Harm Reduction Principles in a Street Medicine Program: A Qualitative Study

There is ample evidence that homelessness is associated with high rates of morbidity and mortality. Street Medicine seeks to eliminate these disparities by providing healthcare on the streets to people who are unsheltered. While extant research describes health disparities for the unsheltered and programmatic approaches to addressing housing instability, there are few published studies describing how healthcare providers build and maintain relationships with patients on the street. This insight is central to specifying how street medicine differs from traditional forms of care and defining aspects of street medicine that contribute to successful patient engagement. Through a collaboration between Operation Safety Net (OSN), a street medicine provider in Pittsburgh, Pennsylvania, and [name redacted], an exploratory qualitative study was designed and implemented using harm reduction principles as a guiding framework. Qualitative interviews were conducted with eleven OSN street medicine providers and a thematic analysis using a deductive approach was used to analyze the data. Findings identified the ways that relational harm reduction was central to all aspects of patient care provided through this program. Major themes included: (1) individualism, or meeting patients where they are figuratively and literally; (2) humanism, which refers to valuing and holding true regard for patients; and (3) nonjudgmental care, in which providers do not hold negative attitudes toward patients and their decisions. These themes are consistent with relational principles of harm reduction. Challenges that were discussed also aligned with these principles and included frustration with systems providing care that did not meet patients' individualized needs, and pain and trauma experienced by providers upon losing patients for whom they genuinely cared. Understanding these relational principles of harm reduction may help providers operationalize ways to effectively engage and maintain homeless patients in care and subsequently bridge the gap to traditional models of care. This study may provide valuable insights to expand the street medicine field in research and applied clinical and community settings.

Implementation evaluation of a teledermatology virtual clinic at an academic medical center

BACKGROUND

Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to use the Exploration, Preparation, Implementation, and Sustainment (EPIS) and the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to evaluate implementation of TD at Duke.

METHODS

The EPIS and RE-AIM frameworks were deployed to design and implement a TD program that leveraged the strengths of the Duke University Health System and addressed previously reported barriers to implementation of store-and-forward and synchronous TD models. In the resultant hybrid TD model, trained primary care providers (PCPs) sent e-comm referrals with clinical and dermatoscopic images to dermatology. These e-consults were reviewed asynchronously and patients were scheduled for a synchronous video visit with dermatology within days. Dermatologists managed the patient plan. This hybrid TD model was piloted at four primary care clinics. Pertinent outcomes from a TD-adapted RE-AIM framework were tracked using electronic health record data. Patient satisfaction was assessed using a post-video visit survey (n = 18). Implementation barriers and facilitators were also collected through provider surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents).

RESULTS

At four PCP clinics throughout 9/1/2021-4/30/2022, there were 218 TD referrals. Video visits occurred on average 7.5 ± 0.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days.

CONCLUSIONS

The use of implementation science frameworks allowed for identification of system and contextual strengths which informed the hybrid TD pilot. Barriers and facilitating interventions will provide guidance for expansion and ongoing maintenance of TD.

A Study Protocol to Increase Engagement in Evidence Based Hospital and Community Based Care Using a Serious Injection Related Infections (SIRI) Checklist and Enhanced Peer for Hospitalized PWID (ShaPe)

Background

With the opioid crisis, surging methamphetamine use, and healthcare disruptions due to SARS-CoV-2, serious injection related infections (SIRIs), like endocarditis, have increased significantly. Hospitalizations for SIRI provide a unique opportunity for persons who inject drugs (PWID) to engage in addiction treatment and infection prevention, yet many providers miss opportunities for evidence-based care due to busy inpatient services and lack of awareness. To improve hospital care, we developed a 5-item SIRI Checklist for providers as a standardized reminder to offer medication for opioid use disorder (MOUD), HIV and HCV screening, harm reduction counseling, and referral to community-based care. We also formalized an Intensive Peer Recovery Coach protocol to support PWID on discharge. We hypothesized that the SIRI Checklist and Intensive Peer Intervention would increase use of hospital-based services (HIV, HCV screening, MOUD) and linkage to community-based care: PrEP prescription, MOUD prescription, and related outpatient visit(s).

Methods

This is a feasibility study and randomized control trial of a checklist and intensive peer intervention for hospitalized PWID with SIRI admitted to UAB Hospital. We will recruit 60 PWID who will be randomized to one of 4 groups (SIRI Checklist, SIRI Checklist + Enhanced Peer, Enhanced Peer, and Standard of Care). Results will be analyzed using a 2x2 factorial design. We will use surveys to collect data on drug use behaviors, stigma, HIV risk, and PrEP interest and awareness. Our primary outcome of feasibility will include the ability to recruit hospitalized PWID and retain them in the study to determine post-discharge clinical outcomes. Additionally, we will explore clinical outcomes using a combination of patient surveys and electronic medical record data (HIV, HCV testing, MOUD and PrEP prescriptions).This study is approved by UAB IRB #300009134.

Discussion

This feasibility study is a necessary step in designing and testing patient-centered interventions to improve public health for rural and Southern PWID. By testing low barrier interventions that are accessible and reproducible in states without access to Medicaid expansion and robust public health infrastructure, we aim to identify models of care that promote linkage and engagement in community care.

Trial Registration

NCT05480956.

Physicians' experiences with buprenorphine: A qualitative study of motivations for becoming X waivered and barriers to and facilitators of prescribing the medication for opioid use disorder

INTRODUCTION

Buprenorphine can only be prescribed for opioid use disorder (OUD) by providers with a Controlled Substance Act waiver (X waiver) from the Substance Abuse and Mental Health Services Administration. This study examines what motivates physicians to become X waivered, as well as what facilitates and hinders physicians' abilities to prescribe buprenorphine to people with OUD.

METHODS

This is a qualitative study of physicians in Birmingham, Alabama. We recruited physicians from the University of Alabama at Birmingham and Cahaba Medical Care to participate in semi-structured interviews and used a Framework-guided Rapid Qualitative Analysis technique to analyze the transcripts for themes aligned with the Social Cognitive Theory.

RESULTS

A total of 27 physicians were interviewed between December 15th, 2021 and July 21st, 2022. The vast majority reported seeking to obtain an X waiver when their employers encouraged or mandated it. Most providers reported being eager to become waivered when first asked by their employers, while a few described some hesitancies. Essentially all participants agreed that having mentors is important when first prescribing buprenorphine and that support from social workers and counselors is needed. Most physicians discussed how stigma, administrative barriers, and a lack of community resources hinder buprenorphine prescription.

CONCLUSIONS

Our findings suggest that employers are effective in encouraging X waiver certification and mentors and allied health professionals are important in ensuring providers continue buprenorphine prescription. Additionally, it is critical to address challenges to successful buprenorphine prescription, like stigma and administrative barriers.

Implementation Evaluation of a Teledermatology Virtual Clinic at an Academic Medical Center

Background

Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to evaluate implementation of TD at four Duke primary care practices.

Methods

We implemented a hybrid TD program where trained primary care providers (PCPs) sent referrals with clinical and dermatoscopic images to dermatology. Patients were seen by dermatologists over video visit within days, and dermatologists managed the patient plan. We evaluated implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework using electronic health record data. Implementation barriers and facilitators were collected through surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents).

Results

At four PCP clinics throughout 9/1/2021-4/30/2022 there were 218 TD referrals. Video visits occurred on average 7.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days.

Conclusions

Addressing TD process fit into PCP clinic flow and reducing time burdens may increase PCP uptake of TD.

Methamphetamines and Serious Injection-Related Infections: Opioid Use Care Continuum and Opportunities to End Alabama's Drug Crisis

Background

Increasingly, injection opioid use and opioid use disorder (OUD) are complicated by methamphetamine use, but the impact of stimulant use on the care of people who inject drugs (PWID) with serious injection-related infections (SIRIs) is unknown. The objective of this study was to explore hospital outcomes and postdischarge trends for a cohort of hospitalized PWID to identify opportunities for intervention.

Methods

We queried the electronic medical record for patients hospitalized at the University of Alabama at Birmingham with injection drug use-related infections between 1/11/2016 and 4/24/2021. Patients were categorized as having OUD only (OUD), OUD plus methamphetamine use (OUD/meth), or injection of other substance(s) (other). We utilized statistical analyses to assess group differences across hospital outcomes and postdischarge trends. We determined the OUD continuum of care for those with OUD, with and without methamphetamine use.

Results

A total of 370 patients met inclusion criteria-many with readmissions (98%) and high mortality (8%). The majority were White, male, and uninsured, with a median age of 38. One in 4 resided outside of a metropolitan area. There were significant differences according to substance use in terms of sociodemographics and hospital outcomes: patients with OUD/meth were more likely to leave via patient-directed discharge, but those with OUD only had the greatest mortality. Comorbid methamphetamine use did not significantly impact the OUD care continuum.

Conclusions

The current drug crisis in AL will require targeted interventions to engage a young, uninsured population with SIRI in evidence-based addiction and infection services.

1410. Methamphetamines and Serious Injection Related Infections: Epidemiology and Outcomes of Alabama’s Drug Crisis

Background

The U.S. is facing a steep increase in infectious consequences of intravenous drug use due to the ongoing opioid crisis, surging methamphetamine use, and health care disruptions caused by COVID-19. We hypothesize that the sociodemographic and clinical outcomes of persons who inject drugs (PWID) differ based on their drug of choice (opioids, methamphetamines). Further, we hypothesize that the OUD (opioid use disorder) continuum, including linkage and retention in OUD treatment, will vary depending on co-occurring methamphetamine use. By elucidating differences in these groups, we aim to identify opportunities for interventions along the care continuum.

Methods

This is a retrospective study of hospitalized PWID receiving care at the University of Alabama at Birmingham Hospital for a serious injection related infection (SIRI) between 1/11/2016 and 4/24/2021. We queried the EMR for clinical data and health outcomes. We extracted data on substance use disorder(s), treatments, and linkage to care through review of primary and addiction medicine consultation notes. Using statistical measures of association, we compared demographic factors and clinical outcomes among groups; delineating between those with and without methamphetamine use, and without OUD. When appropriate, additional comparisons were made to detect statistical differences between factors and those with and without methamphetamine use.

Results

Of 370 PWID, 286 had OUD, 94 had OUD and methamphetamine use, and 84 had another substance use disorder. There were significant differences according to drug use disorder with patients with OUD and meth use being mostly White (99%), 42% female, and younger relative to those who use opioids only. Patient directed discharge was most common among those with OUD plus meth use, but death was highest for those with OUD only. The OUD care continuum was similar and alarming for both groups with many gaps in care. Figure 1.

Identifying facilitators, barriers, and strategies to implement social determinants of health screening, referral, and follow-up in the US: a scoping review protocol

OBJECTIVE

This review will assess the literature exploring facilitators, barriers, and strategies for the implementation of social determinants of health and social needs screening, referral to community resources, and follow-up in clinical settings and clinical training curricula in the United States.

INTRODUCTION

Social determinants of health and social needs are a central cause of health inequity and poor health outcomes in the United States. Existing research primarily focuses on theoretical implications of social determinants of health on health outcomes, with a growing secondary focus on the development of screening tools that identify patients' specific unmet social needs. However, summative research has not yet focused on the barriers, facilitators, and strategies relating to the implementation of social determinants of health and social need screenings into routine clinical care. This scoping review aims to examine literature on the implementation of social determinants of health and social needs screening in clinical settings and clinical training curricula while also identifying gaps that require further exploration.

INCLUSION CRITERIA

This review will include relevant studies examining the facilitators, barriers, and strategies for the implementation of social determinants of health and social needs screening, referral, and follow-up as they relate to human subjects. The literature must be in English from 2010 and focus on United States clinical health settings and curricula.

METHODS

We will search PubMed, CINAHL, and Embase databases for relevant articles. Two independent reviewers will screen abstracts for eligibility. Data will be extracted from eligible articles and results will be presented in narrative and tabular format in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

Transforming Primary Care for Lesbian, Gay, Bisexual, and Transgender People: A Collaborative Quality Improvement Initiative

PURPOSE

Lesbian, gay, bisexual, and transgender (LGBT) people experience multiple disparities in access to care and health outcomes. We developed a quality improvement initiative, Transforming Primary Care for LGBT People, to enhance the capacity of federally qualified health centers (FQHCs) to provide culturally affirming care for this population.

METHODS

The 1-year intervention blended the models of Practice Improvement Collaboratives and Project ECHO (Extension for Community Health Outcomes) to facilitate learning and translate knowledge into action. FQHC teams received coaching in creating LGBT-inclusive environments, collecting sexual orientation and gender identity (SOGI) data, taking risk-based sexual histories, and screening LGBT people for syphilis, chlamydia and gonorrhea, and HIV. We used a preintervention-postintervention evaluation design.

RESULTS

We selected 10 FQHCs serving 441,387 patients in 123 clinical sites in 9 states. The intervention spread from 10 clinicians in 10 clinical sites to 431 clinicians in 79 clinical sites. FQHCs reported increases in culturally affirming practices, including collecting patient pronoun information (42.9% increase) and identifying LGBT patient liaisons (300.0% increase). Postintervention, among 9 FQHCs reporting SOGI data from electronic health records, SOGI documentation increased from 13.5% to 50.8% of patients (276.3% increase). Among 8 FQHCs reporting number of LGBT patients, screening of LGBT patients increased from 22.3% (95% CI, 4.9%-40.0%) to 34.6% (95% CI, 19.4%-48.6%) for syphilis (86.5% increase); from 25.3% (95% CI, 7.6%-43.1%) to 44.1% (95% CI, 30.2%-58.1%) for chlamydia and gonorrhea (109.0% increase); and from 14.8% (95% CI, 3.2%-26.5%) to 30.5% (95% CI, 26.7%-34.3%) for HIV (132.4% increase).

CONCLUSIONS

FQHCs participating in this initiative reported improved capacity to provide culturally affirming care and targeted screening for LGBT patients.

0957 The Association Between Sleep and Sustained Attention Differs in Children vs. Adolescents With ADHD

Introduction

Sleep disturbance in children with attention-deficit/hyperactivity disorder (ADHD) is frequent, and lead to shorter sleep duration which has been associated with lower performance on sustained attention tasks. However, no study has investigated this association in adolescents with ADHD. We sought to explore whether the association between sleep and sustained attention performance of children with ADHD is similar in adolescents with ADHD given that sleep patterns are different.

Methods

Parents of 32 children (mean age = 8.0; SD = 1.3) and 10 adolescents (mean = 15.2; SD = 1.3) with ADHD completed a developmental questionnaire including sleep questions. Children and adolescents were medication free and underwent a comprehensive neuropsychological evaluation. Three sleep variables were extracted from the questionnaire, namely the duration of the sleep period during week nights and weekends as well as the difference between the two (“weekend shift”). The Continuous Performance Test was used to measure sustained attention (omission, commission, hit reaction time). Pearson correlations between sleep variables and sustained attention measures were calculated.

Results

Children showed a positive correlation between hit reaction time and the duration of the sleep period during week nights (r = 0.37; p =0.04), weekends (r = 0.51; p = 0.004) and the weekend shift (r = 0.37; p =0.04). No significant correlations were found in the adolescent group.

Conclusion

The fact that no significant associations were found in the adolescent group suggest an improvement of the arousal system through brain development in ADHD, or that other mechanisms could be involved in the etiology of ADHD in adolescents.

Support

Centre d’apprentissage aux 1001 astuces; Fonds de recherche du Québec - Santé

Separation of [(99m)Tc]pertechnetate and molybdate using polyethylene glycol coated C18 and C30 resins

Hydrophobic adsorbents such as C18 and C30 were coated with PEG and subsequently used for the separation of Mo/Tc. The most effective resin for adsorbing PEG was the C18-U resin, which demonstrated a coating capacity of 97.6±2.8mg PEG per g of resin. The ability to adsorb pertechnetate was proportional to the amount of PEG coated on the hydrophobic resin. The [(99m)Tc]pertechnetate recovery during the separation of cyclotron produced (99m)Tc from (100)Mo was 91.8±0.3% (n=2). The resultant product met relevant USP monograph specifications.

Cognitive impairment in obstructive sleep apnea

Obstructive sleep apnea (OSA) is characterised by repetitive cessation or reduction of airflow due to upper airway obstructions. These respiratory events lead to chronic sleep fragmentation and intermittent hypoxemia. Several studies have shown that OSA is associated with daytime sleepiness and cognitive dysfunctions, characterized by impairments of attention, episodic memory, working memory, and executive functions. This paper reviews the cognitive profile of adults with OSA and discusses the relative role of altered sleep and hypoxemia in the aetiology of these cognitive deficits. Markers of cognitive dysfunctions such as those measured with waking electroencephalography and neuroimaging are also presented. The effects of continuous positive airway pressure (CPAP) on cognitive functioning and the possibility of permanent brain damage associated with OSA are also discussed. Finally, this paper reviews the evidence suggesting that OSA is a risk factor for developing mild cognitive impairment and dementia in the aging population and stresses the importance of its early diagnosis and treatment.

Cyclotron production of ⁹⁹mTc: recycling of enriched ¹⁰⁰Mo metal targets

There is growing interest in the large scale cyclotron production of (99m)Tc via the (100)Mo(p,2n)(99m)Tc reaction. While the use and recycling of cyclotron-irradiated enriched molybdenum targets has been reported previously in the context of (94m)Tc production, to the best of our knowledge, previous recycling studies have been limited to the use of oxide targets. To facilitate reuse of high-power enriched (100)Mo targets, this work presents and evaluates a strategy for recycling of enriched metallic molybdenum. For the irradiated (100)Mo targets in this study, an overall metal to metal recovery of 87% is reported. Evaluation of "new" and "recycled" (100)Mo revealed no changes in the molybdenum isotopic composition (as measured via ICP-MS). For similar irradiation conditions of "new" and "recycled" (100)Mo, (i.e. target thicknesses, irradiation time, and energy), comparable levels of (94g)Tc, (95g)Tc, and (96g)Tc contaminants were observed. Comparable QC specifications (i.e. aluminum ion concentration, pH, and radiochemical purity) were also reported. We finally note that [(99m)Tc]-MDP images obtained by comparing MDP labelled with generator-based (99m)Tc vs. (99m)Tc obtained following the irradiation of recycled (100)Mo demonstrated comparable biodistribution. With the goal of producing large quantities of (99m)Tc, the proposed methodology demonstrates that efficient recycling of enriched metallic (100)Mo targets is feasible and effective.

Assessing the performance and longevity of Nb, Pt, Ta, Ti, Zr, and ZrO₂-sputtered Havar foils for the high-power production of reactive [18F]F by proton irradiation of [18O]H2O

As water-soluble ionic contaminants, which arise following proton irradiation of [18O]H2O have been associated with decreased [18F]FDG yields, the minimization of these contaminants is an asset in improving the [18F]F reactivity. To this end, we have previously demonstrated that the use of Nb-sputtered Havar foils results in decreased radionuclidic and chemical impurities in proton irradiated [18O]H2O, improved [18F]FDG yields, and improved [18F]FDG yield consistency when compared with non-sputtered Havar. Resulting from the highly reactive chemical microenvironment within the target however, this niobium layer is observed to degrade over time. To find a material that displays increased longevity with regards to maintaining high [18F]F reactivity, this project extensively investigated and compared Havar foils sputtered with Nb, Pt, Ta, Ti, Zr and ZrO₂. Of the materials investigated, the results of this study suggest that Ta-sputtered Havar foil is the preferred choice. For similar integrated currents (~1,000,000 μA min), when comparing the Ta-sputtered Havar with Nb-sputtered Havar we observed: (i) greater than an order of magnitude decrease in radionuclidic impurities, (ii) a 6.4 percent increase (p=0.0025) in the average TracerLab MX [18F]FDG yield, and (iii) an overall improvement in the FDG yield consistency. Excellent performance of the Ta-sputtered foil was maintained throughout its ~1,500,000 μA min lifetime.

[Guided tissue regeneration in endodontics (2)]

Part I of this article (J Can Dent Assoc 65:394-8) looked at the application of guided tissue regeneration (GTR) in endodontics, the mechanisms of action of GTR and its various presentations. Part II examines the technique for surgically inserting a membrane for GTR, based on a review of the current literature.

[Guided tissue regeneration in endodontics. Part 1]

Over the past twenty years, Guided Tissue Regeneration (GTR) has become an accepted technique for the treatment of tissue loss consequent to periodontal disease. The principles of GTR have recently begun to be employed in endodontics since pulpal necrosis often leads to periodontal tissue loss as a result of the leakage of noxious irritants through apical foramina and accessory canals. This treatment modality is still in its early days for the management of endo-perio lesions and is most appropriately used in specific types of cases. This article, the first of a two-part series, presents a review of the literature about the mechanisms of action of GTR and discusses some of the products used to bring about GTR.

Retinal manifestations of idiopathic myelofibrosis, a hematologic disorder

BACKGROUND

Idiopathic myelofibrosis (IMF) is a bone marrow and hematologic disorder. Retinal and systemic manifestations are observed and result from inefficient blood cell production and blood cell irregularities.

CASE REPORT

A review of IMF as a disease process is presented by way of case report. A 70-year-old woman came to us with specific systemic symptoms. Further ocular investigation revealed bilateral retinal hemorrhages. The hemorrhages were consistent with the results of subsequently ordered blood tests. An understanding of the underlying systemic condition and recognition of the retinal manifestations of IMF aid in the diagnosis. Recognizing differential diagnoses is important as well because IMF produces retinal findings similar to other blood disorders with comparable blood counts and morphologies. There are certain systemic signs the optometrist may look for to assist in the recognition of IMF as opposed to the other diseases.

CONCLUSION

This is an important disease process to recognize, since the systemic and retinal manifestations are within optometry's scope to co-manage.

Clinical comparison of acoustic and electronic stethoscopes and design of a new electronic stethoscope

This clinical study was performed to evaluate the advantages and limitations of 3 acoustic stethoscopes and 3 electronic stethoscopes. It shows that it is possible to design a new electronic stethoscope by considering the advantages of both the acoustic and electronic stethoscopes.