODS: Cross-sectional study of all established patients with a resident or attending PCP seen at an academic internal medicine practice (two sites) between May 1, 2014, and April 30, 2015. We defined patient-portal use as having accessed any “active” (secure messaging, medication refill request), or “passive” (viewing labs, after visit summaries, or appointments) patient-portal function more than once over the study period. We used generalized linear models clustered on PCP to examine the odds of patient-portal use by PCP type, adjusted for patient age, gender, preferred language, race/ethnicity, insurance, and visits. Among patient-portal users, we examined the association of PCP type with “active use” utilizing the same method. RESULTS: The mean patient age (n = 17,699) was 54.2 (SD 17.5), with 47.2% White, 23.6% Asian, 8.8% Black, 8.4% Latino, and 12% other/unknown. The majority (61.8%) had private insurance, and attending PCPs (76.9%). Although 72.3% enrolled in the patient-portal, only 53.4% were portal users; 40.0% were active users. There were 47 attending and 62 resident physicians. Patients with resident PCPs had lower odds of using the portal compared to those with attending PCPs (OR = 0.54, 95% CI 0.50–0.59). Similarly, among portal users, residents’ patients had lower odds of being active users of the portal (OR = 0.76, 95% CI 0.68–0.87). CONCLUSION: Given the lower patient-portal use among residents’ patients, residency programs should develop curricula to bolster trainee competence in using the patient-portal for communication and to enhance the patient-physician relationship. Future research should explore additional physician factors that impact portal use.

BackgroundDepression is highly prevalent in people living with HIV (PLHIV) and is associated with increased morbidity and mortality. In India, where access to mental health specialists is limited, little is known about the attitude of HIV clinicians toward depression in PLHIV.MethodsWe administered a questionnaire to HIV clinicians attending the 2015 Chennai Antiretroviral Therapy Symposium that assessed respondents' level of agreement with 29 statements regarding the etiology, importance, and management of depression and whether they felt capable and willing to manage depression in PLHIV.ResultsThe 69 respondents were from 9 Indian states. Most respondents agreed that depression in PLHIV is a serious problem (91%) and is associated with poorer HIV-related outcomes (62%-81%). Although most respondents (76%) reported feeling comfortable discussing mental health problems with PLHIV, almost half (48%) admitted that lack of knowledge and training about mental health issues hindered the diagnosis and treatment of depression in PLHIV. With few exceptions, there were no significant differences in responses by gender, urban/rural practice location, or government versus private practice.ConclusionsIndian HIV clinicians believe that depression in PLHIV is important and are willing to manage depression in the HIV primary care setting. These findings suggest that HIV clinicians require further training to deliver evidence-based interventions to treat PLHIV with depression.

Background Stimulant (cocaine and/or methamphetamine) use has increased among people with opioid use disorder. We conducted a systematic review of medications for stimulant use disorders in this population. Methods We searched for randomized controlled trials in multiple databases through April 2019, and dual-screened studies using pre-specified inclusion criteria. Primary outcomes were abstinence defined as stimulant-negative urine screens for ≥3 consecutive weeks; overall use as the proportion of stimulant-negative urine specimens; and retention as the proportion of participants who completed treatment. We rated strength of evidence using established criteria and conducted meta-analyses of comparable interventions and outcomes. Results Thirty-four trials of 22 medications focused on cocaine use disorder in patients with opioid use disorder. Most studies enrolled participants stabilized on opioid maintenence therapy, generally methadone. None of the six studies that assessed abstinence found significant differences between groups. We found moderate-strength evidence that antidepressants (desipramine, bupropion, and fluoxetine) worsened retention. There was moderate-strength evidence that disulfiram worsened treatment retention (N = 605, RR 0.86, 95 % CI 0.77 to 0.95). We found low-strength evidence that psychostimulants (mazindol and dexamphetamine) may reduce cocaine use, though the difference was not statistically significant (standard mean difference 0.35 [95 % CI -0.05 to 0.74]). There was only 1 trial for methamphetamine use disorder, which showed insufficient-strength evidence for naltrexone. Conclusions Co-occurring stimulant/opioid use disorder is an important problem for targeting future research. Medication trials for methamphetamine use disorder are lacking in this population. Most of the medications studied for cocaine use were ineffective, although psychostimulants warrant further study.

In India, there is little evidence on reasons for high rates of loss to HIV care. We conducted a clinic-based qualitative study at the YR Gaitonde Centre for AIDS Research and Education to explore factors that influence loss to care. In all, 17 men and 14 women were interviewed; median age was 42 (interquartile range [IQR], 36-48) and median CD4 count was 448 (IQR, 163-609). A majority reported avoiding treatment freely available at nearby government facilities because of disclosure concerns and perceptions of poor quality. As a result, participants sought care in the private sector where they were subjected to medication and transport costs. Life circumstances causing lost wages or unexpected expenditures therefore prevented participants from attending clinic, resulting in loss to care. Improving perceptions of quality of care in the public sector, addressing disclosure concerns, and reducing economic hardships among people living with HIV may be important in reducing loss to HIV care in India.

Objectives: To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), and combining both treatments in a stepped care pathway for patients with treatment-resistant depression (TRD) in Ontario. Methods: A cost–utility analysis evaluated the lifetime costs and benefits to society of rTMS and ECT as first-line treatments for TRD using a Markov model, which simulates the costs and health benefits of patients over their lifetime. Health states included acute treatment, maintenance treatment, remission, and severe depression. Treatment efficacy and health utility data were extracted and synthesized from randomized controlled trials and meta-analyses evaluating these techniques. Direct costing data were obtained from national and provincial costing databases. Indirect costs were derived from government records. Scenario, threshold, and probabilistic sensitivity analyses were performed to test robustness of the results. Results: rTMS dominated ECT, as it was less costly and produced better health outcomes, measured in quality-adjusted life years (QALYs), in the base case scenario. rTMS patients gained an average of 0.96 additional QALYs (equivalent to approximately 1 year in perfect health) over their lifetime with costs that were $46,094 less than ECT. rTMS remained dominant in the majority of scenario and threshold analyses. However, results from scenarios in which the model’s maximum lifetime allowance of rTMS treatment courses was substantially limited, the dominance of rTMS over ECT was attenuated. The scenario that showed the highest QALY gain (1.19) and the greatest cost-savings ($46,614) was when rTMS nonresponders switched to ECT. Conclusion: From a societal perspective utilizing a lifetime horizon, rTMS is a cost-effective first-line treatment option for TRD relative to ECT, as it is less expensive and produces better health outcomes. The reduced side effect profile and greater patient acceptability of rTMS that allow it to be administered more times than ECT in a patient’s lifetime may contribute to its cost-effectiveness.

OBJECTIVEAcute spine trauma (AST) has a relatively low incidence, but it often results in substantial individual impairments and societal economic burden resulting from the associated disability. Given the key role of neurosurgeons in the decision-making regarding operative management of individuals with AST, the authors performed a systematic search with scoping synthesis of relevant literature to review current knowledge regarding the economic burden of AST.METHODSThis systematic review with scoping synthesis included original articles reporting cost-effectiveness, cost-utility, cost-benefit, cost-minimization, cost-comparison, and economic analyses related to surgical management of AST, whereby AST is defined as trauma to the spine that may result in spinal cord injury with motor, sensory, and/or autonomic impairment. The initial literature search was carried out using MEDLINE, EMBASE, CINAHL, CCTR, and PubMed. All original articles captured in the literature search and published from 1946 to September 27, 2017, were included. Search terms used were the following: (cost analysis, cost effectiveness, cost benefit, economic evaluation or economic impact) AND (spine or spinal cord) AND (surgery or surgical).RESULTSThe literature search captured 5770 titles, of which 11 original studies met the inclusion/exclusion criteria. These 11 studies included 4 cost-utility analyses, 5 cost analyses that compared the cost of intervention with a comparator, and 2 studies examining direct costs without a comparator. There are a few potentially cost-saving strategies in the neurosurgical management of individuals with AST, including 1) early surgical spinal cord decompression for acute traumatic cervical spinal cord injury (or traumatic thoracolumbar fractures, traumatic cervical fractures); 2) surgical treatment of the elderly with type-II odontoid fractures, which is more costly but more effective than the nonoperative approach among individuals with age at AST between 65 and 84 years; 3) surgical treatment of traumatic thoracolumbar spine fractures, which is implicated in greater direct costs but lower general-practitioner visit costs, private expenditures, and absenteeism costs than nonsurgical management; and 4) removal of pedicle screws 1–2 years after posterior instrumented fusion for individuals with thoracolumbar burst fractures, which is more cost-effective than retaining the pedicle screws.CONCLUSIONSThis scoping synthesis underscores a number of potentially cost-saving opportunities for neurosurgeons when managing patients with AST. There are significant knowledge gaps regarding the potential economic impact of therapeutic choices for AST that are commonly used by neurosurgeons.

Introduction Population‐level improvements in knowledge about HIV may reduce the stigma attached to HIV and ensure maximal uptake of HIV prevention initiatives. The extent to which levels of HIV knowledge in the general population of sub‐Saharan Africa have changed in the current era of antiretroviral therapy (ART) scale‐up remains unknown. Methods Data on HIV knowledge in the general population were drawn from the 2003 to 2015 Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) of 33 countries in sub‐Saharan Africa. The DHS/AIS contain five questions on HIV prevention and transmission that have been used by the Joint United Nations Programme on HIV/AIDS (UNAIDS) as a core indicator of HIV knowledge. We created a composite HIV knowledge variable equal to the number of correct responses to these five questions; a participant was considered to have comprehensive knowledge of HIV (yes/no) if he/she answered all five questions correctly. We fitted negative binomial regression models with cluster‐correlated robust standard errors and country fixed effects, adjusted for socio‐demographic variables, specifying HIV knowledge as the dependent variable and year as the explanatory variable. As an alternative parameterization, we also fitted a multivariable linear probability model with cluster‐correlated robust standard errors and country fixed effects specifying comprehensive knowledge of HIV as the dependent variable. Results A total of 791,186 women and 395,891 men participating in 75 DHS/AIS were included in the analyses. The mean HIV knowledge score was 3.7 among women and 3.9 among men (p

Background In India, which has the third largest HIV epidemic in the world, depression and HIV-related stigma may contribute to high rates of poor HIV-related outcomes such as loss to care and lack of virologic suppression. Methods We analyzed data from a large HIV treatment center in southern India to estimate the burden of depressive symptoms and internalized stigma among Indian people living with HIV (PLHIV) entering into HIV care and to test the hypothesis that probable depression was associated with internalized stigma. We fitted modified Poisson regression models, adjusted for sociodemographic variables, with probable depression (PHQ-9 score ≥10 or recent suicidal thoughts) as the outcome variable and the Internalized AIDS-Related Stigma Scale (IARSS) score as the explanatory variable. Findings 521 persons (304 men and 217 women) entering into HIV care between January 2015 and May 2016 were included in the analyses. The prevalence of probable depression was 10% and the mean IARSS score was 2.4 (out of 6), with 82% of participants endorsing at least one item on the IARSS. There was a nearly two times higher risk of probable depression for every additional point on the IARSS score (Adjusted Risk Ratio: 1.83; 95% confidence interval, 1.56-2.14). Conclusions Depression and internalized stigma are highly correlated among PLHIV entering into HIV care in southern India and may provide targets for policymakers seeking to improve HIV-related outcomes in India.

Objectives. We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa. Methods. We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable. Results. Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = −0.226; P = .007; 95% confidence interval [CI] = −0.383, −0.070) and men (b = −0.281; P = .009; 95% CI = −0.480, −0.082) in the general population reporting HIV-related stigma. Conclusions. An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population.

Microparticles (MPs) are small membranous particles (100-1000 nm) released under normal steady-state conditions and are thought to provide a communication network between host cells. Previous studies demonstrated that Mycobacterium tuberculosis (M. tb) infection of macrophages increased the release of MPs, and these MPs induced a proinflammatory response from uninfected macrophages in vitro and in vivo following their transfer into uninfected mice. To determine how M. tb infection modulates the protein composition of the MPs, and if this contributes to their proinflammatory properties, we compared the proteomes of MPs derived from M. tb-infected (TBinf-MP) and uninfected human THP-1 monocytic cells. MP proteins were analyzed by GeLC-MS/MS with spectral counting revealing 68 proteins with statistically significant differential abundances. The 42 proteins increased in abundance in TBinf-MPs included proteins associated with immune function (7), lysosomal/endosomal maturation (4), vesicular formation (12), nucleosome proteins (4), and antigen processing (9). Prominent among these were the type I interferon inducible proteins, ISG15, IFIT1, IFIT2, and IFIT3. Exposure of uninfected THP-1 cells to TBinf-MPs induced increased gene expression of isg15, ifit1, ifit2, and ifit3 and the release of proinflammatory cytokines. These proteins may regulate the proinflammatory potential of the MPs and provide candidate biomarkers for M. tb infection.

© 2015 The Authors. Tuberculosis (TB) remains a major public health issue. New tests to aid diagnoses and monitor the response to therapy are urgently required. There is growing interest in the use of microRNA (miRNA) profiles as diagnostic, prognostic or predictive markers in a range of clinical and infectious diseases, including Mycobacterium tuberculosis infection, however, challenges exist to accurately normalise miRNA levels in cohorts. This study examined the appropriateness of 12 miRs and RNU6B to normalise circulating plasma miRNA levels in individuals with active TB from 2 different geographical and ethnic regions. Twelve miRs (let-7, miR-16, miR-22, miR-26, miR-93, miR-103, miR-191, miR-192, miR-221, miR-423, miR-425 and miR-451) and RNU6B were selected based on their reported production by lung cells, expression in blood and previous use as a reference miRNA. Expression levels were analysed in the plasma of newly diagnosed TB patients from Australia and China compared with individuals with latent TB infection and healthy volunteers. Analysis with both geNorm and NormFinder software identified miR-93 as the most suitable reference miR in both cohorts, either when analysed separately or collectively. Interestingly, there were large variations in the expression levels of some miRs, in particular miR-192 and let-7, between the two cohorts, independent of disease status. These data identify miR-93 is a suitable reference miR for normalizing miRNA levels in TB patients, and highlight how environmental, and possibly ethnic, factors influence miRNA expression levels, demonstrating the necessity of assessing the suitability of reference miRs within the study population.

We used data from 660 people living with HIV in southern India to evaluate the reliability, validity, and factor structure of the Internalized AIDS-Related Stigma Scale. Exploratory factor analysis revealed the presence of 2 factors: a 2-item factor related to disclosure concerns and a 4-item factor related to self-hatred. The self-hatred factor demonstrated acceptable internal consistency (Cronbach α = .80). As evidence of construct validity, both factors were correlated with depression symptom severity as measured by the Patient Health Questionnaire-9. Further study is needed to understand the correlates of these factors and their impact on the Indian HIV care continuum.

Objective: To determine the net cost of hospital-acquired and pre-admission pressure ulcers (PUs) in an acute-care setting in Ontario, Canada. Method: Cases of PUs were identified among hospitalised patients using Ontario Case Costing Initiative (OCCI) data from 2002–2006. Inpatient costs included direct and overhead costs. To determine the net cost of PUs, cases were matched controlling for age, gender, most responsible diagnosis and comorbidity. Mean net costs were estimated using Bayesian linear mixed models methods. Results were also reported by PU severity. Results: In our study, there were 1351 cases of hospital-acquired PUs and 2523 cases of pre-admission PUs over 5 years. Net cost of hospital-acquired PU ranged between CA$44 000 for a category II PU to CA$90 000 for a category IV PU. For pre-admission PU net cost was between CA$11 000 to CA$18 500 for category II and category IV PU, respectively. The net cost of treating hospital-acquired PU is higher than pre-admission PU. Costs increase with increasing PU severity. Conclusion: The total net adjusted hospitalisation cost of a hospital-acquired PU in Ontario was CA$44 000–90 000, compared with CA$11 000–18 500 for a pre-admission PU. Future studies should determine the attributable cost of PU using patient-level data to verify the accuracy of the study results. Declaration of interest: No authors received any payment for services from a third party for any aspect of this study. At the time of this study, B. Chan was funded by the Ontario neurotrauma Foundation for his doctoral studies.