The Case for Alternative Payment Models for Nursing Care.

A policy solution to improve staffing and patient care.

Hepatitis C and obstetrical morbidity in a substance use disorder clinic: a role for telemedicine?

BACKGROUND: Hepatitis C infection often co-occurs with substance use disorders in pregnancy. Accessing hepatitis C treatment is challenging because of loss to follow-up in the postpartum period, attributable to social and financial barriers to care. Telemedicine has been explored as a means of increasing routine postpartum care, but the potential impact on retention in and completion of care for postpartum hepatitis C has not been assessed. OBJECTIVE: This study aimed to evaluate the impact of hepatitis C on obstetrical morbidity in a substance use disorder-specific prenatal clinic, and the effect of Infectious Disease telemedicine consultation on subsequent treatment delivery. STUDY DESIGN: We performed a retrospective cohort study of all patients in our substance use disorder prenatal clinic from June 2018 to February 2023. Telemedicine consults for hepatitis C diagnoses began in March 2020 and included electronic chart review by Infectious Disease when patients were unable to be seen. Our primary outcome was composite obstetrical morbidity (preterm birth, preeclampsia, fetal growth restriction, fetal anomaly, abruption, postpartum hemorrhage, or chorioamnionitis) compared between patients with and without active hepatitis C. We additionally evaluated rates of completed referral and initiation of hepatitis C treatment before and after implementation of telemedicine consult. RESULTS: A total of 224 patients were included. Of the 222 patients who underwent screening, 71 (32%) were positive for active hepatitis C. Compared with patients without hepatitis C, a higher proportion of patients with hepatitis C were White (80% vs 58%; P=.02), had a history of amphetamine use (61% vs 32%; P<.01), injection drug use (72% vs 38%; P<.01), or overdose (56% vs 29%; P<.01), and were on methadone (37% vs 18%; P<.01). There was no difference in the primary outcome of composite obstetrical morbidity. The rate of hepatitis C diagnosis was not statistically significantly different between the pre- and posttelemedicine cohorts (N=29 [41%], N=42 [27%]), and demographics of hepatitis C virus-positive patients were similar, with most being unemployed, single, and publicly insured. A lower proportion of patients in the posttelemedicine group reported heroin use compared with the pretelemedicine cohort (62% vs 90%; P=.013). After implementation of telemedicine, patients were more likely to attend the visit (19% vs 44%; P=.03), and positive patients were much more likely to receive treatment (14% vs 57%; P<.01); 100% of visits in the posttelemedicine group occurred via telemedicine. There were 7 patients who were prescribed treatment by their obstetrician after chart review by Infectious Disease. CONCLUSION: Patients with and without hepatitis C had similar maternal and neonatal outcomes, with multiple indicators of social and financial vulnerability. Telemedicine Infectious Disease consult was associated with increased follow-up and hepatitis C treatment, and obstetricians were able to directly prescribe. Because patients with substance use disorders and hepatitis C may have increased barriers to care, telemedicine may represent an opportunity for intervention.

Control of the Structural Charge Distribution and Hydration State upon Intercalation of CO2 into Expansive Clay Interlayers.

Numerous experimental investigations indicated that expansive clays such as montmorillonite can intercalate CO2 preferentially into their interlayers and therefore potentially act as a material for CO2 separation, capture, and storage. However, an understanding of the energy-structure relationship during the intercalation of CO2 into clay interlayers remains elusive. Here, we use metadynamics molecular dynamics simulations to elucidate the energy landscape associated with CO2 intercalation. Our free energy calculations indicate that CO2 favorably partitions into nanoconfined water in clay interlayers from a gas phase, leading to an increase in the CO2/H2O ratio in clay interlayers as compared to that in bulk water. CO2 molecules prefer to be located at the centers of charge-neutral hydrophobic siloxane rings, whereas interlayer spaces close to structural charges tend to avoid CO2 intercalation. The structural charge distribution significantly affects the amount of CO2 intercalated in the interlayers. These results provide a mechanistic understanding of CO2 intercalation in clays for CO2 separation, capture, and storage.

Number of buprenorphine induction attempts impacts maternal and neonatal outcomes: a multicenter cohort study.

BACKGROUND: Buprenorphine can be used to treat maternal opioid use disorder effectively and decrease obstetrical risks. Compared with the use of other medications to treat opioid use disorder, the use of buprenorphine results in improved neonatal outcomes; however, its use is associated with higher rates of treatment attrition. Initiation of buprenorphine, termed "induction," is a high-risk time for treatment dropout and can require repeated attempts. OBJECTIVE: This study aimed to evaluate the effect of multiple buprenorphine induction attempts on maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of all pregnant patients who underwent sublingual buprenorphine induction for the treatment of opioid use disorder from June 18, 2018, to January 1, 2021, at 3 tertiary care centers. Patients who required only 1 attempt for successful buprenorphine induction were compared with those who required multiple attempts but ultimately were successful in the treatment initiation during pregnancy, confirmed by urine drug screening. The primary outcome was nonprescribed opioid use at the time of delivery. The secondary outcomes included obstetrical and neonatal outcomes associated with opioid use disorder. Background characteristics were compared using Fisher exact, chi-square, Mann-Whitney U, and Student t tests. The outcomes were compared using multivariable logistic regression, and time to delivery after initiation of prenatal care was compared between groups using Kaplan-Meier curves and a Cox proportional-hazards model. RESULTS: Overall, 63 patients undergoing buprenorphine induction during pregnancy were included, with 38 (60.3%) patients with 1 attempt and 25 patients (39.7%) with multiple attempts. There was no statistical difference between the 2 groups in terms of background characteristics. Compared with a single successful attempt, multiple attempts at buprenorphine induction were associated with a significantly increased odds of nonprescribed opioid use at the time of delivery (76.0% vs 15.8%; adjusted odds ratio, 30.00; 95% confidence interval, 5.50-163.90), increased risk of preterm birth (48.0% vs 15.8%; adjusted hazard ratio, 3.24; 95% confidence interval, 1.17-8.95), and decreased rate of breastfeeding at both maternal discharge (24.0% vs 78.9%; adjusted odds ratio, 0.06; 95% confidence interval, 0.00-0.30) and infant discharge (24.0% vs 55.3%; adjusted odds ratio, 0.23; 95% confidence interval, 0.10-0.80). CONCLUSION: Requiring multiple attempts for buprenorphine induction significantly increases the odds of nonprescribed opioid use at the time of delivery and preterm birth and decreases the odds of breastfeeding. As the buprenorphine induction process may affect obstetrical outcomes for patients induced during pregnancy, investigating the techniques that increase the likelihood of successful induction is crucially needed to improve outcomes in patients with maternal opioid use disorder.

Model representations of kerogen structures: An insight from density functional theory calculations and spectroscopic measurements.

Molecular structures of kerogen control hydrocarbon production in unconventional reservoirs. Significant progress has been made in developing model representations of various kerogen structures. These models have been widely used for the prediction of gas adsorption and migration in shale matrix. However, using density functional perturbation theory (DFPT) calculations and vibrational spectroscopic measurements, we here show that a large gap may still remain between the existing model representations and actual kerogen structures, therefore calling for new model development. Using DFPT, we calculated Fourier transform infrared (FTIR) spectra for six most widely used kerogen structure models. The computed spectra were then systematically compared to the FTIR absorption spectra collected for kerogen samples isolated from Mancos, Woodford and Marcellus formations representing a wide range of kerogen origin and maturation conditions. Limited agreement between the model predictions and the measurements highlights that the existing kerogen models may still miss some key features in structural representation. A combination of DFPT calculations with spectroscopic measurements may provide a useful diagnostic tool for assessing the adequacy of a proposed structural model as well as for future model development. This approach may eventually help develop comprehensive infrared (IR)-fingerprints for tracing kerogen evolution.

Iodide uptake by negatively charged clay interlayers?

Understanding iodide interactions with clay minerals is critical to quantifying risk associated with nuclear waste disposal. Current thought assumes that iodide does not interact directly with clay minerals due to electrical repulsion between the iodide and the negatively charged clay layers. However, a growing body of work indicates a weak interaction between iodide and clays. The goal of this contribution is to report a conceptual model for iodide interaction with clays by considering clay mineral structures and emergent behaviors of chemical species in confined spaces. To approach the problem, a suite of clay minerals was used with varying degrees of isomorphic substitution, chemical composition, and mineral structure. Iodide uptake experiments were completed with each of these minerals in a range of swamping electrolyte identities (NaCl, NaBr, KCl) and concentrations. Iodide uptake behaviors form distinct trends with cation exchange capacity and mineral structure. These trends change substantially with electrolyte composition and concentration, but do not appear to be affected by solution pH. The experimental results suggest that iodide may directly interact with clays by forming ion-pairs (e.g., NaI(aq)) which may concentrate within the interlayer space as well as the thin areas surrounding the clay particle where water behavior is more structured relative to bulk water. Ion pairing and iodide concentration in these zones is probably driven by the reduced dielectric constant of water in confined space and by the relatively high polarizability of the iodide species.

Image-guided radiotherapy for cardiac sparing in patients with left-sided breast cancer.

Patients with left-sided breast cancer are at risk of cardiac toxicity because of cardiac irradiation during radiotherapy with the conventional 3-dimensional conformal radiotherapy technique. In addition, many patients may receive chemotherapy prior to radiation, which may damage the myocardium and may increase the potential for late cardiac complications. New radiotherapy techniques such as intensity-modulated radiotherapy (IMRT) may decrease the risk of cardiac toxicity because of the steep dose gradient limiting the volume of the heart irradiated to a high dose. Image-guided radiotherapy (IGRT) is a new technique of IMRT delivery with daily imaging, which may further reduce excessive cardiac irradiation. Preliminary results of IGRT for cardiac sparing in patients with left-sided breast cancer are promising and need to be investigated in future prospective clinical studies.