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BACKGROUND: Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE: To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN: Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS: Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014–2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES: The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS: The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS: Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06389-7.

Objective To incorporate blood pressure (BP), diagnoses codes, and medication fills from electronic medical records (EMR) to identify pregnant women with hypertension. Study design A retrospective cohort study of singleton pregnancies at three US integrated health delivery systems during 2005–2014. Main outcome measures Women were considered hypertensive if they had any of the following: (1) ≥2 high BPs (≥140/90 mmHg) within 30 days during pregnancy (High BP); (2) an antihypertensive medication fill in the 120 days before pregnancy and a hypertension diagnosis from 1 year prior to pregnancy through 20 weeks gestation (Treated Chronic Hypertension); or (3) a high BP, a hypertension diagnosis, and a prescription fill within 7 days during pregnancy (Rapid Treatment). We described characteristics of these pregnancies and conducted medical record review to understand hypertension presence and severity. Results Of 566,624 pregnancies, 27,049 (4.8%) met our hypertension case definition: 24,140 (89.2%) with High BP, 5,409 (20.0%) with Treated Chronic Hypertension, and 5,363 (19.8%) with Rapid Treatment (not mutually exclusive). Of hypertensive pregnancies, 19,298 (71.3%) received a diagnosis, 9,762 (36.1%) received treatment and 11,226 (41.5%) had a BP ≥ 160/110. In a random sample (n = 55) of the 7,559 pregnancies meeting the High BP criterion with no hypertension diagnosis, clinical statements about hypertension were found in medical records for 58% of them. Conclusion Incorporating EMR BP identified many pregnant women with hypertension who would have been missed by using diagnosis codes alone. Future studies should seek to incorporate BP to study treatment and outcomes of hypertension in pregnancy.

Background Programs such as the Pediatric Access Line in Washington state have shown decreases in antipsychotic medication use by youth with non-psychotic disorders. Program outcomes have been studied with observational designs. This manuscript describes the protocol for Targeted and Safer Use of Antipsychotics in Youth (SUAY), a randomized controlled trial of psychiatrist review of prescriptions and facilitated access to psychosocial care. The aim of the intervention is to reduce the number of person-days of antipsychotic use among participants. Methods Recruitment occurs at 4 health systems. Targeted enrollment is 800 youth aged 3–17 years. Clinicians are block randomized to intervention versus usual care prior to the study. Youth are nested within the arm of the prescribing clinician. Clinicians in the intervention group receive an EHR-based best practice alert with options to expedite access to psychosocial care and all medication orders are reviewed by a child and adolescent psychiatrist with feedback provided to the prescriber. The primary outcome is person-days of antipsychotic medication use in the 6 months following the initial order. All randomized individuals contribute data regardless of their level of participation (including declining all services). Discussion The trial has been approved by the institutional review boards at each of the 4 sites. The intervention has 4 novel design features including automated recruitment using a best practice alert, psychiatrist medication order review and consultation, telephone navigation to psychosocial care, and telemental health visits. Recruitment began in March of 2018 and will be completed in June 2020. Follow-up will be completed December 31, 2020. Trial registration Clinicaltrials.gov , NCT03448575

Crimes committed with assault rifles are becoming increasingly prevalent in the United States. In the absence of other evidence, DNA analysis can often provide informative leads. Unfortunately, any DNA transferred to rifle components left behind at a crime scene is likely to be low in quantity and/or quality. Furthermore, collected evidence is unlikely to be processed immediately and may require storage. Long-term storage can subject DNA to damage and degradation, which ultimately affects DNA profile interpretation and may prevent the identification of potential suspects. This study assessed the ability of a new swab storage device, the SwabSaver®, to preserve “touch” DNA from AR-15 magazine rifles using three different collection devices. Three volunteers loaded bullet cartridges into plastic polymer and aluminum AR-15 magazines. DNA was collected with traditional cotton swabs, layered cotton paper swabs, or nylon-flocked swabs. Collection devices were then stored at room-temperature for up to two months in either the SwabSaver® device or an empty centrifuge tube. The results suggest that substrate and swab type had less of an effect on profile completeness than storage type. Furthermore, SwabSaver® storage yielded DNA quantities comparable to “touch” DNA extracted after 24 h.

Objective: Hypertension is a major risk factor for poor pregnancy outcomes. Many observational studies have relied on diagnosis codes, particularly from the delivery hospitalization, to identify hypertension in pregnancy. We augmented diagnosis codes with electronic blood pressure (BP) data to improve the identification of pregnant women with hypertension. Methods: We studied pregnant women aged 15-49 years enrolled in three Kaiser Permanente health plans who delivered during 2005-2014. Using diagnosis codes, BP values, and antihypertensive medication dispensings, we defined hypertension as: (1) ≥ 2 high BPs (≥ 140/90 mmHg) within 30 days of each other (2highBPs); or (2) ≥ 1 antihypertensive medication fill with ≥1 hypertension diagnosis code from 120 days prior to pregnancy through 20 weeks gestation (chronicHTN); or (3) ≥ 1 high BP, a hypertension diagnosis code, and an antihypertensive fill within 7 days (RapidTx). Among women meeting our study definition, we examined receipt of hypertension diagnosis codes and prevalence of severe hypertension (1+ BP ≥160/110 mmHg). Results: Among 553,477 eligible women, 29,933 (5%) met our definition of hypertension, including 26,855 identified via 2highBPs, 5,774 via chronicHTN and 6,198 via RapidTx (not mutually exclusive). Among women meeting our hypertension definition overall, only 64% had 1+ hypertension diagnosis code assigned during pregnancy, and 49% had one at delivery. Among hypertensive women identified via 2highBPs, only 60% (16,057/26,855) had a hypertension diagnosis code in pregnancy and 45% (12,131/ 26,855) at delivery. However, 53% of our hypertensive women (14,972/ 29,933) overall and 56% (14,972/ 26,855) of the 2highBPs women had severe hypertension at some time during pregnancy. Conclusion: Incorporating BP values identifies additional pregnant women with hypertension who would have been missed by approaches using diagnosis codes alone. Women identified by our method frequently had severely elevated BP, showing the importance of including these women in future studies of hypertension during pregnancy.

Castleman disease (CD) comprises 3 poorly understood lymphoproliferative variants sharing several common histopathological features. Unicentric CD (UCD) is localized to a single region of lymph nodes. Multicentric CD (MCD) manifests with systemic inflammatory symptoms and organ dysfunction due to cytokine dysregulation and involves multiple lymph node regions. Human herpesvirus 8 (HHV-8) causes MCD (HHV-8-associated MCD) in immunocompromised individuals, such as HIV-infected patients. However, >50% of MCD cases are HIV and HHV-8 negative (defined as idiopathic [iMCD]). The clinical and biological behavior of CD remains poorly elucidated. Here, we analyzed the clinicopathologic features of 74 patients (43 with UCD and 31 with iMCD) and therapeutic response of 96 patients (43 with UCD and 53 with iMCD) with HIV-/HHV-8-negative CD compared with 51 HIV-/HHV-8-positive patients. Systemic inflammatory symptoms and elevated inflammatory factors were more common in iMCD patients than UCD patients. Abnormal bone marrow features were more frequent in iMCD (77.0%) than UCD (45%); the most frequent was plasmacytosis, which was seen in 3% to 30.4% of marrow cells. In the lymph nodes, higher numbers of CD3+ lymphocytes (median, 58.88 ± 20.57) and lower frequency of CD19+/CD5+ (median, 5.88 ± 6.52) were observed in iMCD patients compared with UCD patients (median CD3+ cells, 43.19 ± 17.37; median CD19+/CD5+ cells, 17.37 ± 15.80). Complete surgical resection is a better option for patients with UCD. Siltuximab had a greater proportion of complete responses and longer progression-free survival (PFS) for iMCD than rituximab. Centricity, histopathological type, and anemia significantly impacted PFS. This study reveals that CD represents a heterogeneous group of diseases with differential immunophenotypic profiling and treatment response.

Background: Imatinib induces durable complete cytogenetic remissions (CCyR) in at least two thirds of pts with chronic phase (CP) CML, most of them also achieving a major molecular response (MMR). However, some pts become intolerant or resistant to imatinib and require change of therapy to a 2nd or 3rd generation TKIs (dasatinib, nilotinib, bosutinib, and/or ponatinib). The projected 3-year survival for these pts was reported as 72% (Kantarjian et al. Cancer 2007) at a time when treatment options for such pts was limited. A smaller subset of pts may require additional changes to a third or fourth TKI. The impact of sequential TKI therapy, although standard practice, has not been well studied. We analyzed the long term outcome of pts receiving multiple TKIs. Method: We analyzed the medical records of 1775 pts with CML-CP treated at a single institution between 02/2000 and 07/2015. Among them 582 (33%) received more than one TKI as follows: 2TKIs (n=370), 3TKIs (n=130), and 4+TKIs (n=82; 4 TKI n=59, 5 TKI n=20, 6 TKI n=1, 7 TKI n=2). For the purpose of this analysis, a TKI used more than once was counted as 2 TKI provided there was a different TKI used between the two periods when the TKI in question was used. We analyzed pt's characteristics, response to therapy, transformation to accelerated and blast phase, and long term outcomes. Overall Survival (OS) and Transformation-Free Survival (TFS) probabilities were measured using Kaplan-Meier method starting from the date they began to use the their 2nd TKI and grouped by the number of TKI used. Results: The number of CML pts in early CP (diagnosis to start of therapy, ≤ 12 months) that used 2, 3, and 4+TKIs was 229, 54, and 34, respectively. The number of pts in late CP (diagnosis to start of therapy >12 months) that used 2, 3, and 4+TKIs was 141, 76 and 48 respectively. The median age (range) for pts that used 2, 3, and 4+ TKIs were 48 yrs (15-81), 52 yrs (18-87), and 53 yrs (18-80), respectively. The ratio of males to females in each cohort was 187:183, 58:72, and 37:45, respectively. The median time from diagnosis to 2nd, 3rd and 4th TKI was 2, 4, and 6 years respectively. For the 3 cohorts (2, 3, 4+TKIs), TKIs used included imatinib (n=322, n=130, n=79), dasatinib (n=227, n=112, n=77), nilotinib (n=119, n=109, n=70), ponatinib (n=44, n=27, n=37) and bosutinib (n=26, n=13, n=29), respectively. The 3-year overall survival probability for pts treated with 2 TKI was 88% (median survival not reached); for those that used 3 TKI 72% (median survival not reached), and for those that used 4+ TKI 48% (median survival 34 months) (Fig. 1). Corresponding 5-year figures are 80%, 53% and 38%. The 3-year transformation-free survival probability for pts treated with 2 TKI was 93%; for those treated with 3 TKI 88%; and for pts treated with 4 TKI 80% (median not reached in any cohort ) (Fig. 2). Corresponding figures for 5-years are 90%, 84%, and 75%. Conclusion: With more and improved treatment options, pts with resistance or intolerance to multiple TKI have the potential for long-term survival. Nearly 80% of pts who receive 2 TKI are alive at 5 years and more than 90% remain in chronic phase. As pts experience subsequent failure, the outcome worsens. These results provide information that may help with treatment planning and set the expectations against which treatment options used in such pts should be measured. Figure 1. Overall Survival Probability Figure 1. Overall Survival Probability Figure 2. Transformation-Free Survival Probability Figure 2. Transformation-Free Survival Probability Disclosures Wierda: Glaxo-Smith-Kline Inc.: Research Funding; Celgene Corp.: Consultancy. Daver:ImmunoGen: Other: clinical trial, Research Funding. Burger:Pharmacyclics LLC, an AbbVie Company: Research Funding. Pemmaraju:Stemline: Research Funding; Incyte: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; LFB: Consultancy, Honoraria. Cortes:Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; BerGenBio AS: Research Funding; BMS: Consultancy, Research Funding; Teva: Research Funding; Ariad: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Ambit: Consultancy, Research Funding; Arog: Research Funding; Celator: Research Funding; Jenssen: Consultancy.