Multilevel Barriers to Engagement in the HIV Care Continuum Among Residents of the State of Rhode Island Living with HIV

An estimated 1.2 million people in the United States are living with HIV. Of those living with HIV, only 40% are engaged in HIV care, 37% are prescribed antiretroviral therapy (ART), and 30% are virally suppressed. Individual-, interpersonal-, and structural-level factors that represent barriers to engagement along the HIV care continuum are important to identify in order to inform priority areas and interventions. 296 adult residents of Rhode Island living with HIV between November 2015 and January 2016 were asked to participate in an observational study (Ryan White Part B Health Resources and Services Administration-funded consumer needs assessment) to identify the multilevel factors associated with engagement in the HIV care continuum outcomes (i.e., being retained in care, being prescribed ART, adhering to ART, and achieving viral suppression-all in the past 12 months). Multivariable logistic regression models were fit to model the four HIV care continuum outcomes. The majority of participants were over age 30 (92.5%), racial/ethnic minorities (67.1%), cisgender men (56.9%), and identified as straight/heterosexual (60.5%). Overall, 95.2% of participants were retained in care in the past 12 months, 93.0% were prescribed ART, 87.1% were currently adherent to ART, and 68.2% were virally suppressed. Factors positively associated with not being retained in HIV care in the past 12 months included having no income and challenges navigating the HIV care system. Being age 18-29 and having a provider who does not know how to treat people with HIV/AIDS were each positively associated with not being prescribed ART. Factors positively associated with not being adherent to ART included being age 18-29 and substance use in the past 12 months. Finally, having private insurance and having a provider who is not trustworthy were each positively associated with not being virally suppressed. Regardless of the fact that many of the individuals living with HIV in this sample are able to achieve an undetectable viral load, challenges with retention in HIV care and ART adherence threaten to undermine the clinical and public health benefits of treatment as prevention. Future longitudinal research conducted to better understand how to boost the effectiveness of treatment as prevention in this population should focus on examining the unique multilevel factors, polymorbidities, and conditions (mostly social determinants of health including housing, socioeconomic position, etc.) associated with suboptimal engagement across the stages of the HIV care continuum.

Rhode Island Department of Health Foodborne Illness Complaint System: A Descriptive and Performance Analysis

Foodborne illnesses create a large impact on both the health and economy of the United States. Early detection of an outbreak is essential to preventing additional illnesses. Foodborne illnesses are commonly identified through foodborne illness complaint systems, and it is vital that public health agencies ensure their systems are functioning effectively for successful detection of foodborne outbreaks. The purpose of this study was to provide a descriptive summary of foodborne illness complaint data in Rhode Island and to evaluate the Rhode Island Department of Health (RIDOH) foodborne illness complaint system's ability to detect foodborne outbreaks using the Council to Improve Foodborne Outbreak Response (CIFOR) target performance measures. Data were collected from all foodborne illness complaints reported to RIDOH by the public from 1 January 2010 to 31 December 2017. During this period, 1,218 foodborne illness complaints in total were reported to RIDOH; 85% of complainants reported their illness within 7 days of symptom onset. Most complainants (73%) did not seek medical attention. There were 54 outbreaks, 80% of which were identified by the complaint system. Most pathogens that were identified during an outbreak detected by the complaint system were nonreportable (69%). CIFOR metrics indicate that the complaint system is functioning (i) at an acceptable level of illness complaints expected based on population size and (ii) at preferable levels for metrics related to outbreak detection. This review of the RIDOH foodborne illness complaint system provides evidence for the vital role of complaint systems in detecting foodborne illness outbreaks. In addition, it demonstrates that complaint systems can detect illnesses in a timely manner, likely preventing further illnesses. This was the first multiyear evaluation of Rhode Island's illness complaint surveillance system and will serve as a baseline for future analyses to monitor trends in performance.

Increasing Syphilis in Rhode Island: Return of an Old Foe

The number of people diagnosed with syphilis has increased significantly in the United States over the last decade. In Rhode Island, the number of new diagnoses has increased more than four-fold since 2008. Syphilis disproportionately impacts gay, bisexual, and other men who have sex with men (MSM), with those from African American and Hispanic/Latino communities most affected. Given these trends, physicians need to be aware of current prevention, diagnosis, and treatment practices for syphilis, especially when working with populations who are most at risk. [Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Helping Ambulatory Practices Succeed: Reflections from Practice Transformation Facilitators

Healthcare reform efforts implemented to optimize primary and specialty care delivery require practices to undertake considerable transformation. To support change efforts, many private insurers and federal and state health-reform efforts provide practices and clinicians with access to practice-transformation facilitators. Healthcentric Advisors provides practice-transformation support and technical assistance to practices in Rhode Island and across New England. From this work we know that strategies and approaches to support transformation and achievement of program recognitions differ by practice characteristics, resource access, and patient panels. Understanding practice attitudes and beliefs about change, recognizing that change occurs on a spectrum, acknowledging that program recognition is only the beginning, and aligning quality-improvement initiatives, are domains that support success regardless of practice type. However, working with a facilitator who engages your entire care team to integrate a culture of quality improvement and process ownership, has the greatest impact on overall transformation.

Distribution of Preventive Dental Care during Pregnancy in Rhode Island, 2012 to 2015

AIMS

To examine the distribution of preventive dental care for pregnant women in Rhode Island.

METHODS

The data used were obtained from the 2012 to 2015 Rhode Island Pregnancy Risk Assessment Monitoring System (RIPRAMS). Statistical analyses were conducted for respondents who had valid information for both preventive dental care receipt and race/ethnicity to examine population differences in the receipt of preventive dental care.

RESULTS

Respondents who identified as Hispanic and had more than 12 years of education had higher odds for preventive dental care receipt in Rhode Island between 2012 to 2015 compared to non-Hispanic whites. Furthermore, respondents with lower household income were the least likely to have received preventive dental care. This was especially true for black and non-Hispanic women who reported being neither black nor white.

CONCLUSION

Preventive dental care in Rhode Island between 2012 and 2015 did not meet the perinatal and Infant Oral Health Quality Improvement (PIOHQI) target of 60% in minority populations.

State Unintentional Drug Overdose Reporting Surveillance: Opioid Overdose Deaths and Characteristics in Rhode Island

Unintentional opioid overdoses are a growing public health epidemic in the United States. Rhode Island is also faced with a challenging crisis of drug overdose deaths. The State Unintentional Drug Overdose Reporting Surveillance (SUDORS) data from the second half of 2016 were used to present opioid overdose deaths and characteristics in Rhode Island. During July-December 2016, 142 individuals died of opioid overdose in Rhode Island. People who died by opioid overdose were more likely to be 25-65 years old, male, and non-Hispanic white. The most common precipitating circumstances were substance abuse (88%), current mental health problems (43%), and physical health problems (27.5%). Over 83% of decedents had 2 or more substances attribute to causing their death, with fentanyl (71.1%) as the most common substance. Only 36.6% of decedents had naloxone administered. Fatal opioid overdose data are important for understanding this public health crisis and can guide overdose intervention efforts.

Overview of Antimicrobial Stewardship Activities in Rhode Island

Due to the rise of antibiotic resistance, and the decrease of novel antibiotics coming to market, the Centers for Disease Control and Prevention (CDC) has formally recognized that action must take place to ensure appropriate antibiotic use, and maintain public health. The RI Department of Health (RIDOH) Director responded by initiating the RI Antimicrobial Stewardship and Environmental Cleaning Task Force (RIAMSEC), a multidisciplinary team that set in motion a set of tasks for RIDOH. As a result, a survey of antibiotic stewardship programs (ASP) at the RI acute care hospitals (ACHs) and long-term care (LTC) facilities revealed gaps in addressing HAI prevention and AMS goals for the state. RIDOH has therefore expanded statewide coordination efforts to form the RI Healthcare-Associated Infection Prevention and Antimicrobial Stewardship Coalition which is intended to effectively prevent HAI and ultimate improve the Centers for Medicare and Medicaid Services Hospital-acquired Condition (HAC) Reduction scores in Rhode Island.[Full article available at http://rimed.org/rimedicaljournal-2018-06.asp].

Respiratory viral testing in laboratories serving acute care hospitals in Rhode Island

BACKGROUND

The rapid detection of respiratory viral infections is associated with several positive health outcomes. However, little is known about the availability of rapid respiratory viral testing in acute care hospital laboratories.

METHODS

A survey was sent to 13 hospital laboratories assessing results' turnaround time, the number of ordered tests and positive results.

RESULTS

Rapid viral panel (RVP), respiratory syncytial virus (RSV), and rapid influenza testing was available in 9 of 13, 13 of 13, and 13 of 13 hospitals, respectively. Results were available within 24 hours of specimen collection in 1 of 9 hospitals for RVP; RSV and rapid influenza results were available within 12 hours in 8 of 13 and 13 of 13 hospitals, respectively.

CONCLUSIONS

Rapid diagnosis of respiratory viral infections in RI acute care hospitals can be made for influenza and RSV. However, rapid results for other respiratory viruses are unavailable in most of RI hospitals. [Full article available at http://rimed.org/rimedicaljournal-2017-09.asp].

Retrospective analysis of heavy metal contamination in Rhode Island based on old and new herbarium specimens

PREMISE OF THE STUDY

Herbarium specimens may provide a record of past environmental conditions, including heavy metal pollution. To explore this potential, we compared concentrations of copper, lead, and zinc in historical and new collections from four sites in Rhode Island, USA.

METHODS

We compared historical specimens (1846 to 1916) to congener specimens collected in 2015 at three former industrial sites in Providence, Rhode Island, and one nonindustrial site on Block Island. Leaf material was prepared by UltraWAVE SRC Microwave Digestion, and heavy metal concentrations were measured by inductively coupled plasma-atomic emission spectroscopy.

RESULTS

Heavy metal concentrations in the historical and new specimens were measurable for all elements tested, and levels of copper and zinc were comparable in the historical and 2015 collections. By contrast, the concentration of lead declined at all sites over time. Significant variability in heavy metal concentration was observed between taxa, reflecting their varied potential for elemental accumulation.

DISCUSSION

It seems clear that herbarium specimens can be used to evaluate past levels of pollution and assess local environmental changes. With careful sampling effort, these specimens can be a valuable part of environmental science research. Broadening the possible applications for herbarium collections in this way increases their relevance in an era of reduced funding for collections-based research.

Preventing Foodborne and Enteric Illnesses Among At-Risk Populations in the United States and Rhode Island

One out of every six people in the United States is estimated to become sick each year from pathogens that can cause foodborne illness. The groups at greatest risk for serious illness, hospitalization, or death include young children, older adults, people with chronic conditions, and pregnant women. Such health disparities must be considered along with those disparities that may exist among racial and ethnic groups and among groups of varying socioeconomic status. We analyzed risk profiles for enteric disease using data from Rhode Island and the nation as a whole, exploring disparities among groups defined by demographic and health characteristics. As expected, disparities in the burden of enteric illnesses are not limited to racial or ethnic differences in disease burden, or in differences otherwise attributable to socioeconomic status. Age is an especially important determinant of risk, as is residential status. Other groups found to be especially vulnerable to foodborne and enteric illnesses in Rhode Island include pregnant women and those with certain health conditions (e.g., cancer, liver disease or immunosuppression). By understanding what groups are at increased risk, providers can more effectively counsel their patients to mitigate risk and effectively treat these conditions. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Diabetes and BMI: Health Equity through Early Intervention on Dysglycemia, and How Providers Can Help

Like most states in the U.S., Rhode Island's rate of type 2 Diabetes Mellitus (DM) is rising as its population has both aged and become heavier. Risk of both BMI>=30 and DM has risen across almost all demographics, but disparities continue to exist in both conditions. We analyzed state health survey data to assess race/ethnicity-stratified DM and BMI and the age-adjusted rate of DM by weight status relative to the late 1990s. The prevalence of obesity increased across almost all demographic groups relative to 15 years ago, but the rise was greatest among non-Hispanic whites. The age-adjusted rate of DM had a similar increase across racial/ethnic categories where BMI>=30, but black adults were still at higher risk of DM even at a BMI<30. In sum, non-Hispanic whites and Hispanics are "catching up" to blacks' historically higher prevalence of obesity and DM, but disparities remain in both conditions. We describe two ways providers can collaborate with the Department of Health to address these growing health problems. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Health Equity, Social Justice, and HIV in Rhode Island: A Contemporary Challenge

From its beginning, HIV has primarily affected marginalized populations, such as injection drug users, gay, bisexual and other men who have sex with men (GBMSM), and minority racial and ethnic groups. HIV is a disease that, from the start, has been strongly influenced by issues related to social justice and health equity due to its intersection with behaviors among at-risk populations. While some of the risks associated with HIV have been successfully mitigated through social justice initiatives related to needle exchange programs and routine HIV testing of pregnant women, Rhode Island remains confronted with the health equity challenges of preventing HIV transmission and ensuring access to HIV care/treatment, especially for Black/African Americans, Hispanics, and GBMSM. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Clinical presentation, pathophysiology, diagnosis, and treatment of acquired and hereditary angioedema: Exploring state-of-the-art therapies in RI

Hereditary and acquired angioedema are potentially life-threatening diseases characterized by spontaneous episodes of subcutaneous and submucosal swelling of face, lips, oral cavity, larynx, and GI tract. Hereditary angioedema (HAE) usually presents within the first and second decades of life, whereas acquired angioedema presents in adults after 40 years of age. These clinical symptoms together with reduced C1 inhibitor levels and/or activity can usually confirm the diagnosis. In recent years, multiple novel therapies for treating hereditary angioedema have emerged including C1 inhibitor concentrates, ecallantide/kallikrein inhibitor, and icatibant/bradykinin receptor antagonist. This article reviews the clinical presentation, diagnosis, treatment, and prophylaxis of HAE. Lastly, this article takes into consideration that, in reality, acute care treatment can often be limited by each hospital's formulary, included is a review of HAE treatments available at the nine major hospitals in Rhode Island. [Full article available at http://rimed.org/rimedicaljournal-2016-06.asp, free with no login].

Cancer and Obesity in Rhode Island

There is growing evidence that obesity increases the risk of certain cancers and cancer mortality. As obesity rates are projected to rise over the next decade, associated cancer morbidity and mortality present a significant public health concern. This is particularly striking in the state of Rhode Island, where nearly a third of the population is obese. Interventions such as taxation of obesity-associated foods or insurance incentive programs promoting positive health behaviors could decrease obesity-associated cancer incidence and mortality over time. Public health programs could be deployed at both the local and national levels. We provide a background on obesity-related cancer, discuss existing evidence to support these ideas, and make recommendations regarding individual and societal factors when considering public policy, health-care delivery, taxation structure, and insurance.

Concordance between Activated Partial Thromboplastin Time and Antifactor Xa Assay for Monitoring Unfractionated Heparin in Hospitalized Hyperbilirubinemic Patients

BACKGROUND

Activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) monitoring methods for unfractionated heparin (UFH) often disagree. The extent of discordance for those with elevated bilirubin remains unclear. Our objective was to evaluate concordance between activated aPTT and anti-Xa methods for hyperbilirubinemic patients on UFH.

METHODS

This was a retrospective cohort study of 26 patients hospitalized at Rhode Island Hospital between August 2014 and September 2014. Patients had at least one bilirubin measurement >5 mg/dL. After categorizing lab values, percent agreement and kappa were used to examine concordance between aPTT and anti-Xa.

RESULTS

Overall percent agreement between aPTT and anti-Xa was 50%. A nontherapeutic aPTT and therapeutic anti-Xa accounted for 98% of all disagreement. Specifically, 76.7% of disagreement was due to a subtherapeutic aPTT and a therapeutic anti-Xa. Unweighted kappa was 0.141 (95%CI: 0.048-0.235).

CONCLUSION

Concordance between aPTT and anti-Xa values was poor in hyperbilirubinemic patients.

Snakebite! Crotalinae Envenomation of a Man in Rhode Island

The incidence of poisonous snakebites has regional variance. Health care providers' knowledge and comfort in treating these envenomated patients depends on the density of poisonous snakes in their environment, with practitioners in the southern U.S. typically treating more exposed patients than those in colder regions in the North. We present a rare case of a confirmed copperhead snakebite that occurred in Rhode Island. We will review Copperhead bites, clinical management and treatment options.

Profiles of medicinal cannabis patients attending compassion centers in rhode island

Little is understood regarding medicinal marijuana dispensary users. We sought to characterize socio-demographics and reasons for medicinal marijuana use among medical cannabis dispensary patients in Rhode Island. Participants (n=200) were recruited from one of two Compassion Centers in Rhode Island and asked to participate in a short survey, which included assessment of pain interference using the Brief Pain Inventory (BPI). The majority of participants were male (73%), Caucasian (80%), college educated (68%), and had health insurance (89%). The most common reason for medicinal marijuana use was determined to be chronic pain management. Participants were more likely to have BPI pain interference scores of > 5 if they were older (OR: 1.36, 95% CI: 1.04-1.78) or reported using cannabis as a substitute for prescription medications (OR: 2.47, 95% CI: 1.23-4.95), and were less likely to have interference scores of >5 if they had higher income levels (OR: 0.53, 95% CI: 0.40-0.70) or reported having ever received treatment for an alcohol use disorder. One-fifth of participants had a history of a drug or alcohol use disorder. Most participants report that medicinal cannabis improves their pain symptomology, and are interested in alternative treatment options to opioid-based treatment regimens.

The Nuts and Bolts of Long-term Care In Rhode Island: Demographics, Services and Costs

Nearly 8,000 people reside in Rhode Island's (RI's) 84 nursing homes at any single point in time. Many of these people are highly vulnerable because of illness or frailty. In this article, we describe the reasons that RI residents seek care from nursing homes, the associated costs (with a focus on Medicare and Medicaid payment), and different ways to assess nursing home quality. We also describe the home- and community-based services that can help people remain in the community. A resource list provides additional information for those seeking to better understand RI nursing homes and long-term care supports and services.

Hepatitis C Prevention and Needle Exchange Programs in Rhode Island: ENCORE

As Rhode Island's only needle exchange program, ENCORE (Education, Needle Exchange, Counseling, Outreach, and REferrals) serves a wide range of clients infected or at risk for infection with hepatitis C virus (HCV). Through its on-site and outreach platforms across Rhode Island, ENCORE is in a unique position to serve at-risk individuals who may not otherwise present for prevention, testing and care for HCV, as well as human immunodeficiency virus (HIV). In this article, we discuss the role of needle exchange programs in preventing HCV transmission, and provide an overview of the history and current operations of ENCORE.

Estimating the true prevalence of hepatitis C in rhode island

Although there is a large health, social, and economic burden of hepatitis C virus (HCV) infection in the United States, the number of persons infected with HCV in Rhode Island (RI) is unknown. To inform the expansion of HCV-related public health efforts in RI, and because surveillance data are lacking and national surveys, including the National Health and Nutrition Examination Survey (NHANES), likely underestimate true HCV prevalence, we reviewed published peer-reviewed and grey literature to more accurately estimate the prevalence of HCV in RI. The results of our review suggest that between 16,603 and 22,660 (1.7%-2.3%) persons in RI have ever been infected with HCV. Assuming a spontaneous clearance rate of 26%, we estimate that between 12,286 and 16,768 (1.2%-1.7%) have ever been or are currently chronically infected with HCV. Findings suggest the urgent need for improved HCV screening in RI, and that reducing morbidity and mortality from HCV will require a dramatic scale-up of testing, linkage to care, treatment and cure.

Prevention and control of hepatitis C in rhode island

Concern about the morbidity and mortality of hepatitis C infection is increasing. Persons born from 1945 to 1965 are most significantly affected, with the majority unaware of their infection, and will otherwise go untreated. Up to three-fourths of hepatitis C-related deaths occur in this population of "baby boomers." Since 2007, mortality from hepatitis C has exceeded that from HIV, nationally and in Rhode Island. New treatment options for hepatitis C emphasize the potential for cure of hepatitis C that is distinct from HIV. Financial resources and integration of hepatitis C partners and services in Rhode Island will be instrumental in reducing hepatitis C infections and increasing the number of cases cured. We describe public health investments in the past, present, and future to implement strategies for effectively addressing hepatitis C in the state.

Hepatitis C virus infection: from margin to center in rhode island and beyond

Physicians, Research Scientists and Public Health Experts Collaborate to Combat Rhode Island’s Hepatitis C Epidemic

The Rhode Island Consortium for Autism Research and Treatment (RI-CART): a new statewide autism collaborative

Autism is a neurodevelopmental disorder characterized by core deficits in social interaction, language and repetitive behaviors. The need for services is rising sharply as the number of children identified with autism increases. The Rhode Island Consortium for Autism Research and Treatment (RI-CART) was founded in 2009 with the goal of increasing communication among autism researchers throughout the state and improving treatment for children with autism. RI-CART members have several exciting projects in progress, with its larger aim being the creation of a statewide research registry. A statewide registry would benefit research in Rhode Island and allow for larger collaborations nationally.

Outpatient parenteral antibiotic therapy in an academic practice in Rhode Island

Outpatient parenteral antimicrobial therapy (OPAT) is an increasingly utilized treatment modality that has been proven to be safe and cost effective for treating infections that require prolonged antimicrobial treatment. Adequate patient selection, a structured OPAT team with an effective communication system, and routine clinical monitoring are key elements to establish a successful OPAT program. The Miriam Hospital Infectious Diseases Clinic offers a multidisciplinary OPAT model coordinated by infectious diseases specialists and serves as a major referral center in Rhode Island.