Deductible double jeopardy: patients may pay more out of pocket when pregnancy crosses 2 years.

OBJECTIVES: This study explores the concern that annual high-deductible commercial insurance plan design may yield higher out-of-pocket costs when an episode of maternity care spans 2 years, exposing patients to their cost-sharing limits twice during their episode of care. STUDY DESIGN: Cross-sectional study of Health Care Cost Institute commercial claims. METHODS: The study sample comprises 1,379,300 deliveries among high-deductible health plan enrollees in years 2012 through 2021. Patients' mean cost sharing is calculated across all service types for 3 time periods: (1) delivery hospitalization, (2) maternity episode from 40 weeks prior to delivery hospitalization through 12 weeks after discharge, and (3) extended period spanning 3 years from January of the year before delivery through December of the year after delivery. RESULTS: For each of the 3 episode measurements, mean out-of-pocket spending is highest among those who deliver in January and declines in each subsequent month until August and September (the delivery months with most pregnancy and postpartum periods within the same year), then flattens for the remainder of the year. Mean cost sharing for the maternity episode was $6308 in January and $4998 in December, a difference of $1310. Patients delivering in January also had mean out-of-pocket costs $1491 greater for delivery hospitalization and $1005 greater over the 3-year period than patients delivering in December. CONCLUSIONS: Higher out-of-pocket spending is observed when patients face their cost-sharing limits twice within an episode of maternity care, and this difference persists even when evaluating 3 calendar years of patients' out-of-pocket spending.

Evaluation of Sequential Oral Versus Intravenous Antibiotic Treatment of Enterococcus faecalis Bloodstream Infections.

BACKGROUND: Intravenous (IV) antibiotics have historically been considered standard of care for treatment of bloodstream infections (BSIs). Recent literature has shown sequential oral (PO) therapy to be noninferior to IV antibiotics for certain pathogens and disease states. However, a gap exists in the literature for BSI caused by Enterococcus faecalis. OBJECTIVE: To compare outcomes of definitive sequential PO therapy to definitive IV therapy in patients with E faecalis BSI. METHODS: Multicenter, retrospective, matched cohort study of adult patients with at least one blood culture positive for E faecalis from January 2017 to November 2022. Patients with polymicrobial BSI, concomitant infections requiring prolonged IV antibiotic therapy, those who did not receive antibiotic therapy, and those who died within 72 hours of index culture were excluded. Subjects were matched based on source of infection in a 2:1 (IV:PO) ratio. The primary outcome was a composite of all-cause mortality and treatment failure. Secondary outcomes included hospital length of stay (LOS), antibiotic duration, and 30-day readmission rate. RESULTS: Of the 186 patients who met criteria for inclusion, there was no statistically significant difference in the primary composite outcome for PO compared to IV therapy (14.5% vs 21.8%; OR 0.53 [0.23-1.25]) or 30-day readmission (17.5% vs 29%; OR 0.53 [0.25-1.13]). Hospital LOS was significantly longer in patients receiving IV-only therapy (6 days vs 14 days; P < 0.001). CONCLUSION AND RELEVANCE: Sequential oral therapy for E faecalis BSI had similar outcomes compared to IV-only treatment and may be considered in eligible patients.

Pre-emptive detection and evolution of relapse in acute myeloid leukemia by flow cytometric measurable residual disease surveillance.

Measurable residual disease (MRD) surveillance in acute myeloid leukemia (AML) may identify patients destined for relapse and thus provide the option of pre-emptive therapy to improve their outcome. Whilst flow cytometric MRD (Flow-MRD) can be applied to high-risk AML/ myelodysplasia patients, its diagnostic performance for detecting impending relapse is unknown. We evaluated this in a cohort comprising 136 true positives (bone marrows preceding relapse by a median of 2.45 months) and 155 true negatives (bone marrows during sustained remission). At an optimal Flow-MRD threshold of 0.040%, clinical sensitivity and specificity for relapse was 74% and 87% respectively (51% and 98% for Flow-MRD ≥ 0.1%) by 'different-from-normal' analysis. Median relapse kinetics were 0.78 log10/month but significantly higher at 0.92 log10/month for FLT3-mutated AML. Computational (unsupervised) Flow-MRD (C-Flow-MRD) generated optimal MRD thresholds of 0.036% and 0.082% with equivalent clinical sensitivity to standard analysis. C-Flow-MRD-identified aberrancies in HLADRlow or CD34+CD38low (LSC-type) subpopulations contributed the greatest clinical accuracy (56% sensitivity, 90% specificity) and notably, by longitudinal profiling expanded rapidly within blasts in > 40% of 86 paired MRD and relapse samples. In conclusion, flow MRD surveillance can detect MRD relapse in high risk AML and its evaluation may be enhanced by computational analysis.

Utility of decision tools for assessing plant health risks from management strategies in natural environments.

Increased imports of plants and timber through global trade networks provide frequent opportunities for the introduction of novel plant pathogens that can cross-over from commercial to natural environments, threatening native species and ecosystem functioning. Prevention or management of such outbreaks relies on a diversity of cross-sectoral stakeholders acting along the invasion pathway. Yet, guidelines are often only produced for a small number of stakeholders, missing opportunities to consider ways to control outbreaks in other parts of the pathway. We used the infection of common juniper with the invasive pathogen Phytophthora austrocedri as a case study to explore the utility of decision tools for managing outbreaks of plant pathogens in the wider environment. We invited stakeholders who manage or monitor juniper populations or supply plants or management advice to participate in a survey exploring their awareness of, and ability to use, an existing decision tree produced by a coalition of statutory agencies augmented with new distribution maps designed by the authors. Awareness of the decision tree was low across all stakeholder groups including those planting juniper for restoration purposes. Stakeholders requested that decision tools contain greater detail about environmental conditions that increase host vulnerability to the pathogen, and clearer examples of when management practices implicated in pathogen introduction or spread should not be adopted. The results demonstrate the need to set clear objectives for the purpose of decision tools and to frame and co-produce them with many different stakeholders, including overlooked groups, such as growers and advisory agents, to improve management of pathogens in the wider environment.

Molecular variations to the proteome of zebrafish larvae induced by environmentally relevant copper concentrations.

Contaminants are increasingly accumulating in aquatic environments and biota, with potential adverse effects on individual organisms, communities and ecosystems. However, studies that explore the molecular changes in fish caused by environmentally relevant concentrations of metals, such as copper (Cu), are limited. This study uses embryos of the model organism zebrafish (Danio rerio) to investigate effect of Cu on the proteome and amino acid (AA) composition of fish. Wild-type embryos at 24 h post-fertilisation were exposed to Cu (2 µg L-1 to 120 µg L-1) for 96 h and the number of healthy larvae were determined based on larvae that had hatched and did not display loss of equilibrium (LOE). The effect concentrations where Cu caused a 10 % (EC10) or 50 % (EC50) decrease in the number of healthy larvae were calculated as 3.7 µg L-1 and 10.9 µg L-1, respectively. Proteomics analysis of embryos exposed to the EC10 and EC50 concentrations of Cu revealed the proteome to differ more strongly after 48 h than 96 h, suggesting the acclimatisation of some larvae. Exposure to excess Cu caused differentially expressed proteins (DEPs) involved in oxidative stress, mitochondrial respiration, and neural transduction as well as the modulation of the AAs (Proline, Glycine and Alanine). This is the first study to suggest that LOE displayed by Cu-stressed fish may involve the disruption to GABAergic proteins and the calcium-dependent inhibitory neurotransmitter GABA. Moreover, this study highlights that proteomics and AA analysis can be used to identify potential biomarkers for environmental monitoring.

Perioperative anaphylaxis and the principle of primum non nocere.

Perioperative anaphylaxis is a rare and unpredictable event that continues to cause patient harm. More work is needed to decrease the risk to patients through measures to limit sensitisation, optimise management and investigation, and ensure that patients are not inadvertently re-exposed to allergens. Robust epidemiological data such as that provided by the consecutive GERAP surveys over the past 30 yr have been invaluable in defining the problem, identifying emerging allergens, acting as a catalyst for change, and stimulating research.

Pulse oximeter bench tests under different simulated skin tones.

Pulse oximeters' (POs) varying performance based on skin tones has been highly publicised. Compared to arterial blood gas analysis, POs tend to overestimate oxygen saturation (SpO2) values for people with darker skin (occult hypoxemia). The objective is to develop a test bench for assessing commercial home and hospital-based POs in controlled laboratory conditions. A laboratory simulator was used to mimic different SpO2 values (~ 70 to 100%). Different neutral density and synthetic melanin filters were used to reproduce low signal and varying melanin attenuation levels. Six devices consisting of commercial home (Biolight, N = 13; ChoiceMMed, N = 18; MedLinket, N = 9) and hospital-based (Masimo Radical 7 with Neo L, N = 1; GE B450 Masimo SET with LNCS Neo L, N = 1; Nonin 9550 Onyx II™, N = 1) POs were reviewed and their response documented. Significant variations were observed in the recorded SpO2 values among different POs when exposed to identical simulated signals. Differences were greatest for lower SpO2 (< 80%) where empirical data is limited. All PO responses under low signal and melanin attenuation did not change across various simulated SpO2 values. The bench tests do not provide conclusive evidence that melanin does not affect in vivo SpO2 measurements. Research in the areas of instrument calibration, theory and design needs to be further developed.

Lipidomic changes occurring in platelets during extended cold storage.

OBJECTIVES: Cold storage is being implemented as an alternative to conventional room-temperature storage for extending the shelf-life of platelet components beyond 5-7 days. The aim of this study was to characterise the lipid profile of platelets stored under standard room-temperature or cold (refrigerated) conditions. METHODS: Matched apheresis derived platelet components in 60% PAS-E/40% plasma (n = 8) were stored at room-temperature (20-24°C with agitation) or in the cold (2-6°C without agitation). Platelets were sampled on day 1, 5 and 14. The lipidome was assessed by ultra-pressure liquid chromatography ion mobility quadrupole time of flight mass spectrometry (UPLC IMS QToF). Changes in bioactive lipid mediators were measured by ELISA. RESULTS: The total phospholipid and sphingolipid content of the platelets and supernatant were 44 544 ± 2915 µg/mL and 38 990 ± 10 880 µg/mL, respectively, and was similar over 14 days, regardless of storage temperature. The proportion of the procoagulant lipids, phosphatidylserine (PS) and phosphatidylethanolamine (PE), increased by 2.7% and 12.2%, respectively, during extended cold storage. Cold storage for 14 days increased sphingomyelin (SM) by 4.1% and decreased ceramide by 1.6% compared to day 1. Further, lysophosphatidylcholine (LPC) species remained unchanged during cold storage for 14 days. The concentration of 12- and 15-hydroxyeicosatetraenoic acid (HETE) were lower in the supernatant of cold-stored platelets than room-temperature controls stored for 14 days. CONCLUSION: The lipid profile of platelets was relatively unchanged during storage for 5 days, regardless of temperature. However, during extended cold storage (14 days) the proportion of the procoagulant lipids, PS and PE, increased, while LPC and bioactive lipids were stable.

Identifying antinuclear antibody positive individuals at risk for developing systemic autoimmune disease: development and validation of a real-time risk model.

Objective: Positive antinuclear antibodies (ANAs) cause diagnostic dilemmas for clinicians. Currently, no tools exist to help clinicians interpret the significance of a positive ANA in individuals without diagnosed autoimmune diseases. We developed and validated a risk model to predict risk of developing autoimmune disease in positive ANA individuals. Methods: Using a de-identified electronic health record (EHR), we randomly chart reviewed 2,000 positive ANA individuals to determine if a systemic autoimmune disease was diagnosed by a rheumatologist. A priori, we considered demographics, billing codes for autoimmune disease-related symptoms, and laboratory values as variables for the risk model. We performed logistic regression and machine learning models using training and validation samples. Results: We assembled training (n = 1030) and validation (n = 449) sets. Positive ANA individuals who were younger, female, had a higher titer ANA, higher platelet count, disease-specific autoantibodies, and more billing codes related to symptoms of autoimmune diseases were all more likely to develop autoimmune diseases. The most important variables included having a disease-specific autoantibody, number of billing codes for autoimmune disease-related symptoms, and platelet count. In the logistic regression model, AUC was 0.83 (95% CI 0.79-0.86) in the training set and 0.75 (95% CI 0.68-0.81) in the validation set. Conclusion: We developed and validated a risk model that predicts risk for developing systemic autoimmune diseases and can be deployed easily within the EHR. The model can risk stratify positive ANA individuals to ensure high-risk individuals receive urgent rheumatology referrals while reassuring low-risk individuals and reducing unnecessary referrals.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2022.

Keeping abreast of the antimicrobial stewardship-related articles published each year is challenging. The Southeastern Research Group Endeavor identified antimicrobial stewardship-related, peer-reviewed literature that detailed an actionable intervention during 2022. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight actionable interventions used by antimicrobial stewardship programs to capture potentially effective strategies for local implementation.

Epidemiology and treatment of invasive Bartonella spp. infections in the United States.

OBJECTIVES: Bartonella spp., renowned for cat-scratch disease, has limited reports of dissemination. Tissue and blood cultures have limitations in detecting this fastidious pathogen. Molecular testing (polymerase chain reaction, PCR) and cell-free DNA have provided an avenue for diagnoses. This retrospective observational multicenter study describes the incidence of disseminated Bartonella spp. and treatment-related outcomes. METHODS: Inclusion criteria were diagnosis of bartonellosis via diagnosis code, serology testing of blood, polymerase chain reaction (PCR) of blood, 16/18S tests of blood or tissue, cultures of blood or tissue, or cell-free DNA of blood or tissue from January 1, 2014, through September 1, 2021. Exclusions were patients who did not receive treatment, insufficient data on treatment course, absence of dissemination, or retinitis as dissemination. RESULTS: Patients were primarily male (n = 25, 61.0%), white (n = 28, 68.3%), with mean age of 50 years (SD 14.4), and mean Charlson comorbidity index of 3.5 (SD 2.1). Diagnosis was primarily by serology (n = 34, 82.9%), with Bartonella henselae (n = 40, 97.6%) as the causative pathogen. Treatment was principally doxycycline with rifampin (n = 17, 41.5%). Treatment failure occurred in 16 (39.0%) patients, due to escalation of therapy during treatment (n = 5, 31.3%) or discontinuation of therapy due to an adverse event or tolerability (n = 5, 31.3%). CONCLUSIONS: In conclusion, this is the largest United States-based cohort of disseminated Bartonella spp. infections to date with a reported 39% treatment failure. This adds to literature supporting obtaining multiple diagnostic tests when Bartonella is suspected and describes treatment options.

Nephrotoxic Risk Associated With Combination Therapy of Vancomycin and Piperacillin-Tazobactam in Critically Ill Patients With Chronic Kidney Disease.

Background: The combination of vancomycin and piperacillin-tazobactam (VPT) has been associated with acute kidney injury (AKI) in hospitalized patients when compared to similar combinations. Additional studies examining this nephrotoxic risk in critically ill patients have not consistently demonstrated the aforementioned association. Furthermore, patients with baseline renal dysfunction have been excluded from almost all of these studies, creating a need to examine the risk in this patient population. Methods: This was a retrospective cohort analysis of critically ill adults with baseline chronic kidney disease (CKD) who received vancomycin plus an anti-pseudomonal beta-lactam at Emory University Hospital. The primary outcome was incidence of AKI. Secondary outcomes included stage of AKI, time to development of AKI, time to return to baseline renal function, new requirement for renal replacement therapy, intensive care unit and hospital length of stay, and in-hospital mortality. Results: A total of 109 patients were included. There was no difference observed in the primary outcome between the VPT (50%) and comparator (58%) group (P = .4), stage 2 or 3 AKI (15.9% vs 6%; P = .98), time to AKI development (1.7 vs 2 days; P = .5), time to return to baseline renal function (4 vs 3 days; P = .2), new requirement for RRT (4.5% vs 1.5%; P = .3), ICU length of stay (7.3 vs 7.4 days; P = .9), hospital length of stay (19.3 vs 20.1 days; P = .87), or in-hospital mortality (15.9% vs 10.8%; P = .4). A significant difference was observed in the duration of antibiotic exposure (3.32 vs 2.62 days; P = .045 days). Conclusion: VPT was not associated with an increased risk of AKI or adverse renal outcomes. Our findings suggest that the use of this antibiotic combination should not be avoided in this patient population. More robust prospective studies are warranted to confirm these findings.

High PEEP extubation as guided by esophageal manometry.

The ventilatory management of morbidly obese patients presents an ongoing challenge in the Intensive Care Unit (ICU) as multiple physiologic changes in the respiratory system complicate weaning efforts and make extubation more difficult, often leading to increased time on the ventilator. We report the case of a young adult male who presented to our ICU on two separate occasions with hypoxemic respiratory failure requiring intubation. Esophageal manometry (EM) guided positive end expiratory pressure (PEEP) titration was utilized during both ICU admissions to improve oxygenation and aid in extubation with spontaneous breathing trials performed on higher-than-normal PEEP settings and successful liberation on both occasions.

The feasibility and acceptability of a physician-led ICU follow-up service: A prospective cohort study.

BACKGROUND: Increased recognition of post-intensive care syndrome has led to widespread development of intensive care follow-up services internationally. OBJECTIVE: The objective of this study was to determine the feasibility and acceptability of an intensive care unit (ICU) follow-up clinic in Australia for patients and their caregivers and to describe satisfaction with this service. METHODS: This was a prospective cohort study in a mixed tertiary ICU in Australia. Eligible patients were adults admitted to the ICU for 7 days or more and/or ventilated for 48 h or more, as well as their primary caregiver. Patients and their primary caregivers were invited to attend a follow-up clinic 4-8 weeks after hospital discharge. The clinic appointment was attended by an ICU physician and nurse, with multidisciplinary support. Feasibility and acceptability were defined as the proportion of clinic attendance and frequency of interventions initiated at the clinic. Satisfaction was measured by a 5-point satisfaction survey (very dissatisfied to very satisfied). The burden of ongoing disease was reported via multiple validated instruments. RESULTS: From April 2020-July 2021, 386 patients met the inclusion criteria. Only 146 patients were approached for consent due to site staffing limitations. Eighty-three patients and 32 caregivers consented to attend the clinic. Seventy percent (54/77) of patients attended scheduled appointments and 50% (16/32) of caregivers. For patients, 23 medical referrals were made, 8 patients had medication changes, and 10 patients were offered social work support. Satisfaction surveys were completed by 65% (35/54) of attending patients; 97% (34) patients reported either being 'very satisfied' or 'satisfied' with the service. All responding caregivers (10) were either 'very satisfied' or 'satisfied' with the clinic. CONCLUSION: There were a large number of patients meeting the inclusion criteria to the ICU follow-up clinic, and clinic attendance was moderate for patients but lower for caregivers. Reported satisfaction with the service was high for both patients and their caregiver.

Integrating Social Care Into a Specialized Medical Home for Sex-Trafficked Youth.

After a series of meetings between medical personnel and community stakeholders, the Children's Hospital of Philadelphia successfully launched the Adolescent Protection Collaborative in July 2021. This novel clinic created a specialized medical home for sex-trafficked youth. The clinic was staffed by a core team of child abuse pediatrics and adolescent medicine physicians and a social worker who provided coordinated evaluations and same-day services, followed by ongoing long-term care. The Adolescent Protection Collaborative model was built on interdisciplinary collaboration with the goal of consolidating medical services and reducing fragmentation of care. A Community Advisory Committee was formed and aided in linking interested youth with additional services. Healthcare navigation was facilitated through support of a clinic-specific social worker, and transportation barriers were largely eliminated through a grant-funded program. Pilot data from the initial 21 months of clinical operations revealed that 88% of 43 referred patients (ages ranging from 13-22 years with a mean of 16 years) attended a scheduled appointment with 55% returning for follow up. Most patients (68%) identified as Black. All (100%) had past or present involvement with child protective services. Fifty percent of referrals tested positive for a sexually transmitted infection with a total of 33 sexually transmitted infections diagnosed and treated. Patient-desired contraception was facilitated for approximately 67% of referrals. Social care needs, such as referrals for educational support, case management, housing and employment resources, and mental health linkages, were offered alongside standard medical services. The described clinic model demonstrates promise in meeting the unique healthcare needs of sex-trafficked youth.

Short life fission products extracted from molten salt reactor fuel for radiopharmaceutical applications.

This work studies the potential of using short life fission product (AFp) radioisotopes e.g. 82Br, 86Rb, (90Sr) - 90mY, (99Mo) - 99mTc, 103Ru - 103mRh, 111Ag, 127Sb - 127(m)Te, 126I, 131I, 133Xe, 136Cs, 141Ce, 143Ce, 143Pr, 147Nd - 147Pm, 149Pm, 153Sm, 156Eu, 159Gd and 161Tb, extracted from a molten salt reactor and their separation using specific thermodynamic and radiochemical conditions. Their utilisation for coupled radiodiagnostics and radiotherapy is a key consideration. A molten salt reactor produces fission products during operation. These radioisotopes can be separated at line from the liquid fuel by evaporation/distillation, chemical reduction (using H2 doped gas), electro-deposition and/or chemical oxidation (using Cl2 doped gas). They can be refined and chemically treated for radiopharmaceutical use for imaging and radiodiagnostics utilising γ radioscopy or positron emission tomography, and potentially in radiotherapy to target specific cancers or viral diseases using ß- emitters. Some of the AFp isotopes are currently used for radiodiagnostics because they emit γ rays of energy 50-200 keV. However, some may also be used in parallel for radiotherapy utilising their ß- (EMean ≈ 100 keV) emission whose mean free pathway of c.a. 100 nm in biological tissue is much smaller than their penetration depth. Focus is given to 86Rb, 90Y, 99mTc, 131I and 133Xe as well as on the ALn isotopes (141Ce, 143Ce - 143Pr, 147Nd - 147Pm, 149Pm and 153Sm) because of their strong potential for complexation with bio-ligands (e.g. DOTA) or for their ability to form micro-nano-spheres, and because of their potential for dual radiodiagnostics and radiotherapy. It is shown that these radio-lanthanides could also replace 177Lu for the treatment of specific cancers.

Long-term Dalbavancin for Suppression of Gram-Positive Chronic Left Ventricular Assist Device Infections.

Background: Infection is the leading cause of morbidity and mortality in patients with left ventricular assist devices (LVADs). Prolonged suppressive therapy should be strongly considered and is often used in patients with recurrent infections when source control cannot be achieved. Dalbavancin is a promising option in patients with LVADs requiring prolonged durations of antibiotic therapy, especially when no oral alternatives are available. Methods: This case series included 8 patients receiving dalbavancin for the long-term suppression of gram-positive infections at Emory University Hospital and Emory St Joseph's Hospital. Results: The overall incidence of breakthrough infections occurred in 5 of the 8 patients included in the study. One patient experienced an early breakthrough infection within 1 month of dalbavancin initiation. Another experienced a breakthrough infection within 3 and 6 months of dalbavancin initiation, and the final 3 patients experienced a breakthrough infection within 6 and 12 months. The average duration of dalbavancin suppression therapy among all patients was 229 days, and no adverse effects were reported. Conclusions: Dalbavancin is a promising option in patients who require long-term suppression for chronic gram-positive LVAD infections, given its unique pharmacokinetic profile and excellent tissue penetration. The use of biweekly dalbavancin infusions in our 8 patients prevented infection for an extended period of time despite some of the patients not being able to consistently receive infusions. Larger studies are needed to determine the efficacy and safety of using dalbavancin for long-term suppression of gram-positive LVAD infections.

Pathways to lung cancer diagnosis among individuals who did not receive lung cancer screening: a qualitative study.

BACKGROUND: Although early detection of lung cancer through screening is associated with better prognosis, most lung cancers are diagnosed among unscreened individuals. We therefore sought to characterize pathways to lung cancer diagnosis among unscreened individuals. METHODS: Participants were individuals with lung cancer who did not undergo asymptomatic lung cancer screening (n = 13) and healthcare providers who may be involved in the pathway to lung cancer diagnosis (n = 13). We conducted semi-structured interviews to identify themes in lung cancer patients' narratives of their cancer diagnoses and providers' personal and/or professional experiences of various pathways to lung cancer diagnoses, to identify delays in diagnosis. We audio-recorded, transcribed, and coded interviews in two stages. First, we conducted deductive coding using three time-period intervals from the Models of Pathways to Treatment framework: appraisal, help-seeking, and diagnostic (i.e., excluding pre-treatment). Second, we conducted inductive coding to identify themes within each time-period interval, and classified these themes as either barriers or facilitators to diagnosis. Coding and thematic summarization were completed independently by two separate analysts who discussed for consensus. RESULTS: Eight of the patient participants had formerly smoked, and five had never smoked. We identified eight barrier/facilitator themes within the three time-period intervals. Within the appraisal interval, the barrier theme was (1) minimization or misattribution of symptoms, and the facilitator theme was (2) acknowledgment of symptoms. Within the help-seeking interval, the barrier theme was (3) hesitancy to seek care, and the facilitator theme was (4) routine care. Within the diagnosis interval, barrier themes were (5) health system challenges, and (6) social determinants of health; and facilitator themes were (7) severe symptoms and known risk factors, and (8) self-advocacy. Many themes were interrelated, including minimization or misattribution of symptoms and hesitancy to seek care, which may collectively contribute to care and imaging delays. CONCLUSIONS: Interventions to reduce hesitancy to seek care may facilitate timely lung cancer diagnoses. More prompt referral to imaging-especially computed tomography (CT)-among symptomatic patients, along with patient self-advocacy for imaging, may reduce delays in diagnosis.

Rubella virus-associated necrotizing granulomatous inflammation with extensive eyelid, ocular, and orbital involvement.

We present a case of cutaneous granulomatous disease associated with rubella virus in a 4-year-old girl without an identifiable immunodeficiency. In this case, a combination of anti-inflammatory, anti-viral, and anti-neutrophil therapies successfully treated vision-threatening eyelid, conjunctival, scleral, and orbital inflammation.

Rationale, evidence, and steps for implementation of medication for opioid use disorder treatment programs in HIV primary care settings.

As the opioid crisis continues to escalate, the management of patients with opioid use disorder has crossed over to the care of patients with chronic infectious diseases, specifically HIV, HBV, and HCV, typically managed in the primary care setting. Consensus guidelines recommend testing for HIV and hepatitis in persons who inject drugs at least annually, but high-risk sexual activity may put other patients at risk as well. Significant barriers to robust care of these patient populations include low rates of HIV and hepatitis testing, limited access to methadone treatment programs, lack of widespread knowledge of how to prescribe office-based opioid treatment, and ongoing stigma surrounding prescribing of HIV treatment and prophylaxis medications. Clinical pharmacists across ambulatory, infectious diseases, and opioid stewardship specialties have the opportunity to play a key role in the implementation and support of harm reduction and medication for opioid use disorder services in the outpatient setting. The goal of this article is to discuss the rationale and evidence for these services and provide a framework for implementation.