Influenza Vaccinations During the COVID-19 Pandemic - 11 U.S. Jurisdictions, September-December 2020.

Influenza causes considerable morbidity and mortality in the United States. Between 2010 and 2020, an estimated 9-41 million cases resulted in 140,000-710,000 hospitalizations and 12,000-52,000 deaths annually (1). As the United States enters the 2021-22 influenza season, the potential impact of influenza illnesses is of concern given that influenza season will again coincide with the ongoing COVID-19 pandemic, which could further strain overburdened health care systems. The Advisory Committee on Immunization Practices (ACIP) recommends routine annual influenza vaccination for the 2021-22 influenza season for all persons aged ≥6 months who have no contraindications (2). To assess the potential impact of the COVID-19 pandemic on influenza vaccination coverage, the percentage change between administration of at least 1 dose of influenza vaccine during September-December 2020 was compared with the average administered in the corresponding periods in 2018 and 2019. The data analyzed were reported from 11 U.S. jurisdictions with high-performing state immunization information systems.* Overall, influenza vaccine administration was 9.0% higher in 2020 compared with the average in 2018 and 2019, combined. However, in 2020, the number of influenza vaccine doses administered to children aged 6-23 months and children aged 2-4 years, was 13.9% and 11.9% lower, respectively than the average for each age group in 2018 and 2019. Strategic efforts are needed to ensure high influenza vaccination coverage among all age groups, especially children aged 6 months-4 years who are not yet eligible to receive a COVID-19 vaccine. Administration of influenza vaccine and a COVID-19 vaccine among eligible populations is especially important to reduce the potential strain that influenza and COVID-19 cases could place on health care systems already overburdened by COVID-19.

Outcomes of dialectical behavior therapy administered by an interdisciplinary team.

INTRODUCTION: 87 female and 10 male adult outpatients with BPD diagnoses presenting with acute suicidal and self-harm behaviors were offered a 12-Month Intensive DBT Program delivered by an interdisciplinary team of psychotherapists, including social workers, nurses, and a psychologist. METHODS: Clients were administered self-report measures at pre-treatment, and at 3-, 6-, and 12-month intervals in a single-group longitudinal design. Our analyses of treatment outcomes (ANOVA and Bonferroni-corrected comparisons) considered: BPD-specific symptoms, using the BSL-23 (n = 44), ZAN-BPD (n = 39), and DBT-WCCL Adaptive Skills Use and Dysfunctional Coping subscales (n = 43); transdiagnostic psychiatric symptoms, using the BSL Global Severity Index (n = 35); and quality of life, using QOLI t-scores (n = 42). We also evaluated changes in the proportions of clients who used services for mental health-related crises, visited the ER, or were admitted as inpatients. RESULTS: Significant reductions in both BPD-specific and transdiagnostic psychiatric symptoms were found. Quality of life improved. DBT skills use notably increased and dysfunctional coping scores declined inversely. Fewer clients tended to use crisis services and visit the ER. DISCUSSION: These results illustrate the potential for accessible, effective treatment for BPD delivered by interdisciplinary staff.

Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse.

BACKGROUND & AIMS: Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR). METHODS: We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR. RESULTS: Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups. CONCLUSIONS: Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.

Association of platelet satellitism with immune thrombocytopenia: A case report and review of literature.

Platelet satellitism refers to the rosetting of the platelets around white blood cells, mostly neutrophils that could lead to spuriously low platelet counts on automated analyzers. The phenomenon has usually been described in EDTA processed blood samples. We describe the clinical course of a patient with immune thrombocytopenia with platelet satellitism in both EDTA as well as non EDTA processed blood samples. We also review the literature describing two other reports of the platelet satellitism in patients with immune thrombocytopenia. We also reference the literature describing the heterogeneity of the presence of platelet satellitism in different clinical and laboratory settings.

Development and integration of a music therapy program in the neurologic inpatient setting: a qualitative study.

PURPOSE: Explore facilitators and barriers to development and integration of an inpatient music therapy (MT) program from the perspective of the patient, family member, and health care professional. MATERIALS AND METHODS: This qualitative study recruited patients on acute neurosciences/neurorehabilitation units having participated in the hospital MT program, their family, and members of their health care team. Semi-structured individual interviews and focus groups were conducted with 35 participants (14 patients, 5 family members, 16 health care professionals). Interviews/focus groups were audio recorded and transcribed verbatim. Data were coded in duplicate and a codebook was developed through an iterative process. RESULTS: Four dominant themes emerged from the data: (1) facilitators of program operations; (2) barriers to program establishment; (3) perceived positive impact on patient outcomes; and (4) opportunity for improvement. Facilitator sub-themes included a love for music that encouraged participation, broad appeal of MT, and support of the health care team. CONCLUSIONS: Patients, health care professionals, and family members accepted MT as a treatment modality. While there is growing evidence for MT in neurorehabilitation, practical challenges remain in developing inpatient MT services, including funding, and optimal integration of music therapists into existing care teams.

Music therapy (MT) is a therapy modality that can be used to target breath control, speech, motor control, and emotional regulation goals in neurorehabilitation.Development of an MT program was facilitated by the broad appeal of the therapy and support from the health care team.Multi-pronged education efforts are needed to increase staff awareness of specific indications and benefits of MT.MT sessions should be offered more than once per week on neurorehabilitation units.

Alcohol attenuates activation in the bilateral anterior insula during an emotional processing task: a pilot study.

AIMS: Alcohol acutely reduces agitation and is widely used in social situations, but the neural substrates of emotion processing during its intoxication are not well understood. We examine whether alcohol's social stress dampening effect may be via reduced activity in the cortical systems that subserve awareness of bodily sensations, and are associated with affective distress. METHODS: Blood oxygen level-dependent activation was measured through 24 functional magnetic resonance imaging sessions in 12 healthy volunteers during an emotional face-processing task following ingestion of a moderate dose of alcohol and a placebo beverage. RESULTS: Results revealed that bilateral anterior insula response to emotional faces was significantly attenuated following consumption of alcohol, when compared with placebo (clusters >1472 µl; corrected P < 0.05). CONCLUSION: Attenuated response in the anterior insula after alcohol intake may explain some of the decreased interoceptive awareness described during intoxication.

Predictors of treatment retention for substance-dependent adults with co-occurring depression.

Low attendance in addiction treatment, particularly in cases of comorbidity, has been identified as a pervasive challenge. We examine predictors of treatment retention in a sample of veterans (N = 253) participating in a clinical trial comparing two types of psychotherapy for co-occurring depression and substance use disorders. The study protocol included 24 weeks of outpatient group psychotherapy in either a newly developed Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation Therapy (TSF). Using a model of treatment utilization developed by Aday and Anderson, we analyzed predictors categorized into predisposing factors, enabling resources, need for treatment, and type of treatment received. Outcome included total number of sessions attended (maximum of 36 sessions). Treatment retention did not differ between the two study interventions. Bivariate analyses indicated that predisposing factors were most predictive, with older participants, Caucasians, and those using only alcohol in the month before treatment attending more sessions, and individuals who had recently experienced a health event remained in treatment longer. Importantly, several factors were not related to treatment retention: marital status, education, neuropsychological functioning, financial stress, chronic health problems, treatment motivation, and psychiatric severity. In the combined model of predisposing, enabling and need factors, age and ethnicity were the only significant predictors.

Acute ethanol effects on brain activation in low- and high-level responders to alcohol.

BACKGROUND: A low level of response (LR) to alcohol is an important endophenotype associated with an increased risk of alcoholism. However, little is known about how neural functioning may differ between individuals with low and high LRs to alcohol. This study examined whether LR group effects on neural activity varied as a function of acute alcohol consumption. METHODS: A total of 30 matched high- and low-LR pairs (N = 60 healthy young adults) were recruited from the University of California, San Diego, and administered a structured diagnostic interview and laboratory alcohol challenge followed by two functional magnetic resonance imaging (fMRI) sessions under placebo and alcohol conditions, in randomized order. Task performance and blood oxygen level-dependent response contrast to high relative to low working memory load in an event-related visual working memory (VWM) task were examined across 120 fMRI sessions. RESULTS: Both LR groups performed similarly on the VWM task across conditions. A significant LR group by condition interaction effect was observed in inferior frontal and cingulate regions, such that alcohol attenuated the LR group differences found under placebo (p < 0.05). The LR group by condition effect remained even after controlling for cerebral blood flow, age, and typical drinking quantity. CONCLUSIONS: Alcohol had differential effects on brain activation for low- and high-LR individuals within frontal and cingulate regions. These findings represent an additional step in the search for physiological correlates of a low LR and identify brain regions that may be associated with the low LR response.

Management of chronic hepatitis C in veterans: the potential of integrated care models.

The prevalence of hepatitis C virus (HCV) infection is higher among veterans than nonveterans, but only about 14% of all identified infected veterans have ever received antiviral therapy. High rates of comorbid psychiatric and substance use disorders are major barriers to receiving antiviral treatment for veterans, and characteristics associated with poor virologic response are more common in this population. However, accumulating evidence indicates that patients with psychiatric and substance use disorders can successfully receive interferon-based antiviral therapies in an integrated or multidisciplinary health-care setting. The broad aims of integrated care models include reducing fragmentation and improving continuity and coordination of care. Although, to date, there are no randomized controlled trials of specific care models for patients with HCV, studies of integrated care for other chronic diseases suggest several strategies for optimizing outcomes for patients with HCV. Components of an HCV clinic incorporating these principles have been tested in a nonrandomized setting and include routine screening of all patients for psychiatric and substance use disorder risk factors, collaboration with mental health providers within the HCV clinic, following a defined integrated medical/psychiatric clinical protocol, provision of ongoing integrated support during antiviral treatment or retreatment, and educating patients on principles of chronic disease self-management.

A randomized controlled trial of cognitive-behavior therapy for tinnitus.

This study is a randomized, waitlist-controlled trial testing the effect of a brief, "manualized" cognitive-behavioral group therapy on distress associated with tinnitus, quality of well-being, psychological distress including depression, and internal focus. Cognitive-behavioral therapy (CBT) included training in activity planning, relaxation training and, primarily, cognitive restructuring. Sixty-five participants were recruited, and 41 completed treatment. Participants were randomly assigned to receive 8 weeks of manualized group CBT either immediately or after an 8-week waiting period. Participants completed outcome measures at the time of their random assignment and at 8, 16, and 52 weeks later. Repeated-measure analysis of covariance revealed significant group-by-time interactions on measures of tinnitus distress and depression, indicating that CBT led to greater improvement in those symptoms. The current results suggest that CBT, applied in a group format using a manual, can reduce the negative emotional distress, including depression, associated with tinnitus.

RNNbow: Visualizing Learning Via Backpropagation Gradients in RNNs.

We present RNNbow, an interactive tool for visualizing the gradient flow during backpropagation in training of recurrent neural networks. By visualizing the gradient, as opposed to activations, RNNbow offers insight into how the network is learning. We show how it illustrates the vanishing gradient and the training process.

Antidepressants for treatment of tinnitus.

Antidepressants are commonly prescribed for tinnitus. Research thus far provides some support for that treatment, but the literature also raises concerns because tinnitus is a side effect of antidepressant medication. In this chapter, four published double blind placebo-controlled trials of antidepressants for tinnitus are reviewed. Explanations for the discrepant results are offered, including that antidepressants appear to work best for tinnitus patients who are depressed or anxious, who have more severe tinnitus or who are treated for a longer time with an adequate dose of medication. Possible mechanisms of action are reviewed, with serotonergic and antimuscarinic mechanisms appearing to be the most important. At this time there is no indication that one specific type of antidepressant is more likely to lead to tinnitus as a side effect, or have a beneficial effect on tinnitus. Given SSRIs are tolerated better, these antidepressants have advantages over tricyclic antidepressants and should be used as a first line of treatment.

Antidepressant therapy in tinnitus.

OBJECTIVE: Review the literature on the co-morbidity of depression and anxiety with tinnitus. Briefly consider proposed mechanisms by which antidepressants might be helpful for tinnitus, including treatment of co-morbid depression and anxiety and a more direct serotonergic mechanism of tinnitus. Survey the literature on antidepressants and tinnitus including tinnitus reported as a side effect of antidepressants (phenelzine, amitriptyline, protriptyline, doxepin, imipramine, fluoxetine, trazadone, bupropion, venlafaxine), tinnitus associated with withdrawal of antidepressants (venlafaxine and sertraline) and antidepressants as a treatment for tinnitus (case reports--fluoxetine and paroxetine, retrospective reviews--imipramine and selective serotonin reuptake inhibitors, single blind trials of amitriptyline and double blind placebo controlled trials of trimipramine, nortriptyline, paroxetine and sertraline). Provide suggestions on future directions, specifically replication of prior studies and a dose finding study of paroxetine for the treatment of tinnitus.

Associations between disordered eating behaviors and licit and illicit substance use and abuse in a university sample.

OBJECTIVES: To examine associations between discrete eating disordered behaviors as well as clusters of eating disordered behaviors in relation to the use and abuse of a wide spectrum of substance classes, both licit and illicit, in a female university sample. METHODS: Women with particular types of eating disordered behaviors were selected from a pool of 526 students who completed the Women's Health Survey. Analyses compared the frequencies of lifetime engagement in a wide range of licit and illicit substances between each of the eating disorder groups and the normal control group. RESULTS: Associations were found between severe levels of alcohol consumption and binge eating, dieting with purging and the use of central nervous stimulants, and bingeing with dieting and tobacco use and the abuse of prescription medications. CONCLUSION: Examining a broad range of substance classes, with differing physiological properties and effects, in relation to specific disordered eating behaviors, could contribute to theory development regarding the functions of the specific co-occurring behaviors.

Randomized placebo-controlled trial of a selective serotonin reuptake inhibitor in the treatment of nondepressed tinnitus subjects.

OBJECTIVE: To assess the efficacy of a selective serotonin reuptake inhibitor (paroxetine) for relief of tinnitus. DESIGN: One hundred twenty tinnitus sufferers participated in a randomized double-blind placebo-controlled trial. Paroxetine or placebo was increased to a maximally tolerated dose (up to 50 mg/day), and patients were treated for a total of 31 days at the maximal dose. METHODS: Patients with chronic tinnitus were recruited from our university-based specialty clinic by referral from otolaryngologists and audiologists in the local community and by advertisement. Patients with psychotic or substance use disorders or suicidal ideation were excluded, as were those using psychoactive medications (this resulted in only 1 subject with major depression in the study) or any other medications that interact with paroxetine and those with inability to hear at one's tinnitus sensation level. Fifty-eight percent of patients were male, 92% were Caucasian, and the average age was 57. OUTCOMES MEASURES: Tinnitus matching, the Tinnitus Handicap Questionnaire, the question: How severe (bothered, aggravating) is your tinnitus? Quality of Well-Being and other psychological questionnaires. RESULTS: Paroxetine was not statistically superior to placebo on the following tinnitus measures (tinnitus matching, 5- or 10-db drop, Tinnitus Handicap Questionnaire, quality of well-being measures, how severe, how bothered, positive change). There was a significant improvement in the single item question, How aggravating is your tinnitus? for those in the paroxetine group compared with the placebo group. CONCLUSIONS: These results suggest that the majority of individuals in this study did not benefit from paroxetine in a consistent fashion. Further work remains to be done to determine if subgroups of patients (e.g., those who tolerate higher doses, those who are depressed) may benefit.

Rapid oral loading of extended release divalproex in patients with acute mania.

BACKGROUND: Oral loading with the delayed release formulation of divalproex sodium is widely used for the treatment of patients with acute mania and produces rapid attainment of therapeutic serum levels. Recently, an extended release formulation of divalproex sodium (divalproex ER) was approved for treatment of migraine headaches. This formulation may be a useful treatment option for patients with acute mania. METHOD: A retrospective review of medical records was conducted on 14 inpatients with acute mania whose treatment included initiation of divalproex ER at a dose of 30 mg kg(-1) day(-1) in a single dose. Doses, serum levels and side effects associated with this treatment were recorded from the medical records of these patients. RESULTS: The average dose of divalproex ER was 2034 mg day(-1) (range, 1500-3000 mg day(-1)). Two of the 14 patients (14%) had documented side effects, none of which were severe. The average level obtained on day 3 after initiation of divalproex ER treatment was 93.2 mug ml(-1) (range, 47-136 mug ml(-1)), and in all but three patients valproate levels at this time point were within the therapeutic range of 50-125 mug ml(-1). In no case was divalproex ER discontinued due to a perceived lack of efficacy. CONCLUSION: The results suggest that divalproex ER can be safely administered by oral loading in inpatients with acute mania and that using a standard loading protocol can result in therapeutic serum levels in most patients in 3 days or less.

Multiple 5-HT receptors are involved in the effects of acute MDMA treatment: studies on locomotor activity and responding for conditioned reinforcement.

RATIONALE: Responding for conditioned reinforcement is increased by the dopamine releasing agent amphetamine, but reduced by drugs that enhance serotonin (5-HT) function. The amphetamine derivative 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy) releases both monoamines. OBJECTIVES: The primary purpose of this study was to examine the effects of MDMA on responding for conditioned reinforcement as well as on locomotor activity. The roles of several 5-HT receptor sub-types in mediating these behavioural effects of MDMA were also examined. METHODS: Locomotion was measured in photocell activity monitors. For conditioned reinforcement experiments thirsty rats learned to associate a conditioned stimulus (CS) with water in operant chambers. Subsequently, two response levers were available; responding on one lever delivered the CS, while responding on the second lever had no consequences. Drug effects on this operant response were measured. RESULTS: MDMA dose-dependently increased locomotion but reduced responding for conditioned reinforcement. This latter effect differs from that induced by amphetamine, which potentiates conditioned reinforcement responding. The stimulant effect of MDMA was attenuated by GR127935 and ketanserin, indicating facilitatory roles of 5-HT(1B) and 5-HT(2A) receptors in mediating this effect. The 5-HT(2C) antagonist SB242084 enhanced the stimulant effect of MDMA. Only SB242084 attenuated the suppressant effect of MDMA on responding for conditioned reinforcement. CONCLUSIONS: The results show that 5-HT(2A) and 5-HT(1B/1D) receptors play a facilitatory role in mediating the stimulant effect of MDMA, whereas 5-HT(2C) receptors are inhibitory. Activation of 5-HT(2C) receptors also contributes to the deficit in operant responding. Multiple 5-HT receptor sub-types appear to contribute to the behavioural effects of MDMA.

Relationship of tinnitus questionnaires to depressive symptoms, quality of well-being, and internal focus.

Twenty percent of people endure tinnitus to a degree that their quality of well-being and productivity in life are impaired, and up to 60% report depression. Four measures are widely used to assess tinnitus-related distress, yet the relationship among all four measures or their relationship to relevant psychiatric variables has yet to be studied. This study assessed the association between the four commonly used measures of tinnitus and their relationship to depressive symptoms, quality of well-being, and internal focus. Sixty-five people with tinnitus completed the following measures: Iowa Tinnitus Handicap Questionnaire (THQ); Tinnitus Reaction Questionnaire (TRQ); Tinnitus Handicap Inventory (THI); Tinnitus Questionnaire (TQ); Hamilton Rating Scale for Depression (HRSD); Beck Depression Inventory (BDI); Quality of Well-Being Scale (QWBS); Modified Somatic Perception Questionnaire (MSPQ); and Private Self-Consciousness Scale (PSCS). All the tinnitus measures were highly intercorrelated (r = .76-.90; all p values < .001), and related to depressive symptoms (r = .48-.66; p < .001) and QWBS (r = .37-.48; all p values < 0.008). The tinnitus measures correlated with the MSPQ (r = .37-.52; all p values < .01) but not with the PSCS. When controlling for the shared variance between tinnitus measures, the THQ independently predicted the HRSD, whereas the TRQ independently predicted the BDI.

Group medication management for buprenorphine/naloxone in opioid-dependent veterans.

OBJECTIVE: Substance use disorders are a key concern among US veterans. Substance use disorder pharmacotherapies with support for effectiveness are limited. Buprenorphine/naloxone (Suboxone) is an effective opioid replacement treatment option for opioid use disorder when used as part of a comprehensive treatment program. In June 2011, the Veterans Affairs San Diego Healthcare System began using a group format to prescribe buprenorphine/naloxone. This study aimed at examining outcomes of retention rates and percentage opioid negative urine samples. Results were compared for veteran patients seen in group versus individual formats. METHODS: This retrospective chart review included data from 32 patients who were prescribed buprenorphine/naloxone between a 3-year window (ie, January 1, 2010, and December 31, 2012). RESULTS: Overall results were 46% retention in treatment after 1 year, and 94% of opioid urine samples were negative. More patients seen in group were retained in treatment at 1 year compared with those seen individually (69% vs 27%, respectively; P < 0.03). CONCLUSIONS: This study found that veterans prescribed buprenorphine/naloxone in a group setting as part of a drug and alcohol treatment program were retained in treatment longer than veterans prescribed this medication individually. Because of inherent limitations in the study design, no causality can be determined; however, given the results found here, group medication management of buprenorphine/naloxone should be explored further.