Mobile resonance frequency breathing smartphone application to support recovery among people with opioid use disorder: Study protocol for feasibility study

BACKGROUND

Experiencing drug cravings is an aspect of substance use disorders that frequently compromises the recovery efforts of people who use drugs. Most treatment approaches that address drug cravings either involve cognitive strategies or medication. Few interventions directly address the physiological aspects of craving, such as increased heart rate. Previous research has demonstrated that slow-paced breathing may be effective in managing drug cravings by manipulating an individual's heart rate. The purpose of this paper is to describe a study protocol for an intervention that offers resonance frequency breathing training for managing cravings via a smartphone application (app).

METHODS

This trial is registered in ClinicalTrials.gov (Identifier: NCT05830773). The intervention focuses on persons in recovery from opioid use disorder who receive services from the Texas Health and Human Service Commission Recovery Support Services division. Participants will be trained to use Camera Heart Rate Variability (CHRV), a resonance frequency breathing app. The CHRV app measures heart rate and the volumetric variations of blood circulation. When experiencing stress, anxiety, or cravings, participants will use the app to practice breathing exercises. Participants (N = 60) will also complete surveys at baseline, 4 weeks, and 8 weeks; the survey questions, covers demographic characteristics, personal trauma history, substance use experience, and utilization of substance use treatment services. The surveys will also include psychosocial measures of craving, stress, and anxiety to allow the study team to assess changes between baseline and study completion. Participants who complete the full 8-week intervention will be invited to participate in a 30-minute interview about their experience with the app. Interviews will provide details on implementation outcomes, including acceptability, appropriateness, and feasibility.

CONCLUSION

Many evidence-based interventions for opioid use require interpersonal communication with individuals in one's recovery network. However, individuals may be unable to engage others in their recovery network in the moments when they are experiencing cravings or stress- and anxiety-related triggers. Therefore, recovery support interventions that emphasize individual self-management of cravings, stress, and anxiety when they occur can empower individuals in recovery and enhance existing interventions.

"If It Didn't Get Reported, It Didn't Happen": Current Nonfatal Overdose Reporting Practices among Nontraditional Reporters in Texas

Background: Drug overdose deaths in Texas have been accelerating in recent years with an increase of 33% in the 12 months leading up to December 2020. Accurate counts of nonfatal overdoses - including associated aspects of overdose, such as substances involved, demographic information, and reversal agents administered is critical to increase timely and adequate response to individuals and communities in need. Methods: Twenty semi-structured interviews were conducted with harm reduction workers across four Texas counties to understand existing methods of reporting overdoses, naloxone dissemination/administration, and recommendations for improving overdose surveillance. Interviews were transcribed and emergent themes were identified based on the a priori research goals. Results: Findings highlighted a variety of overdose data collection methods and tools among harm reduction organizations including Excel spreadsheet, web-based TONI application, notes on personal cell phones, and paper notes. Types of overdose data collected varied widely. Participants noted existing methods are suboptimal and that there is a need for a unified, statewide reporting system to improve overdose data capture. Participants also highlighted that overdose surveillance should include "hidden populations" of people who use drugs that are not currently counted in surveillance methods as a result of not interacting with the healthcare system. Conclusions: Texas lacks a unified overdose reporting system to capture critical data to inform overdose response and prevention efforts. Nontraditional reporters may be critical toward improving overdose syndromic efforts and capturing data among hard-to-reach populations. Harm reduction organizations are uniquely positioned to facilitate reporting among community gatekeepers and people who use drugs.

Achieving Reductions in Opioid Dispensing: A Qualitative Comparative Analysis of State-Level Efforts to Improve Prescribing

OBJECTIVE

To determine whether any combinations of state-level public health activities were necessary or sufficient to reduce prescription opioid dispensing.

DESIGN

We examined 2016-2019 annual progress reports, 2014-2019 national opioid dispensing data (IQVIA), and interview data from states to categorize activities. We used crisp-set Qualitative Comparative Analysis to determine which program activities, individually or in combination, were necessary or sufficient for a better than average decrease in morphine milligram equivalent (MME) per capita.

SETTING

Twenty-nine US state health departments.

PARTICIPANTS

State health departments implementing the Centers for Disease Control and Prevention's Prevention for States (PfS) program.

MAIN OUTCOME

Combinations of prevention activities related to changes in the rate of prescription opioid MME per capita dispensing from 2014 to 2019.

RESULTS

Three combinations were sufficient for greater than average state-level reductions in MME per capita: (1) expanding and improving proactive reporting in combination with enhancing the uptake of evidence-based opioid prescribing guidelines and not moving toward a real-time Prescription Drug Monitoring Program; (2) implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with enhancing the uptake of evidence-based opioid prescribing guidelines; and (3) not implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with not enhancing the uptake of evidence-based opioid prescribing guidelines. Interview data suggested that the 3 combinations indicate how state contexts and history with addressing opioid overdose shaped programming and the ability to reduce MME per capita.

CONCLUSIONS

States successful in reducing opioid dispensing selected activities that built upon existing policies and interventions, which may indicate thoughtful use of resources. To maximize impact in addressing the opioid overdose epidemic, states and agencies may benefit from building on existing policies and interventions.

A qualitative exploration of unintentional versus intentional exposure to fentanyl among people who use drugs in Austin, TX

BACKGROUND

The prevalence of deaths involving synthetic opioids has historically been lower in Texas than most U.S. states but more than quadrupled from January 2020 to January 2022. This paper explores the emergence of fentanyl in a drug supply where black tar heroin predominates, a factor considered protective against fentanyl adulteration, through the perspectives of people who use drugs (PWUD).

OBJECTIVES

We describe experiences of unintentional exposure to fentanyl, illustrate how some people identify fentanyl in their supply, and present harm reduction strategies that PWUD use to avoid overdose.

METHODS

Thirty rapid assessment interviews were conducted in July 2021 at 2 mobile outreach sites of a harm reduction organization in Austin, Texas. The brief semistructured interviews were designed to assess participant fentanyl exposure experiences.

RESULTS

Participants were clients who reported using heroin or fentanyl in the past week and had lived in Texas for at least 6 months. Seventeen participants identified as male, 10 as female, and 3 as nonbinary. Half identified as white; other participants were Latinx (6), black (2), American Indian (1), and mixed race (6). Two-thirds were unhoused or in transitional housing. The drug supply in Texas has evolved; most participants reported that the heroin and other drugs they obtained contain fentanyl. Participants detected differences by observing changes in the physical characteristics of the drug, experiencing unexpected effects, and using fentanyl test strips. Many had been unintentionally exposed to fentanyl and expressed concerns about fentanyl's presence. The presence of fentanyl had negative unintended consequences for participants, including adverse effects and developing a dependence on opioids.

CONCLUSION

PWUD in Austin, Texas, report increasing prevalence of unintentional fentanyl exposure, despite the predominance of black tar heroin. Pharmacists can provide crucial supplies and education to safeguard the health of this vulnerable population.

Approaches for Implementing Healthy Food Interventions in Settings With Limited Resources: A Case Study of Sodium Reduction Interventions in Emergency Food Programs Addressing Food Insecurity

PURPOSE

This study describes how recipients of the Centers for Disease Control and Prevention funded Sodium Reduction in Communities Program (SRCP) worked with emergency food programs to improve access to healthy food to address chronic conditions.

DESIGN

SRCP recipients partnered with emergency food programs to implement sodium reduction strategies including nutrition standards, procurement practices, environmental strategies, and behavioral economics approaches.

SETTING

SRCP recipients and emergency food programs in Washington County and Benton County, Arkansas and King County, Washington.

SUBJECTS

SRCP recipient staff, emergency food program staff, and key stakeholders.

MEASURES

We conducted semi-structured interviews with key stakeholders and systematic review of program documents.

ANALYSIS

Data were analyzed using effects matrices for each recipient. Matrices were organized using select implementation science constructs and compared in a cross-case analysis.

RESULTS

Despite limited resources, emergency food programs can implement sodium reduction interventions which may provide greater access to healthy foods and lead to reductions in health disparities. Emergency food programs successfully implemented sodium reduction interventions by building on the external and internal settings; selecting strategies that align with existing processes; implementing change incrementally and engaging staff, volunteers, and clients; and sustaining changes.

CONCLUSION

Findings contribute to understanding the ways in which emergency food programs and other organizations with limited resources have implemented public health nutrition interventions addressing food insecurity and improving access to healthy foods. These strategies may be transferable to other settings with limited resources.

Understanding State-Level Variations in Implementing Academic Detailing for Prescribing Opioids (Findings from 11 States within the US)

OBJECTIVE

Academic detailing is a clinical education technique characterized by targeted, one-on-one, interactive conversations between trained staff and the clinician. This study describes variations in implementing academic detailing among jurisdictions receiving funding from the U.S. Centers for Disease Control and Prevention (CDC) to prevent prescription drug overdoses.

DESIGN

In 2015, CDC started the Prescription Drug Overdose Prevention for States (PfS) program.

SUBJECTS

This study focuses on 11 of the 29 funded jurisdictions that implemented academic detailing as part of their PfS efforts.

METHODS

Jurisdictions provided annual progress reports from 2016 to 2019. We conducted semi-structured interviews in 2017 and 2018 with all funded jurisdictions and conducted follow-up interviews with three jurisdictions in 2020 to obtain additional context. We used an analytic matrix display to identify themes from annual progress report data, the coding report from the 2017/2018 interviews, and the three follow-up interviews from 2020.

RESULTS

Two academic detailing models emerged: 1) one-on-one detailing where centrally trained staff conducted all visits and 2) a train-the-trainer model. Jurisdictions also described a hybrid model, which they referred to as academic detailing despite not meeting the definition of academic detailing. We identified variations in delivery strategies, staffing, and curriculum development within and between models. Despite these differences, common themes included the need to use data to focus academic detailing and the importance of partnerships.

CONCLUSIONS

Adoption of academic detailing as a strategy for improving opioid prescribing behaviors has increased. However, there is limited guidance and standardization to guide and evaluate implementation and outcomes.

[Rhegmatogenous retinal detachment: Topography of breaks and agreement with lincoff's rules]

PURPOSE

To study the topography of retinal breaks and their agreement with Lincoff's rules.

MATERIALS AND METHODS

We performed a retrospective descriptive study of patients with recent rhegmatogenous retinal detachments followed on the ophthalmology service of Abass Ndao Hospital from January 2006 through December 2016. Patients with no prior retinal treatment were included.

RESULTS

Over 11 years, we reviewed 97 patients with 107 eyes with retinal detachments. The mean age of our patients was 51.7 years, range 23-79 years. There were 69 male patients, for a male:female ratio of 2.46. Refraction revealed that 38.1% of patients were myopes. Fourteen percent (14%) of patients had experienced trauma to the eye with the detachment. The right eye was involved in 54.6% of patients. The onset was insidious in 54.6% of cases and sudden in 23.7% of cases. All patients had decreased visual acuity, associated with a scotoma in 26.8% of cases. Visual acuity was decreased to light perception through 7/10. In 64.9% of cases, Lincoff's rules were observed.

DISCUSSION

Lincoff's rules are still relevant for localization of the breaks in retinal detachments.

CONCLUSION

Diagnosis of a retinal detachment is an essential step, since it determines the treatment. Lincoff's rules still have a role in finding the retinal break in retinal detachments.

[Role of CT in diagnosis and monitoring of retinoblastoma in Senegal]

INTRODUCTION

Retinoblastoma is a malignant tumor of neuroepithelial origin, developed from young retinal cells, occurring in infants and young children. The goal of the study was to assess the role of CT in the diagnosis of retinoblastoma at the Aristide le Dantec Hospital in Dakar.

PATIENTS AND METHODS

This is an 11-year retrospective study of 160 patient records in the ophthalmology department and pediatric oncology unit of the same hospital.

RESULTS

One hundred and sixty (160) patients were recruited. The male:female ratio was 1.05. The mean age was 32.19 months. Leukocoria was the most common clinical sign, occurring in 105 cases (65.62 %). The retinoblastoma was intraocular in 97 cases (60.62 %). We saw 122 (76.25 %) unilateral and 3 (1.87 %) trilateral presentations. CT was performed in 150 children with 110 cases (73.33 %) of calcifications ; 62 cases (41.33 %) of optic nerve invasion ; 24 cases (16 %) of extraocular muscle invasion and 18 cases (12 %) endocranial extension. Associated tumors were found on CT: 2 cases of suprasellar mass and 1 case of pineoblastoma. In patients whose specimens were analyzed, histology showed 48.15 % optic nerve invasion, consistent with the CT findings.

DISCUSSION

CT has an important role in the diagnosis of retinoblastoma, despite its recent contraindication in bilateral and unilateral multinodular forms.

CONCLUSION

CT is a good alternative to MRI in the diagnosis of retinoblastoma in developing countries with limited technological resources.

[Ametropia among senegalese children in a hospital setting]

INTRODUCTION

Ametropia is common in children and cause strabismus and amblyopia. The goal was to establish its prevalence in a hospital setting among Senegalese children.

PATIENTS AND METHODS

This was a retrospective study of patients under 15 years of age with clear ocular media. The marital status, circumstances of discovery, and results of cycloplegic refraction were recorded.

RESULTS

Of 1506 children, 175 demonstrated ametropia. The mean age was 8 years, and the male : female ratio was 0.68. Family history of ametropia was present in 8.5 %. Decreased VA was present in 39.66 %, headache 10.06 %, and strabismus 4.47 %. Automated refraction in 109 patients and skiascopy in one patient showed 58.18 % cases of myopia, 18.18 % of hyperopia and 36.57 % of astigmatism.

DISCUSSION

The most common ametropia was myopia. Patients were referred for symptomatic ametropia.

CONCLUSION

Screening for ametropia might occur earlier if it is associated with pediatric monitoring in our regions.

[Giant retinal tears: Senegalese experience]

PURPOSE

To appreciate the epidemiological characteristics and to show the therapeutic aspects of the giant retinal tears.

PATIENTS AND METHODS

We conducted a retrospective study from January 2014 to June 2017 on subjects with giant retinal tears. Patients with media opacities limiting examination were excluded.

RESULTS

We identified 17 cases of giant retinal tears. The frequency of detachments related to a giant retinal tear was 17% compared to all retinal tears. The mean age was 50.75 years with a sex ratio (M/F) of 6.5. We found three cases of high myopia, one case of hyperopia and four trauma cases. All patients had a decrease in visual acuity. The average time to consultation was four weeks. The mean intraocular pressure was 8mmHg. The tear was found in the left eye in eight cases and in the right eye in five cases; two cases were bilateral. We performed intraocular surgery in five eyes and laser in four eyes. We achieved anatomical reattachment and functional improvement in all operated patients.

COMMENTS AND CONCLUSION

The prognosis of a giant retinal tear remains guarded, especially if patients are seen and treated late. Laser photocoagulation of giant tears remains effective, especially in cases of early diagnosis.

[Evaluation of mean macular thickness by optical coherence tomography (SD OCT) in black Senegalese subjects]

INTRODUCTION

Our goal was to evaluate the normal macular thickness in Blacks by OCT and to determine socio-demographic and clinical parameters which may influence it.

MATERIALS AND METHODS

This was a multicenter, prospective, descriptive study over 6 months. It included Black adults followed in the ophthalmology departments of Abass Ndao and Aristide-Le-Dantec hospitals in Dakar. Included subjects had corrected visual acuity of 10/10 (0 logMAR) and P2 (+0.1 logMAR), clear ocular media, and no retinal abnormalities. We used the Topcon 3D 2000 OCT to measure the central thicknesses of the cornea (CT) and of the macula (MT), and cup to disc ratio (C/D) in each eye. Socio-demographic, clinical and tomographic data were collected on a survey form and correlated to the MT. The analysis was carried out by the Epi info 7 software. We used the Chi² comparison test with a P value˂0.05.

RESULTS

One hundred and nine patients were included. The mean age was 27.39 years with a male/female ratio of 0.65. The subjects were emmetropic in 54.13% of cases. The mean CT was 519.97μm, the mean C/D was 0.23, and the mean MT was 264.35μm. The P-value (P) was greater than or equal to 0.1 for all the factors studied.

CONCLUSION

MT in our study was lower than that of Whites, and the various parameters studied did not demonstrate a statistically significant influence on MT.

[Perception of ocular blinding manifestations of sickle cell disease by practitioners in Dakar university hospital]

INTRODUCTION

In Senegal, 10% of the population are said to be carriers of hemoglobin S, the most widespread hemoglobinopathy in the world. It is responsible for potentially blinding ophthalmological manifestations. Few practitioners refer patients for ophthalmologic screening. The goal of our study was to assess the level of knowledge of practitioners of the blinding ocular lesions of sickle cell disease.

MATERIALS AND METHODS

A cross-sectional prospective study was carried out over five months. It included Dakar university hospital practitioners aside from ophthalmologists. On the survey form, each practitioner specified his or her specialty and responded to eight questions regarding sickle cell patients seen in consultation, knowledge of the blinding lesions related to the disease, and ocular monitoring for blinding systemic diseases. The practitioners were divided into three groups: department of medicine and medical specialties (group I), surgery and surgical specialties (group II), and biology and functional testing (group III). The descriptive analysis was done with the EPI-INFO software version 6.04.

RESULTS

The participation rate was 45.88%. Group I represented 45.29% of the sample, Group II 35.85% and Group III 18.86%. In all, 87.73% of practitioners saw sickle cell patients in consultation, 75.47% were aware of ocular involvement related to sickle cell disease, and 58.49% were aware of blinding lesions. 94.62% of practitioners saw sickle cell disease patients without systematically recommending ophthalmological consultation.

CONCLUSION

Practitioners' level of knowledge of the blinding ocular lesions of sickle cell disease is considered to be low.

Projecting the Adequacy of the Multiple Sclerosis Neurologist Workforce

Background

Anecdotal reports suggest shortages among neurologists who provide multiple sclerosis (MS) patient care. However, little information is available regarding the current and future supply of and demand for this neurologist workforce.

Methods

We used information from neurologist and neurology resident surveys, professional organizations, and previously reported studies to develop a model assessing the projected supply and demand (ie, expected physician visits) of neurologists providing MS patient care. Model projections extended through 2035.

Results

The capacity for MS patient visits among the overall neurologist workforce is projected to increase by approximately 1% by 2025 and by 12% by 2035. However, the number of individuals with MS may increase at a greater rate, potentially resulting in decreased access to timely and high-quality care for this patient population. Shortages in the MS neurologist workforce may be particularly acute in small cities and rural areas. Based on model sensitivity analyses, potential strategies to substantially increase the capacity for MS physicians include increasing the number of patients with MS seen per neurologist, offering incentives to decrease neurologist retirement rates, and increasing the number of MS fellowship program positions.

Conclusions

The neurologist workforce may be adequate for providing MS care currently, but shortages are projected over the next 2 decades. To help ensure access to needed care and support optimal outcomes among individuals with MS, policies and strategies to enhance the MS neurologist workforce must be explored now.

[Rare causes of childhood leukocoria]

PURPOSE

The purpose was to record the causes of leukocoria among children under 10years of age and to determine the proportion of rare causes of leukocoria.

PATIENTS AND METHODS

This retrospective study was conducted over a period of ten years, from January 1, 2004 to December 31, 2013, in patients under 10years of age who were referred for leukocoria.

RESULTS

Leukocoria represented one of the ten reasons for consultation among children under 10years of age. The mean age of our patients was 42.5months. In 76 % of cases, the leukocoria patients were children under 6years of age. Male patients were affected more commonly, with a sex-ratio of 1.5. Patients coming from Dakar and its suburbs represented two thirds of the total. Bilateral involvement represented 53.7 % of the total. Cataracts were responsible for 74.3 % of cases, retinoblastoma 20.58 %, retinal detachment 0.96 %, retinopathy of prematurity 0.96 %, pupillary membrane persistence 0.96 %, persistent hyperplastic primary vitreous 0.64 %, endophthalmitis 0.64 %, optic nerve coloboma 0.32 %, iris heterochromia 0.32 % and ametropia 0.32 %.

DISCUSSION

The total percentage of rare causes was 5.12 % in our study, including one case of hyperopia. These etiologies, although rare, do exist.

CONCLUSION

Rare causes of leukocoria require special attention. The discovery of leukocoria necessitates rigorous etiological work-up. Ametropia must be a diagnosis of exclusion.

First outbreak of colonization by linezolid- and glycopeptide-resistant Enterococcus faecium harbouring the cfr gene in a UK nephrology unit

AIM

To describe an outbreak of colonization by linezolid- and glycopeptide-resistant Enterococcus faecium harbouring the cfr gene in a UK nephrology unit.

METHODS

Isolates of linezolid-resistant E. faecium were typed by pulsed-field gel electrophoresis (PFGE), and examined by polymerase chain reaction (PCR) and sequencing for the transmissible cfr gene that confers resistance to linezolid. Enhanced environmental cleaning, initial and weekly screening of all patients, and monitoring of adherence to standard infection control precautions were implemented.

FINDINGS

Five patients with pre-existing renal disease were found to have rectal colonization with linezolid-resistant E. faecium over a two-week period. The index case was a 57-year-old male from India who had travelled to the UK. One patient also had a linezolid-resistant E. faecium of a different PFGE profile isolated from a heel wound. All isolates were confirmed to harbour the cfr gene by PCR and Sanger sequencing, and all were resistant to glycopeptides (VanA phenotype).

CONCLUSIONS

This article describes the first UK outbreak with a single strain of linezolid- and glycopeptide-resistant E. faecium harbouring the cfr gene, affecting five patients in a nephrology unit. Following the implementation of aggressive infection control measures, no further cases were detected beyond a two-week period.

[Senegalese experience with acute viral conjunctivitis]

PURPOSE

To study the epidemiological and clinical aspects of acute enteroviral and adenoviral conjunctivitis.

PATIENTS AND METHODS

A prospective study was conducted between January 1st and October 31st, 2015, jointly between two Ophthalmology services and a virology laboratory, which identified 51 patients. Were included all patients who presented a painful red eye without loss of visual acuity associated with secretions,evolving for less than 4weeks RESULTS: The mean age was 32 years, and the sex ratio 1:1. Over half of our patients (61%) came from populous districts. A history of the virus "going around" was reported by 30 patients (59% of cases). Virological testing was positive in 35 patients (68.7% of cases). Over 90% of samples collected during the first week of clinical signs were positive.

CONCLUSION

Viral conjunctivitis is a contagious condition, the spread of which is favored by promiscuity. Adenovirus and enterovirus are the main causative agents. They are present on an endemic scale in Senegal; thus, the need for better epidemiological surveillance in order to limit spread.

[Isolated microspherophakia in a Senegalese family]

PURPOSE

To report the clinical investigation of isolated microspherophakia involving a Senegalese family in order to appreciate its functional impact.

OBSERVATIONS

This is a rural family comprised of 7 members. The sibship included three girls and two boys. One of the girls, who lived in a distant zone, was unable to be examined. Of all the examined members of the family, only the father was unaffected by the illness. There was no consanguinity. The general medical examination was normal. The best-corrected visual acuity (VA) for the girls was 2/10. For one of the boys, BCVA was 8/10 for both eyes, and for the other, BCVA was 10/10 for the right eye and 8/10 for the left eye. The mother's VA was 10/10 and P2 without correction. Myopia and astigmatism were present in the 4 children of the sibship. During the examination, we noted the presence of small crystalline lenses, which were very round and presented an abnormal visibility of the lens equator and zonular fibers. The diagnosis of microspherophakia was confirmed by measurement of the lens diameters by ultrasound biomicroscopy. Complications were present in the girls, including pupillary block glaucoma and amblyopia for the elder, and retinal degeneration and amblyopia for the younger daughter. The elder daughter was managed medically with glaucoma drops. The younger daughter received optical correction and a prophylactic Argon LASER treatment. The two boys received optical correction. No treatment was recommended for the mother.

CONCLUSION

Microspherophakia is a rare condition. Some serious complications can lead to amblyopia. A better multidisciplinary evaluation would allow for early detection and a better prognosis.

Identifying configurations of behavior change techniques in effective medication adherence interventions: a qualitative comparative analysis

BACKGROUND

Interventions to improve medication adherence are diverse and complex. Consequently, synthesizing this evidence is challenging. We aimed to extend the results from an existing systematic review of interventions to improve medication adherence by using qualitative comparative analysis (QCA) to identify necessary or sufficient configurations of behavior change techniques among effective interventions.

METHODS

We used data from 60 studies in a completed systematic review to examine the combinations of nine behavior change techniques (increasing knowledge, increasing awareness, changing attitude, increasing self-efficacy, increasing intention formation, increasing action control, facilitation, increasing maintenance support, and motivational interviewing) among studies demonstrating improvements in adherence.

RESULTS

Among the 60 studies, 34 demonstrated improved medication adherence. Among effective studies, increasing patient knowledge was a necessary but not sufficient technique. We identified seven configurations of behavior change techniques sufficient for improving adherence, which together accounted for 26 (76 %) of the effective studies. The intervention configuration that included increasing knowledge and self-efficacy was the most empirically relevant, accounting for 17 studies (50 %) and uniquely accounting for 15 (44 %).

CONCLUSIONS

This analysis extends the completed review findings by identifying multiple combinations of behavior change techniques that improve adherence. Our findings offer direction for policy makers, practitioners, and future comparative effectiveness research on improving adherence.

Using qualitative comparative analysis in a systematic review of a complex intervention

BACKGROUND

Systematic reviews evaluating complex interventions often encounter substantial clinical heterogeneity in intervention components and implementation features making synthesis challenging. Qualitative comparative analysis (QCA) is a non-probabilistic method that uses mathematical set theory to study complex phenomena; it has been proposed as a potential method to complement traditional evidence synthesis in reviews of complex interventions to identify key intervention components or implementation features that might explain effectiveness or ineffectiveness. The objective of this study was to describe our approach in detail and examine the suitability of using QCA within the context of a systematic review.

METHODS

We used data from a completed systematic review of behavioral interventions to improve medication adherence to conduct two substantive analyses using QCA. The first analysis sought to identify combinations of nine behavior change techniques/components (BCTs) found among effective interventions, and the second analysis sought to identify combinations of five implementation features (e.g., agent, target, mode, time span, exposure) found among effective interventions. For each substantive analysis, we reframed the review's research questions to be designed for use with QCA, calibrated sets (i.e., transformed raw data into data used in analysis), and identified the necessary and/or sufficient combinations of BCTs and implementation features found in effective interventions.

RESULTS

Our application of QCA for each substantive analysis is described in detail. We extended the original review findings by identifying seven combinations of BCTs and four combinations of implementation features that were sufficient for improving adherence. We found reasonable alignment between several systematic review steps and processes used in QCA except that typical approaches to study abstraction for some intervention components and features did not support a robust calibration for QCA.

CONCLUSIONS

QCA was suitable for use within a systematic review of medication adherence interventions and offered insights beyond the single dimension stratifications used in the original completed review. Future prospective use of QCA during a review is needed to determine the optimal way to efficiently integrate QCA into existing approaches to evidence synthesis of complex interventions.

Factors influencing the desire to provide MS patient care in clinical practice among physiatrists

BACKGROUND

Rehabilitation care is an important part of care for individuals with multiple sclerosis (MS). Little is known about factors influencing physiatrists' desire to provide MS care.

OBJECTIVE

This study examines factors associated with physiatrists' attitudes towards providing MS care.

METHODS

We collaborated with the American Academy of Physical Medicine and Rehabilitation to survey a sample of 300 U.S. physiatrists. Analyses examined the association of exposure to MS care resources during residency, physician demographic and practice characteristics with attitudes toward providing MS care.

RESULTS

Physiatrists indicating negative factors limiting the number of MS patients seen in clinical practice were more likely to practice in a setting other than a major city and less likely to have interacted with MS specialists during residency. Physiatrists indicating factors having a positive influence on providing MS patient care were more likely to practice within a major city, see one or more MS patients per week, and serve as the primary physiatrist directing care for one or more MS patients.

CONCLUSIONS

Physiatrists indicated positive and negative attitudes towards MS care. Increasing exposure to MS patients, providing resources for MS care, and participating in continuing education on MS, may encourage physiatrists to provide MS patient care.

Factors influencing interest in providing MS patient care among physiatry residents

BACKGROUND

Rehabilitation care is an important part of comprehensive care for MS patients. Little is known about the number of physiatry residents who are interested in providing care to individuals with multiple sclerosis [MS].

OBJECTIVE

This study examines factors that influence physiatry residents' interest in providing care to MS patients.

METHODS

We randomly sampled half of all Accreditation Council for Graduate Medical Education-certified physical medicine and rehabilitation residency programs in the continental United States and Puerto Rico. Surveys were received from 74% of programs (Stage 1 response rate) and from 221 residents (45% Stage 2 response rate).

RESULTS

Residents expressing interest in providing MS care were more likely to be female, Asian, and to select statements emphasizing multidisciplinary care approaches and a community of dedicated professional colleagues as positive features of MS patient care. Residents interested in teaching and with more education debt were marginally more likely to express interest in MS care.

CONCLUSIONS

Medical education should emphasize the need for physical medicine and rehabilitative care among individuals with MS, the ability of physiatrists to improve the functional status and quality of life for MS patients, and the team-based nature of MS care.

Using qualitative comparative analysis to understand and quantify translation and implementation

Understanding the factors that facilitate implementation of behavioral medicine programs into practice can advance translational science. Often, translation or implementation studies use case study methods with small sample sizes. Methodological approaches that systematize findings from these types of studies are needed to improve rigor and advance the field. Qualitative comparative analysis (QCA) is a method and analytical approach that can advance implementation science. QCA offers an approach for rigorously conducting translational and implementation research limited by a small number of cases. We describe the methodological and analytic approach for using QCA and provide examples of its use in the health and health services literature. QCA brings together qualitative or quantitative data derived from cases to identify necessary and sufficient conditions for an outcome. QCA offers advantages for researchers interested in analyzing complex programs and for practitioners interested in developing programs that achieve successful health outcomes.

Lessons learned from community-based approaches to sodium reduction

PURPOSE

This article describes lessons from a Centers for Disease Control and Prevention initiative encompassing sodium reduction interventions in six communities.

DESIGN

A multiple case study design was used.

SETTING

This evaluation examined data from programs implemented in six communities located in New York (Broome County, Schenectady County, and New York City); California (Los Angeles County and Shasta County); and Kansas (Shawnee County).

SUBJECTS

Participants (n = 80) included program staff, program directors, state-level staff, and partners.

MEASURES

Measures for this evaluation included challenges, facilitators, and lessons learned from implementing sodium reduction strategies.

ANALYSIS

The project team conducted a document review of program materials and semistructured interviews 12 to 14 months after implementation. The team coded and analyzed data deductively and inductively.

RESULTS

Five lessons for implementing community-based sodium reduction approaches emerged: (1) build relationships with partners to understand their concerns, (2) involve individuals knowledgeable about specific venues early, (3) incorporate sodium reduction efforts and messaging into broader nutrition efforts, (4) design the program to reduce sodium gradually to take into account consumer preferences and taste transitions, and (5) identify ways to address the cost of lower-sodium products.

CONCLUSION

The experiences of the six communities may assist practitioners in planning community-based sodium reduction interventions. Addressing sodium reduction using a community-based approach can foster meaningful change in dietary sodium consumption.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan

CONTEXT

A literature review and environmental scan were conducted to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts.

EVIDENCE ACQUISITION

A search was made of four major health services and social science electronic databases and an Internet search was conducted to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity.

EVIDENCE SYNTHESIS

In all, 49 interventions were identified, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics.

CONCLUSIONS

An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan

OBJECTIVES

We conducted a literature review and environmental scan to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts.

METHODS

We searched 4 major health services and social science electronic databases and conducted an Internet search to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity.

RESULTS

We identified 49 interventions, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics.

CONCLUSIONS

An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Successive outbreaks of Group A streptococcus (GAS) in care of the elderly settings; lessons learned

Group A streptococcal (GAS) outbreaks in care of the elderly settings are rare. We describe two successive outbreaks involving care of the elderly patients. The first outbreak involved 18 patients and the second involved six patients and two healthcare workers. We describe the difficulties encountered controlling GAS outbreaks in care of the elderly settings and how the lessons learned from the first outbreak influenced management of the second incident. Stringent infection control measures including isolation until completion of treatment and re-screening for evidence of eradication were required to bring outbreak one under control. These measures were adopted early in outbreak two and we suspect that these measures and the rapid identification of carriers brought this second outbreak under control quickly.

Best practices in the Veterans Health Administration's MOVE! Weight management program

BACKGROUND

Obesity is a substantial problem in the Veterans Health Administration (VHA). VHA developed and disseminated the MOVE! Weight Management Program for Veterans to its medical facilities but implementation of the program has been variable.

PURPOSE

The objective was to explore variation in MOVE! program implementation to identify facility structure, policies, and processes associated with larger patient weight-loss outcomes.

METHODS

Qualitative comparative analysis (QCA) was used to identify facility conditions or combinations of conditions associated with larger 6-month patient weight-loss outcomes. QCA is a method that allows for systematic cross-case comparison to better understand causal complexity. Eleven sites with larger outcomes and 11 sites with smaller outcomes were identified and data were collected with site interviews, facility-completed program summary forms, and medical record abstraction in 2009 and 2010. Conditions were selected based on theory and experience implementing MOVE! and were calibrated using QCA methods. Configuration patterns were examined to identify necessary conditions (i.e., always present when outcome present, but alone do not guarantee outcome) and sufficient conditions (i.e., presence guarantees outcome) at sites with larger and smaller outcomes. A thematic analysis of site interview data supplemented QCA findings.

RESULTS

No two sites shared the same condition pattern. Necessary conditions included the use of a standard curriculum and group care-delivery format, and they were present at all sites with larger outcomes but at only six sites with smaller outcomes. At the 17 sites with both necessary conditions, four combinations of conditions were identified that accounted for all sites with larger outcomes. These included high program complexity combined with high staff involvement; group care-delivery format combined with low accountability to facility leadership; an active physician champion combined with low accountability to facility leadership; and the use of quality-improvement strategies combined with not using a waiting list.

CONCLUSIONS

The use of a standard curriculum delivered with a group care-delivery format is an essential feature of successful VHA facility MOVE! Weight Management Programs, but alone does not guarantee success. Program development and policy will be used to ensure dissemination of the best practices identified in this evaluation.

Bacterial diversity in an industrial wastewater bioreactor

Industrial wastewater bioreactors are potentially important sources of novel biocatalysts. However, the microbial populations in these bioreactors are not well characterized. The microbial community in an industrial wastewater bioreactor was surveyed by extracting DNA from a sample of activated sludge, followed by PCR amplification and sequencing of cloned 16S rRNA genes. A total of 407 cloned 16S rRNA gene sequences were compared with 88 bacterial isolates cultured from the same sample of sludge using a variety of standard media. Most of the bacteria detected by the PCR-based approach were beta-subdivision Proteobacteria, whereas most of the cultured bacteria were gamma-subdivision Proteobacteria. Only a few types of bacteria were detected by both approaches. These observations indicate that multiple techniques are necessary to characterize the microbial diversity in any complex ecosystem.

Secular declines in Spearman's g: some evidence from the United States

The Flynn Effect (J. Flynn, 1987) refers to the apparent increases in intelligence quotient (IQ) observed over the past few decades. A related phenomenon is that the variance in test scores accounted for by Spearman's g (C. Spearman, 1904) varies according to IQ level. That is, g accounts for less variance in high IQ groups than in low IQ groups. Spearman termed this variant aspect of g the "law of diminishing returns." This study extends prior research on the Flynn Effect and the law of diminishing returns by examining changes in the statistical importance of Spearman's g that may accompany secular increases in IQ. Based on the standardization data from the United States versions of the Wechsler scales (i.e., Wechsler Preschool and Primary Scales of Intelligence, D. Wechsler, 1967; Wechsler Intelligence Scale for Children, D. Wechsler, 1949; Wechsler Adult Intelligence Scale, D. Wechsler, 1955), this study indicated that, in most cases, the statistical significance of Spearman's g has indeed declined over the past several years. A. R. Jensen (1998) suggested that the components of the Flynn Effect warrant special investigation. The present study addresses this issue, in part by analyzing the Verbal and Performance subscales of the Wechsler scales. Additionally, this study further confirms the law of diminishing returns as applicable to different ages and time periods.

Comparison of Neoral and Sandimmun cyclosporin A pharmacokinetic profiles in young renal transplant recipients

A major factor influencing whole blood cyclosporin A levels in young children with renal transplants is the variable absorption of Sandimmun (SIM). Neoral (NEO) is a new microemulsion of cyclosporin A (CYA) that has been reported to have better absorption characteristics. We compared the pharmacokinetics of SIM and NEO in nine renal transplant recipients aged less than 11 years (range 4.8-10.9 years) and observed clinical parameters during 6 months of NEO therapy. Median CYA dosage was 149 mg/m2 per day (range 98-226). We observed an increase in the maximum CYA concentration (Cmax) of 114%, an increase in area under the curve (AUC) of 71% and the time to reach Cmax was reduced from 1.75 h to 1.25 h with NEO, while 12-h trough levels (C12 h) did not change significantly. AUC correlated with C12 h for SIM (r2 = 0.833) and NEO (r2 = 0.699) and also C1.5 h for NEO (r2 = 0.775). During 24 weeks' follow-up, the coefficient of variation of CYA levels was lower for NEO (13%) than for SIM (20%). Although CYA dosages at the start and the end of 6 months on NEO were similar, only one patient was maintained on a constant dose. Four patients had acute reversible rises in plasma creatinine which responded to a 11% reduction in NEO dose; their increase in AUC was greater than those patients not showing a rise in plasma creatinine. Overall, median plasma creatinine was unchanged at the end of the study. NEO was well tolerated by the patients; temporary nausea and headache were experienced by three patients and one of them stopped NEO after 20 days. Other biochemical parameters were not significantly different on NEO.

Response of filtered eyes to digital ocular pressure

PURPOSE

To examine the effect of digital ocular pressure (DOP) on the intraocular pressure (IOP) of eyes 3 months or longer after successful glaucoma filtering surgery.

METHODS

Fifteen patients participated in this study. Each had one eye with a successful filtering operation (IOP < or = 21 mmHg without medications) and a fellow eye that was not operated on, which served as a control. The authors measured IOP in both eyes before and serially after DOP until return to baseline or for 3 hours to determine the amounts and durations of reductions. The authors monitored changes of bleb morphology and searched for complications.

RESULTS

Digital ocular pressure 3 months or more after successful filtering surgery reduced IOP by approximately 50% of baseline. The time after DOP for 50% of eyes to have intraocular pressure return to within 2 mmHg of baseline was 95 minutes; 40% recovered within 20 minutes and 30% had not recovered by 3 hours. Eyes with localized blebs recovered faster than did eyes with diffuse blebs. Transient shallowing of the anterior chamber developed in one eye. Otherwise, there were no adverse effects. Time since surgery and baseline IOP were not correlated with response. Fellow eyes had minimal response to DOP and recovered within 30 minutes.

CONCLUSION

This study shows that a substantial, transient decrease of IOP after DOP occurs in glaucomatous eyes with a well-functioning bleb 3 months to 6 years after filtering surgery. The duration exceeds 90 minutes in more than 50% of the eyes tested and 180 minutes in more than 30% of the eyes tested.

A controlled study of the psycho-social development of children conceived following insemination with donor semen

Although donor insemination has been used to produce pregnancies for many years, there has been little information on how children conceived in this unusual manner develop psycho-socially. We have therefore carried out a controlled quantitative assessment comparing children who were conceived by donor insemination to adoptees and naturally conceived children who were matched for age and sex. We conclude that the psycho-social development of donor insemination children was no different from the two control groups.

Lateral flagellum of Vibrio fluvialis: a species-specific antigen

Antiserum against lateral flagella (L flagella) of Vibrio fluvialis AQ 0007 was prepared, and H agglutination tests of V. fluvialis strains were carried out with the antiserum. Thirty-seven strains isolated from human patients, marine products, or seawater were tested. All strains, except three which had lost the ability to form L flagella, agglutinated with that antiserum. The antiserum did not agglutinate other vibrio species having L flagella, whereas antisera against L flagella of other vibrios did not agglutinate V. fluvialis. These results suggest that the L flagellar antigen of V. fluvialis is common and specific to the species, and is a useful tool for serological identification of the organism.

Serological method for identification of Vibrio parahaemolyticus from marine samples

Use of agglutination with antiserum against lateral flagella (H-agglutination) for the identification of Vibrio parahaemolyticus was studied. Sucrose-negative bacteria were isolated from seawater, and their characterization was carried out by traditional biological tests and slide agglutination with antiserum specific to lateral flagella of V. parahaemolyticus. Of 135 strains isolated, 78 were identified as V. parahaemolyticus by biological tests and were agglutinated with the above serum. Fifty-five strains did not agglutinate with the serum, and their biological characteristics were different from those of V. parahaemolyticus. Two strains also differed from V. parahaemolyticus in some biological characteristics but agglutinated with the antiserum. All clinically isolated V. parahaemolyticus strains also agglutinated with the above serum. These results suggest that our serological method is useful for the identification of V. parahaemolyticus, especially for samples in which there are many organisms related to V. parahaemolyticus, because many biological tests can be omitted.