Level of Evidence of Telehealth Rehabilitation and Behavioral Health Services for Traumatic Brain Injury: A Scoping Review.

Traumatic brain injury (TBI) can result in significant impairments in functioning associated with partial or permanent disabilities. Examining the evidence for domain-specific telehealth interventions is necessary to guide the development of effective clinical and research programs for this population. The present scoping review characterizes the level of evidence across a range of TBI-related disabilities and impairments. A literature search was performed across comprehensive databases using search terms related to TBI, rehabilitation, telehealth, and outcome. A total of 19 publications from 17 studies met inclusion criteria. Articles focused on telehealth interventions to improve global, cognitive, emotional, and physical functioning post-TBI. Levels of evidence ranged from 1 to 4 across domains, with predominantly experimental designs (level 1). Outcomes demonstrating improvement or benefit from telehealth treatments were reported across all functional domains (50-80% of studies). Results highlight the potential of telehealth interventions across the span of comprehensive interdisciplinary rehabilitation care. Expanded research is needed on remote treatment options for physical symptoms, for subgroups within TBI populations (i.e., mild TBI, military populations), as well as on remote and hybrid comprehensive rehabilitation programs.

Examining community-based pharmacist perceptions on the care of transgender patients.

OBJECTIVE: The objective of this study was to determine whether community-based pharmacists in North Carolina have the personal confidence, comfort level, and resources needed to care appropriately for and interact with transgender patients. METHODS: Using the North Carolina Board of Pharmacy database, a link to a 25-item questionnaire was e-mailed to all actively licensed community pharmacists in North Carolina. Survey items included pharmacist demographics, prior or current education on transgender health care, comfort regarding care provision for transgender patients, and the ability to care for transgender patients at the practice site. Questionnaire items were developed in collaboration with a pharmacist who actively participates in the care of transgender patients. The questionnaire was pilot-tested among a convenience sample of student pharmacists and pharmacists for feedback on validity and question structure. The survey was open for 30 days with a reminder sent on day 15. Upon survey completion, participants had the option to be entered into a drawing to receive a gift card incentive. RESULTS: In total, 342 surveys were completed of 4784 surveys distributed, yielding a 7.1% response rate. Three percent of survey respondents reported receiving education on treating transgender patients during their respective pharmacy school curricula, and 12% of respondents sought other forms of transgender education (i.e., continuing education). Seventy-one percent of respondents viewed the role of the pharmacist as important in the care of transgender patients. Sixty-six percent of respondents were comfortable welcoming transgender patients into their practice sites, and 36% were comfortable asking for pronouns. CONCLUSION: Survey participants reported a lack of formal or postgraduate education, which describes a need for accessible education on transgender care. North Carolina community-based pharmacists believe that it is within their role as pharmacists to provide gender-affirming care, but they may need additional training to feel comfortable in providing this care.

Iatrogenic Cushing's syndrome after triamcinolone plus ritonavir-boosted atazanavir.

OBJECTIVE: To describe a case of iatrogenic Cushing's syndrome (ICS) following a triamcinolone injection for subscapular bursitis in an HIV-positive patient receiving an antiretroviral regimen that included ritonavir boosted-atazanavir. SETTING: University outpatient HIV clinic. CASE SUMMARY: A 60-year-old HIV-positive man on a ritonavir-boosted, atazanavir-containing antiretroviral regimen was diagnosed with subscapular bursitis. The patient received two intrabursal injections with 1% lidocaine plus triamcinolone 20 mg. Four weeks after the injections, the patient experienced symptoms of Cushing's syndrome with a pronounced drop in his CD4+ T-cell count, requiring treatment of oral candidiasis and prophylaxis for opportunistic infections. CONCLUSION: The interaction between ritonavir and oral corticosteroids, resulting in ICS, has been established. This case adds to the literature as one of the few cases illustrating that interaction can also occur between ritonavir and intrabursal administration of corticosteroids. This case further supports concerns regarding use of corticosteroids in HIV-infected patients who are treated with ritonavir-containing antiretroviral regimens.

Implementation of telehealth and hybrid service delivery of interdisciplinary rehabilitation for military populations with traumatic brain injury.

BACKGROUND: The COVID-19 pandemic necessitated the implementation of telehealth and hybrid service delivery models and provided an opportunity to study the impact of this care model in military populations with history of traumatic brain injury (TBI). OBJECTIVE: To present telehealth service utilization rates across rehabilitation specialties, treatment outcome indicators, and patient satisfaction outcomes from a retrospective clinical sample. METHODS: The study sample consists of 34 patients who underwent telehealth/hybrid Intensive Outpatient Programming (IOP) at a major rehabilitation hospital. Retrospective chart review and clinical data extraction were performed. A historical cohort receiving in-person care was used as a comparison group. Statistical analyses included partial correlations, mixed method analysis of variance (ANOVA), and independent sample t-tests. RESULTS: Medical, behavioral health, physical, occupational, and speech-language therapy providers exhibited similar rates of telehealth service delivery (35 to 41% of all sessions). No significant association was found between percent telehealth sessions and the global treatment outcome indicator. Comparison of treatment effects across cohorts revealed similar benefits of IOP. No between-group differences were noted in satisfaction ratings. CONCLUSION: The comparable treatment-related gains and reports of positive patient experience support the use of a telehealth and hybrid delivery model for military service members and veterans with TBI.

Factors in the neurodevelopment of negative urgency: Findings from a community-dwelling sample.

This study investigated neuroanatomic, genetic, cognitive, sociodemographic and emotional underpinnings of the Negative Urgency subscale of the Urgency, Premeditation, Perseverance, Sensation-Seeking and Positive Urgency Impulsive Behavior Scale in a healthy developmental sample. The goal of the investigation is to contribute to the harmonisation of behavioural, brain and neurogenetic aspects of behavioural self-control. Three domains - (1) Demographic, developmental, psychiatric and cognitive ability; (2) Regional brain volumes (neurobiological); and (3) Genetic variability (single nucleotide polymorphisms) - were examined, and models with relevant predictor variables were selected. Least absolute shrinkage and selection operator and best subset regressions were used to identify sparse models predicting negative urgency scores, which revealed that variables related to emotional regulation and right cingulate volume, as well as single nucleotide polymorphisms in CADM2 and SLC6A4, were associated with negative urgency. Our results contribute to the construct and criterion validity of negative urgency and support the hypothesis that negative urgency is a result of a complex array of influences across domains whose integration furthers developmental psychopathology research.

Underprescribing of statin therapy in people with HIV at risk for atherosclerotic cardiovascular disease.

PURPOSE: People with HIV (PWH) are at increased risk for developing atherosclerotic cardiovascular disease (ASCVD). The primary objective of this study was to evaluate adherence to guideline recommendations on statin use in PWH for both primary and secondary ASCVD prevention in a single healthcare institution. METHODS: A retrospective chart review was performed to evaluate statin use for cardiovascular risk reduction in PWH 40 to 75 years of age at an HIV clinic over a 1-year evaluation period. The study included patients who met one of the 4 criteria for statin therapy defined in the "ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults." Patient demographics were collected and a 10-year ASCVD risk score was calculated. RESULTS: A total of 432 PWH were evaluated for statin therapy; 205 patients (47.5%) met criteria for statin therapy. The majority of patients were male, the average age was 58 years, and the average time since HIV diagnosis was 19 years. The mean ASCVD risk score was 14.2%. Only 79 patients (38.5%) who met criteria were prescribed statin therapy, and only 45 (56.9%) were prescribed statin therapy of appropriate intensity. Use of ART pharmacokinetic enhancer was low and did not affect statin prescribing. Multivariable analysis found that age, diabetes, clinical ASCVD, and an appointment with a pharmacist clinician prescriber predicted statin utilization. A high ASCVD risk score (>20%) did not predict statin treatment. CONCLUSION: Statin prescribing is low in PWH, who are at increased risk for ASCVD. Future research in PWH should focus on improving ASCVD risk assessment and exploring causes for statin underprescribing.

Acute Flaccid Myelitis: A Single Pediatric Center Experience From 2014 to 2019.

BACKGROUND: Acute flaccid myelitis has emerged as the leading cause of acute flaccid paralysis in children. Acute flaccid myelitis leads to significant physical disability; hence, objective outcome measures to study disease severity and progression are desirable. In addition, nerve transfer to improve motor function in affected children needs further study. METHODS: Retrospective study of acute flaccid myelitis subjects managed at Children's Healthcare of Atlanta from August 2014 to December 2019. Clinical, electromyography and nerve conduction study, neuropsychological functional independence (WeeFIM), and nerve transfer data were reviewed. RESULTS: Fifteen children (11 boys and 4 girls) mean age 5.1±3.2 years (range 14 months to 12 years) were included. All subjects (n = 15) presented with severe asymmetric motor weakness and absent tendon reflexes. Motor nerve conduction study of the affected limbs in 93% (n = 14) showed absent or markedly reduced amplitude. Ten patients received comprehensive inpatient rehabilitation and neuropsychological evaluation. Admission and discharge WeeFIM scores showed deficits most consistent and pronounced in the domains of self-care and mobility. Multiple nerve transfer surgery was performed on 13 limbs (9 upper and 4 lower extremities) in 6 children. Postsurgery (mean duration of 10.4 ± 5.7 months) follow-up demonstrated improvement on active movement scale (AMS) in 4 subjects. CONCLUSION: Acute flaccid myelitis affects school-age children with asymmetric motor weakness, absent tendon reflexes, and reduced or absent motor amplitude on nerve conduction study. Comprehensive rehabilitation and nerve transfer led to improvement in motor function on neuropsychology WeeFIM and AMS scores.

A cross-sectional survey evaluating transgender-related care education in United States pharmacy school curricula.

INTRODUCTION: The objectives of this study are to evaluate the extent of transgender-related care in current pharmacy school curricula, identify where transgender-related care is covered in the curriculum, describe how the content is delivered to pharmacy students, and review how student knowledge of transgender-related care is evaluated. METHODS: This cross-sectional study utilized an online survey of curricular contacts of 142 pharmacy schools in the United States. Survey questions regarding transgender-related care were presented as multiple choice, ranking, and free-response. The survey inquired about transgender-related care information taught, teaching methods, hours of education, and student assessment. RESULTS: Of the 66 schools that responded to the survey, 53% indicated that transgender-related education is a topic that is currently addressed somewhere within the curriculum. Twenty-two pharmacy schools incorporate this topic into the didactic curriculum, two into the experiential curriculum, and 10 into both didactic and experiential. Transgender-related care is only taught in the required curriculum of 41.2% of schools that responded to the survey. CONCLUSION: Transgender-related care education is taught to variable degrees throughout US doctor of pharmacy programs. This study should serve as a call to action to incorporate this necessary transgender-related care education and training into pharmacy curricula to effectively reduce health disparities among this population that is increasingly seeking care.

Long-Acting Basal Insulins: A Review of the More Recently Approved Agents.

Long-acting basal insulins are used for the management of both type 1 and type 2 diabetes mellitus. Long-acting basal insulins were developed utilizing recombinant DNA technology and have been available since 2000 with the approval of insulin glargine U-100 followed by insulin detemir in 2005. In recent years, diabetes management has become more complex with the approval of insulin glargine U-300 and insulin degludec U-100 and U-200. Both insulin glargine U-300 and insulin degludec have been compared with insulin glargine U-100 and have demonstrated longer durations of action, as well as lower rates of hypoglycemia. This review discusses the Food and Drug Administration-approved long-acting insulins with a focus on recently approved agents and their efficacy and safety compared with the first long-acting basal insulins.

Treatment of patients with HIV or hepatitis C by pharmacist clinicians in a patient-centered medical home.

PURPOSE: This report describes an innovative pharmacy practice model assisting in the care of patients living with or at risk of acquiring human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV). SUMMARY: In the state of New Mexico, pharmacists can obtain prescribing privileges through a Pharmacist Clinician (PhC) license. The license allows PhCs to assess patients, order laboratory/diagnostic tests, prescribe medication, and bill select insurances. PhCs have developed a practice model for patients living with or at risk of HIV and/or HCV at a Level 3 National Committee for Quality Assurance Patient-Centered Medical Home in Albuquerque, New Mexico. In 2015, 5 PhCs, employed part time, were involved with 8 different clinics: (1) HIV Adherence and Complex Care, (2) HIV Transitions of Care, (3) HCV Mono- and Co-Infection, (4) HIV Pre-Exposure Prophylaxis (PrEP), (5) HIV Primary Care and Cardiovascular Risk Reduction, (6) Young Adult Clinic, (7) Perinatal HIV, and (8) Pediatric HIV. In 2015, PhCs at the clinic billed for 774 direct patient encounters. CONCLUSION: Pharmacists with the PhC license are able to provide high-quality medical care to patients living with or at risk of HIV and/or HCV infections within an interprofessional medical home model.

Addition of Care for Transgender-Related Patient Care into Doctorate of Pharmacy Curriculum: Implementation and Preliminary Evaluation.

The number of transgender and gender-diverse patients seeking medical care in the United States is increasing. For many of these patients, pharmacotherapy is a part of their gender-affirming transition. Effective instructional methods and resources for teaching pharmacy students about this patient population's social considerations and medical treatments is lacking. Three hours of educational material on caring for transgender patients was added to a third-year course in a four-year Doctorate of Pharmacy program in the United States. The content included cultural, empathy, and medical considerations. Students in the course were given a survey to assess their perception of each instructional method's effectiveness and self-assess their confidence in providing competent gender-affirming care to transgender people before and after the learning session. The survey response rate was 36% (54/152). Students' self-assessed confidence to provide competent care to people who are transgender increased significantly. Before the learning session, the median confidence level was 4/10 (Interquartile range (IQR) 3⁻6), after the class session, the median confidence increased to 7/10 (IQR 6⁻8, p < 0.01). Students rated the pre-class video, jeopardy game, and patient panel as most helpful to improving their skills. The addition of transgender-related patient care material into the Doctorate of Pharmacy curriculum significantly increased the students' confidence to provide competent care to people who are transgender.

Health literacy of student pharmacists.

INTRODUCTION: The primary purpose of this study was to assess the health literacy levels of doctorate of pharmacy students. A secondary objective was to determine if a correlation exists between age, degree prior to pharmacy school, work experience, and health literacy status among these students. METHODS: Participants were first year doctorate of pharmacy students at an accredited college of pharmacy in the Southwestern United States. The design was cross-sectional. Health literacy scores were collected using the Newest Vital Sign (NVS) in English. Health literacy was dichotomized with a score of 0-3 indicating inadequate and 4-6 indicating adequate. A two sample t-test or Fisher's exact test was used to compare cofactors between health literacy groups. RESULTS: Of the 72 first year students, 64 (88.9%) participated. The median NVS score was 5 (lower quartile 5, upper quartile 6). Nearly 90% of students (n = 57) obtained a score of ''always adequate literacy.'' Student age, having a degree before pharmacy school, nor healthcare work experience were significantly different between the two groups. DISCUSSION: If students enter pharmacy school with a high level of health literacy, they may have difficulties relating to and appropriately educating patients with low health literacy. Knowing this information, we can tailor our teaching about health literacy in curriculums to include strategies that assist students to understand what patients with low heath literacy may experience when interacting with the healthcare system. CONCLUSIONS: Nearly all student pharmacists in the study displayed high health literacy and no correlations to collected characteristics were noted.

Incorporating a pharmacist into an interprofessional team providing transgender care under a medical home model.

PURPOSE: A pharmacist's role in providing care to transgender and gender-nonconforming (TGNC) patients within a medical home model of care is described. SUMMARY: A comprehensive transgender services clinic was established in February 2015 in New Mexico. Clinic services are provided under an "informed consent" model of care, as opposed to the traditional "gatekeeper" approach. The clinic's interprofessional team consists of a clinical pharmacist, a psychiatrist, a nurse practitioner, an endocrinologist, a diabetes educator, a massage therapist, a nurse, a nutritionist, and medical assistants. The clinical pharmacist has served in the following roles: (1) assessing health literacy and tailoring the consent process to the patient's literacy level, (2) initiating in-depth discussion of the medical risks and benefits of cross-sex hormone therapy (HT), as well as HT alternatives, (3) discussing typical timelines for physical outcomes of HT, (4) discussing a patient's expectations and goals for csHT, (5) discussing the different HT formulations and helping to determine which formulation is best suited to meeting patient's goals, (6) helping the team obtain prior authorizations for csHT, and (7) managing risk reduction strategies such as smoking cessation and weight loss. Involvement of a pharmacist in the clinic has improved care access and quality for TGNC patients in the southwestern United States. CONCLUSION: A pharmacist in an interprofessional team staffing a clinic for TGNC people has assumed multiple responsibilities and helped improve patient care.

Care transitions service: a pharmacy-driven program for medication reconciliation through the continuum of care.

PURPOSE: A quality-improvement program at University of New Mexico Hospital (UNMH) encompassing admission, discharge, and postdischarge medication reconciliation activities is described, with a report on initial assessments of the program's impact on rates of medication-related problems (MRPs). METHODS: Pharmacists conducted a five-month evaluation of the UNMH Care Transitions Service (CTS), which serves inpatients admitted to the hospital's family medicine service, providing medication reconciliation and targeted MRP interventions. Selected patients who received CTS services from November 2012 through March 2013 (n = 191) were included in the analysis. The study endpoints were the rates and types of MRPs identified, the most commonly implicated medication classes, and predictors of MRPs. Postdischarge MRP rates during a two-month trial of CTS services at a UNMH outpatient clinic were also evaluated. RESULTS: During the five-month evaluation of inpatient CTS services, a total of 1140 MRPs were identified (an average of 6 per patient), about 70% of which were resolved independently of provider review using pharmacy-driven protocols. During the two-month pilot test of CTS outpatient services (n = 16), a total of 28 MRPs were identified; in over 80% of cases, there was a decline in the number of MRPs from the admission to the postdischarge medication reconciliation. CONCLUSION: MRPs were identified through the continuum of care. The majority of MRPs identified in both the inpatient and outpatient settings involved patient variables and patient nonadherence. Seventy percent of inpatient MRPs were resolved independently by the CTS team under pharmacy-driven protocols.