State-led opioid overdose prevention efforts: Challenges, solutions and lessons learned from the CDC Prevention for States Program (PfS).

Background: The Centers for Disease Control and Prevention's Prevention for States (PfS) program funded 29 state health departments to prevent opioid overdose by implementing evidence-based prevention strategies. The objectives of this analysis were to describe the scope of activities implemented across the four PfS strategies and identify implementation challenges. Methods: PfS recipients submitted annual progress reports (APRs) to state support staff at CDC from 2015 to 2017. APR data were used to calculate the number of required and optional activities implemented under each PfS strategy. APR data were qualitatively analyzed using a systematic content analysis approach to identify key implementation challenges. Results: From 2015 to 2017, PfS recipients implemented 177 activities across four strategies from 2015 to 2017. Cross-cutting implementation challenges were (1) multi-sector collaboration, (2) lack of knowledge and misperceptions about opioid used disorder (OUD) among some partners and local communities and; (3) management and access to opioid data among PfS recipients. Conclusions: PfS recipients implemented an array of prevention interventions to address the opioid overdose crisis and encountered several cross-cutting implementation challenges. Challenges and state driven solutions over the course of implementing PfS led to several lessons learned and actions that CDC enacted to continue to support and expand overdose prevention.

Biallelic TET2 mutations confer sensitivity to 5'-azacitidine in acute myeloid leukemia.

Precision medicine can significantly improve outcomes for patients with cancer, but implementation requires comprehensive characterization of tumor cells to identify therapeutically exploitable vulnerabilities. Here, we describe somatic biallelic TET2 mutations in an elderly patient with acute myeloid leukemia (AML) that was chemoresistant to anthracycline and cytarabine but acutely sensitive to 5'-azacitidine (5'-Aza) hypomethylating monotherapy, resulting in long-term morphological remission. Given the role of TET2 as a regulator of genomic methylation, we hypothesized that mutant TET2 allele dosage affects response to 5'-Aza. Using an isogenic cell model system and an orthotopic mouse xenograft, we demonstrate that biallelic TET2 mutations confer sensitivity to 5'-Aza compared with cells with monoallelic mutations. Our data argue in favor of using hypomethylating agents for chemoresistant disease or as first-line therapy in patients with biallelic TET2-mutated AML and demonstrate the importance of considering mutant allele dosage in the implementation of precision medicine for patients with cancer.

A Thematic Analysis of Overdose Prevention and Response Efforts in States Experiencing Declines in Rates of Opioid-Involved Overdose Deaths.

OBJECTIVE: To address the opioid overdose epidemic, it is important to understand the broad scope of efforts under way in states, particularly states in which the rate of opioid-involved overdose deaths is declining. The primary objective of this study was to examine core elements of overdose prevention activities in 4 states with a high rate of opioid-involved overdose deaths that experienced a decrease in opioid-involved overdose deaths from 2016 to 2017. METHODS: We identified 5 states experiencing decreases in age-adjusted mortality rates for opioid-involved overdoses from 2016 to 2017 and examined their overdose prevention programs via program narratives developed with collaborators from each state's overdose prevention program. These program narratives used 10 predetermined categories to organize activities: legislative policies; strategic planning; data access, capacity, and dissemination; capacity building; public-facing resources (eg, web-based dashboards); training resources; enhancements and improvements to prescription drug monitoring programs; linkage to care; treatment; and community-focused initiatives. Using qualitative thematic analysis techniques, core elements and context-specific activities emerged. RESULTS: In the predetermined categories of programmatic activities, we identified the following core elements of overdose prevention and response: comprehensive state policies; strategic planning; local engagement; data access, capacity, and dissemination; training of professional audiences (eg, prescribers); treatment infrastructure; and harm reduction. CONCLUSIONS: The identification of core elements and context-specific activities underscores the importance of implementation and adaptation of evidence-based prevention strategies, interdisciplinary partnerships, and collaborations to address opioid overdose. Further evaluation of these state programs and other overdose prevention efforts in states where mortality rates for opioid-involved overdoses declined should focus on impact, optimal timing, and combinations of program activities during the life span of an overdose prevention program.

Development and Validation of a Model to Identify Critical Brain Injuries Using Natural Language Processing of Text Computed Tomography Reports.

Importance: Clinical text reports from head computed tomography (CT) represent rich, incompletely utilized information regarding acute brain injuries and neurologic outcomes. CT reports are unstructured; thus, extracting information at scale requires automated natural language processing (NLP). However, designing new NLP algorithms for each individual injury category is an unwieldy proposition. An NLP tool that summarizes all injuries in head CT reports would facilitate exploration of large data sets for clinical significance of neuroradiological findings. Objective: To automatically extract acute brain pathological data and their features from head CT reports. Design, Setting, and Participants: This diagnostic study developed a 2-part named entity recognition (NER) NLP model to extract and summarize data on acute brain injuries from head CT reports. The model, termed BrainNERD, extracts and summarizes detailed brain injury information for research applications. Model development included building and comparing 2 NER models using a custom dictionary of terms, including lesion type, location, size, and age, then designing a rule-based decoder using NER outputs to evaluate for the presence or absence of injury subtypes. BrainNERD was evaluated against independent test data sets of manually classified reports, including 2 external validation sets. The model was trained on head CT reports from 1152 patients generated by neuroradiologists at the Yale Acute Brain Injury Biorepository. External validation was conducted using reports from 2 outside institutions. Analyses were conducted from May 2020 to December 2021. Main Outcomes and Measures: Performance of the BrainNERD model was evaluated using precision, recall, and F1 scores based on manually labeled independent test data sets. Results: A total of 1152 patients (mean [SD] age, 67.6 [16.1] years; 586 [52%] men), were included in the training set. NER training using transformer architecture and bidirectional encoder representations from transformers was significantly faster than spaCy. For all metrics, the 10-fold cross-validation performance was 93% to 99%. The final test performance metrics for the NER test data set were 98.82% (95% CI, 98.37%-98.93%) for precision, 98.81% (95% CI, 98.46%-99.06%) for recall, and 98.81% (95% CI, 98.40%-98.94%) for the F score. The expert review comparison metrics were 99.06% (95% CI, 97.89%-99.13%) for precision, 98.10% (95% CI, 97.93%-98.77%) for recall, and 98.57% (95% CI, 97.78%-99.10%) for the F score. The decoder test set metrics were 96.06% (95% CI, 95.01%-97.16%) for precision, 96.42% (95% CI, 94.50%-97.87%) for recall, and 96.18% (95% CI, 95.151%-97.16%) for the F score. Performance in external institution report validation including 1053 head CR reports was greater than 96%. Conclusions and Relevance: These findings suggest that the BrainNERD model accurately extracted acute brain injury terms and their properties from head CT text reports. This freely available new tool could advance clinical research by integrating information in easily gathered head CT reports to expand knowledge of acute brain injury radiographic phenotypes.

Missed Opportunities for Addressing Intimate Partner Violence Through Microcredit: Qualitative Findings From Bangladesh.

Microcredit has shown mixed results when used to reduce intimate partner violence (IPV). This study explored microcredit and IPV in Bangladesh by conducting 12 focus groups with married men and women. Participants described challenges to microcredit participation highlighting "missed opportunities" for reducing IPV, including needs to (a) prevent violence sparked by loan disputes, (b) incorporate skill development to improve women's agency as a means of reducing IPV, and (c) mindfully engage men in the loan process to help address men's unequal gender ideologies. These modifications to microcredit programs are proposed to maximize positive change on gender and IPV.

Association between county-level sociodemographic characteristics and county-level differences in opioid dispensing.

BACKGROUND: While overall opioid prescribing has been decreasing in the United States, the rates of prescribing at the county level have been variable. Previous studies show that social determinants of health (the social and economic conditions in which we live) may play a role in opioid prescribing; however, researchers have not examined this relationship across US counties. This cross-sectional study seeks to determine whether county-level sociodemographic characteristics (e.g., economic, housing, social environment, healthcare environment, and population characteristics) are associated with county level differences in opioid dispensing. METHODS: Data from 2,881 counties in the United States from 2017 to 2018 were used for this study. Opioid dispensing was measured using morphine milligram equivalents (MME) per capita. Spatial error models were used to measure the association between county-level sociodemographic characteristics and MME per capita while adjusting for spatial correlation between neighboring counties. RESULTS: In the adjusted model, counties with a higher percentage of people below the poverty line, with less than a 4-year college degree, and without health insurance were associated with higher MME dispensed per capita, as were counties with higher percentages of families headed by a single parent, persons separated or divorced, and those with disabilities. Conversely, minority race/ethnicity and rural population were associated with lower opioid dispensing. CONCLUSIONS: County-level sociodemographics can differ in their association with opioid dispensing, hence examining which county-level factors help in improving opioid prescribing, and implementing overdose prevention strategies that tackle these factors is important.

From the CDC: The Prevention for States program: Preventing opioid overdose through evidence-based intervention and innovation.

INTRODUCTION: Since 1999, overdose deaths involving opioids have substantially increased. In 2016, 42,249 opioid-related deaths occurred-a 27.7% increase from the previous year (Hedegaard et al., 2017). As the nation's public health agency, the Centers for Disease Control and Prevention (CDC) has been actively involved in efforts to prevent opioid misuse, opioid use disorder, and opioid overdose since 2014. One of CDC's three principal opioid overdose prevention programs, the Prevention for States (PfS) program, began funding 16 state partners in August 2015 and then expanded to fund a total of 29 states in March 2016. The PfS program aims to prevent opioid morbidity and mortality by implementing evidence-based strategies such as enhancing and maximizing prescription drug monitoring programs (PDMPs) and implementing community or health systems interventions. METHODS: In this article, we will describe the origins of the PfS program, provide an overview of program strategies, and locate PfS strategies in the larger landscape of nation-wide opioid overdose prevention efforts advanced by other partners and stakeholders. To describe the implementation of PfS, we offer an iterative model of using information to inform strategy selection, implementation, and evaluation. This model is a product of our observations of program implementation over time and has emerged, post hoc, as a helpful framework for organizing our insights and reflections on the work. RESULTS: For each step of the model, we provide examples of how CDC has supported funded state partners in these efforts. Lastly, we describe innovative facets of the program and implications for both ongoing and future programs. Practical applications: Opioid overdose morbidity and mortality continues to increase across the United States. Adoption of the strategies and the program implementation paradigm described in this article when implementing prevention activities could improve the ability of public health programs to reverse this trend.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis.

BACKGROUND: Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States. METHODS: We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations. RESULTS: The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting. CONCLUSIONS: Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations.

BACKGROUND: Although this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support. METHODS: In this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies. RESULTS: In the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to » of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25-30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude. CONCLUSIONS: Simple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage.

Music therapy and the effects on laboring women.

Wiand's (1997) study supported the use of music therapy to decrease pain and anxiety. The results of this study could be used to support a research utilization project to educate nurses on the potential benefits of music therapy among laboring women. Nurses and physicians could collaborate together to educate clients on music therapy to decrease pain and anxiety. Feasibility issues would include education of the nurses to use music therapy and the cost of developing different types of music. Future research could be done to study a larger sample size. Other research is needed to determine what type of music works best with laboring women.

A novel technology to screen for cognitive impairment in the elderly.

BACKGROUND: Traditional evaluation of mild cognitive impairment (MCI) can be costly, time consuming, and impractical for widespread screening. DETECT is a portable device developed to rapidly perform cognitive testing in diverse settings. This study compares DETECT with formal clinical assessment. METHODS: A prospective cross-sectional comparison of the DETECT device versus an expert neuropsychologist's assessment (NPA). A total of 405 participants ≥65 years old, recruited from geriatric clinics and retirement facilities, completed both DETECT and NPA. Multivariable logistic regression methods were used to evaluate the degree of correlation between DETECT testing and the NPA diagnosis. RESULTS: Predictive modeling demonstrated very good ability to discriminate between normal, MCI, and dementia per the NPA reference standard using DETECT subtests (c = 0.85 for any impairment; c = 0.99 for dementia). CONCLUSION: DETECT scores closely correlate with NPA. DETECT can identify and discriminate between normal, MCI, and dementia and could be incorporated as a screener for MCI.