Establishment of Amblyomma maculatum Ticks and Rickettsia parkeri the Northeastern United States.

We document a case of Rickettsia parkeri rickettsiosis in a patient in Connecticut, USA, who became ill after a bite from a Gulf Coast tick (Amblyomma maculatum). We used PCR to amplify R. parkeri DNA from the detached tick. The patient showed a 4-fold rise in IgG reactive with R. parkeri antigens.

A PrEP decision aid for women survivors of intimate partner violence: Task-shifting implementation to domestic violence service settings.

BACKGROUND: Women exposed to intimate partner violence (IPV) experience multiple social and structural barriers to accessing HIV pre-exposure prophylaxis (PrEP), despite being at increased risk for HIV. In addition, few existing HIV prevention interventions address IPV. A recently developed PrEP decision aid for women has the potential to reach IPV survivors at risk for HIV if it could be integrated into existing domestic violence agencies that prioritize trust and rapport with female IPV survivors. Leveraging non-traditional service delivery mechanisms in the community could expand reach to women who are IPV survivors for PrEP. METHODS: We conducted qualitative interviews and online qualitative surveys with 33 IPV survivors and 9 domestic violence agency staff at two agencies in Connecticut. We applied the Consolidated Framework for Implementation Research (CFIR) to understand barriers and facilitators to delivering a novel PrEP decision aid to IPV survivors in the context of domestic violence service agencies. RESULTS: Most IPV survivors and agency staff thought the PrEP decision aid intervention could be compatible with agencies' existing practices, especially if adapted to be trauma-responsive and delivered by trusted counselors and staff members. PrEP conversations could be packaged into already well-developed safety planning and wellness practices. Agency staff noted some concerns about prioritizing urgent safety needs over longer-term preventive health needs during crisis periods and expressed interest in receiving further training on PrEP to provide resources for their clients. CONCLUSIONS: IPV survivors and agency staff identified key intervention characteristics of a PrEP decision aid and inner setting factors of the service agencies that are compatible. Any HIV prevention intervention in this setting would need to be adapted to be trauma-responsive and staff would need to be equipped with proper training to be successful.

A Digital Cognitive Behavioral Therapy Program for Adults With Alcohol Use Disorder: A Randomized Clinical Trial.

Importance: Cognitive behavioral therapy (CBT) is an evidence-based treatment for alcohol use, yet patient access is limited and may be enhanced through digital therapeutics. Objective: To evaluate the efficacy of a digital CBT program (Computer-Based Training for Cognitive Behavioral Therapy [CBT4CBT]) or clinician-delivered CBT compared with standard treatment for reducing alcohol use. Design, Setting, and Participants: A 3-arm randomized clinical trial was conducted at outpatient substance use treatment facilities in Connecticut between February 14, 2017, and December 31, 2021, that included an 8-week treatment period with a 6-month follow-up period. Treatment-seeking adults were included who met criteria for current alcohol use disorder and reported drinking at least 14 (men) or 7 (women) drinks per week in the past month and were sufficiently stable for outpatient treatment. Interventions: Participants were randomly assigned to 1 of the following groups: (1) treatment as usual (TAU) consisting of weekly group or individual counseling, (2) CBT delivered weekly by trained and fidelity-monitored clinicians, or (3) web-based CBT plus brief weekly clinical monitoring. Main Outcomes and Measures: Rates of alcohol use were measured weekly during the treatment period and at 1-, 3-, and 6-month follow-up using the timeline follow-back method. The primary outcome was the percentage of days abstinent (PDA) from alcohol per month. Intention-to-treat analyses were conducted. Results: Of the 99 randomized participants (mean [SD] age, 45.5 [12.7]), 66 were male (66.7%); 39 identified as Black/African American (39.8%), 19 (19.2%) as Hispanic, and 47 (48.0%) as White. Mean (SD) rates of PDA from baseline to 6-month follow-up were 49.3% (27.8%) to 69.6% (34.4%) for TAU; 53.7% (29.8%) to 70.2% (35.1%) for CBT; and 47.6% (31.8%) to 82.6% (25.3%) for digital CBT. Results of random-effects regression showed a significant increase in PDA during the study period, with those assigned to digital CBT increasing PDA at a faster rate than TAU (t733 = 2.55; P = .01) and CBT (t733 = 3.36; P < .001). However, there was no statistically significant difference between treatment groups during the 8-week treatment period. Conclusions and Relevance: In this randomized clinical trial, while there was no significant difference between treatment groups during the 8-week treatment period, there was differential change between treatments during the 8-month study period that provides support for the efficacy of this digital CBT program. Trial Registration: ClinicalTrials.gov Identifier: NCT02742246.

Promoting Collaborative Scholarship During the COVID-19 Pandemic Through an Innovative COVID-19 Data Explorer and Repository at Yale School of Medicine: Development and Usability Study.

BACKGROUND: The COVID-19 pandemic sparked a surge of research publications spanning epidemiology, basic science, and clinical science. Thanks to the digital revolution, large data sets are now accessible, which also enables real-time epidemic tracking. However, despite this, academic faculty and their trainees have been struggling to access comprehensive clinical data. To tackle this issue, we have devised a clinical data repository that streamlines research processes and promotes interdisciplinary collaboration. OBJECTIVE: This study aimed to present an easily accessible up-to-date database that promotes access to local COVID-19 clinical data, thereby increasing efficiency, streamlining, and democratizing the research enterprise. By providing a robust database, a broad range of researchers (faculty and trainees) and clinicians from different areas of medicine are encouraged to explore and collaborate on novel clinically relevant research questions. METHODS: A research platform, called the Yale Department of Medicine COVID-19 Explorer and Repository (DOM-CovX), was constructed to house cleaned, highly granular, deidentified, and continually updated data from over 18,000 patients hospitalized with COVID-19 from January 2020 to January 2023, across the Yale New Haven Health System. Data across several key domains were extracted including demographics, past medical history, laboratory values during hospitalization, vital signs, medications, imaging, procedures, and outcomes. Given the time-varying nature of several data domains, summary statistics were constructed to limit the computational size of the database and provide a reasonable data file that the broader research community could use for basic statistical analyses. The initiative also included a front-end user interface, the DOM-CovX Explorer, for simple data visualization of aggregate data. The detailed clinical data sets were made available for researchers after a review board process. RESULTS: As of January 2023, the DOM-CovX Explorer has received 38 requests from different groups of scientists at Yale and the repository has expanded research capability to a diverse group of stakeholders including clinical and research-based faculty and trainees within 15 different surgical and nonsurgical specialties. A dedicated DOM-CovX team guides access and use of the database, which has enhanced interdepartmental collaborations, resulting in the publication of 16 peer-reviewed papers, 2 projects available in preprint servers, and 8 presentations in scientific conferences. Currently, the DOM-CovX Explorer continues to expand and improve its interface. The repository includes up to 3997 variables across 7 different clinical domains, with continued growth in response to researchers' requests and data availability. CONCLUSIONS: The DOM-CovX Data Explorer and Repository is a user-friendly tool for analyzing data and accessing a consistently updated, standardized, and large-scale database. Its innovative approach fosters collaboration, diversity of scholarly pursuits, and expands medical education. In addition, it can be applied to other diseases beyond COVID-19.

Suicide Prevention Effects of Extreme Risk Protection Order Laws in Four States.

More than half of suicide deaths in the United States result from self-inflicted firearm injuries. Extreme risk protection order (ERPO) laws in 21 states and the District of Columbia temporarily limit access to firearms for individuals found in a civil court process to pose an imminent risk of harm to themselves or others. Research with large multistate study populations has been lacking to determine effectiveness of these laws. This study assembled records pertaining to 4,583 ERPO respondents in California, Connecticut, Maryland, and Washington. Matched records identified suicide decedents and self-injury method. Researchers applied case fatality rates for each suicide method to estimate nonfatal suicide attempts corresponding to observed deaths. Comparison of counterfactual to observed data patterns yielded estimates of the number of lives saved and number of ERPOs needed to avert one suicide. Estimates varied depending on the assumed probability that a gun owner who attempts suicide will use a gun. Two evidence-based approaches yielded estimates of 17 and 23 ERPOs needed to prevent one suicide. For the subset of 2,850 ERPO respondents with documented suicide concern, comparable estimates were 13 and 18, respectively. This study's findings add to growing evidence that ERPOs can be an effective and important suicide prevention tool.

In-person learning during the pandemic: Student take-up and school-level effects of remote and hybrid instruction on student outcomes.

While studies have examined the effects of schools offering in-person learning during the pandemic, this study provides analysis of student enrollment decisions (remote versus in-person) in response to schools providing in-person learning opportunities. In Connecticut during the 2020-21 school year, we find that student take-up of in-person learning opportunities was low with students on average enrolled in-person for only half of the days offered, and take-up was even lower in schools with larger shares of disadvantaged students. The provision of in-person learning opportunities has been previously shown to mitigate pandemic learning losses. By exploiting data on actual enrollment, we show that the protective benefits of in-person learning are twice as large as previously estimated once we account for the low rates of student take-up. Finally, we provide evidence suggesting that a key mechanism behind the benefits of in-person learning is alleviating the burden faced by schools and teachers in delivering remote education. First, we show that the benefits to individual students of their in-person learning are substantially smaller than the overall benefits a student receives from their school average level of in-person enrollment. Second, we show that a combination of remote and in-person learning (hybrid) with a full-time on-line presence of students when at home was worse than hybrid learning with students never or only partially online. This second finding is consistent with qualitative evidence showing that teachers found hybrid learning especially challenging when having to manage both in-person and remote students for the entire class period.

Modeling platform to assess the effectiveness of single and integrated Ixodes scapularis tick control methods.

BACKGROUND: Lyme disease continues to expand in Canada and the USA and no single intervention is likely to curb the epidemic. METHODS: We propose a platform to quantitatively assess the effectiveness of a subset of Ixodes scapularis tick management approaches. The platform allows us to assess the impact of different control treatments, conducted either individually (single interventions) or in combination (combined efforts), with varying timings and durations. Interventions include three low environmental toxicity measures in differing combinations, namely reductions in white-tailed deer (Odocoileus virginianus) populations, broadcast area-application of the entomopathogenic fungus Metarhizium anisopliae, and fipronil-based rodent-targeted bait boxes. To assess the impact of these control efforts, we calibrated a process-based mathematical model to data collected from residential properties in the town of Redding, southwestern Connecticut, where an integrated tick management program to reduce I.xodes scapularis nymphs was conducted from 2013 through 2016. We estimated parameters mechanistically for each of the three treatments, simulated multiple combinations and timings of interventions, and computed the resulting percent reduction of the nymphal peak and of the area under the phenology curve. RESULTS: Simulation outputs suggest that the three-treatment combination and the bait boxes-deer reduction combination had the overall highest impacts on suppressing I. scapularis nymphs. All (single or combined) interventions were more efficacious when implemented for a higher number of years. When implemented for at least 4 years, most interventions (except the single application of the entomopathogenic fungus) were predicted to strongly reduce the nymphal peak compared with the no intervention scenario. Finally, we determined the optimal period to apply the entomopathogenic fungus in residential yards, depending on the number of applications. CONCLUSIONS: Computer simulation is a powerful tool to identify the optimal deployment of individual and combined tick management approaches, which can synergistically contribute to short-to-long-term, costeffective, and sustainable control of tick-borne diseases in integrated tick management (ITM) interventions.

Providers' knowledge and perception of xylazine in the unregulated drug supply: a sequential explanatory mixed-methods study.

BACKGROUND: Xylazine is increasingly prevalent in the unregulated opioid supply in the United States. Exposure to this adulterant can lead to significant harm, including prolonged sedation and necrotic wounds. In the absence of literature describing healthcare providers' experiences with treating patients who have been exposed to xylazine, we aimed to explore what gaps must be addressed to improve healthcare education and best practices. METHODS: From October 2023 to February 2024, we conducted a sequential explanatory mixed-methods study, with (1) a quantitative survey phase utilizing convenience sampling of healthcare providers treating patients in Connecticut and (2) a qualitative semi-structured interview phase utilizing purposive sampling of providers with experience treating patients with xylazine exposure. Summary statistics from the survey were tabulated; interview transcripts were analyzed using thematic analysis. RESULTS: Seventy-eight eligible healthcare providers participated in our survey. Most participants had heard of xylazine (n = 69, 95.8%) and had some knowledge about this adulterant; however, fewer reported seeing one or more patients exposed to xylazine (n = 46, 59.8%). After sampling from this subgroup, we conducted fifteen in-depth interviews. This qualitative phase revealed five themes: (1) while xylazine is novel and of concern, this is not necessarily exceptional (i.e., there are other emerging issues for patients who use drugs); (2) participants perceived that xylazine was increasingly prevalent in the drug supply, even if they were not necessarily seeing more patients with xylazine-related outcomes (XROs); (3) patients primarily presented with non-XROs, making it difficult to know when conversations about xylazine were appropriate; (4) patients with XROs may experience issues accessing healthcare; (5) providers and their patients are learning together about how to minimize XROs and reduce the sense of helplessness in the face of a novel adulterant. CONCLUSIONS: Xylazine-specific education for healthcare providers is currently insufficient. Improving this education, as well as resources (e.g., drug checking technologies) and data (e.g., research on prevention and treatment of XROs), is crucial to improve care for patients who use drugs.

Connecticut Implements a Team-Based Approach to Cardiovascular Disease Prevention Using Community Health Workers and Mobile Medical Devices.

The Connecticut Department of Public Health's Early Detection and Prevention Program uses an integrated approach to deliver breast and cervical cancer screening services, cardiovascular disease risk assessment, health coaching, and the identification of social determinants of health to women from economically disadvantaged and minority communities. Statewide contracted providers who represent twenty hospitals and their fee-for-service providers employ community health workers (CHWs) to conduct outreach, screening assessments using mobile medical devices, and risk reduction counseling in community settings to reduce service access barriers, while also engaging eligible women who may not typically frequent clinical services. Mobile medical screening devices enhance healthcare accessibility by enabling screenings to be conducted in a participants preferred setting, whether it is a clinic or within the community, with the added benefit of delivering rapid screening results. Utilizing these results, CHWs provide risk reduction counseling to develop individualized health action plans at the outreach session.

Food Resource Management and Healthy Eating Focus Associates with Diet Quality and Health Behaviors in Low-Income Adults.

Nutrition education and food resource management (FRM) can assist food-insecure individuals in acquiring healthy and affordable food. We aimed to assess the relationships between FRM skills and healthy eating focus with diet quality and health-related behaviors in low-income adults during the COVID-19 pandemic. This cross-sectional study was conducted using an online survey of 276 low-income adults living in a low-food-access community in Northeast Connecticut. Through analysis of covariance, adults who usually or always had a meal plan, considered reading nutrition labels important, made a grocery list, were concerned about their food healthiness, and rated their diet quality as very good/excellent reported higher diet quality (frequency-based and liking-based scores) (p < 0.05 for all). Individuals who considered reading food labels very important and reported having a good diet reported less frequent pandemic-related unhealthy behaviors (consumption of candy and snack chips, soda or sugary drinks, weight gain, smoking) (p < 0.001). Furthermore, higher-frequency-based diet quality was associated with lower risk of overweight or obesity (OR: 0.37; 95% CI: 0.18, 0.76; p-trend < 0.01). Thus, FRM skills and healthy eating focus were associated with higher diet quality and healthier self-reported changes in diet, weight, and smoking behaviors during the pandemic.

Long-Term HIV Pre-Exposure Prophylaxis Persistence and Reinitiation in Connecticut from 2012 to 2018.

HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention for HIV infections. PrEP persistence is critical to achieving optimal protection against HIV infection. However, little is known about PrEP persistence in the United States. This study utilized the Connecticut All-Payer Claims Database (APCD) to identify PrEP persistence among patients who filled their PrEP prescriptions in the state. The authors identified 1,576 PrEP patients who picked up PrEP prescriptions and extracted medical and pharmacy claims to evaluate a longitudinal cohort during 2012-2018 based on the Connecticut APCD. Patients who did not pick up medication for one consecutive month (ie, 30 days) were defined as discontinuing PrEP. Kaplan-Meier Survival Curve and proportional hazard regression were used to describe PrEP persistence. Of the 1,576 patients who picked up PrEP prescriptions, the median age was 32.0 (interquartile range [IQR]: 22.0-44.0). The majority were male individuals (93%). Of 1,040 patients who discontinued PrEP, 702 (67.5%) restarted PrEP at least once. The median time of PrEP persistence was 3 months (IQR: 1-6 months) for initial PrEP use. The median time on PrEP was also around 3 months in the following episodes of PrEP use. Being female, being on parent's insurance, and having high co-pays were associated with shorter periods of PrEP persistence. PrEP persistence was low among patients who picked up PrEP prescriptions. Although many patients restarted PrEP, persistence remained low during follow-up PrEP use and possibly led to periods of increased HIV risk. Effective interventions are needed to improve PrEP persistence and reduce HIV incidence.

Accuracy and transportability of machine learning models for adolescent suicide prediction with longitudinal clinical records.

Machine Learning models trained from real-world data have demonstrated promise in predicting suicide attempts in adolescents. However, their transportability, namely the performance of a model trained on one dataset and applied to different data, is largely unknown, hindering the clinical adoption of these models. Here we developed different machine learning-based suicide prediction models based on real-world data collected in different contexts (inpatient, outpatient, and all encounters) with varying purposes (administrative claims and electronic health records), and compared their cross-data performance. The three datasets used were the All-Payer Claims Database in Connecticut, the Hospital Inpatient Discharge Database in Connecticut, and the Electronic Health Records data provided by the Kansas Health Information Network. We included 285,320 patients among whom we identified 3389 (1.2%) suicide attempters and 66% of the suicide attempters were female. Different machine learning models were evaluated on source datasets where models were trained and then applied to target datasets. More complex models, particularly deep long short-term memory neural network models, did not outperform simpler regularized logistic regression models in terms of both local and transported performance. Transported models exhibited varying performance, showing drops or even improvements compared to their source performance. While they can achieve satisfactory transported performance, they are usually upper-bounded by the best performance of locally developed models, and they can identify additional new cases in target data. Our study uncovers complex transportability patterns and could facilitate the development of suicide prediction models with better performance and generalizability.

Barriers and Opportunities to Improve Healthcare Access for Uninsured Patients at a Student-Run Free Clinic in New Haven, Connecticut.

INTRODUCTION: Uninsured patients have limited options to pay for necessary medical services. Most United States hospitals offer financial assistance programs (FAPs) to help patients pay for care, but the challenges of accessing these programs demonstrate a need for more solutions. METHODS: This study was a retrospective review of 200 randomly sampled HAVEN Free Clinic patients from September 2022 to September 2023. Patients were eligible to be seen at HAVEN if 18-65 years old, without health insurance, and living in New Haven County, Connecticut. Application histories to Medicaid and hospital FAP at a non-profit tertiary care center in Connecticut were assessed. RESULTS: In the 200-patient sample, average age was 43.4 ± 11.2 years old, 61.0% were female, and 86.5% were Hispanic or Latino. 68% were employed with a median household yearly income of $18,200 [$7,293-$26,741]. 80% had applied for a hospital FAP-71.1% were currently approved for Free Care or Discounted Care. 6% were approved for Medicaid; 2.5% were approved for Emergency Medicaid. Of those who applied for a hospital FAP, 28.3% received ≥ 1 application denial. Most common hospital FAP denial reasons were missing, wrong, or outdated proof of income (93.9%), and incomplete application (6.1%). CONCLUSION: Hospital FAPs and Medicaid provide important access to care for uninsured patients, but are not without barriers and should not be viewed as the only solution. Improving hospital FAP access involves assessing eligibility at presentation, extending approval duration, and advocating for more funding. Addressing these barriers can advance equitable care for all.

Abundance of microplastics at and near a shellfish aquaculture farm: An eastern oyster (Crassostrea virginica) transplant study.

Microplastics (MP) have repeatedly been found in commercially cultured species of bivalves. There are concerns regarding the amount of MP released into the environment by aquaculture activities, and questions regarding possible higher MP loads in farm-grown shellfish compared to levels in shellfish collected from recreational beds. To explore this concept, seawater, aquaculture gear, and eastern oysters (Crassostrea virginica) were sampled from an aquaculture site in Niantic Bay, CT, USA, and a 2-week transplantation experiment was performed in which oysters were transplanted between the aquaculture site and a plastic-free cage off the dock at the University of Connecticut-Avery Point campus. The digestive gland-stomach complex (gut) was dissected from the oysters and MP were extracted from the adjacent seawater and oyster gut samples using previously validated extraction methods. Extensive quality assurance and control measures were taken to reduce MP contamination. Particles in all samples were isolated, imaged under a stereomicroscope, and characterized (size, shape, polymer) using ImageJ software and micro-Fourier transform infrared spectroscopy. Water samples contained 0-0.3 MP/L and oyster gut samples contained 0-1.3 MP/g wet weight indicating very low concentrations of MP at the farm (0-2 MP/individual) or away from the farm (0-3 MP/individual). Aquaculture gear in this area is not contributing to MP ingestion in farmed oysters or elevated MP levels in the surrounding water.

Development and validation of statewide survey-based measures of livability in Connecticut.

Livability, or how a place and its systems (e.g., housing, transportation) supports the ability to lead a livable life, is a determinant of health. There is a lack of standard, validated measures to assess livability in the US. This study employed factor analytic methods to create measures of livability in Connecticut using data from the DataHaven Community Wellbeing Survey (DCWS) (n = 32,262). Results identified a 3-factor model (safety, opportunity, and infrastructure) as the best fit, explaining 69% of the variance in survey items. Newly created livability measures had high internal consistency, in addition to high convergent validity with other area-level measures.

Qualitative Analysis of Women's Experiences of Education About POST-BIRTH Warning Signs.

OBJECTIVE: To explore the experiences of women in the postpartum period who received the Association of Women's Health, Obstetric and Neonatal Nurses' "POST-BIRTH Warning Signs Save Your Life" (PBWS-SYL) educational handout at discharge. DESIGN: Qualitative content analysis. SETTING: Virtual or in-person interviews in Connecticut, New York, and Florida. PARTICIPANTS: Women (N = 41) who gave birth in the previous 12 months. METHODS: In individual audio-recorded interviews, we asked participants to describe their experiences of receiving the PBWS-SYL educational handout. We used Krippendorff's method for qualitative content analysis to cluster units within the data to identify emergent themes. RESULTS: Participants who received the handout emphasized that they recognized potential warning signs during the postpartum period. Conversely, participants who reported that the PBWS-SYL educational handout was not adequately reviewed with them during discharge expressed heightened levels of distress and doubt when they encountered concerns. Analysis of transcripts revealed six overarching themes: TheInvisible Pain of the Postpartum Period, Stronger Together, The Art of Active Listening, Lost in the Pile, Postbirth Revelations, and Optimal Discharge Education. CONCLUSION: Our findings suggest that the consistent and thorough application of the PBWS-SYL handout education process is a pivotal factor in safeguarding women's health after childbirth. This education is essential to equip women with the knowledge and confidence needed to detect and address any warning signs that may emerge after birth. Nurses and health care providers can empower women to recognize and address warning signs during the postpartum period, which can lead to improved health outcomes for women.

Outcomes Following Implementation of an Electronic Model for Perioperative Hematologic Consultation.

INTRODUCTION: Electronic consultations (e-consults) for periprocedural hematologic questions were introduced at the VA Connecticut Healthcare System in 2011. We sought to explore the relationship between the availability of e-consults, referral patterns, and surgical outcomes. METHODS: A single-center retrospective study of all perioperative hematologic consultations from 2006 to 2018 was conducted. Patient characteristics, indications, and outcomes were analyzed. Primary outcome measures were time from consult to surgery and operative morbidity via Clavien-Dindo classification. Secondary outcomes included consult volume and procedural outcomes of interest. RESULTS: Of 357 consultations, 62% were conducted via e-consults. 68.3% had associated procedural data and constituted the study cohort. Annual consult volume increased from 7 in 2006 to 41 in 2018, a 5.8-fold increase. E-consults comprised 20% of consults in 2011 but had risen to 92.3% in 2018. Time to resolution of e-consults after 2011 improved compared to pre-face-to-face (FTF-pre, P = 0.001) and FTF-post (P = 0.002). Time from consult to surgery remained unchanged. 8.4% had major complications (Clavien-Dindo >2) with readmission or reoperation occurring in 4.0% and 3.7%, respectively. Intraoperative and postoperative transfusions were required in 15.2% and 13.1% of cases, respectively. Hematologic complications (i.e., deep vein thrombosis/pulmonary embolism) occurred in 3.5%. Comparison between FTF and e-consults revealed no significant differences in these outcomes (P > 0.05, all). CONCLUSIONS: E-consults for perioperative hematologic issues were rapidly adopted and addressed more quickly than FTF consultation while time to surgery was unchanged despite increased consult volume. Adoption of the e-consult model was not associated with changes in the assessed operative outcomes.

Extreme Risk Protection Orders in Connecticut, 2013-2020.

Twenty-one states and the District of Columbia have enacted Extreme Risk Protection Order (ERPO) statutes, which allow temporary removal of firearms from individuals who pose an imminent risk of harm to themselves or others. Connecticut was the first state to enact such a law in 1999. The law's implementation and use between 1999 and 2013 were previously described, finding that ERPOs were pursued rarely for the first decade and that most orders were issued in response to concerns about suicide or self-harm rather than about interpersonal violence. The current study analyzes over 1,400 ERPOs in Connecticut between 2013 and 2020 in several domains: respondent demographics, circumstances leading to ERPO filing, type of threat (suicide, violence to others, or both), number and type of firearms removed, prevalence of mental illness and drug and alcohol use, and legal outcomes. Results are similar to the earlier study, indicating that ERPO respondents in Connecticut are primarily White, male, middle-aged residents of small towns and suburbs who pose a risk of harm to themselves (67.9%) more often than to others (42.8%). Significant gender differences between ERPO respondents are discussed, as are state-specific trends over time and differences between Connecticut and other states with published ERPO data.

Using qualitative system dynamics modeling to understand overdose bystander behavior in the context of Connecticut's Good Samaritan Laws and identify effective policy options.

BACKGROUND: Good Samaritan Laws are a harm reduction policy intended to facilitate a reduction in fatal opioid overdoses by enabling bystanders, first responders, and health care providers to assist individuals experiencing an overdose without facing civil or criminal liability. However, Good Samaritan Laws may not be reaching their full impact in many communities due to a lack of knowledge of protections under these laws, distrust in law enforcement, and fear of legal consequences among potential bystanders. The purpose of this study was to develop a systems-level understanding of the factors influencing bystander responses to opioid overdose in the context of Connecticut's Good Samaritan Laws and identify high-leverage policies for improving opioid-related outcomes and implementation of these laws in Connecticut (CT). METHODS: We conducted six group model building (GMB) workshops that engaged a diverse set of participants with medical and community expertise and lived bystander experience. Through an iterative, stakeholder-engaged process, we developed, refined, and validated a qualitative system dynamics (SD) model in the form of a causal loop diagram (CLD). RESULTS: Our resulting qualitative SD model captures our GMB participants' collective understanding of the dynamics driving bystander behavior and other factors influencing the effectiveness of Good Samaritan Laws in the state of CT. In this model, we identified seven balancing (B) and eight reinforcing (R) feedback loops within four narrative domains: Narrative 1 - Overdose, Calling 911, and First Responder Burnout; Narrative 2 - Naloxone Use, Acceptability, and Linking Patients to Services; Narrative 3 - Drug Arrests, Belief in Good Samaritan Laws, and Community Trust in Police; and Narrative 4 - Bystander Naloxone Use, Community Participation in Harm Reduction, and Cultural Change Towards Carrying Naloxone. CONCLUSIONS: Our qualitative SD model brings a nuanced systems perspective to the literature on bystander behavior in the context of Good Samaritan Laws. Our model, grounded in local knowledge and experience, shows how the hypothesized non-linear interdependencies of the social, structural, and policy determinants of bystander behavior collectively form endogenous feedback loops that can be leveraged to design policies to advance and sustain systems change.

Understanding Barriers and Facilitators of Primary Care Use Among Assertive Community Treatment Teams Via Qualitative Analysis of Clients and Clinicians.

Individuals with severe mental illness and substance use disorders face complex barriers to achieving physical health. This study aims to explore the barriers and facilitators of primary care access among an Assertive Community Treatment (ACT) team. Semi-structured qualitative interviews were conducted with 14 clients and 7 clinicians from an ACT team at a community mental health center in Connecticut. Data analysis followed a grounded theory approach, with codes and themes emerging iteratively during the interview process. The study identified multifaceted barriers to accessing primary care, including economic challenges, homelessness, and the prioritization of mental health and substance use symptoms over healthcare. The conceptual framework consists of nine dominant themes: clients' attitudes, knowledge, mental health, and motivations ("Client-Level Barriers and Facilitators"); ACT team-directed care coordination and relationship-building as well as primary care provider communication ("Provider-Level Barriers and Facilitators"); and clients' experiences with medical care and socioeconomic status ("Systemic-Level Barriers and Facilitators"). This research provides valuable insights into the various barriers faced by ACT clients in accessing primary care. Improving primary care access for individuals with severe mental illness and substance use disorders is crucial for reducing health disparities in this vulnerable population.