Mutual Mistrust: The Multilayered Experiences at the Intersection of Healthcare and Early Parenting Among Mothers With Opioid Use Disorder.

OBJECTIVE: The aim of the study is to explore the early parenting experiences among a cohort of postpartum individuals with opioid use disorder (OUD) both during and after the delivery hospitalization to identify areas of intervention to strengthen bonding and attachment. METHODS: Semistructured qualitative interviews with recently pregnant people with OUD assessed parenting needs, supports, and goals in the context of the demands of addiction treatment and early motherhood. Probes explored the relationship between early parenting experiences, addiction, and recovery, as well as enabling factors and barriers to mother-infant bonding. Interviews were completed between 2019 to 2020. A constant comparative methods approach was used for codebook development and analysis. RESULTS: Twenty-six women completed interviews a mean of 10.1 months postpartum. Twenty-four women were receiving methadone or buprenorphine treatment at delivery for OUD. Four interrelated themes emerged. Women experienced the following: (1) increased surveillance from healthcare workers who doubted their parenting ability; (2) a desire for a "normal" early parenting experience that was not disrupted by increased medical monitoring and surveillance; (3) complex and intersecting identities of being both a mother and a person in recovery; and (4) the importance of support from and advocacy by clinicians and peers to developing maternal confidence and connection. CONCLUSIONS: Interventions are needed to improve the early parenting experiences of opioid-exposed mother-infant dyads, to address the mutual mistrust between health care providers and parents, and to provide additional supports to families. Promotion of positive attachment and parental self-efficacy should be prioritized over increased surveillance and scrutiny to sustain maternal recovery trajectories into early childhood and foster family well-being.

Research Compensation and Enhanced Contacts in Studies With Persons Who Use Drugs: Lessons From the COVID-19 Pandemic Demand a Reset.

Policy changes resulting from the coronavirus 2019 (COVID-19) pandemic have had a substantial and positive impact on the clinical care of persons with opioid use disorder. These innovative paradigm shifts created a ripe environment for re-evaluating traditional approaches to recruiting and retaining persons who use drugs into research studies. For example, changes to methadone prescribing requirements and authorization of buprenorphine prescriptions via telehealth have both increased access to medications. In this commentary, we contribute to ongoing conversations about the ethics of compensation for participants in addiction-related clinical research and share methods of payment that proved successful in research performed during the pandemic. We also discuss approaches to enrollment and follow-up that were implemented during the height of COVID restrictions. These approaches may mutually benefit both participants and researchers in a post-pandemic era.

Prescribed and Penalized: The Detrimental Impact of Mandated Reporting for Prenatal Utilization of Medication for Opioid Use Disorder.

OBJECTIVES: Some states, including Massachusetts, require automatic filing of child abuse and neglect for substance-exposed newborns, including infants exposed in-utero to clinician-prescribed medications to treat opioid use disorder (MOUD). The aim of this article is to explore effects of these mandated reporting policies on pregnant and postpartum people receiving MOUD. METHODS: We used modified grounded research theory, literature findings, and constant comparative methods to extract, analyze and contextualize perinatal experiences with child protection systems (CPS) and explore the impact of the Massachusetts mandated reporting policy on healthcare experiences and OUD treatment decisions. We drew from 26 semi-structured interviews originally conducted within a parent study of perinatal MOUD use in pregnancy and the postpartum period. RESULTS: Three themes unique to CPS reporting policies and involvement emerged. First, mothers who received MOUD during pregnancy identified mandated reporting for prenatally prescribed medication utilization as unjust and stigmatizing. Second, the stress caused by an impending CPS filing at delivery and the realities of CPS surveillance and involvement after filing were both perceived as harmful to family health and wellbeing. Finally, pregnant and postpartum individuals with OUD felt pressure to make medical decisions in a complex environment in which medical recommendations and the requirements of CPS agencies often compete. CONCLUSIONS FOR PRACTICE: Uncoupling of OUD treatment decisions in the perinatal period from mandated CPS reporting at time of delivery is essential. The primary focus for families affected by OUD must shift from surveillance and stigma to evidence-based treatment and access to supportive services and resources.

What is already known on this subject? Child protection systems (CPS) reporting is associated with barriers to prenatal care and family resources and services. Some state policies in the United States mandate reporting to CPS for prenatal substance exposure, including prescribed medications for opioid use disorder.What this study adds? This study centers the experiences of pregnant and postpartum people with opioid use disorder with mandated reporting policies for prenatal substance exposure, describes the harms to families associated with these policies, and makes recommendations for policy change. Findings emphasize the need to uncouple medical decisions from CPS reporting and involvement.

Recruitment and Enrollment of Low-income, Minority Residents of Urban Public Housing into Research.

Research participation among vulnerable populations is often limited by the same socioeconomic factors that contribute to poor health. Identifying best practices for inclusion is critical to addressing health disparities. Urban public housing communities bear a disproportionate burden of chronic disease and may represent an opportunity to directly engage historically vulnerable populations in research designed to ultimately reduce that burden. We used mixed-method data to analyze recruitment effectiveness among a random sample of households (N = 380) across two public housing developments in Boston, MA who were approached for participation in a pre-COVID oral health study. Quantitative data from detailed recruitment tracking methods was analyzed to assess the relative efficiency of the methods employed. Field journals of study staff were qualitatively analyzed to identify community-specific recruitment barriers and facilitators. The participation rate among randomly sampled households was 28.6% (N = 131), with participation from primarily Hispanic (59.5%) or Black (26%) residents. Door-to-door knocking with response yielded the highest participation (44.8%), followed by responses to informational study flyers (31%). Primary barriers to enrollment included references to unemployment and employment variations, shift work, childcare responsibilities, time demands, and managing multiple appointments and social services. This study finds active, door-to-door knocking and return visits resolved barriers to participation, and reduced safety concerns and historic distrust. It's time to consider how best to adapt effective pre-COVID recruitment practices for utilization under current and future exposure conditions as effective recruitment of populations such as urban public housing residents into research is only becoming more important.

Peer recovery coaching for comprehensive HIV, hepatitis C, and opioid use disorder management: The CHORUS pilot study.

Introduction: Amidst a surge in HIV and hepatitis C virus (HCV) infections in persons who use drugs, medications that effectively prevent HIV and treat opioid use disorder and HCV remain underutilized. Methods: We developed a 6-month peer recovery coaching intervention (brief motivational interviewing followed by weekly virtual or in-person coaching) and collected data on uptake of medications for opioid use disorder (MOUD), HIV pre-exposure prophylaxis (PrEP), and HCV treatment. The primary outcomes were intervention acceptability and feasibility. Results: At a Boston substance use disorder bridge clinic, we enrolled 31 HIV-negative patients who used opioids. Participants reported high intervention satisfaction at 6 months (95% "satisfied" or "very satisfied"). At study completion, 48% of the participants were on MOUD, 43% who met CDC guidelines were on PrEP, and 22% with HCV were engaged with treatment. Conclusions: A peer recovery coaching intervention is feasible and acceptable, with positive preliminary findings regarding MOUD, PrEP and HCV treatment uptake.

"I've been 95% safe": perspectives on HIV pre-exposure prophylaxis at a drug detoxification center: a qualitative study.

Pre-exposure prophylaxis (PrEP) decreases human immunodeficiency virus (HIV) acquisition among persons who inject drugs (PWID); however, its uptake has been suboptimal. We explored HIV risk perceptions and PrEP interest among drug detoxification center patients in the context of the ongoing opioid overdose epidemic. We conducted in-depth interviews of patients (n = 24) and professional key informants (n = 10 physicians, case managers, nurses, and harm reduction educators), and thematic analysis of coded data. The mean age of participants (patients) was 37 years; 54% identified as male and 67% as White. Although 71% reported injecting drugs and 62% had condomless sex in the past 6 months, participants had mixed HIV risk perceptions, and some viewed PrEP as an undesirable indicator of elevated HIV risk. Nevertheless, many participants viewed drug detoxification as a first step towards embarking on a "healthier lifestyle," with some narratives identifying opportunities for delivering PrEP information and services in this setting. Opportunities exist to expand PrEP at drug detoxification centers, but initiatives are needed to educate patients and staff on indications and benefits of this prevention tool. Interventions are also needed to determine the best strategies for implementing PrEP adoption in this setting.

Barriers to accessing treatment for substance use after inpatient managed withdrawal (Detox): A qualitative study.

INTRODUCTION: Access to and uptake of evidence-based treatment for substance use disorder, specifically opioid use disorder (OUD), are limited despite the high death toll from drug overdose in the United States in recent years. Patient perceived barriers to evidence-based treatment after completion of short-term inpatient medically managed withdrawal programs (detox) have not been well studied. The purpose of the current study is to elicit patients' perspectives on challenges to transition to treatment, including medications for OUD (MOUD), after detox and potential solutions. METHODS: We conducted semi-structured interviews (N = 24) at a detox center (2018-2019) to explore patients' perspectives on obstacles to treatment. The study managed the data in NVivo and we used content analysis to identify themes. RESULTS: Patients' characteristics included the following: 54 % male; mean age 37 years; self-identified as White 67 %, Black 13 %, Latinx 8 %, Native Hawaiian/Pacific Islander 4 %, and other 8 %; heroin use in the past 3 months 67 %; and ever injecting drugs 71 %. Patients identified the following barriers: 1) lack of continuity of care; 2) limited number of detox and residential treatment program beds; 3) unstable housing; and 4) lack of options when choosing a treatment pathway. Solutions proposed by participants included: 1) increase low-barrier access to community MOUD; 2) add case managers at the detox center to establish continuity of care after discharge; 3) increase assistance with housing; and 4) encourage patient participation in treatment decisions. CONCLUSIONS: Patients identified lack of continuity of care, especially care coordination, as a major barrier to substance use treatment. Increasing treatment utilization, including MOUD, necessitates a multimodal approach to continuity of care, low-barrier access to MOUD, and support to address unstable housing. Patients want care that incorporates options and respect for. individualized preferences and needs.

"You have to take this medication, but then you get punished for taking it:" lack of agency, choice, and fear of medications to treat opioid use disorder across the perinatal period.

INTRODUCTION: Medications to treat opioid use disorder (MOUD) during pregnancy and in the postpartum period remain underutilized. A need exists to enhance our understanding of modifiable factors, facilitators, and barriers to MOUD utilization and adherence in the perinatal period to improve maternal and child outcomes. METHODS: The study conducted semi-structured qualitative interviews with recently pregnant people with opioid use disorder (OUD) to explore experiences as a pregnant and/or parenting person with OUD, perceptions of enabling factors and barriers to treatment utilization, incentivizing factors for maintaining adherence, and acceptability of ongoing supports to sustain treatment adherence. The study team used constant comparative methods to analyze transcripts and develop the codebook. The team double coded the transcripts, with an overall kappa coefficient of 0.88. RESULTS: The study team interviewed twenty-six women on average 10.1 months after delivery. All women had some prior experience using MOUD. Four unique themes emerged as barriers to medication utilization and adherence in the perinatal period: 1) Lack of agency and autonomy surrounding medication decisions because pregnancy or parenting status affected treatment adherence; 2) Hesitancy to use MOUD to minimize risk of newborn withdrawal; 3) Concern about increased scrutiny and potential loss of custody due to mandated child protective services reporting for opioid-exposure at delivery in Massachusetts; and 4) Perception that treatment environments, particularly methadone clinics, did not provide gender-responsive or equitable care, and standardized, inflexible visit regulations were particularly difficult to comply with in the early postpartum period. CONCLUSIONS: Women with OUD experienced a double bind when making perinatal treatment decisions, describing pressure to use MOUD with negative consequences after delivery. Key areas for possible intervention emerged from interviews. These areas include improving uptake of shared decision-making to increase patient autonomy and agency, particularly among those in the earliest stages of recovery during pregnancy; ongoing education around perinatal MOUD safety and efficacy; detangling MOUD and neonatal withdrawal signs from mandated child protective services reporting; and improving gender-responsive and equitable care in substance use disorder treatment programs, including incorporating the utilization of home visiting services for dosing assessments and administration in the early postpartum period.

Características clínicas y microbiológicas de infecciones de piel y partes blandas en pacientes pediátricos de dos hospitales de Buenos Aires / Skin and soft tissue infections in pediatrics

Las infecciones de piel y partes blandas (IPPB) en niños son una de las principales causas de prescripción de antimicrobianos. El objetivo del estudio fue describir las características clínicas y microbiológicas de las IPPB ambulatorias de niños asistidos en dos hospitales zonales. Se realizó un estudio prospectivo entre el 1/11/2017 y el 1/11/2018. Se incluyeron pacientes entre 1 mes y 15 años internados en dos hospitales. Se evaluó: edad, sexo, localidad, factores predisponentes, tipo de IPPB, muestras biológicas realizadas, aislamiento microbiológico, tratamiento empírico indicado y evolución del cuadro. Se realizó antibiograma y determinación genética. Se calculó chi2, IC95, OR; α=5%. N= 94. 58,7% masculinos. 12 pacientes <1 año, 85 >1 año (promedio de edad 4 años, 1-15). El 36% de Tandil y 63,8% de Florencio Varela. El 59,6% corresponden a IPPB purulentas. Se aislaron microorganismos en un 59,6%. Los aislamientos principales: SAMR (40,4%), SAMS (7,4%), S. agalactiae (2,1%) y S. pyogenes (2,1%). El 100% de SAMR son portadores de gen mecA y SCCmec tipo IV, sin multirresistencia. No hubo diferencia estadística entre los factores de riesgo evaluados para el desarrollo de IPPB por SAMR. El 52,1% de los niños recibió tratamiento antibiótico combinado, siendo la más indicada TMS-SMX + CLI en 36 eventos. (38,3%). La evolución fue favorable: no hubo diferencia significativa entre el subgrupo que se aisló SAMR y el que no se aisló SAMR; 91,9% (34/37) y 92,6% (50/54) correspondientemente (chi2: 0,01; p= 0,97 IC95: 0,26-3,88). El principal agente etiológico fue SAMRco, debiendo adecuar los tratamientos a este microorganismo.

Skin and soft tissue infections (SSIs) in children are one of the main causes of antimicrobial prescription. The aim of the study was to describe the clinical and microbiological characteristics of outpatient SSIs in children attended in two hospitals. A prospective study was conducted between 11/1/2017 and 11/1/2018. Patients between 1 month and 15 years old, hospitalized were included. We evaluated: age, sex, locality, predisposing factors, type of IPPB, biological samples taken, microbiological isolation, empirical treatment indicated and evolution of the condition. An antibiogram and genetic determination were performed. Chi2, CI95, OR; α=5% were calculated. N= 94. 58.7% male. 12 patients <1 year, 85 >1 year (mean age 4 years, 1-15). 36% were from Tandil and 63.8% from Florencio Varela. 59.6% corresponded to purulent SSIs. The diagnostic yield was 59.6%. Main isolates: MRSA (40.4%), MSSA (7.4%), S. agalactiae (2.1%) and S. pyogenes (2.1%). 100% of MRSA carried the mecA gene and SCCmec type IV, with no multidrug resistance. There was no statistical difference between the risk factors evaluated. 52.1% of children received combined antibiotic treatment, the most indicated being TMS-SMX + CLI in 36 events. (38,3%). Evolution was favorable: there was no significant difference between the subgroup that isolated MRSA and the subgroup that did not isolate MRSA; 91.9% (34/37) and 92.6% (50/54) respectively (chi2: 0.01; p= 0.97 CI95: 0.26-3.88). The main etiological agent was MRSA, and treatments should be adapted to this microorganism

Perinatal Opioid Use Disorder Research, Race, and Racism: A Scoping Review.

CONTEXT: Racial/ethnic inequities are well documented in both maternal-infant health and substance use disorder treatment outcomes. OBJECTIVE: To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data. DATA SOURCES: Peer-reviewed literature in MEDLINE, Embase, and Web of Science from 2000 to 2020. STUDY SELECTION: Research reporting health utilization and outcomes data on dyads affected by OUD during pregnancy through the infant's first birthday. DATA EXTRACTION: We extracted data on race/ethnicity, study exposures/outcomes, how race/ethnicity data were analyzed, how authors discussed findings associated with race/ethnicity, and whether racism was mentioned as an explanation for findings. RESULTS: Of 2023 articles reviewed, 152 quantitative and 17 qualitative studies were included. Among quantitative studies, 66% examined infant outcomes (n = 101). Three articles explicitly focused on evaluating racial/ethnic differences among dyads. Among quantitative studies, 112 mentioned race/ethnicity, 63 performed analyses assessing for differences between exposure groups, 27 identified racial/ethnic differences, 22 adjusted outcomes for race/ethnicity in multivariable analyses, and 11 presented adjusted models stratified by race/ethnicity. None of the qualitative studies addressed the role that race, ethnicity, or racism may have had on the presented themes. CONCLUSIONS: Few studies were designed to evaluate racial/ethnic inequities among maternal-infant dyads affected by OUD. Data on race/ethnicity have been poorly reported in this literature. To achieve health equity across perinatal OUD, researchers should prioritize the inclusion of marginalized groups to better address the role that structural racism plays.

Caring for Families Impacted by Opioid Use: A Qualitative Analysis of Integrated Program Designs.

OBJECTIVE: We sought to 1) identify models of integrated care that offer medical care and social services for children and families impacted by opioid use disorder (OUD) in the postpartum year; and 2) describe how each program was developed, designed, and sustained, and explore facilitators and barriers to implementation of a dyadic, two-generation approach to care. METHODS: In-depth semi-structured interviews (n = 23) were conducted with programs for women and children affected by OUD across North America. Using a phenomenologic approach, key program components and themes were identified. Following thematic saturation, these results were triangulated with experts in program implementation and with a subset of key informants to ensure data integrity. RESULTS: Five distinct types of programs were identified that varied in the degree of medical and behavioral care for families. Three themes emerged unique to the provision of dyadic care: 1) families require supportive, frequent visits with a range of providers, but constraints around billable services limit care integration across the perinatal continuum; 2) individual program champions are critical, but degree and reach of interdisciplinary care is limited by siloed systems for medical and behavioral care; and 3) addressing dual, sometimes competing, responsibilities for both parental and infant health following recurrence of parental substance use presents unique challenges. CONCLUSIONS: The key components of dyadic care models for families impacted by OUD included prioritizing care coordination, removing barriers to integrating medical and behavioral services, and ensuring the safety of children in homes with ongoing parental substance use while maintaining parental trust.

Provider and Practice Experience Integrating the Dose-HPV Intervention into Clinical Practice.

INTRODUCTION: Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention. METHODS: Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model. RESULTS: Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff. DISCUSSION: Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.

Methadone and buprenorphine discontinuation among postpartum women with opioid use disorder.

BACKGROUND: The postpartum year is a vulnerable period for women with opioid use disorder, with increased rates of fatal and nonfatal overdose; however, data on the continuation of medications for opioid use disorder on a population level are limited. OBJECTIVE: This study aimed to examine the effect of discontinuing methadone and buprenorphine in women with opioid use disorder in the year following delivery and determine the extent to which maternal and infant characteristics are associated with time to discontinuation of medications for opioid use disorder. STUDY DESIGN: This population-based retrospective cohort study used linked administrative data of 211,096 deliveries in Massachusetts between 2011 and 2014 to examine the adherence to medications for opioid use disorder. Individuals receiving medications for opioid use disorder after delivery were included in the study. Here, demographic, psychosocial, prenatal, and delivery characteristics are described. Kaplan-Meier survival analysis and Cox regression modeling were used to examine factors associated with medication discontinuation. RESULTS: A total of 2314 women who received medications for opioid use disorder at delivery were included in our study. Overall, 1484 women (64.1%) continued receiving medications for opioid use disorder for a full 12 months following delivery. The rate of continued medication use varied from 34% if women started on medications for opioid use disorder the month before delivery to 80% if the medications were used throughout pregnancy. Kaplan-Meier survival curves differed by maternal race and ethnicity (the 12-month continuation probability was .65 for White non-Hispanic women and .51 for non-White women; P<.001) and duration of use of prenatal medications for opioid use disorder (12-month continuation probability was .78 for women with full prenatal engagement and .60 and .44 for those receiving medications for opioid use disorder ≥5 months [but not throughout pregnancy] and ≤4 months prenatally, respectively; P<.001). In all multivariable models, duration of receipt of prenatal medications for opioid use disorder (≤4 months vs throughout pregnancy: adjusted hazard ratio, 3.26; 95% confidence interval, 2.72-3.91) and incarceration (incarceration during pregnancy or after delivery vs none: adjusted hazard ratio, 1.79; 95% confidence interval, 1.52-2.12) were most strongly associated with the discontinuation of medications for opioid use disorder. CONCLUSION: Almost two-thirds of women with opioid use disorder continued using medications for opioid use disorder for a full year after delivery; however, the rates of medication continuation varied significantly by race and ethnicity, degree of use of prenatal medications for opioid use disorder, and incarceration status. Prioritizing medication continuation across the perinatal continuum, enhancing sex-specific and family-friendly recovery supports, and expanding access to medications for opioid use disorder despite being incarcerated can help improve postpartum medication adherence.

Integrating patient perspectives in the development of a mobile health intervention to address chronic pain and heavy drinking in primary care: a qualitative study of patients in an urban, safety-net hospital setting.

BACKGROUND: Chronic pain and heavy drinking are conditions that commonly co-occur among primary care patients. Despite the availability of behavioral interventions that target these conditions individually, engagement and adherence to treatment remain a challenge, and there have been no interventions designed to address both of these conditions together for patients presenting to primary care. This study seeks to incorporate the perspectives of patients regarding symptoms, treatment experiences, views on behavior change, and technology use to develop a tailored, integrated mobile health intervention that addresses both pain and heavy drinking among patients in primary care. METHODS: Twelve participants with moderate or greater chronic pain intensity and heavy drinking were recruited from primary care clinics in a large urban safety-net hospital. One-on-one interviews were recorded and transcribed. Codes were developed from interview transcripts, followed by thematic analysis in which specific meanings were assigned to codes. Participants also completed a series of Likert-based rating scales to evaluate components of the proposed intervention to supplement qualitative interviews. RESULTS: A number of themes were identified that had implications for intervention tailoring including: ambivalence about changing drinking, low expectations about pain treatment success, desire for contact with a designated provider, common use of smartphones but lack of familiarity with functions as a potential barrier to use, and strategies to maintain engagement and adherence. Evaluative ratings indicated that the proposed intervention content was perceived as helpful and the proposed structure, layout and design of the mobile intervention was acceptable to patients. CONCLUSIONS: Results supported the view that a mobile health intervention delivered via smartphone with electronic coaching is an acceptable method of addressing chronic pain and heavy drinking among patients in primary care. The interviews highlight the need to utilize an intervention approach that addresses motivation to change drinking, sets realistic expectations for change, provides careful attention to training/education of the use of technology components, and fosters engagement through the use of reminders, feedback, and personalized activities.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action.

BACKGROUND: Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS: We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS: Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS: The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Patients at a drug detoxification center share perspectives on how to increase hepatitis C treatment uptake: A qualitative study.

BACKGROUND: The US opioid crisis is associated with a surge in hepatitis C virus (HCV) infections among persons who inject drugs (PWID), and yet the uptake of HCV curative therapy among PWID is low. PURPOSE: To explore potential solutions to overcome barriers to HCV treatment uptake among individuals at a drug detoxification center. METHODS: Qualitative study with in-depth interviews and thematic analysis of coded data. RESULTS: Patients (N = 24) had the following characteristics: mean age 37 years; 67 % White, 13 % Black, 8 % Latinx, 4 % Native Hawaiian/Pacific Islander, 8 % other; 71 % with a history of injecting drugs. Most patients with a positive HCV test had not pursued treatment due to few perceived immediate consequences from a positive test and possible complications arising in a distant poorly imagined future. Active substance use was a major barrier to HCV treatment uptake because of disruptions to routine activities. In addition, re-infection after treatment was perceived as inevitable. Patients had suggestions to improve HCV treatment uptake: high-intensity wraparound care characterized by frequent interactions with supportive services; same-day/walk-in options; low-barrier access to substance use treatment; assistance with navigating the health care system; attention to immediate needs, such as housing; and the opportunity to select an approach that best fits individual circumstances. CONCLUSIONS: Active substance use was a major barrier to treatment initiation. To improve uptake, affected individuals recommended that HCV treatment be integrated within substance use treatment programs. Such a model should incorporate patient education within low-barrier, high-intensity wraparound care, tailored to patients' needs and priorities.

Setting the Agenda for Reproductive and Maternal Health in the Era of COVID-19: Lessons from a Cruel and Radical Teacher.

BACKGROUND: COVID-19 exposes major gaps in the MCH safety net and illuminates the disproportionate consequences borne by people living in low resource communities where systemic racism, community disinvestment, and social marginalization creates a perfect storm of vulnerability. METHODS: We draw eight lessons from the first 8 months of the pandemic, describing how COVID-19 has intensified pre-existing gaps in the MCH support network and created new problems. For each lesson identified, we present supporting evidence and a call for specific actions that can be taken by MCH practitioners, researchers and advocates. RESULTS: LESSON #1: COVID-19 hits communities of color hardest, exposing and exacerbating health inequities caused by systemic racism. LESSON #2: Women experience the most devastating social, economic and mental health tolls during COVID-19. LESSON #3: Virulent pathogens find and exacerbate cracks in our public health and health care systems. LESSON #4: COVID-19 has become a pretext to limit access to sexual and reproductive health care. LESSON #5: COVID-19 has exposed and deepened fault lines in maternity care: over-medicalization, discrimination, lack of workforce diversity, underutilization of collaborative team approaches, and lack of post-delivery follow-up. LESSON #6: The pandemic adds impetus to much-needed Medicaid policy reforms that can have a lasting positive effect on maternal health. LESSON #7: Social and health policy changes, heretofore deemed infeasible, ARE possible under pandemic threat. LESSON #8: Finally, an overarching COVID-19 lesson: We are all inextricably connected. CONCLUSION: COVID-19 is a loud wake up call for renewed action by MCH epidemiologists, policy-makers, and advocates.

Bacteriemia por Staphylococcus aureus con sensibilidad disminuida heterogénea a vancomicina: reporte de un caso / Staphylococcus aureus bacteremia with heterogeneous intermediate-level vancomycin resistance: a case report

Staphylococcus aureusmeticilina-resistente (SAMR)es una causa frecuente de bacteriemias intrahospitalarias. Para su tratamiento se utiliza vancomicina y han emergido cepas con sensibilidad disminuida heterogénea (h-VISA) que albergan subpoblaciones con sensibi-lidad reducida a vancomicina. Se comunica un caso de bacteriemia intra-tratamiento con vancomicina por SAMR h-VISA. El aislamiento muestra sensibilidad a vancomicina (CIMvan: 1 µg/mL), sin embargo E-test GRD sugiere h-VISA (CIMvan: 2 µg/mL y CIMtei: 8 µg/mL). El análisis del perfil poblacional - área bajo la curva (PAP-AUC) valida este hallazgo. Se rota a linezolid con resolución clínica.

Methicillin-resistant Staphylococcus aureus (SAMR) is a common cause of nosocomial bacteremia. Vancomycin, a glycopeptide, is widely employed for the therapy of SAMR infections. In recent years, heterogeneous vancomycin-intermediate strains (h-VISA) have emerged. We report a case of intra-treatment bacteremia caused by SAMR h-VISA. The isolate shows susceptibility to vancomycin (MICvan: 1 µg/mL). But the GRD E-test suggests h-VISA (MICvan: 2 µg/mL and MICtei: 8 µg/mL). The population analysis profile - area under the curve (PAP-AUC) validates SAMR h-VISA. Rotation of antibiotic therapy with linezolid is done, with good clinical outcome.

Medicaid member perspectives on innovation in prenatal care delivery: A call to action from pregnant people using unscheduled care.

BACKGROUND: Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes. METHODS: We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features. RESULTS: We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage. CONCLUSIONS: Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions. IMPLICATIONS: Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes. LEVEL OF EVIDENCE: III.