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Goff A, Lujan-Bear S, Titus H, Englander H. Integrating Hospital-Based Harm Reduction Care-Harnessing the Nursing Model. Subst Use Addctn J 2024; 45:307-313. [PMID: 38258867 DOI: 10.1177/29767342231219577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Hospitals are risk environments for people who use drugs, and most hospitals are unprepared to deliver substance use disorder (SUD) care, including harm reduction (HR) interventions. HR philosophy clashes with traditional hospital hierarchy and norms, and staff may resist HR interventions due to stigma, fear of enabling substance use, legal and safety concerns. Nurses are central to hospital culture and care and could promote and deliver HR care. Our US hospital has an inter-professional addiction consult service (ACS) that includes medical providers, social workers, and peers. We developed and launched a hospital-based registered nurse-(RN) led HR intervention, including distributing safe-use supplies (eg, syringes). We describe model development and early experience, using an Exploration, Preparation, Implementation, and Sustainment framework. ACS experiences and community HR interventions informed our exploration phase. In the preparation phase we secured funding from Medicaid payers for a 2-year pilot, including full-time RN salary and HR supplies. We elicited buy-in from hospital executive leaders, partly by partnering with nurse champions who described unmet patient care and staff education needs. We consulted hospital lawyers and developed an institution-wide media campaign targeting staff, including in-person booths distributing naloxone and materials promoting international overdose awareness day (eg, "#EndOverdose" buttons). We collaborated with local and national experts to develop the intervention, which includes RN bedside HR education and staff trainings. The Implementation was from September 2022 to March 2023. We trained 459 staff (over 15 trainings) and conducted 209 patient encounters. Generally, patients and staff embraced the HR RN role, including previously controversial safe-use supply distribution. Sustainment efforts include engaging stakeholders in continuous improvement and evaluation efforts. A nurse-led hospital-based HR intervention can expand patient services, support staff, and bridge HR and medical models.
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Affiliation(s)
- Amelia Goff
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Susannah Lujan-Bear
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Hope Titus
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Honora Englander
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Hospital Medicine, Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR, USA
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Abstract
BACKGROUND Hospitals struggle to engage patients with stimulant use disorders, and little is known about how to adapt evidence-based behavioral interventions, such as contingency management (CM), for hospital settings. Our study is the first step in informing the design of a hospital CM intervention. METHODS We performed a qualitative study at a quaternary referral academic medical center in Portland, Oregon. We conducted semistructured qualitative interviews with CM experts, hospital staff, and hospitalized patients, eliciting input about hospital CM adaptations, anticipated challenges, and potential opportunities. We performed a reflexive thematic analysis at a semantic level and shared results for respondent validation. RESULTS We interviewed 8 CM experts (researchers and clinicians), 5 hospital staff, and 8 patients. Participants felt CM could benefit hospitalized patients by supporting patient substance use disorder and physical health goals, especially by addressing the boredom, sadness, and loneliness of hospitalization. Participants emphasized that in-person interactions could improve patient-staff relationships by using "super positive" experiences to improve rapport. For successful hospital CM, participants emphasized CM core concepts and potential hospital adaptations, including identifying hospital-specific high-yield target behaviors, ensuring staff training, and using CM to support the hospital discharge transition. Participants also encouraged considering novel mobile app interventions, which may offer more flexibility in the hospital, recommending that such interventions include an in-person CM facilitator. CONCLUSIONS Contingency management has potential to support hospitalized patients and improve patient and staff experience. Our findings can inform CM interventions for hospital systems seeking to expand access to CM and stimulant use disorder treatment.
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Affiliation(s)
- Linda Peng
- From the Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR (LP, HT, HE); and Oregon Health and Science University School of Medicine, Oregon Health and Science University, Portland, OR (PR)
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McEvoy CT, Shorey-Kendrick LE, Milner K, Harris J, Vuylsteke B, Cunningham M, Tiller C, Stewart J, Schilling D, Brownsberger J, Titus H, MacDonald KD, Gonzales D, Vu A, Park BS, Spindel ER, Morris CD, Tepper RS. Effect of Vitamin C Supplementation for Pregnant Smokers on Offspring Airway Function and Wheeze at Age 5 Years: Follow-up of a Randomized Clinical Trial. JAMA Pediatr 2023; 177:16-24. [PMID: 36409489 PMCID: PMC9679962 DOI: 10.1001/jamapediatrics.2022.4401] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022]
Abstract
Importance Vitamin C supplementation (500 mg/d) for pregnant smokers has been reported to increase offspring airway function as measured by forced expiratory flow (FEF) through age 12 months; however, its effects on airway function at age 5 years remain to be assessed. Objective To assess whether vitamin C supplementation in pregnant smokers is associated with increased and/or improved airway function in their offspring at age 5 years and whether vitamin C decreases the occurrence of wheeze. Design, Setting, and Participants This study followed up the Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP) double-blind, placebo-controlled randomized clinical trial conducted at 3 centers in the US (in Oregon, Washington, and Indiana) between 2012 and 2016. Investigators and participants remain unaware of the treatment assignments. Forced expiratory flow measurements at age 5 years were completed from 2018 to 2021. Interventions Pregnant smokers were randomized to vitamin C (500 mg/d) or placebo treatment. Main Outcomes and Measures The primary outcome was the prespecified measurement of FEF between 25% and 75% expired volume (FEF25-75) by spirometry at age 5 years. Secondary outcomes included FEF measurements at 50% and 75% of expiration (FEF50 and FEF75), forced expiratory volume in 1 second (FEV1), and occurrence of wheeze. Results Of the 251 pregnant smokers included in this study, 125 (49.8%) were randomized to vitamin C and 126 (50.2%) were randomized to placebo. Of 213 children from the VCSIP trial who were reconsented into this follow-up study, 192 (90.1%) had successful FEF measurements at age 5 years; 212 (99.5%) were included in the analysis of wheeze. Analysis of covariance demonstrated that offspring of pregnant smokers allocated to vitamin C compared with placebo had 17.2% significantly higher mean (SE) measurements of FEF25-75 at age 5 years (1.45 [0.04] vs 1.24 [0.04] L/s; adjusted mean difference, 0.21 [95% CI, 0.13-0.30]; P < .001). Mean (SE) measurements were also significantly increased by 14.1% for FEF50 (1.59 [0.04] vs 1.39 [0.04] L/s; adjusted mean difference, 0.20 [95% CI, 0.11-0.30]; P < .001), 25.9% for FEF75 (0.79 [0.02] vs 0.63 [0.02] L/s; 0.16 [95% CI, 0.11-0.22]; P < .001), and 4.4% for FEV1 (1.13 [0.02] vs 1.09 [0.02] L; 0.05 [95% CI, 0.01-0.09]; P = .02). In addition, offspring of pregnant smokers randomized to vitamin C had significantly decreased wheeze (28.3% vs 47.2%; estimated odds ratio, 0.41 [95% CI, 0.23-0.74]; P = .003). Conclusions and Relevance In this follow-up study of offspring of pregnant smokers randomized to vitamin C vs placebo, vitamin C supplementation during pregnancy resulted in significantly increased airway function of offspring at age 5 years and significantly decreased the occurrence of wheeze. These findings suggest that vitamin C supplementation for pregnant smokers may decrease the effects of smoking in pregnancy on childhood airway function and respiratory health. Trial Registration ClinicalTrials.gov Identifier: NCT03203603.
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Affiliation(s)
- Cindy T. McEvoy
- Department of Pediatrics, Oregon Health & Science University, Portland
| | | | - Kristin Milner
- Department of Pediatrics, Oregon Health & Science University, Portland
| | - Julia Harris
- Department of Pediatrics, Oregon Health & Science University, Portland
| | | | - Michelle Cunningham
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Christina Tiller
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Jaclene Stewart
- Department of Pediatrics, Oregon Health & Science University, Portland
| | - Diane Schilling
- Department of Pediatrics, Oregon Health & Science University, Portland
| | | | - Hope Titus
- Department of Pediatrics, Oregon Health & Science University, Portland
| | | | - David Gonzales
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Annette Vu
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Byung S. Park
- Oregon Health & Science University−Portland State University School of Public Health and Knight Cancer Institute, Portland
| | - Eliot R. Spindel
- Division of Neuroscience, Oregon National Primate Research Center, Beaverton
| | - Cynthia D. Morris
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland
| | - Robert S. Tepper
- Department of Pediatrics, Well Center for Research, Indiana University School of Medicine, Indianapolis
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Yang P, Lockard R, Titus H, Hiblar J, Weller K, Wafai D, Weleber RG, Duvoisin RM, Morgans CW, Pennesi ME. Suppression of cGMP-Dependent Photoreceptor Cytotoxicity With Mycophenolate Is Neuroprotective in Murine Models of Retinitis Pigmentosa. Invest Ophthalmol Vis Sci 2021; 61:25. [PMID: 32785677 PMCID: PMC7441375 DOI: 10.1167/iovs.61.10.25] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose To determine the effect of mycophenolate mofetil (MMF) on retinal degeneration on two mouse models of retinitis pigmentosa. Methods Intraperitoneal injections of MMF were administered daily in rd10 and c57 mice starting at postoperative day 12 (P12) and rd1 mice starting at P8. The effect of MMF was assessed with optical coherence tomography, immunohistochemistry, electroretinography, and OptoMotry. Whole retinal cyclic guanosine monophosphate (cGMP) and mycophenolic acid levels were quantified with mass spectrometry. Photoreceptor cGMP cytotoxicity was evaluated with cell counts of cGMP immunostaining. Results MMF treatment significantly delays the onset of retinal degeneration and cGMP-dependent photoreceptor cytotoxicity in rd10 and rd1 mice, albeit a more modest effect in the latter. In rd10 mice, treatment with MMF showed robust preservation of the photoreceptors up to P22 with associated suppression of cGMP immunostaining and microglial activation; The neuroprotective effect diminished after P22, but outer retinal thickness was still significantly thicker by P35 and OptoMotry response was significantly better up to P60. Whereas cGMP immunostaining of the photoreceptors were present in rd10 and rd1 mice, hyperphysiological whole retinal cGMP levels were observed only in rd1 mice. Conclusions Early treatment with MMF confers potent neuroprotection in two animal models of RP by suppressing the cGMP-dependent common pathway for photoreceptor cell death. The neuroprotective effect of MMF on cGMP-dependent cytotoxicity occurs independently of the presence of hyperphysiological whole retinal cGMP levels. Thus our data suggest that MMF may be an important new class of neuroprotective agent that could be useful in the treatment of patients with RP.
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Affiliation(s)
- Paul Yang
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Rachel Lockard
- School of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Hope Titus
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Jordan Hiblar
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Kyle Weller
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Dahlia Wafai
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Richard G Weleber
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Robert M Duvoisin
- Chemical Physiology & Biochemistry, Oregon Health & Science University, Portland, Oregon, United States
| | - Catherine W Morgans
- Chemical Physiology & Biochemistry, Oregon Health & Science University, Portland, Oregon, United States
| | - Mark E Pennesi
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
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Ryals RC, Huang SJ, Wafai D, Bernert C, Steele W, Six M, Bonthala S, Titus H, Yang P, Gillingham M, Pennesi ME. A Ketogenic & Low-Protein Diet Slows Retinal Degeneration in rd10 Mice. Transl Vis Sci Technol 2020; 9:18. [PMID: 33117609 PMCID: PMC7571290 DOI: 10.1167/tvst.9.11.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/23/2020] [Indexed: 01/01/2023] Open
Abstract
Purpose Treatments that delay retinal cell death regardless of genetic causation are needed for inherited retinal degeneration (IRD) patients. The ketogenic diet is a high-fat, low-carbohydrate diet, used to treat epilepsy, and has beneficial effects for neurodegenerative diseases. This study aimed to determine whether the ketogenic diet could slow retinal degeneration. Methods Early weaned, rd10 and wild-type (WT) mice were placed on either standard chow, a ketogenic diet, or a ketogenic & low-protein diet. From postnatal day (PD) 23 to PD50, weight and blood β-hydroxybutyrate levels were recorded. Retinal thickness, retinal function, and visual performance were measured via optical coherence tomography, electroretinography (ERG), and optokinetic tracking (OKT). At PD40, serum albumin, rhodopsin protein, and phototransduction gene expression were measured. Results Both ketogenic diets elicited a systemic induction of ketosis. However, rd10 mice on the ketogenic & low-protein diet had significant increases in photoreceptor thickness, ERG amplitudes, and OKT thresholds, whereas rd10 mice on the ketogenic diet showed no photoreceptor preservation. In both rd10 and WT mice, the ketogenic & low-protein diet was associated with abnormal weight gain and decreases in serum albumin levels, 27% and 56%, respectively. In WT mice, the ketogenic & low-protein diet was also associated with an ∼20% to 30% reduction in ERG amplitudes. Conclusions The ketogenic & low-protein diet slowed retinal degeneration in a clinically relevant IRD model. In WT mice, the ketogenic & low-protein diet was associated with a decrease in phototransduction and serum albumin, which could serve as a protective mechanism in the rd10 model. Although ketosis was associated with protection, its role remains unclear. Translational Relevance Neuroprotective mechanisms associated with the ketogenic & low-protein diet have potential to slow retinal degeneration.
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Affiliation(s)
- Renee C Ryals
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Samuel J Huang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Dahlia Wafai
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Claire Bernert
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - William Steele
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Makayla Six
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Shasank Bonthala
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Hope Titus
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Paul Yang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Melanie Gillingham
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - Mark E Pennesi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
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Yang P, Lockard RA, Titus H. Techniques to Quantify cGMP Dysregulation as a Common Pathway Associated with Photoreceptor Cell Death in Retinitis Pigmentosa. Adv Exp Med Biol 2020; 1185:407-411. [PMID: 31884646 DOI: 10.1007/978-3-030-27378-1_67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The targeted development of neuroprotective therapies for retinitis pigmentosa (RP) depends upon a better understanding of the mechanisms of photoreceptor cell death. Nucleotide metabolite-associated photoreceptor cell death is an emerging area of research that is important in multiple models of RP, yet the exact pathophysiology remains to be elucidated. One common pathway of photoreceptor cell death in RP is cGMP dysregulation, which is underscored by its potential to be relevant in up to 30% of patients with RP. Optimizing tools for detecting and quantifying nucleotide metabolites in the retina is vital to expanding this area of research. Immunohistochemistry is useful for localizing abnormally high levels of cGMP in a cell-specific manner, while enzyme-linked immunosorbent assay and liquid chromatography-mass spectrometry are quantitative and more sensitive. These techniques can form the basis for more sophisticated experiments to elucidate upstream events in photoreceptor cell death, which will hopefully lead to the development of novel therapies for patients with RP.
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Affiliation(s)
- Paul Yang
- Casey Eye Institute, Orgeon Health and Science University, Portland, OR, USA.
| | - Rachel A Lockard
- Casey Eye Institute, Orgeon Health and Science University, Portland, OR, USA
| | - Hope Titus
- Casey Eye Institute, Orgeon Health and Science University, Portland, OR, USA
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Titus H. The public image of nurses--today and yesterday. Nurs News (Meriden) 1968; 42:14-5. [PMID: 5193334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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