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Recent work involving survey administration among emergency department (ED) patients has demonstrated very low response rates using single-mode (e.g., mail-only or web-only) approaches. In this study, the authors tested several mixed-mode protocols that focus on a push-to-web approach for survey administration in this challenging but important setting. A random sample of 26,991 ED discharged-to-community (DTC) patients discharged in January 2018–March 2018 from 16 hospital-based EDs nationwide were randomized to nine survey arms, eight of which involved a web survey with one or more of the following methods of invitation to the web survey: an emailed link to the web survey, a texted link to the web survey, and/or a mailed paper invitation with information on how to access the web survey. The reference arm was standard mixed mode (mailed survey with telephone follow-up). Invitation(s) to the web survey was followed by (1) a mailed survey, (2) telephone follow-up, or (3) both. The overall response rate across all arms was 18.6% (American Association for Public Opinion Research [AAPOR] RR1). None of the tested web-survey arms had significantly higher response rates than standard mixed mode (25.5%). Protocol comparisons demonstrated that both text outreach and including a telephone mode increased response rates. When examining response by completion mode, the arms involving text invitation had a higher percentage of completed surveys that were completed by web than arms not involving text invitation. Characteristics (e.g., age) of telephone and web respondents were more representative of the sampled population than mail respondents. Older patients and male patients were significantly less likely to be reachable by email or text. These results demonstrate that sequential multi-mode approaches involving web, mail, and telephone with multiple methods of web survey invitation show the greatest promise for obtaining higher response rates and more representative respondents from the ED population.

Standard single survey mode approaches, such as mail-only or telephone-only, generally produce lower response rates than sequential mixed mode (SMM) approaches. SMM approaches may be particularly important when lower response propensities and/or poor contact information exist, as with emergency department (ED) patients. Results were examined from a randomized feasibility study testing five survey administration modes among ED patients who are discharged-to-community. A total of 4,017 discharged patients from eight EDs during February 2016 were randomized in equal numbers to five modes: on-site distribution of a paper survey; mail notification of a web survey; email notification of a web survey; two-stage SMM (mailed survey with telephone follow-up); and three-stage SMM (email notification of a web survey with mail follow-up and then telephone follow-up). Sampled patients received a 43-item instrument focusing on ED patient experience. The two-stage SMM, commonly used for other patient experience surveys, was the reference mode. Three-stage SMM had a higher response rate (30.7%) than two-stage SMM (25.3%); the other three experimental modes had significantly lower response rates (0.8–9.6%; p

The emergency department (ED) setting is unique and measuring quality of care in the ED requires the development of ED-specific tools. The Emergency Department Patient Experience of Care Discharged to Community Survey was designed to measure patient experience in the ED setting.Describe results from the Emergency Department Patient Experience of Care Discharged to Community Survey including respondent characteristics and reported patient experience, and examine factors, including mode of survey administration, associated with response propensity and response patterns.In total, 16,006 discharges were sampled from 50 hospitals nationwide to receive the survey using a mode experiment design. Logistic regression modeled response propensity; linear regression examined associations between response patterns and patient characteristics and mode.In total, 3122 survey respondents.Measures of patient experience.Patients reported that hospitals consistently informed them of the purpose of any new medications (84% yes, definitely), but did not consistently explain their possible side effects (53%). Age, education, health, and arrival by ambulance were significantly associated with response patterns. There were significant differences in response rate by mode: 29% mixed mode, 22% telephone only and 14% mail only. Mode of administration was significantly associated with response patterns whereby patients surveyed using telephone-only or mixed mode tended to respond more positively than those surveyed using mail only.There is room for improvement in terms of patient experience in the ED setting. Effects of patient characteristics and survey mode on responses were large enough to necessitate appropriate adjustments if hospitals are to be compared in the future.

Background Opioid use disorders (OUDs) have devastating effects on individuals, families, and communities. While medication treatments for OUD save lives and are increasingly utilized, rates of treatment dropout are very high. In addition, most existing medication treatments for OUD may often neglect the impact of untreated OUD on relationships and ignore the potential role support persons (SPs) could have on encouraging long-term recovery, which can also impact patient treatment retention. Methods/design The current study adapts Community Reinforcement and Family Training (CRAFT) for use with SPs (family member, spouse or friend) of patients using buprenorphine/naloxone (buprenorphine) in an outpatient community clinic setting. The study will evaluate whether the adapted intervention, also known as integrating support persons into recovery (INSPIRE), is effective in increasing patient retention on buprenorphine when compared to usual care. We will utilize a two-group randomized design where patients starting or restarting buprenorphine will be screened for support person status and recruited with their support person if eligible. Support persons will be randomly assigned to the INSPIRE intervention, which will consist of 10 rolling group sessions led by two facilitators. Patients and SPs will each be assessed at baseline, 3 months post-baseline, and 12 months post-baseline. Patient electronic medical record data will be collected at six and 12 months post-baseline. We will examine mechanisms of intervention effectiveness and also conduct pre/post-implementation surveys with clinic staff to assess issues that would affect sustainability. Discussion Incorporating the patient’s support system may be an important way to improve treatment retention in medication treatments for OUD. If SPs can serve to support patient retention, this study would significantly advance work to help support the delivery of effective treatments that prevent the devastating consequences associated with OUD. Trial registration This study was registered with ClinicalTrials.gov, NCT04239235. Registered 27 January 2020, https://clinicaltrials.gov/ct2/show/NCT04239235.

Ecological momentary assessment (EMA) is a popular assessment method in psychology that aims to capture events, emotions, and cognitions in real time, usually repeatedly throughout the day. Because EMA typically involves more intensive monitoring than traditional assessment methods, missing data are commonly an issue and this missingness may bias results. EMA can involve two types of missing data: known missingness, arising from nonresponse to scheduled prompts, and hidden missingness, arising from nonreporting of focal events (e.g., an urge to smoke or a meal). Prior research on missing data in EMA has focused almost exclusively on nonresponse to scheduled prompts. In this study, we introduce a scaled inverse probability weighting approach to assess the risk of bias due to nonreporting of events due to fatigue on estimates of exposure or correlates of exposure. In our proposed approach, the inverse probability is the estimated probability of compliance with random prompts from a model that uses participant and contextual factors to predict this compliance and a fatigue factor that adjusts for attrition in event reporting over time. We demonstrate the use and utility of our bias assessment method with the Tracking and Recording Alcohol Communications Study, an EMA study of adolescent exposure to alcohol advertising.

Little is known about the extent and nature of youth exposure to online alcohol advertising, or factors that may be associated with exposure. The current study recruited middle school students who completed a paper survey and then logged each alcohol advertisement that they encountered over a 2-week period using cell phones as part of an ecological momentary assessment design. We examined the percentage of youth who reported exposure to online alcohol advertising in the past 2 weeks, average weekly rate of exposure, types of online alcohol advertisements youth reported seeing, and factors that increased youths' risk of exposure to online alcohol advertising. Analyses are based on 485 participants (47% female; 25% Hispanic, 25% White, 27% Black; 6% Asian, 16% other). Youth logged exposures to a total of 3,966 (16,018 weighted for underreporting) alcohol advertisements across the monitoring period; 154 (568 weighted) or 3.6% were online ads. Seventeen percent of youth reported seeing any online alcohol ad; the majority of online ads seen were video commercials (44.8%) and banner/side ads (26.6%). Factors associated with greater ad exposure were being older, rebellious, and Black race; greater parental monitoring and more hours spent on social media were associated with less exposure. Findings provide important information about adolescents' exposure to online alcohol advertising and what might contribute to a greater likelihood of exposure. Given that online ad exposure is linked to drinking behavior, prevention programming for younger adolescents should continue to address this issue to help youth make healthy choices regarding alcohol use. (PsycINFO Database Record

Purpose To evaluate the momentary association between exposure to alcohol advertising and middle-school students' beliefs about alcohol in real-world settings and to explore racial/ethnic differences in this association. Methods Middle-school students (N = 588) carried handheld data collection devices for 14 days, recording their exposures to all forms of alcohol advertising during the assessment period. Students also responded to three investigator-initiated control prompts (programmed to occur randomly) on each day of the assessment period. After each exposure to advertising and at each control prompt, students reported their beliefs about alcohol. Mixed-effects regression models compared students' beliefs about alcohol between moments of exposure to alcohol advertising and control prompts. Results Students perceived the typical person their age who drinks alcohol (prototype perceptions) more favorably and perceived alcohol use as more normative at times of exposure to alcohol advertising than at times of nonexposure (i.e., at control prompts). Exposure to alcohol advertising was not associated with shifts in the perceived norms of black and Hispanic students, however, and the association between exposure and prototype perceptions was stronger among non-Hispanic students than among Hispanic students. Conclusions Exposure to alcohol advertising is associated with acute shifts in adolescents' perceptions of the typical person that drinks alcohol and the normativeness of drinking. These associations are both statistically and substantively meaningful.

OBJECTIVE: The purpose of this study was to quantify the persistence of immediate changes in adolescents’ alcohol-related beliefs associated with exposure to alcohol advertising. METHOD: Middle school students (N = 606) carried handheld devices for 14 days and logged all of their exposures to alcohol advertisements as they naturally occurred. Perceptions of the typical person one’s age who drinks (“prototype perceptions”) and perceived norms regarding alcohol use were assessed after each exposure to advertising and at random prompts issued daily throughout the assessment period. Generalized additive modeling was used to determine how long pro-drinking shifts in beliefs persisted after exposure to advertising. RESULTS: Following exposure to advertisements, positivity of youth’s prototype perceptions immediately increased (β = .07, 95% CI [.06, .09]) and then decreased (β = -.05, 95% CI [-.07, -.03]) over the subsequent 1.5 days, whereas perceived normativeness of alcohol use immediately increased (β = .04, 95% CI [.01, .06]) and then decreased (β = -.03, 95% CI [-.05, -.01]) over the subsequent 2 days. Changes in beliefs occurring after 1.5 days for prototype perceptions and after 2 days for perceived norms were not statistically significant, suggesting that these beliefs were no longer affected by the advertising exposure. CONCLUSIONS: Findings are consistent with theories of alcohol advertising effects that presume that repeated exposure results in cumulative, enduring effects on beliefs. Given the rate of decay of alcohol advertising effects, it may be important to limit youth exposures to one every 2 days to avoid cumulative, lasting pro-drinking shifts in beliefs or to devise ways to interrupt cumulative effects with counter-messaging through media, parents, or other influential others at similar intervals.

Youths in this study (ages 11–14) were exposed to an average of three alcohol ads per day; black and Hispanic youths' exposure was roughly double that of white youths. Exposure to alcohol ads led youths to view alcohol and drinking more positively.

Importance Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD. Objective To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care. Design, Setting, and Participants A randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months. Interventions Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41(11.7) years for the CC group, and 43 (12.2) yearsfor the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals. Main Outcomes and Measures The primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD. Results At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.7%; adjusted OR, 3.54; 95% CI, 2.02-6.20; P P P = .01). Conclusions and Relevance Among adults with OAUD in primary care, the SUMMIT collaborative care intervention resulted in significantly more access to treatment and abstinence from alcohol and drugs at 6 months, than usual care. Trial Registration clinicaltrials.gov Identifier:NCT01810159

Untreated substance use disorders remain a pervasive public health problem in the United States, especially among medically-underserved and low-income populations, with opioid and alcohol use disorders (OAUD) being of particular concern. Primary care is an underutilized resource for delivering treatment for OAUD, but little is known about the organizational capacity of community-based primary care clinics to integrate treatment for OAUD. The objective of this study was to use an organizational capacity framework to examine perceived barriers to implementing the continuum of care for OAUD in a community-based primary care organization over three time points: pre-implementation (preparation), early implementation (practice), and full implementation. Clinic administrators and medical and mental health providers from two clinics participated in interviews and focus groups. Barriers were organized by type and size, and are presented over the three time points. Although some barriers persisted, most barriers decreased over time, and respondents reported feeling more efficacious in their ability to successfully deliver OAUD treatment. Findings contribute to the needed literature on building capacity to implement OAUD treatment in primary care and suggest that while barriers may be sizable and inevitable, successful implementation is still possible.

OBJECTIVE: Recent research revealed momentary associations between exposure to alcohol advertising and positive beliefs about alcohol among adolescents (Martino et al., 2016). We reanalyzed those data to determine whether associations depend on adolescents' appraisal of ads. METHOD: Over a 10-month period in 2013, 589 youth, ages 11-14, in the Los Angeles, CA, area, participated in a 14-day ecological momentary assessment, logging all exposures to alcohol advertisements as they occurred and completing brief assessments of their skepticism toward, liking of, and identification with any people in each ad, as well as their alcohol-related beliefs at the moment. Participants also completed measures of their alcohol- related beliefs at random moments of nonexposure throughout each day. Mixed-effects regression models compared beliefs about alcohol at moments of exposure to alcohol advertising that was appraised in a particular way (e.g., with liking, without liking) to beliefs at random moments. RESULTS: When youth encountered ads they appraised positively, their beliefs about alcohol were significantly more positive than when they were queried at random moments. Beliefs in the presence of ads that were not positively appraised were generally similar to beliefs at random moments. CONCLUSION: Youth are active participants in the advertising process. How they respond to and process alcohol advertising strongly moderates the association between exposure and alcohol-related beliefs. More effort is needed to identify attributes of alcohol advertisements, and of youth, that determine how youth process alcohol ads. This information can be used to either limit exposure to problematic ads or make youth more resilient to such exposure. (PsycINFO Database Record(c) 2017 APA, all rights reserved). Language: en

Pyruvate is a key intermediary in energy metabolism and can exert antioxidant and anti-inflammatory effects. However, the fate of pyruvate during AKI remains unknown. Here, we assessed renal cortical pyruvate and its major determinants (glycolysis, gluconeogenesis, pyruvate dehydrogenase [PDH], and H2O2 levels) in mice subjected to unilateral ischemia (15-60 minutes; 0-18 hours of vascular reflow) or glycerol-induced ARF. The fate of postischemic lactate, which can be converted back to pyruvate by lactate dehydrogenase, was also addressed. Ischemia and glycerol each induced persistent pyruvate depletion. During ischemia, decreasing pyruvate levels correlated with increasing lactate levels. During early reperfusion, pyruvate levels remained depressed, but lactate levels fell below control levels, likely as a result of rapid renal lactate efflux. During late reperfusion and glycerol-induced AKI, pyruvate depletion corresponded with increased gluconeogenesis (pyruvate consumption). This finding was underscored by observations that pyruvate injection increased renal cortical glucose content in AKI but not normal kidneys. AKI decreased PDH levels, potentially limiting pyruvate to acetyl CoA conversion. Notably, pyruvate therapy mitigated the severity of AKI. This renoprotection corresponded with increases in cytoprotective heme oxygenase 1 and IL-10 mRNAs, selective reductions in proinflammatory mRNAs (e.g., MCP-1 and TNF-α), and improved tissue ATP levels. Paradoxically, pyruvate increased cortical H2O2 levels. We conclude that AKI induces a profound and persistent depletion of renal cortical pyruvate, which may induce additional injury.

This study assessed whether endothelin-1 (ET-1) helps mediate postischemic acute kidney injury (AKI) progression to chronic kidney disease (CKD). The impact(s) of potent ETA or ETB receptor-specific antagonists (Atrasentan and BQ-788, respectively) on disease progression were assessed 24 h or 2 weeks following 30 min of unilateral ischemia in CD-1 mice. Unilateral ischemia caused progressive renal ET-1 protein/mRNA increases with concomitant ETA, but not ETB, mRNA elevations. Extensive histone remodeling consistent with gene activation and increased RNA polymerase II (Pol II) binding occurred at the ET-1 gene. Unilateral ischemia produced progressive renal injury as indicated by severe histologic injury and a 40% loss of renal mass. Pre- and post-ischemia or just postischemic treatment with Atrasentan conferred dramatic protective effects such as decreased tubule/microvascular injury, normalized tissue lactate, and total preservation of renal mass. Nuclear KI-67 staining was not increased by Atrasentan, implying that increased tubule proliferation was not involved. Conversely, ETB blockade had no protective effect. Thus, our findings provide the first evidence that ET-1 operating through ETA can have a critical role in ischemic AKI progression to CKD. Blockade of ETA provided dramatic protection, indicating the functional significance of these results.

Background. Recent experimental work suggests a paradox: although uremia evokes systemic toxicities, in the setting of AKI, it can induce intrarenal cytoprotective and anti-inflammatory effects. Whether these influences can attenuate post-ischemic kidney disease progression remains unknown. Methods. To explore this possibility, male CD-1 mice were subjected to a 30-min unilateral (left) kidney ischemia model, previously shown to reduce renal mass by ∼50% over 2–3 weeks. Stepwise azotemia/acute uremia was superimposed by inducing different lengths of contralateral (right) kidney ischemia (0, 15, 18, 20 min). Subsequent loss of left renal mass (kidney weight) was assessed 2 weeks later and contrasted with the degree of initial azotemia 24-h BUN. Results. A striking correlation between 24-h BUNs and 2-week left renal mass was observed (r, 0.77; P < 0.001). With 20 min of right kidney ischemia, left kidney size was completely preserved. This preservation did not result from increased tubular cell proliferation or decreased microvascular loss, as gauged by KI-67 and CD-34 immunohistochemistry, respectively. Rather, an early reduction in proximal tubule cell dropout (as judged by renal cortical N-acetyl-glucosaminidase content), with a subsequent preservation of tubule mass, was observed. Conclusions. In summary, these findings advance a novel concept: acute uremia can confer early post-ischemic cytoprotection resulting in a slowed progression of post-ischemic kidney disease.

The purpose of this study was to quantify middle school youth's exposure to alcohol advertisements across media and venues, determine venues of greatest exposure, and identify characteristics of youth who are most exposed.Over a 10-month period in 2013, 589 Los Angeles-area youth ages 11-14 from diverse racial/ethnic backgrounds completed a short paper-and-pencil survey assessing background characteristics and then participated in a 14-day ecological momentary assessment, logging all exposures to alcohol advertisements on handheld computers as they occurred.African American and Hispanic youth were exposed to an average of 4.1 and 3.4 advertisements per day, respectively, nearly two times as many as non-Hispanic White youth, who were exposed to 2.0 advertisements per day. Girls were exposed to 30% more advertisements than boys. Most exposures were to outdoor advertisements, with television advertisements a close second.Exposure to alcohol advertising is frequent among middle school-age youth and may put them at risk for earlier or more frequent underage drinking. Greater restrictions on alcohol advertising outdoors and on television should be considered by regulators and by the alcohol industry and should focus particularly on reducing exposure among minority youth.

There is an emerging concept in clinical nephrology that acute kidney injury (AKI) can initiate chronic kidney disease (CKD). However, potential mechanisms by which this may occur remain elusive. Hence, this study tested the hypotheses that 1) AKI triggers progressive activation of selected proinflammatory genes, 2) there is a relative failure of compensatory anti-inflammatory gene expression, 3) proinflammatory lipid accumulation occurs, 4) these changes correspond with “gene-activating” histone acetylation, and 5) in concert, progressive renal disease results. CD-1 mice were subjected to 30 min of unilateral renal ischemia. Assessments were made 1 day, 1 wk, or 3 wk later. Results were contrasted to those observed in uninjured contralateral kidneys or in kidneys from normal mice. Progressive renal injury occurred throughout the 3-wk postischemic period, as denoted by stepwise increases in neutrophil gelatinase-associated lipocalin gene induction and ongoing histologic damage. By 3 wk postischemia, progressive renal disease was observed (massive tubular dropout; 2/3rds reduction in renal weight). These changes corresponded with progressive increases in proinflammatory cytokine/chemokine gene expression (MCP-1, TNF-α, TGF-β1), a relative failure of anti-inflammatory enzyme/cytokine (heme oxygenase-1; IL-10) upregulation, and progressive renal lipid (cholesterol/triglyceride) loading. Stepwise increases in collagen III mRNA and collagen deposition (Sirius red staining) indicated a progressive profibrotic response. Postischemic dexamethasone treatment significantly preserved renal mass, indicating functional significance of the observed proinflammatory state. Progressive gene-activating H3 acetylation was observed by ELISA, rising from 5% at baseline to 75% at 3 wk. This was confirmed by chromatin immunoprecipitation assay of target genes. In sum, these results provide experimental support for the clinical concept that AKI can trigger CKD, this is partially mediated by progressive postischemic inflammation, ongoing lipid accumulation results (potentially evoking “lipotoxicity”), and increasing histone acetylation at proinflammatory/profibrotic genes may contribute to this self-sustaining injury-promoting state.

Despite their prooxidant effects, ferric iron compounds are routinely administered to patients with renal disease to correct Fe deficiency. This study assessed relative degrees to which three clinically employed Fe formulations [Fe sucrose (FeS); Fe gluconate (FeG); ferumoxytol (FMX)] impact renal redox- sensitive signaling, cytotoxicity, and responses to superimposed stress [endotoxin; glycerol-induced acute renal failure (ARF)]. Cultured human proximal tubule (HK-2) cells, isolated proximal tubule segments (PTS), or mice were exposed to variable, but equal, amounts of FeS, FeG, or FMX. Oxidant-stimulated signaling was assessed by heme oxygenase-1 (HO-1) or monocyte chemoattractant protein (MCP)-1 mRNA induction. Cell injury was gauged by MTT assay (HK-2 cells), %LDH release (PTS), or renal cortical neutrophil gelatinase-associated lipoprotein (NGAL) protein/mRNA levels. Endotoxin sensitivity and ARF severity were assessed by TNF-alpha and blood urea nitrogen concentrations, respectively. FeS and FeG induced lethal cell injury (in HK-2 cells, PTS), increased HO-1 and MCP-1 mRNAs (HK-2 cells; in vivo), and markedly raised plasma ( approximately 10 times), and renal cortical ( approximately 3 times) NGAL protein levels. Both renal and extrarenal (e.g., hepatic) NGAL production likely contributed to these results, based on assessments of tissue and HK-2 cell NGAL mRNA. FeS pretreatment exacerbated endotoxemia. However, it conferred marked protection against the glycerol model of ARF (halving azotemia). FMX appeared to be "bioneutral," as it exerted none of the above noted FeS/FeG effects. We conclude that 1) parenteral iron formulations that stimulate redox signaling can evoke cyto/nephrotoxicity; 2) secondary adaptive responses to this injury (e.g., HO-1/NGAL induction) can initiate a renal tubular cytoresistant state; this suggests a potential new clinical application for intravenous Fe therapy; and 3) FMX is bioneutral regarding these responses. The clinical implication(s) of the latter, vis a vis the treatment of Fe deficiency in renal disease patients, remains to be defined.

A growing literature on adolescent drug treatment interventions demonstrates the efficacy of “research therapies,” but few rigorous studies examine the effectiveness of community-based treatments that are more commonly available to and utilized by youths and their families, the criminal justice system and other referring agencies. Even less is known about the long term effects of these community based treatments. This study evaluates the effects 72 to 102 months after intake to a widely disseminated community based treatment model, residential therapeutic community treatment, using data from RAND's Adolescent Outcomes Project. Weighting is used to control for pre-existing differences between adolescent probationers disposed to Phoenix Academy and those assigned to one of six alternative group homes serving as the comparison conditions. Although Phoenix Academy therapeutic community treatment had positive effects on substance use and psychological functioning during the first 12 months following intake, we find no evidence of positive long term effects on 16 outcomes measuring substance use and problems, criminal activity, institutionalization, psychological functioning and general functioning; but there is a significant negative effect for property crimes. We discuss the implications of these findings and the failure to maintain the effects observed in during the first year follow-up.

The US Centers for Disease Control and Prevention recommends the expanded use of rapid HIV antibody tests in community settings to increase the proportion of persons who are aware of their HIV status. The cost of providing rapid testing services in these settings is not known. We conducted a cost survey of non-profit community clinics and community-based organizations (CBOs). The final study sample for the cost analyses included 28 community clinics and seven CBOs that offered rapid HIV testing, all of which used OraSure's OraQuick oral fluid assay. Overall, the mean per-client rapid testing cost was 36.68 dollars for HIV-negative clients (2006 dollars, provider perspective) and 44.22 dollars for preliminary-positive clients. Personnel costs accounted for 55.6% of overall testing costs for negative clients and 63.2% for preliminary-positive clients. This study contributes unique empirical data about the costs of OralQuick rapid testing that can be used by clinic and CBO directors to assess the economic impact of implementing rapid testing at their sites. The findings also could be used to inform discussions regarding national and local HIV testing policies.

Objectives. We examined important life outcomes for adolescent offenders to describe how they were faring in young adulthood. Methods. We assessed 449 adolescent offenders (aged 13–17 years) in Los Angeles, CA, whose cases had been adjudicated by the Los Angeles Superior Court and who had been referred to group homes between February 1999 and May 2000. We used the Global Appraisal of Individual Needs to interview respondents at baseline and at 3, 6, 12, 72, and 87 months after baseline. A total of 395 respondents (88%) were interviewed or confirmed as dead at the final interview. Results. At final interview, 12 respondents had died, 7 of them from gunshot wounds. Thirty-six percent of respondents reported recent hard drug use, and 27% reported 5 or more symptoms of substance dependence. Sixty-six percent reported committing an illegal activity within the previous year, 37% reported being arrested within the previous year, and 25% reported being in jail or prison every day for the previous 90 days. Fifty-eight percent had completed high school or obtained a GED, and 63% reported working at a job in the previous year. Conclusions. The high rates of negative life outcomes presented here suggest the need for more effective rehabilitation programs for juvenile offenders.

We examined provider-reported barriers to rapid HIV testing in U.S. urban non-profit community clinics, community-based organizations (CBOs), and hospitals. 12 primary metropolitan statistical areas (PMSAs; three per region) were sampled randomly, with sampling weights proportional to AIDS case reports. Across PMSAs, all 671 hospitals and a random sample of 738 clinics/CBOs were telephoned for a survey on rapid HIV test availability. Of the 671 hospitals, 172 hospitals were randomly selected for barriers questions, for which 158 laboratory and 136 department staff were eligible and interviewed in 2005. Of the 738 clinics/CBOs, 276 were randomly selected for barriers questions, 206 were reached, and 118 were eligible and interviewed in 2005-2006. In multivariate models, barriers regarding translation of administrative/quality assurance policies into practice were significantly associated with rapid HIV testing availability. For greater rapid testing diffusion, policies are needed to reduce administrative barriers and provide quality assurance training to non-laboratory staff.

Objectives. We examined patterns of rapid HIV testing in a multistage national random sample of private, nonprofit, urban community clinics and community-based organizations to determine the extent of rapid HIV test availability outside the public health system. Methods. We randomly sampled 12 primary metropolitan statistical areas in 4 regions; 746 sites were randomly sampled across areas and telephoned. Staff at 575 of the sites (78%) were reached, of which 375 were eligible and subsequently interviewed from 2005 to 2006. Results. Seventeen percent of the sites offered rapid HIV tests (22% of clinics, 10% of community-based organizations). In multivariate models, rapid test availability was more likely among community clinics in the South (vs West), clinics in high HIV/AIDS prevalence areas, clinics with on-site laboratories and multiple locations, and clinics that performed other diagnostic tests. Conclusions. Rapid HIV tests were provided infrequently in private, nonprofit, urban community settings. Policies that encourage greater diffusion of rapid testing are needed, especially in community-based organizations and venues with fewer resources and less access to laboratories.

In this article, the authors describe the refinement and preliminary evaluation of the Dimensions of Change in Therapeutic Community Treatment Instrument (DCI), a measure of treatment process. In Study 1, a 99-item DCI, administered to a cross-sectional sample of substance abuse clients (N = 990), was shortened to 54 items on the basis of results from confirmatory factor analyses and item response theory invariance tests. In Study 2, confirmatory factor analyses of the 54-item DCI, completed by a longitudinal cohort of 993 clients, established and validated an 8-factor solution across 2 subpopulations (adults and adolescents) and 2 time points (treatment entry and 30-days postentry). The results of the 2 studies are encouraging and support use of the 54-item DCI as a tool to measure treatment process.

Trauma exposure and related symptoms interfere with adult adherence to drug treatment. Whether these findings hold true for adolescents is unknown. We examined trauma exposure, PTSD symptoms, and psychosocial functioning among 212 adolescents upon admission to long-term residential drug treatment and examined retention in treatment at 6 months. Seventy-one percent reported lifetime trauma exposure, and 29% of the trauma-exposed met criteria for current PTSD. Trauma-exposed adolescents reported more behavioral problems, with gender differences apparent. We divided the sample into three groups: no trauma exposure (21%), trauma-exposed without PTSD (59%), and trauma-exposed with PTSD (20%). Survival analysis showed that trauma-exposed adolescents without PTSD left treatment sooner than the nonexposed. Need for attention to trauma in substance abuse treatment programs is discussed.

Prior research has demonstrated that therapeutic communities (TCs) are effective at improving posttreatment outcomes for substance abusers. However, little is known about the in-treatment experience for clients with different backgrounds, experiences, and needs. The aim of this study is to examine the in-treatment experience for different clients by exploring the relationships between treatment process and client characteristics. A comprehensive measure of treatment process, operationalized as Community Environment and Personal Change and Development and change was administered to 447 adults and 148 adolescents receiving treatment at community-based TC programs in New York, California, and Texas. Data on demographic characteristics, substance use and treatment history, and client risk factors were extracted from intake interviews and analyzed separately for adolescent and adult residents. Multivariate general linear models were used to examine the effect of client variables on treatment process, after controlling for treatment duration and program effects. Within adult programs, clients who were 25 years or older, female, and had a prior drug treatment experience had higher Community Environment scores. Adolescents with one or more arrests within the past 2 years had lower scores on both process dimensions of Community Environment and Personal Development and Change. Our results indicate the need to understand why adult clients who are younger, male, and have no prior treatment history and adolescent clients with recent arrests reported lower ratings of treatment process. Future research should also examine the role of modifiable mediators so that appropriate strategies to enhance therapeutic engagement may be developed as necessary.

Introduction: Community health clinics (CHCs) are an opportune setting to identify and treat substance misuse. This study assessed the characteristics of patients who presented to a CHC with substance misuse. Methods: Personnel at a large CHC administered a 5-question screener to patients between June 3, 2014, and January 15, 2016, to assess past 3-month alcohol use, prescription opioid misuse, or illicit drug use. We stratified screen-positive patients into 4 diagnostic groups: (1) probable alcohol use disorder (AUD) and no comorbid opioid use disorder (OUD); (2) probable heroin use disorder; (3) probable prescription OUD, with or without comorbid AUD; and (4) no probable substance use disorder. We describe substance use and mental health characteristics of screen-positive patients and compare the characteristics of patients in the diagnostic groups. Results: Compared to the clinic population, screen-positive patients (N = 733) included more males ( P < .0001) and had a higher prevalence of probable bipolar disorder ( P < .0001) and schizophrenia ( P < .0001). Eighty-seven percent of screen-positive patients had probable AUD or OUD; only 7% were currently receiving substance use treatment. The prescription opioid and heroin groups had higher rates of past bipolar disorder and consequences of mental health conditions than the alcohol only or no diagnosis groups ( P < .0001). Conclusions: Patients presenting to CHCs who screen positive for alcohol or opioid misuse have a high likelihood of having an AUD or OUD, with or without a comorbid serious mental illness. Community health clinics offering substance use treatment may be an important resource for addressing unmet need for substance use treatment and comorbid mental illness.

The Centers for Medicare & Medicaid Services (CMS) have implemented Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys to assess patient experience in a number of settings. Following CAHPS principles, RAND researchers designed and field tested an Emergency Department Patient Experience of Care Survey that consists of three survey instruments for use with adult patients who have visited the emergency department (ED). One instrument is for use with those patients who are discharged to the community following their ED visit; the other two are for use with those patients who are admitted to the hospital from the ED (one for use on its own and one to supplement an existing inpatient survey). The authors conducted a field test of these instruments in 12 hospitals in late 2013 and early 2014 and analyzed the resulting data from 4,101 ED patients. The analyses identified four composite measures (measures composed of responses to multiple survey questions) and ten measures that are each composed of a single survey question. As of September 2014, CMS plans to conduct additional testing on these instruments.

Zusammenfassung: Wir berichten über eine 14-jährige Patientin, die fünf Tage nach dem Eisenbahnsuizid ihres neu erworbenen Freundes den Suizid als Problemlösemechanismus bei vorher nicht vorhandener Suizidalität imitierte und dessen Methode kopierte. Theorien zu Ursachen von Suizidalität im Allgemeinen und in der Adoleszenz im Besonderen werden diskutiert.

Substance use is high among gay and bisexual men attending weekend dance events, yet little research has investigated motivations for drug use and contextual factors influencing use in these settings. We hypothesized that beliefs about peer drug use interact with individuals’ own drug use intentions to predict use. 489 men attending weekend dance events completed an anonymous assessment asking about their own and their beliefs about other attendants’ drug use intentions – 47% completed a follow-up assessment after the event. Forty-four percent reported intending to use ecstasy at the event; intentions to use GHB, marijuana, cocaine, unprescribed Erectile Dysfunction Drugs (EDDs), and poppers were also high. Perceptions about other attendant’s drug use predicted use among those intending and those not intending to use drugs. Normative beliefs are important predictors of drug use at weekend dance events; event-specific prevention strategies should encompass messages that correct misperceptions of drug use among party attendants.

Hemopexin (Hpx) is a liver-generated acute phase reactant that binds and neutralizes prooxidant free heme. This study tested whether acute kidney injury (AKI) triggers renal Hpx accumulation, potentially impacting heme Fe-mediated tubular injury. Mice were subjected to glycerol, cisplatin, ischemia-reperfusion (I/R), or endotoxemic [lipopolysaccharide (LPS)] AKI. In each instance, 3- to 30-fold renal cortical and isolated proximal tubule segment (PTS) Hpx increases resulted. Although renal cortex and PTS showed variable Hpx mRNA increases, due, in part, to increased mRNA stability, mRNA levels did not correlate with renal Hpx protein accumulation. Conversely, AKI evoked three- to fourfold increases in hepatic Hpx gene induction, which corresponded with three- to fourfold plasma Hpx increases. Renal immunohistochemistry, and increased urinary Hpx excretion, indicated that circulating Hpx gains tubule luminal/urinary access, followed by proximal tubule endocytic uptake. Paradoxically, in cultured renal cells (HK-2, HEK-293), Fe depletion, and not free heme excess, increased Hpx mRNA. LPS acutely increased HK-2 cell Hpx mRNA. This finding, coupled with observations that LPS evoked ∼30-fold greater renal Hpx mRNA increases than any other AKI model, suggests that inflammation, not heme exposure, activates the renal Hpx gene. Each form of AKI evoked early increases in circulating free heme, which subsequently fell to subnormal levels as plasma Hpx rose. In addition, purified Hpx blunted free Fe-mediated HK-2 cell death. In sum, these data indicated that AKI-associated hepatic stress generates Hpx, which gains renal tubule access. Given its ability to bind free heme and mitigate free Fe toxicity, Hpx loading can potentially confer cytoprotective effects.

AKI induces upregulation of heme oxygenase 1 (HO-1), which exerts cytoprotective effects and modulates the renal response to injury, suggesting that a biomarker of intrarenal HO-1 activity may be useful. Because HO-1 largely localizes to the endoplasmic reticulum and has no known secretory pathway, it is unclear whether plasma or urinary levels of HO-1 reflect intrarenal HO-1 expression. We measured plasma and urinary levels of HO-1 by ELISA during the induction and/or maintenance phases of four mouse models of AKI: ischemia/reperfusion, glycerol-induced rhabdomyolysis, cisplatin nephrotoxicity, and bilateral ureteral obstruction. In addition, we measured levels of HO-1 mRNA and protein in the renal cortex. Each AKI model increased renal HO-1 gene expression, which corresponded with release of HO-1 into plasma and urine by 4 hours. Over time, the magnitudes of plasma and urinary HO-1 paralleled renal cortical gene expression. AKI and the associated uremia did not seem to affect extrarenal HO-1 gene activity assessed in the liver, lung, and spleen. In iron-challenged, cultured proximal tubule cells, we observed a positive correlation between HO-1 mRNA level and HO-1 release. In humans, 10 patients with AKI demonstrated markedly higher levels of plasma and urine HO-1 levels than 10 critically ill patients without AKI or 20 patients with CKD or ESRD. In summary, these data suggest that plasma and urinary HO-1 levels may serve as biomarkers of AKI and intrarenal HO-1 gene activity.

PartyIntents examines whether portal survey methods could be used to anonymously survey gay and bisexual men about HIV-risk behaviors before and after a weekend party–oriented vacation. The study recruited 97% of eligible men and of these 489 participants 47% completed the follow-up assessment. Approximately one half of the men intended to use illegal drugs over the weekend, and almost 20% thought that they might have anal intercourse and not use a condom. The methodology can be applied and provides useful information about HIV risk at these events, though refinements may be needed to increase the follow-up rates.

This report focuses on the association between oral health-related quality of life (OHRQoL) and depression/anxiety of a homogeneous group of cancer patients who were recurrence-free for 8 years after treatment for advanced oral squamous cell. Participants were 24 patients (mean age 55 years, 75% men) treated with neoadjuvant concurrent radiochemotherapy followed by surgery with a mean recurrence-free period of 95 months (from 39 to 164 months). The OHRQoL (OHIP) and the anxiety/depression (HADS) were assessed twice (1 year between t1 and t2). OHRQoL was impaired in this group (mean OHIP score 65 units). In cross-lagged correlation analysis, the correlation between OHRQoL to t1 and depression to t2 was significant and greater than the non-significant correlation for depression to t1 and OHRQoL to t2 indicating that OHRQoL predicts depression better than vice versa. However, the difference in the correlation coefficients was not significant (ZPF-test). The same was true for OHRQoL and anxiety. The OHRQoL measured with the OHIP was impaired in comparison to the normal population. In the limitations of the study design and bearing the small sample size in mind, the results give evidence that OHRQoL predicts psychological outcomes, namely depression and anxiety, better than vice versa.

In 2006, the United States Centers for Disease Control and Prevention (CDC) recommended expanded and routine use of single-session rapid HIV tests in all health care settings to increase the proportion of persons who learn their HIV status. Limited empiric information is available regarding the costs of rapid testing and pre- and posttest counseling in health care settings. We surveyed 45 U.S. hospitals during 2005 through 2006 to assess the costs associated with rapid testing and counseling. Cost analyses were conducted from the provider (hospital) perspective, and results were expressed in year 2006 U.S. dollars. The mean per-test cost of rapid HIV testing and counseling was $48.07 for an HIV-negative test and $64.17 for a preliminary-positive test. Pre- and posttest counseling costs accounted for 38.4% of the total cost of rapid testing for HIV-negative patients. Counseling costs were significantly correlated with overall test costs. Many hospitals contained overall test costs by limiting time spent in pre- and posttest counseling or by using lower-paid personnel for counseling activities or both. Counseling costs constituted a significant proportion of the overall costs of rapid testing and counseling activities at study hospitals. Our data provide useful baseline data before implementation of the CDC's 2006 recommendations. Costs can be reduced by limiting time spent in pre- and posttest counseling or by using lower-paid personnel for counseling activities or both.

Objective. The present study examined the scope of rapid human immunodeficiency virus (HIV) testing in urban U.S. hospitals. Methods. In a multistage national probability sample, 12 primary metropolitan statistical areas (three per region) were sampled randomly, with weights proportionate to acquired immunodeficiency syndrome (AIDS) populations. All 671 eligible hospitals within areas were selected. Laboratory staff from 584 hospitals (87%) were interviewed by telephone in 2005. Results. About 52% reported rapid HIV test availability (50% in occupational health, 29% in labor and delivery, and 13% in emergency department/urgent care), and 86% of hospitals offering rapid tests processed them in the laboratory. In multivariate models, rapid test availability was more likely in hospitals serving more patients, and located in high-poverty, high-AIDS prevalence areas, and in the South or Midwest vs. West. It was less likely in hospitals serving areas with large percentages of people who were black/African American or Hispanic/Latino ( pConclusions. Rapid HIV testing is increasing across urban U.S. hospitals, primarily for occupational exposure and in hospitals with greater resources and need. To achieve routine HIV screening, policies should encourage greater breadth of diffusion of rapid testing at the point of care, especially in smaller facilities, the West, and communities with racial/ethnic diversity.

BACKGROUND: Violence against women, substance use and disorder, and HIV represent three significant threats to the health of women, yet little is known about the extent of these epidemics among indigent women. This study investigates and documents differences in the prevalence and co-occurrence of physical and sexual violence, substance use and disorder, and HIV risk behavior in sizable probability samples of sheltered homeless and low-income housed women. METHODS: Retrospective self-reports were obtained through structured interviews with stratified random samples of women residing in shelters (N = 460) and low-income housing (N = 438) in Los Angeles County, California. RESULTS: Sheltered women were more likely than housed women to report experiencing physical and sexual violence, substance use and disorder, HIV risk behavior, and co-occurrence of these problems in the past year. Differences remained when propensity weights were used to equate the groups on demographic and background characteristics. CONCLUSIONS: Findings suggest remarkable need for services among communities of indigent women. Higher rates of problems among women in shelters highlight the importance of differentiating among subgroups of indigent women in community-based prevention and intervention activities and tentatively suggest a protective influence of housing. Language: en

Despite strong homology, the roles of TP53 and TP73 in tumorigenesis seem to be fundamentally different. In contrast to TP53, tumor-associated overexpression of TP73 in many different cancers, combined with virtual absence of inactivating mutations and lack of a cancer phenotype in the TP73 null mouse are inconsistent with a suppressor function but instead support an oncogenic function. The discovery of NH2-terminally truncated p73 isoforms, collectively called ΔTAp73, is now the focus of intense interest because they act as potent transdominant inihibitors of wild-type p53 and transactivation-competent TAp73. Therefore, establishing deregulated ΔTAp73 expression in tumors could be the crucial link to decipher which of the two opposing roles of this bipolar gene is the biologically relevant one. This study is the largest to date and encompasses 100 ovarian carcinomas with complete expression profile of all NH2-terminal isoforms, discriminating between TAp73 and ΔTAp73 (ΔNp73, ΔN′p73, Ex2p73, and Ex2/3p73) by isoform-specific real-time reverse transcription-PCR. We find that the set of NH2-terminal p73 isoforms distinguishes ovarian cancer patients from healthy controls and thus is a molecular marker for this diagnosis. Ovarian cancers strongly and almost universally overexpress ΔN′p73 compared with normal tissues (95% of cancers). About one-third of tumors also exhibit concomitant up-regulation of the antagonistic TAp73, whereas only a small subgroup of tumors overexpress ΔNp73. Thus, deregulation of the E2F1-responsive P1 promoter, rather than the alternate P2 promoter, is mainly responsible for the production of transdominant p53/TAp73 antagonists in ovarian cancer. Tumor stage, grade, presence of metastases, p53 status, and residual disease after resection are significant prognostic markers for overall and recurrence-free survival. A trend is found for better overall survival in patients with low expression of ΔN′p73/ΔNp73, compared with patients with high expression. A strong correlation between deregulated ΔTAp73 and p53 status exists. p53 wild-type cancers exhibit significantly higher deregulation of ΔN′p73, ΔNp73, and Ex2/3p73 than p53 mutant cancers. This data strongly supports the hypothesis that overexpression of transdominant p73 isoforms can function as epigenetic inhibitors of p53 in vivo, thereby alleviating selection pressure for p53 mutations in tumors.