Optimal hepatitis C treatment adherence patterns and sustained virologic response among people who inject drugs: The HERO study

BACKGROUND & AIMS

Direct-acting antivirals (DAAs) are highly effective for treating HCV infection even among people who inject drugs (PWID). Yet, little is known about patients' adherence patterns and their association with sustained virologic response (SVR) rates. We aimed to summarize various adherence patterns and determine their associations with SVR.

METHODS

Electronic blister packs were used to measure daily adherence to once-a-day sofosbuvir/velpatasvir during the 12-week treatment period among active PWIDs. Blister pack data were available for 496 participants who initiated DAAs for whom SVR status was known. Adherence was summarized in multiple patterns, such as total adherent days, consecutive missed days, and early discontinuations. Thresholds for adherence patterns associated with >90% SVR rates were also determined.

RESULTS

The overall SVR rate was 92.7%, with a median adherence rate of 75%. All adherence patterns indicating greater adherence were significantly associated with achieving SVR. Participant groups with ≥50% (>42/84) adherent days or <26 consecutive missed days achieved an SVR rate of >90%. Greater total adherent days during 9-12 weeks and no early discontinuation were significantly associated with higher SVR rates only in those with <50% adherence. Participants with first month discontinuation and ≥2 weeks of treatment interruption had low SVR rates, 25% and 85%, respectively. However, greater adherent days were significantly associated with SVR (adjusted odds ratio 1.10; 95% CI 1.04-1.16; p <0.001) even among participants with ≥14 consecutive missed days.

CONCLUSIONS

High SVR rates can be achieved in the PWID population despite suboptimal adherence. Encouraging patients to take as much medication as possible, with <2 weeks consecutive missed days and without early discontinuation, was found to be important for achieving SVR.

IMPACT AND IMPLICATIONS

People who inject drugs can be cured of HCV in >90% of cases, even with relatively low adherence to direct-acting antivirals, but early discontinuations and long treatment interruptions can significantly reduce the likelihood of achieving cure. Clinicians should encourage people who inject drugs who are living with HCV to adhere daily to direct-acting antivirals as consistently as possible, but if any days are interrupted, to continue and complete treatment. These results from the HERO study are important for patients living with HCV, clinicians, experts writing clinical guidelines, and payers.

CLINICAL TRIAL NUMBER

NCT02824640.

Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder

BACKGROUND

Hospitalization presents an opportunity to begin people with opioid use disorder (OUD) on medications for opioid use disorder (MOUD) and link them to care after discharge; regrettably, people admitted to the hospital with an underlying OUD typically do not receive MOUD and are not connected with subsequent treatment for their condition. To address this gap, we launched a multi-site randomized controlled trial to test the effectiveness of a hospital-based addiction consultation team (the Substance Use Treatment and Recovery Team (START)) consisting of an addiction medicine specialist and care manager team that provide collaborative care and a specified intervention to people with OUD during the inpatient stay. Successful implementation of new practices can be impacted by organizational context, though no previous studies have examined context prior to implementation of addiction consultation services (ACS). This study assessed pre-implementation context for implementing a specialized ACS and tailoring it accordingly.

METHODS

We conducted semi-structured interviews with hospital administrators, physicians, physician assistants, nurses, and social workers at the three study sites between April and August 2021 before the launch of the pragmatic trial. Using an analytical framework based on the Consolidated Framework for Implementation Research, we completed a thematic analysis of interview data to understand potential barriers or enablers and perceptions about acceptability and feasibility.

RESULTS

We interviewed 28 participants across three sites. The following themes emerged across sites: (1) START is an urgently needed model for people with OUD; (2) Intervention adaptations are recommended to meet local and cultural needs; (3) Linking people with OUD to community clinicians is a highly needed component of START; (4) It is important to engage stakeholders across departments and roles throughout implementation. Across sites, participants generally saw a need for change from usual care to support people with OUD, and thought the START was acceptable and feasible to implement. Differences among sites included tailoring the START to support the needs of varying patient populations and different perceptions of the prevalence of OUD.

CONCLUSIONS

Hospitals planning to implement an ACS in the inpatient setting may wish to engage in a systematic pre-implementation contextual assessment using a similar framework to understand and address potential barriers and contextual factors that may impact implementation. Pre-implementation work can help ensure the ACS and other new practices fit within each unique hospital context.

Association of Cytomegalovirus (CMV) DNAemia With Long-Term Mortality in a Randomized Trial of Preemptive Therapy and Antiviral Prophylaxis for Prevention of CMV Disease in High-Risk Donor Seropositive, Recipient Seronegative Liver Transplant Recipients

In a post-hoc analysis of the association of CMV DNAemia with long-term mortality in a randomized trial of CMV preemptive therapy vs. antiviral prophylaxis in D+R- liver transplant recipients, post-intervention CMV DNAemia was associated with increased mortality after adjusting for study arm.

Overreporting of adherence to hepatitis C direct-acting antiviral therapy and sustained virologic response among people who inject drugs in the HERO study

BACKGROUND

Self-reported adherence to direct-acting antivirals (DAAs) to treat hepatitis C virus (HCV) among persons who inject drugs (PWID) is often an overreport of objectively measured adherence. The association of such overreporting with sustained virologic response (SVR) is understudied. This study among PWID aimed to determine a threshold of overreporting adherence that optimally predicts lower SVR rates, and to explore correlates of the optimal overreporting threshold.

METHODS

This study analyzed per-protocol data of participants with adherence data (N = 493) from the HERO (Hepatitis C Real Options) study. Self-reported and objective adherence to a 12-week DAA regimen were measured using visual analogue scales and electronic blister packs, respectively. The difference (Δ) between self-reported and objectively measured adherence was calculated. We used the Youden index based on receiver operating characteristic (ROC) curve analysis to identify an optimal threshold of overreporting for predicting lower SVR rates. Factors associated with the optimal threshold of overreporting were identified by comparing baseline characteristics between participants at/above versus those below the threshold.

RESULTS

The self-reported, objective, and Δ adherence averages were 95.1% (SD = 8.9), 75.9% (SD = 16.3), and 19.2% (SD = 15.2), respectively. The ≥ 25% overreporting threshold was determined to be optimal. The SVR rate was lower for ≥ 25% vs. < 25% overreporting (86.7% vs. 95.8%, p <.001). The factors associated with ≥ 25% Δ adherence were unemployment; higher number of days and times/day of injecting drugs; higher proportion of positive urine drug screening for amphetamine, methamphetamine, and oxycodone, and negative urine screening for THC (tetrahydrocannabinol)/cannabis.

CONCLUSIONS

Self-reported DAA adherence was significantly greater than objectively measured adherence among PWID by 19.2%. Having ≥ 25% overreported adherence was associated with optimal prediction of lower SVR rates. PWID with risk factors for high overreporting may need to be more intensively managed to promote actual adherence.

The Cascade of Care for Early Psychosis Detection in a College Counseling Center

OBJECTIVE

Programs for early detection of psychosis help identify individuals experiencing emerging psychosis and link them with appropriate services, thereby reducing the duration of untreated psychosis (DUP). The authors used the cascade-of-care framework to identify various care stages between screening and enrollment in coordinated specialty care (CSC) and to determine attrition at each stage, with the goal of identifying points in the referral process that may affect DUP.

METHODS

Project partners included a college counseling center and CSC program. All college students seeking mental health services at a counseling center between 2020 and 2022 (N=1,945) completed the Prodromal Questionnaire-Brief (PQ-B) at intake. Students who met the distress cutoff score were referred for a phone screening. Those who met criteria on the basis of this screening were referred for assessment and possible enrollment into CSC.

RESULTS

Six stages in the cascade of care for early detection were identified. Of the students who completed the PQ-B as part of intake (stage 1), 547 (28%) met the PQ-B cutoff score (stage 2). Counselors referred 428 (78%) students who met the PQ-B cutoff score (stage 3), and 212 (50%) of these students completed the phone screening (stage 4). Seventy-two (34%) students completed a CSC eligibility assessment (stage 5), 21 (29%) of whom were enrolled in CSC (stage 6).

CONCLUSIONS

The cascade-of-care framework helped conceptualize the flow within a program for early psychosis detection in order to identify stages that may contribute to lengthier DUP. Future research is warranted to better understand the factors that contribute to DUP at these stages.

Self-reported and measured adherence to hepatitis C direct-acting antiviral therapy and sustained virologic response among people who inject drugs: The HERO study

BACKGROUND

Objective adherence measures, such as electronic blister pack (BP), for direct-acting antivirals (DAAs) for hepatitis C virus (HCV) treatment have high accuracy, but their use is limited in real practice settings. We examined the association of self-reported adherence using a visual analogue scale (VAS) with objective BP adherence and sustained virologic response (SVR) among people who inject drugs.

METHODS

We conducted secondary analyses using a subset of participants (N = 493) from the per-protocol sample of the HERO study, a pragmatic randomized trial of HCV treatment interventions that used both VAS and BP to measure adherence to a 12-week sofosbuvir/velpatasvir DAA regimen. Multivariable mixed-effects regression models tested the association of self-report adherence level with longitudinal weekly objective adherence. Multivariable logistic regression tested the association of self-report adherence with SVR.

RESULTS

The average VAS and BP adherences were 95.1 % (SD = 8.9 %) and 76.0 % (16.0 %), respectively, and the proportion of the participants achieving SVR was 92.9 %. The estimated adjusted mean objective adherence was significantly different (-16 %; 95 % CI: -22 %, -11 %, p < .001) between participants with 100 % and <80 % VAS adherence. The likelihood of SVR was significantly lower for those with <80 % VAS adherence [adjusted OR = 0.07; 95 % CI: 0.02, 0.24; p < .001] compared to those with 100 %.

CONCLUSION

Self-reported adherence overestimated objective adherence. However, higher self-report adherence was significantly associated with higher objective adherence. Also, self-reported adherence ≥80 % was significantly associated with SVR. Thus, the self-report measure has utility as a monitoring tool for adherence during DAA treatment.

A Systematic Review and Meta-analysis of Optimized CMV Preemptive Therapy and Antiviral Prophylaxis for CMV Disease Prevention in CMV High-Risk (D+R-) Kidney Transplant Recipients

The optimal strategy for cytomegalovirus (CMV) disease prevention in CMV donor/recipient kidney transplant recipients remains uncertain. Conclusions of prior meta-analyses that CMV disease rates with preemptive therapy (PET) and universal prophylaxis (UP) were comparable may have been affected by inclusion of studies lacking key determinants of efficacy of the respective strategies.

Methods

We conducted a systematic review and meta-analysis of PET with weekly CMV polymerase chain reaction monitoring for ≥3 mo and UP with 6 mo of valganciclovir. PubMed and Embase databases were reviewed from January 1, 2010, to April 1, 2022. Risk of bias was assessed with 3 instruments (Cochrane RoB, Cochrane RoBINS-I, and an instrument for assessing risk in observational studies). The primary outcome was CMV disease incidence by 1-y posttransplant. Secondary outcomes by 1-y were graft loss, acute allograft rejection, and mortality. Results were synthesized using generalized linear mixed model meta-analysis. PET studies were stratified into low-threshold (LT) and high-threshold (HT) PET based on the viral load threshold for initiation of antiviral therapy.

Results

Twenty-five studies met inclusion criteria (6 PET, 19 UP). CMV disease incidence was significantly higher in HT (0.30 [95% confidence interval (CI), 0.22-0.39]) versus LT PET (0.06 [95% CI, 0.03-0.12]). LT PET was associated with a significantly lower CMV disease incidence (0.06 [95% CI, 0.03-0.12]) versus UP (0.21 [95% CI, 0.17-0.27]). Incidence of graft loss, acute allograft rejection, or mortality was not significantly different between LT PET and UP (P > 0.05 for all comparisons). Receipt of lymphocyte-depleting antibodies was not associated with a significant difference in CMV disease incidence (odds ratio = 1.34 [95% CI, 0.80-2.25]).

Conclusions

LT PET is associated with a significantly lower incidence of CMV disease compared to UP with similar rates of other clinical outcomes. These findings provide rationale and preliminary data for a randomized superiority trial of optimized LT-PET versus UP in donor seropositive recipient seronegative kidney transplant recipients.

Injecting practices during and after hepatitis C treatment and associations with not achieving cure among persons who inject drugs

BACKGROUND

Persons who inject drugs (PWID) are a key population for hepatitis C virus (HCV) treatment. Study aims were to describe injection practices of PWID during HCV treatment with direct-acting antivirals (DAAs) and assess whether injection practices were associated with not achieving a sustained virologic response (SVR).

METHODS

Secondary analysis of the HERO Study (ClinicalTrials.gov, NCT02824640), a pragmatic randomized trial in 8 U.S. states to evaluate the effectiveness of HCV care models among active PWID seen in opioid treatment programs and community clinics. Frequency, sharing and reuse of injecting equipment were assessed at baseline, end-of-treatment (EOT) and quarterly visits up to 60 weeks post-treatment. Generalized Estimating Equations logistic regression models with linear spline were used to compare trends in injecting behaviors during vs. post-treatment. Multivariable logistic regression models explored associations between injecting behaviors during treatment and lack of SVR.

RESULTS

Among 501 participants, 27% were female, 35% were non-white, mean age was 44 (SD 11.5) years and nearly half (49%) were unhoused. At baseline, 41% reported receptive sharing of injecting equipment, declining to 16% at EOT visit. Receptive sharing of cookers, rinses, or needles/syringes during treatment was associated with a nearly 5-fold increase in not achieving SVR (adjusted odds ratio (aOR)=4.83; 95% CI: 2.26, 10.28) as was reuse of one's own needles/syringes (aOR=2.37; 95% CI: 1.11, 4.92).

CONCLUSIONS

PWID in the HERO study adopted safer injecting behaviors during DAA treatment; receptive sharing of injecting equipment and reuse of one's own equipment during treatment were associated with not achieving cure.

Associations between depression and diabetes among Latinx patients from low-income households in New Mexico

Depression and diabetes are co-occurring epidemics. This article explores the association between depression and diabetes in a cohort of Latinx patients with diabetes from low-income households. Data were gathered in Albuquerque, New Mexico (U.S.) between 2016 and 2020 as part of a patient-engaged comparative effectiveness trial comparing two culturally appropriate diabetes self-management programs-the Chronic Care Model (CCM) and the standard of care, Diabetes Self-Management Support Empowerment Model (DSMS). We proposed that the program most culturally and contextually situated in the life of the patient would have the greatest impact on diabetes self-management. Participants were enrolled as dyads-226 Latinx diabetes patient participants (PPs) from low-income households and 226 social support participants (SSPs). Data gathered at baseline, 3, 6, and 12 months included a measure of depression and A1c testing. Outcomes between programs were analyzed using longitudinal linear mixed modeling, adjusted for patient demographic characteristics and other potential confounding covariates. Patient A1c had an initial slight decrease at 3 months in both programs. At CCM, patients with a very high A1c (greater than 10%) demonstrated a clinically meaningful decrease in A1c over time. Patients at CCM experienced a large initial decrease in depression and continued to decrease throughout the study, while patients at DSMS showed a slight initial decrease through 6 months, but depression increased again by 12 months, nearly rebounding to baseline levels. A subgroup analysis revealed that a higher baseline A1c was associated with higher depression, and patients with higher A1c achieved greater reductions in depression at CCM than at DSMS. CCM scored higher on Consumer Assessment of Healthcare Providers and Systems cultural competence (CAHPS-CC). Interpretation of results suggests that the more culturally, contextually situated program, CCM, had better outcomes. This study demonstrates that culturally and contextually situating a diabetes intervention can deliver improved benefits for Latinx patients.

A patient-centered comparative effectiveness research study of culturally appropriate options for diabetes self-management

This project compared the effectiveness of two evidence-based models of culturally competent diabetes health promotion: The Diabetes Self-Management Support Empowerment Model (DSMS), and The Chronic Care Model (CCM). Our primary outcome was improvement in patient capacity for diabetes self-management as measured by the Diabetes Knowledge Questionnaire (DKQ) and the Patient Activation Measure (PAM). Our secondary outcome was patient success at diabetes self-management as measured by improvement in A1c, depression sores using the PHQ-9, and Body Mass Index (BMI). We also gathered data on the cultural competence of the program using the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Set (CAHPS-CC). We compared patient outcomes in two existing sites in Albuquerque, New Mexico that serve a large population of Latino diabetes patients from low-income households. Participants were enrolled as dyads-a patient participant (n=226) and a social support participant (n=226). Outcomes over time and by program were analyzed using longitudinal linear mixed modeling, adjusted for patient participant demographic characteristics and other potential confounding covariates. Secondary outcomes were also adjusted for potential confounders. Interactions with both time and program helped to assess outcomes. This study did not find a difference between the two sites with respect to the primary outcome measures and only one of the three secondary outcomes showed differential results. The main difference between programs was that depression decreased more for CCM than for DSMS. An exploratory, subgroup analysis revealed that at CCM, patient participants with a very high A1c (>10) demonstrated a clinically meaningful decrease. However, given the higher cultural competence rating for the CCM, statistically significant improvement in depression, and the importance of social support to the patients, results suggest that a culturally and contextually situated diabetes self-management and education program design may deliver benefit for patients, especially for patients with higher A1c levels.

Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico

BACKGROUND

Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses.

METHODS

This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios.

RESULTS

Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%).

CONCLUSIONS

Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.

Patient-centred models of hepatitis C treatment for people who inject drugs: a multicentre, pragmatic randomised trial

BACKGROUND

To achieve WHO targets for the elimination of hepatitis C virus (HCV) as a public threat, an increased uptake of HCV treatment among people who inject drugs (PWID) is urgently needed. Optimal HCV co-located treatment models for PWID have not yet been identified. We aimed to compare two patient-centred models of HCV care in PWID with active drug use.

METHODS

We did a pragmatic randomised controlled trial at eight US cities in eight opioid treatment programmes and 15 community health centres. PWID actively injecting within 90 days of study entry were randomly assigned (1:1) to either patient navigation or modified directly observed therapy (mDOT) using computer-generated variable block sizes of 2-6 stratified by city, clinical settings, and cirrhosis status. The randomisation code was concealed, in a centralised REDCap database platform, from all investigators and research staff except for an authorised data manager at the data coordinating centre. All participants received a fixed-dose combination tablet (sofosbuvir 400 mg plus velpatasvir 100 mg) orally once daily for 12 weeks. The primary outcome was sustained virological response (SVR; determined by chart review between 70 days and 365 days after end of treatment and if unavailable, by study blood draws), and secondary outcomes were treatment initiation, adherence (measured by electronic blister packs), and treatment completion. Analyses were conducted within the modified intention-to-treat (mITT; all who initiated treatment), intention-to-treat (all who were randomised), and per-protocol populations. This trial is registered with ClinicalTrials.gov, NCT02824640.

FINDINGS

Between Sept 15, 2016, and Aug 14, 2018, 1891 individuals were screened and 1136 were excluded (213 declined to participate and 923 did not meet the eligibility criteria). We randomly assigned 755 participants to patient navigation (n=379) or mDOT (n=376). In the mITT sample of participants who were randomised and initiated treatment (n=623), 226 (74% [95% CI 69-79]) of 306 participants in the mDOT group and 236 (76% [69-79]) of 317 in the patient navigation group had an SVR, with no significant difference between the groups (adjusted odds ratio [AOR] 0·97 [95% CI 0·66-1·42]; p=0·35). In the ITT sample (n=755), 226 (60% [95% CI 55-65]) of 376 participants in the mDOT group and 236 (62% [57-67]) of 379 in the patient navigation group had an SVR (AOR 0·92 [0·68-1·25]; p=0·61) and in the per-protocol sample (n=501), 226 (91% [87-94]) of 248 participants in the mDOT group and 235 (93% [89-96]) of 253 in the patient navigation group had an SVR (AOR 0·79 [0·41-1·55]; p=0·44). 306 (81%) of 376 participants in the mDOT group and 317 (84%) of 379 participants in the patient navigation group initiated treatment (AOR 0·86 [0·58-1·26]; p=0·44) and, among those, 251 (82%) participants in the mDOT group and 264 (83%) participants in the patient navigation group completed treatment (AOR 0·90 [0·58-1·39]; p=0·63). Mean daily adherence was higher in the mDOT group (78% [95% CI 75-81]) versus the patient navigation group (73% [70-77]), with a difference of 4·7% ([1·9-7·4]; p=0·0010). 421 serious adverse events were reported (217 in the mDOT group and 204 in the patient navigation group), with the most common being hospital admission (176 in the mDOT group vs 161 in the patient navigation group).

INTERPRETATION

In this trial of active PWID, both models resulted in high SVR. Although adherence was significantly higher in the mDOT group versus the patient navigation group, there was no significant difference in SVR between the groups. Increases in adherence and treatment completion were associated with an increased likelihood of SVR. These results suggest that active PWID can reach high SVRs in diverse settings with either mDOT or patient navigation support.

FUNDING

Patient-Centered Outcomes Research Institute, Gilead Sciences, Quest Diagnostics, Monogram Biosciences, and OraSure Technologies.

A Study of a Culturally and Contextually Situated Multimedia Approach to Recruit a Hard-to-Reach Spanish-Speaking Population for a Randomized Control Trial (RCT)

Study designs involving randomization can be difficult to communicate to participants, especially those with low literacy. The literature on strategies to explain research concepts is limited, especially for non-English speakers. We measured the effectiveness of a culturally and contextually situated multimedia approach to recruit a cohort of 60 female Mexican immigrants (FMI) to a randomized control trial (RCT) to reduce social isolation and depression. This strategy was designed to explain the concept of randomization, explain what participating in the research study entailed, and ensure informed consent. Potential participants viewed a presentation explaining the study and a video including animation with voice-over explaining the concept of randomization. We administered a pre/post survey. Respondents (N = 59) reported an increase in their understanding of randomization, intention to enroll, and attitude towards participating in research. We conclude that a culturally and contextually situated multimedia approach is an effective model when recruiting underrepresented populations with low literacy for RCTs.

Design of CLARO (Collaboration Leading to Addiction Treatment and Recovery from other Stresses): A randomized trial of collaborative care for opioid use disorder and co-occurring depression and/or posttraumatic stress disorder

INTRODUCTION

Opioid use disorder (OUD) co-occurring with depression and/or posttraumatic stress disorder (PTSD) is common and, if untreated, may lead to devastating consequences. Despite the availability of evidence-based treatments for these disorders, receipt of treatment is low. Even when treatment is provided, quality is variable. Primary care is an important and underutilized setting for treating co-occurring disorders (COD) because OUD, depression and PTSD are frequently co-morbid with medical conditions and most people visit a primary care provider at least once a year. With rising rates of OUD and opioid-related fatalities, this is a critical treatment and quality gap in a vulnerable and stigmatized population.

METHODS

CLARO (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses) is a multi-site, randomized pragmatic trial of collaborative care (CC) for co-occurring disorders in 13 rural and urban primary care clinics in New Mexico to improve care for patients with OUD and co-occurring depression and/or PTSD. CC, a service delivery approach that uses multi-faceted interventions, has not been tested with COD. We will enroll and randomize 900 patients to either CC adapted for COD (CC-COD) or enhanced usual care (EUC) and will collect patient data at baseline, 3-, and 6-month follow-up. Our primary outcomes are medications for OUD (MOUD) access, MOUD continuity of care, depression symptoms, and PTSD symptoms.

DISCUSSION

Although CC is effective for improving outcomes in primary care among patients with mental health conditions, it has not been tested for COD. This article describes the CLARO CC-COD intervention and clinical trial.

A randomized control trial to test a peer support group approach for reducing social isolation and depression among female Mexican immigrants

BACKGROUND

Female Mexican Immigrants (FMIs) experience high rates of depression compared with other populations. For this population, depression is often exacerbated by social isolation associated with the experience of immigration. Aim 1. To measure whether a culturally situated peer group intervention will reduce depression and stress associated with the experience of immigration. Aim 2. To test whether an intervention using a "women's funds of knowledge" approach results in improved resilience, knowledge and empowerment. Aim 3. To investigate whether a culturally situated peer group intervention using a women's funds of knowledge approach can give participants a sense and experience of social and physical connection ("emplacement") that is lost in the process of immigration.

METHODS

This mixed-methods study will implement "Tertulias" ("conversational gatherings" in Spanish), a peer support group intervention designed to improve health outcomes for FMI participants in Albuquerque, New Mexico. We will document results of the intervention on our primary hypotheses of a decrease in depression, and increases in resilience and social support, as well as on our secondary hypotheses of decreased stress (including testing of hair cortisol as a biomarker for chronic stress), and an increase in social connectedness and positive assessment of knowledge and empowerment.

DISCUSSION

This project will address mental health disparities in an underserved population that experiences high rates of social isolation. Successful completion of this project will demonstrate that health challenges that may appear too complex and too hard to address can be using a multi-level, holistic approach. Our use of hair samples to test for the 3-month average levels of systemic cortisol will contribute to the literature on an emerging biomarker for analyzing chronic stress.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov on 2/3/20, Identifier # NCT04254198 .

Traveling for rights: Abortion trends in New Mexico after passage of restrictive Texas legislation

OBJECTIVES

To determine the proportion of abortions provided to patients from Texas in New Mexico before and after the 2013 enactment of Texas House Bill 2 (HB2), an omnibus bill of abortion restrictions, and to compare the gestational ages at which Texans presented for abortion in New Mexico before and after HB2.

STUDY DESIGN

We conducted a chart review of Texas and New Mexico patients obtaining an abortion in New Mexico abortion clinics before HB 2 was signed and implemented (time period 1: January 1, 2012 to December 31, 2012) and after HB 2 went into effect (time period 2: May 1, 2014 to April 30, 2015). We used random sampling of corresponding 7-day periods (by week number during the one-year sample) to obtain data until we reached the desired sample of at least 300 patients. We compared proportions of individuals from Texas obtaining abortions and the gestational age at which they presented in the two time periods.

RESULTS

We abstracted data from 350 and 300 Texas and New Mexico patients, respectively. The proportion of procedures provided to women from Texas increased from 10 (3%) pre-HB2 to 43 (14%) post-HB2 (p < 0.0001). The proportion of procedures in Texas patients at 13 to ≤24 weeks increased from 1 of 29 (3%) pre-HB2 to 10 of 38 (26%) post-HB2 (p = 0.012).

CONCLUSION

The proportion of Texans scheduling abortions in New Mexico within the first 24 weeks of gestation increased after passage of HB2. Restrictive legislation may force more people to travel across state lines to obtain abortion care.

IMPLICATIONS

Patients residing in Texas and seeking abortion care in Texas experienced barriers to abortion care, likely related to restrictions imposed by HB2.

Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population

BACKGROUND

Few studies have evaluated the impact of Baby Friendly Hospital Initiative (BFHI) implementation on underserved populations in the United States. We undertook this study in New Mexico, a large southwestern state with a diverse population and limited health care access.

METHODS

A quasi-experimental, retrospective cohort design was used to compare short-term breastfeeding duration between a pre-BFHI and a post-BFHI cohort. Among the post-BFHI cohort, logistic regression models were fitted to predict short-term breastfeeding duration from both individual and cumulative exposure to inpatient maternity care practices (Steps 4 to 9).

RESULTS

Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 ("Give no pacifiers or artificial nipples") uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times, whereas Step 6 ("Give infants no food or drink other than breastmilk") increased the rate of exclusive breastfeeding by 4.4 times at 2-6 weeks postpartum.

CONCLUSION

These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

Effectiveness of Peer-Delivered Trauma Treatment in a Rural Community: A Randomized Non-inferiority Trial

This randomized controlled non-inferiority trial explored the effectiveness of Seeking Safety (SS) delivered by peer providers compared to its delivery by licensed behavioral health clinicians. The study enrolled 291 adults with PTSD and/or substance use disorders. Data were collected at 3 and 6-months post start of treatment. With respect to long-term outcomes, at 6 months PTSD symptoms decreased by 5.1 points [95% CI (- 9.0, - 1.1)] and by 4.9 points [95% CI (- 8.6, - 1.1)] and coping skills increased by 5.5 points [95% CI (0.4, 10.6)] and by 5.6 points [95% CI (0.8, 10.4)], in the peer- and clinician-led groups, respectively. This study demonstrated non-inferiority of peer-delivered SS compared to clinician-delivered SS for reducing PTSD symptoms and similar outcomes for both groups with respect to coping skills. A confirmatory study on the effectiveness of peer-delivered trauma-specific services is warranted, especially given the potential for increasing access to such treatment in underserved rural communities.

Phase II Trial Using a Combination of Oxaliplatin, Capecitabine, and Celecoxib with Concurrent Radiation for Newly Diagnosed Resectable Rectal Cancer

LESSONS LEARNED

Colorectal cancers exhibit a high level of cyclooxygenase-2 (COX-2) expression with strong preclinical rationale for improved clinical outcomes with COX-2 inhibition. Celecoxib is a COX-2 inhibitor and we have shown that it can be safely combined with capecitabine and oxaliplatin as part of neoadjuvant treatment with radiation therapy (RT) in rectal cancer.There was a significant improvement in skin toxicity with this combination as compared with historical data. Considering the field has moved on to single-agent capecitabine, we believe future trials with capecitabine and celecoxib hold potential.

BACKGROUND

Improved survival is seen among patients with rectal cancer who achieve pathologic complete response (pCR) after neoadjuvant therapy. Cyclooxygenase-2 (COX-2) expression is increased in gastrointestinal malignancies and it may serve as a target to enhance pathologic response. A trial combining chemoradiation and COX-2 inhibition was conducted to evaluate the pCR rate, surgical outcomes, survival, and treatment toxicity.

METHODS

Patients with resectable (T3-4, N1-2) rectal cancer within 12 cm of the anal verge were included in this phase II clinical trial. The neoadjuvant treatment consisted of capecitabine 850 mg/m² b.i.d. Monday through Friday for 5 weeks, weekly oxaliplatin 50 mg/m² intravenous (IV), celecoxib 200 mg b.i.d. daily, along with concurrent 45 gray radiation therapy in 25 fractions.

RESULTS

Thirty-two patients were included in the final analysis. The primary endpoint was pCR: 31% (95% confidence interval [CI]: 16%-50%). Secondary endpoints were surgical downstaging (SD): 75% (95% CI: 57%-89%) and sphincter-sparing surgery (SSS): 56% (95% CI: 38%-74%). Common grade >3 toxicities were diarrhea and abnormal liver function tests (9% each). Grade 0 and 1 toxicities included radiation dermatitis (59% and 34%, respectively) and proctitis (63% and 28%, respectively). At 3 years, disease-free survival and overall survival (OS) were 84% (95% CI: 65%-93%) and 94% (95% CI: 77%-98%), respectively.

CONCLUSION

Chemoradiation with celecoxib in rectal cancer was well tolerated and demonstrated high rates of pCR, SD, and SSS. Improvement in skin toxicity (34% grade 1 and no grade 3/4) as compared with historical results (43%-78% grade 3/4) seems to be a significant improvement with addition of celecoxib to neoadjuvant chemotherapy.

A comparative effectiveness study of two culturally competent models of diabetes self-management programming for Latinos from low-income households

BACKGROUND

Diabetes risk is extremely high for Latinos from low-income households. Health guidelines recommend that individuals learn strategies to self-manage their diabetes, but getting people to adopt required lifestyle changes is challenging and many people are not able to prevent their pre-diabetes from escalating or effectively control their diabetes. Systematic reviews show that culturally competent self-management programs can significantly improve diabetes outcomes and different models for culturally competent programming have been developed.

METHODS

This patient-engaged study will compare the effectiveness of two distinct evidence-based models for culturally competent diabetes health promotion at two sites that serve a large Latino patient population from low-income households: 1) The Diabetes Self-Management Support Empowerment Model, an educational session approach, and 2) The Chronic Care Model, a holistic community-based program. Data collection will involve interviews, focus groups, surveys and assessments of each program; and testing of patient participants for A1c, depression, Body Mass Index (BMI), and chronic stress with hair cortisol levels. We will recruit a total of 240 patient-social support pairs: Patients will be adults (men and women over the age of 18) who: 1.) Enter one of the two diabetes programs during the study; 2.) Self-identify as "Latino;" 3.) Are able to identify a social support person or key member of their social network who also agrees to participate with them; 4.) Are not pregnant (participants who become pregnant during the study will be excluded); and 5.) Have household income 250% of the Federal Poverty Level (FPL) or below. Social supports will be adults who are identified by the patient participants.

PRIMARY OUTCOME

Improved capacity for diabetes self-management measured through improvements in diabetes knowledge and diabetes-related patient activation.

SECONDARY OUTCOME

Successful diabetes self-management as measured by improvements in A1c, depression scale scores, BMI, and circulating levels of cortisol to determine chronic stress.

DISCUSSION

Our hypothesis is that the program model that interfaces most synergistically with patients' culture and everyday life circumstances will have the best diabetes health outcomes.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov on December 16, 2016 (Registration # NCT03004664 ).

Inaccuracies in the Use of Magnification Markers in Digital Hip Radiographs

BACKGROUND

With the ubiquity of digital radiographs, the use of digital templating for arthroplasty has become commonplace. Although improved accuracy with digital radiographs and magnification markers is assumed, it has not been shown.

QUESTIONS/PURPOSES

We wanted to (1) evaluate the accuracy of magnification markers in estimating the magnification of the true hip and (2) determine if the use of magnification markers improves on older techniques of assuming a magnification of 20% for all patients.

METHODS

Between April 2013 and September 2013 we collected 100 AP pelvis radiographs of patients who had a THA prosthesis in situ and a magnification marker placed per the manufacturer's instructions. Radiographs seen during our standard radiographic review process, which met our inclusion criteria (AP pelvic view that included a well-positioned and observed magnification marker, and a prior total hip replacement with a known femoral head size), were included in the analysis. We then used OrthoView(TM) software program to calculate magnification of the radiograph using the magnification marker (measured magnification) and the femoral head of known size (true magnification).

RESULTS

The mean true magnification using the femoral head was 21% (SD, 2%). The mean magnification using the marker was 15% (SD, 5%). The 95% CI for the mean difference between the two measurements was 6% to 7% (p < 0.001). The use of a magnification marker to estimate magnification at the level of the hip using standard radiographic techniques was shown in this study to routinely underestimate the magnification of the radiograph using an arthroplasty femoral head of known diameter as the reference. If we assume a magnification of 20%, this more closely approximated the true magnification routinely. With this assumption, we were within 2% magnification in 64 of the 100 hips and off by 4% or more in only four hips. In contrast, using the magnification marker we were within 2% of true magnification in only 20 hips and were off by 4% or more in 59 hips.

CONCLUSION

We found the use of a magnification marker with digital radiographs for preoperative templating to be generally inaccurate, with a mean error of 6% and range from -5% to 15%. Additionally, these data suggest that the use of a magnification marker while taking preoperative radiographs of the hip may be unnecessary, as simply setting the software to assume a 20% magnification actually was more accurate.

LEVEL OF EVIDENCE

Level III, diagnostic study.

A Prospective Trial of Ayurveda for Coronary Heart Disease: A Pilot Study

CONTEXT

Coronary heart disease is the leading cause of death worldwide, and its incidence is rapidly accelerating in developing nations. Patients often search for therapies that are alternatives to traditional treatments, such as heart medicines, coronary bypass surgery, or coronary stenting. Ayurveda is an ancient, East Indian, holistic approach to health care, and its use has never been formally evaluated for patients with coronary heart disease.

OBJECTIVES

The study intended to examine the feasibility and effectiveness of comprehensive ayurvedic therapy-incorporating diet, meditation, breathing exercises, yoga, and herbs-for patients with established coronary heart disease.

DESIGN

The study was a prospective, single-group, pilot study.

SETTING

The study took place at the University of New Mexico Cardiology Clinic and at the Ayurvedic Institute in Albuquerque, NM, USA.

PARTICIPANTS

The participants were adults with a history of a prior heart attack, coronary bypass surgery, or a coronary intervention (ie, a coronary angioplasty and/or stent).

INTERVENTION

All enrolled patients were evaluated by a single ayurvedic physician with >40 y of experience, and each received therapy consisting of a calorically unrestricted ayurvedic diet; instruction in yoga, meditation, and breathing; and use of ayurvedic herbs.

OUTCOME MEASURES

The primary endpoint was arterial pulse wave velocity, a marker of arterial function and vascular health. Secondary endpoints included the following measurements: (1) body mass index (BMI); (2) blood pressure (BP) and amount of reduction in BP medications; and (3) levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides. All parameters were measured at baseline and after 90 d of therapy.

RESULTS

Twenty-two patients were enrolled in the study, and 19 patients completed it. The research team observed significant improvements in arterial pulse wave velocity (P = .015), and favorable reductions in BMI (P < .0001), total cholesterol (P = .028), LDL cholesterol (P = .024), and triglycerides (P = .046). HDL cholesterol did not change significantly (P = .90). A majority of hypertensive patients were able to reduce or eliminate their antihypertensive medications (P = .0058).

CONCLUSIONS

The study's results suggest a favorable effect for ayurveda on arterial function and multiple risk factors in patients with established coronary heart disease.

R-Ketorolac Targets Cdc42 and Rac1 and Alters Ovarian Cancer Cell Behaviors Critical for Invasion and Metastasis

Cdc42 (cell division control protein 42) and Rac1 (Ras-related C3 botulinum toxin substrate 1) are attractive therapeutic targets in ovarian cancer based on established importance in tumor cell migration, adhesion, and invasion. Despite a predicted benefit, targeting GTPases has not yet been translated to clinical practice. We previously established that Cdc42 and constitutively active Rac1b are overexpressed in primary ovarian tumor tissues. Through high-throughput screening and computational shape homology approaches, we identified R-ketorolac as a Cdc42 and Rac1 inhibitor, distinct from the anti-inflammatory, cyclooxygenase inhibitory activity of S-ketorolac. In the present study, we establish R-ketorolac as an allosteric inhibitor of Cdc42 and Rac1. Cell-based assays validate R-ketorolac activity against Cdc42 and Rac1. Studies on immortalized human ovarian adenocarcinoma cells (SKOV3ip) and primary patient-derived ovarian cancer cells show that R-ketorolac is a robust inhibitor of growth factor or serum-dependent Cdc42 and Rac1 activation with a potency and cellular efficacy similar to small-molecule inhibitors of Cdc42 (CID2950007/ML141) and Rac1 (NSC23766). Furthermore, GTPase inhibition by R-ketorolac reduces downstream p21-activated kinases (PAK1/PAK2) effector activation by >80%. Multiple assays of cell behavior using SKOV3ip and primary patient-derived ovarian cancer cells show that R-ketorolac significantly inhibits cell adhesion, migration, and invasion. In summary, we provide evidence for R-ketorolac as a direct inhibitor of Cdc42 and Rac1 that is capable of modulating downstream GTPase-dependent, physiologic responses, which are critical to tumor metastasis. Our findings demonstrate the selective inhibition of Cdc42 and Rac1 GTPases by an FDA-approved drug, racemic ketorolac, that can be used in humans.

A novel single twist-drill access device for multimodal intracranial monitoring: a 5-year single-institution experience

BACKGROUND

Multimodal intracranial monitoring in the neurosurgical patient requires insertion of probes through multiple craniostomies.

OBJECTIVE

To report our 5-year experience with a novel device allowing multimodal monitoring though a single twist-drill hole.

METHODS

All devices (Hummingbird Synergy, Innerspace) were placed at the Kocher point between 2008 and 2013 at our institution. An independent clinical research nurse prospectively collected data on all bedside placements. Placement accuracy was graded on computed tomography scan as grade 1 (ipsilateral frontal horn or third ventricle), grade 2 (contralateral lateral ventricle), and grade 3 (anywhere else). Infection was monitored with serial cerebrospinal fluid samples.

RESULTS

Two hundred seventy-five devices (198 at bedside, 77 in operating room) were placed in patients with spontaneous subarachnoid hemorrhage (49%), traumatic brain injury (47%), and others (4%) for a median duration of 6 days. A junior (postgraduate year 1-2), midlevel (postgraduate year 3-4), or senior resident (postgraduate year 5-6) placed 39%, 32%, and 29% of the devices, respectively. Ninety-two percent of all devices placed were draining cerebrospinal fluid, ie, were grade 1 (75%) or 2 (17%). Placement accuracy did not vary with level of training. Complications included hemorrhage (10%) and infection (4%), with 1 patient requiring intraparenchymal hematoma evacuation and a second requiring abscess drainage. These rates were lower than reported in the literature for standard external ventricular drains.

CONCLUSION

Hummingbird Synergy is a novel single-port access device for multimodal intracranial monitoring that can be placed safely at the bedside or in the operating room with placement accuracy and has a complication profile similar to or better than that for standard external ventricular drains.

The incidence of autoimmune hemolytic anemia in pediatric hematopoietic stem cell recipients post-first and post-second hematopoietic stem cell transplant

The reported incidence of post-allogeneic HSCT AIHA was between 4.4% and 6% following a single transplant. Cord blood transplantation, T-cell depletion, and chronic GvHD are significantly associated with post-transplant AIHA. During an 11-yr period, data for 500 pediatric HSCT recipients were eligible for evaluation of the incidence of AIHA post-first and post-second transplants. Demographic, transplant, and post-transplant-related variables were analyzed. Twelve of 500 (2.4%) recipients at a median of 273 days and seven of 72 (9.7%) recipients at a median of 157 days developed AIHA post-first and post-second HSCT, respectively. Post-first HSCT, none of the MRD recipients developed AIHA (0/175 MRD vs. 12/325 other donors, p = 0.04). Four of 12 required a second HSCT to control the AIHA. After the second HSCT, MUD was significantly associated with the development of AIHA. No other variables were associated with the post-second transplant AIHA. The incidence of AIHA post-first and post-second HSCT was less than the reported. The increased incidence of AIHA among recipients of second HSCT is most likely due to the profound immune dysregulation. A much larger, prospective study would be needed to evaluate the incidence, complications, and management of post-transplant AIHA.

Titanium mesh as a low-profile alternative for tension-band augmentation in patella fracture fixation: A biomechanical study

OBJECTIVES

We performed a simple biomechanical study to compare the fixation strength of titanium mesh with traditional tension-band augmentation, which is a standard treatment for transverse patella fractures. We hypothesised that titanium mesh augmentation is not inferior in fixation strength to the standard treatment.

METHODS

Twenty-four synthetic patellae were tested. Twelve were fixed with stainless steel wire and parallel cannulated screws. Twelve were fixed with parallel cannulated screws, augmented with anterior titanium mesh and four screws. A custom test fixture was developed to simulate a knee flexed to 90°. A uniaxial force was applied to the simulated extensor mechanism at this angle. A non-inferiority study design was used to evaluate ultimate force required for failure of each construct as a measure of fixation strength. Stiffness of the bone/implant construct, fracture gap immediately prior to failure, and modes of failure are also reported.

RESULTS

The mean difference in force at failure was -23.0 N (95% CI: -123.6 to 77.6N) between mesh and wire constructs, well within the pre-defined non-inferiority margin of -260 N. Mean stiffness of the mesh and wire constructs were 19.42 N/mm (95% CI: 18.57-20.27 N/mm) and 19.49 N/mm (95% CI: 18.64-20.35 N/mm), respectively. Mean gap distance for the mesh constructs immediately prior to failure was 2.11 mm (95% CI: 1.35-2.88 mm) and 3.87 mm (95% CI: 2.60-5.13 mm) for wire constructs.

CONCLUSIONS

Titanium mesh augmentation is not inferior to tension-band wire augmentation when comparing ultimate force required for failure in this simplified biomechanical model. Results also indicate that stiffness of the two constructs is similar but that the mesh maintains a smaller fracture gap prior to failure. The results of this study indicate that the use of titanium mesh plating augmentation as a low-profile alternative to tension-band wiring for fixation of transverse patella fractures warrants further investigation.

Comparison of parenchymal and ventricular intracranial pressure readings utilizing a novel multi-parameter intracranial access system

Introduction

Both ventricular and parenchymal devices are available for measurement of intracranial pressure (ICP). The Hummingbird^® Synergy Ventricular System is a novel device allowing multi-parametric neurological monitoring, including both ventricular and parenchymal ICP. The purpose of this study is to compare the congruence of the device’s ventricular and parenchymal ICP readings.

Methods

This single-center, quantitative, interventional study compared parenchymal and ventricular ICP readings from 35 patients with the Hummingbird^® System. If a difference of > ± 3 mmHg existed between an individual patient’s parenchymal and ventricular values, progressive intervention strategies were applied to correct identified issues.

Results

From a total of 2,259 observations, statistical analysis revealed congruence (within ±0-3 mmHg) of 93% of readings comparing parenchymal and ventricular ICP. Of the observations requiring intervention, 58% involved the parenchymal component, 30% involved the ventricular component, and 12% involved both components. Following prescribed interventions, 98% of readings became congruent (within ±0-3 mmHg). The adjusted mean difference between the two methods was -0.95 (95% CI: -0.97,-0.93) mmHg and all mean ICP readings fell between -2 and 2 mmHg.

Conclusion

The Hummingbird^® Synergy Ventricular System demonstrates congruence between ventricular and parenchymal ICP measurements within accepted parameters. Interventions required to realign parenchymal and ventricular readings serve as reminders to clinicians to be vigilant with catheter/cable connections and to maintain appropriate positioning of the ventricular drainage system. The results of this study support the recommendation to use the parenchymal ICP component for routine ICP monitoring, allowing dedication of the ventricular catheter to drainage of cerebrospinal fluid (CSF).

How accurately does the VIVO Harvester reflect actual Clinical and Translational Sciences Award-affiliated faculty member publications?

OBJECTIVE

The research tested the accuracy of the VIVO Harvester software in identifying publications authored by faculty members affiliated with a National Institutes of Health Clinical and Translational Sciences Award (CTSA) site.

METHODS

Health sciences librarians created "gold standard" lists of references for the years 2001 to 2011 from PubMed for twenty-five randomly selected investigators from one CTSA site. These gold standard lists were compared to the same twenty-five investigators' reference lists produced by VIVO Harvester. The authors subjected the discrepancies between the lists to sensitivity and specificity analyses.

RESULTS

The VIVO Harvester correctly identified only about 65% of the total eligible PubMed references for the years 2001-2011 for the CTSA-affiliated investigators. The identified references produced by VIVO Harvester were precise yet incomplete. The sensitivity rate was 0.65, and the specificity rate was 1.00.

CONCLUSION

While the references produced by VIVO Harvester could be confirmed in PubMed, the VIVO Harvester retrieved only two-thirds of the required references from PubMed. National Institutes of Health CTSA sites will need to supplement VIVO Harvester-produced references with the expert searching skills of health sciences librarians.

IMPLICATIONS

Health sciences librarians with searching skills need to alert their CTSA sites about these deficiencies and offer their skills to advance their sites' missions.

A pilot study on providing ophthalmic training to medical students while initiating a sustainable eye care effort for the underserved

IMPORTANCE

We present a method to reintroduce ophthalmic training into the medical school curriculum.

OBJECTIVES

To evaluate knowledge and skills acquired when participating in a service project, the Community Vision Project, and to develop a quantitative method for testing skills with the direct ophthalmoscope in patients.

DESIGN

Second-year medical students participated in the study. After 1 month, their knowledge was compared with that of peers and graduates (internal medicine residents). Also at 1 month, their direct ophthalmoscope skills were compared with those of upperclassmen who had completed all core clerkships. One year later, after the participants had completed their core clerkships, long-term ophthalmoscope skills retention was tested, and their performance was compared with that of their classmates.

SETTING AND PARTICIPANTS

Training occurred in mobile eye clinics. Knowledge and skills assessments were performed in the hospital eye clinic among students and residents at The University of New Mexico School of Medicine. Patients were recruited from the hospital eye clinic. Participants attended a 3-hour training session held by an attending physician in the hospital eye clinic and took part in at least 1 mobile eye clinic.

MAIN OUTCOMES AND MEASURES

A knowledge assessment quiz was administered to participants (n = 12), their classmates (n = 18), and internal medicine residents (n = 33). Skills assessment with the direct ophthalmoscope was performed at 1 month and at 1 year in 5 participants and 5 nonparticipants. Tonometer skills were assessed by comparing participants' readings with those of an ophthalmologist's obtained in patients at the mobile eye clinics. RESULTS Participants' median knowledge assessment scores were 48% higher than those of their classmates and 37% higher than those of internal medicine residents (P < .001 for both). Short-term (1 month) direct ophthalmoscopy median scores were 60% (quartile 1 to quartile 3 range, 40%-80%) for participants and 40% (quartile 1 to quartile 3 range, 20%-60%) for nonparticipating upperclassmen (P = .24). Long-term direct ophthalmoscopy median scores were 100% (quartile 1 to quartile 3 range, 75%-100%) for participants and 0% (quartile 1 to quartile 3 range, 0%-25%) for nonparticipating classmates (P = .11). Participants' tonometer readings were similar to those of the ophthalmologist's; their median reading was 2 mm Hg (quartile 1 to quartile 3 range, 0-4 mm Hg) higher than that of the ophthalmologist's (P = .05, sign test).

CONCLUSIONS AND RELEVANCE

Service-based learning offered an efficient model for incorporating ophthalmic training into the medical school curriculum. A viable tool for quantitatively testing ophthalmoscope skills is presented.

Randomized, placebo-controlled trial to assess the safety and immunogenicity of an adenovirus type 35-based circumsporozoite malaria vaccine in healthy adults

Malaria results in over 650,000 deaths each year; thus, there is an urgent need for an effective vaccine. Pre-clinical studies and recently reported human trials suggest that pre-erythrocytic stage vaccines can provide protection against infection. A Phase 1, randomized, placebo-controlled, dose-escalation study was conducted with a vaccine composed of a replication-deficient adenovirus-35 backbone with P. falciparum circumsporozoite (CS) surface antigen (Ad35.CS.01). Healthy adult subjects received three doses of 10 (8), 10 (9), 10 (10), or 10 (11) vp/mL Ad35.CS.01 vaccine or saline placebo intramuscularly at 0, 1, and 6-mo intervals. Adverse events were assessed and anti-CS antibody responses were determined by ELISA. Seventy-two individuals were enrolled, with age, gender, and ethnicity similar across each study arm. While the vaccine was generally well tolerated, adverse events were more frequent in the highest dose groups (10 (10) and 10 (11) vp/mL). More robust humoral responses were also noted at the highest doses, with 73% developing a positive ELISA response after the three dose series of 10 (11) vp/mL. The Ad35.CS.01 vaccine was most immunogenic at the highest dosages (10 (10) and 10 (11) vp/mL). Reactogenicity findings were more common after the 10 (11) vp/mL dose, although most were mild or moderate in nature and resolved without therapy.

Oral health assessment in the San Blas and Santa Ana populations of Nicaragua

AIM

The aim of this study was to assess the oral health of a population in rural Nicaragua.

METHODS

A total of 241 individuals were recruited from areas around San Blas and Santa Ana, Nicaragua. A demographic questionnaire assessing income, access to oral health care, means of transportation and presence of dental/health insurance was collected for each patient. Oral screenings were also conducted to assess for evidence of untreated decayed teeth, restorations, missing/extracted teeth and presence/absence of periodontal disease.

RESULTS

The majority of residents in San Blas and Santa Ana, Nicaragua, have little income if any, no medical or dental insurance of any kind and no means of transportation. There was a very high prevalence of untreated decayed teeth among the population studied where 51.1% of our sample had three or more dental caries. Children aged fewer than 20 years had five times the prevalence of dental decay than those in the United States. No statistically significant difference was found in untreated decayed teeth by age or gender. A smaller percentage (25.2%) of all patients had restorations with a statistically significant difference found between genders (P < 0.0001). There was also a relationship between gender and number of missing/extracted teeth (P < 0.001). There was no significant difference in amount of untreated decayed teeth among those who reported having been seen by a dentist within the previous one-to-three, greater than 3 years or never at all.

CONCLUSION

Among a population of individuals from San Blas and Santa Ana, Nicaragua, there are major socio-economic barriers present, and a significant burden of oral pathology is evident.

Long-term follow-up of endovascular abdominal aortic aneurysm repair in a rural veteran patient population

BACKGROUND

The endovascular repair of abdominal aortic aneurysms (EVARs) requires follow-up to detect and treat late complications.

METHODS

Two hundred eleven patients underwent EVAR for infrarenal, nonruptured abdominal aortic aneurysms from 1999 to 2010 at the Raymond G. Murphy VA Medical Center, Albuquerque, NM. A retrospective review examined patient demographics, comorbidities, the distance the patient lived from the facility, early and late complications, and the device implanted. Statistical analysis included the chi-square test for independence, the Fisher exact test, and the 2-sample Mann-Whitney U test for means.

RESULTS

The mean time from the operation to the first complication was 21 months (standard deviation = 20 months) with a mean follow-up of 48 months (standard deviation = 36 months). The late complication rate was 22.8% (54 patients). Sixteen percent did not require any reinterventions, 57% were treated with percutaneous interventions, and 27% required an open surgical procedure. No single comorbidity, combination of comorbidities, distance the patient lived from the facility, or device implanted was predictive of complications.

CONCLUSIONS

EVAR follow-up is essential to detect complications. When complications occur, the majority occur well after the initial treatment, and most can be treated with minimally invasive percutaneous techniques.

Enhancement of temporal resolution and BOLD sensitivity in real-time fMRI using multi-slab echo-volumar imaging

In this study, a new approach to high-speed fMRI using multi-slab echo-volumar imaging (EVI) is developed that minimizes geometrical image distortion and spatial blurring, and enables nonaliased sampling of physiological signal fluctuation to increase BOLD sensitivity compared to conventional echo-planar imaging (EPI). Real-time fMRI using whole brain 4-slab EVI with 286 ms temporal resolution (4mm isotropic voxel size) and partial brain 2-slab EVI with 136 ms temporal resolution (4×4×6 mm(3) voxel size) was performed on a clinical 3 Tesla MRI scanner equipped with 12-channel head coil. Four-slab EVI of visual and motor tasks significantly increased mean (visual: 96%, motor: 66%) and maximum t-score (visual: 263%, motor: 124%) and mean (visual: 59%, motor: 131%) and maximum (visual: 29%, motor: 67%) BOLD signal amplitude compared with EPI. Time domain moving average filtering (2s width) to suppress physiological noise from cardiac and respiratory fluctuations further improved mean (visual: 196%, motor: 140%) and maximum (visual: 384%, motor: 200%) t-scores and increased extents of activation (visual: 73%, motor: 70%) compared to EPI. Similar sensitivity enhancement, which is attributed to high sampling rate at only moderately reduced temporal signal-to-noise ratio (mean: -52%) and longer sampling of the BOLD effect in the echo-time domain compared to EPI, was measured in auditory cortex. Two-slab EVI further improved temporal resolution for measuring task-related activation and enabled mapping of five major resting state networks (RSNs) in individual subjects in 5 min scans. The bilateral sensorimotor, the default mode and the occipital RSNs were detectable in time frames as short as 75 s. In conclusion, the high sampling rate of real-time multi-slab EVI significantly improves sensitivity for studying the temporal dynamics of hemodynamic responses and for characterizing functional networks at high field strength in short measurement times.

Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature

OBJECTIVE

To evaluate the efficacy of routine follow-up CT scans of the head after complicated mild traumatic brain injury (TBI).

METHODS

74 English language studies published from 1999 to February 2011 were reviewed. The papers were found by searching the PubMed database using a combination of keywords according to Cochrane guidelines. Excluding studies with missing or inappropriate data, 1630 patients in 19 studies met the inclusion criteria: complicated mild TBI, defined as a GCS score 13-15 with abnormal initial CT findings and the presence of follow-up CT scans. For these studies, the progression and type of intracranial haemorrhage, time from trauma to first scan, time between first and second scans, whether second scans were obtained routinely or for neurological decline and the number of patients who had a neurosurgical intervention were recorded.

RESULTS

Routine follow-up CT scans showed hemorrhagic progression in 324 patients (19.9%). Routine follow-up head CT scans did not predict the need for neurosurgical intervention (p=0.10) but a CT scan of the head performed for decline in status did (p=0.00046). For the 56 patients (3.4%) who declined neurologically, findings on the second CT scan were worse in 38 subjects (67%) and unchanged in the rest. Overall, 39 patients (2.4%) underwent neurosurgical intervention.

CONCLUSION

Routine follow-up CT scans rarely alter treatment for patients with complicated mild TBI. Follow-up CT scans based on neurological decline alter treatment five times more often than routine follow-up CT scans.

Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury

OBJECT

Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need.

METHODS

The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded.

RESULTS

During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6-131.8; OR 9.7 for SDH, 95% CI 2.4-39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15.

CONCLUSIONS

Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.