Presentation and patterns of reinterventions after revascularization in patients with premature peripheral arterial disease.

OBJECTIVE: Premature peripheral arterial disease (PAD) (age ≤50 years) has been shown to negatively impact the outcomes of lower extremity revascularization (LER). Patients with premature PAD have an increased risk of major amputation compared with older patients. The primary goal of this study is to compare the frequency of reinterventions after LER in patients with premature PAD to their older counterparts with common age of presentation (ie, 60-80 years). METHODS: A retrospective review of consecutive patients undergoing LER for PAD in a single center was performed. Clinical, procedural, and socioeconomic characteristics were compared between patients with premature PAD and the older group. Perioperative and long-term outcomes were captured and compared including mortality, major amputation, reintervention rate and frequency, as well as major adverse limb events. RESULTS: There were 1274 patients who underwent LER (4.3% premature, 61.8% age 60-80). Patients with premature PAD were more likely to be females of racial minorities. Notably, the mean Distressed Communities Index score was significantly higher in the premature PAD group compared with the older patients. Patients with premature PAD were significantly more likely to have end-stage renal disease but less likely to have hypertension, hyperlipidemia, and coronary artery disease compared with older patients. There was no significant difference in perioperative complications. After a mean follow-up of 5 years, patients with premature PAD were significantly more likely to undergo more frequent reinterventions compared with older patients. Kaplan-Meier curves showed similar overall survival and major adverse limb event-free survival between the two groups. CONCLUSIONS: Patients with premature PAD are likely to undergo more frequent reinterventions after initial LER and have similar 5-year survival curves compared with patients at least 20 years older. Demographic and socioeconomic differences impacting patients with premature PAD, even in this relatively underpowered institutional experience, are striking and warrant further investigation.

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.

Precise epigenomic editing with a SunTag-based modular epigenetic toolkit.

Epigenetic regulation is a crucial factor controlling gene expression. Here, we report our CRISPR/dCas9-based modular epigenetic toolkit that enables gene-specific modulation of epigenetic architecture. By modifying the SunTag framework of dCas9 tagged with five GCN4 moieties, each epigenetic writer is bound to scFv and target-specific sgRNA, and this system is able to modify multiple epigenetic marks in a target-specific manner. We successfully demonstrated that this system is efficient in modifying individual histone post-translational modifications. We display its utility as a tool to understand the contributions of specific histone marks on gene expression by screening a large promoter region and identifying differential outcomes with high base-pair resolution. This epigenetic toolkit can be easily altered with a large variety of epigenetic effectors and is a useful tool for researchers to use in understanding gene-specific epigenetic changes and their relation to gene expression.

Treatment of Hepatitis C virus among people who inject drugs at a syringe service program during the COVID-19 response: The potential role of telehealth, medications for opioid use disorder and minimal demands on patients.

BACKGROUND: Healthcare delivery was disrupted during the COVID-19 pandemic, requiring minimized in-person contact between patients and clinicians. During the pandemic, people with opioid use disorder (OUD) were not only at elevated risk for COVID-19, but had markedly reduced access to treatment for OUD, Hepatitis C virus (HCV) and HIV due to recommended decreased in-person visits. METHODS: From March 15-June 15, 2020 at the syringe services program (SSP) in New Haven, Connecticut, USA, a differentiated care model evolved with reduced clinical demands on people who inject drugs (PWID) to ensure screening and treatment for HCV, HIV and OUD, with a focus on HCV treatment. This model involved a single, bundled screening, evaluation, testing (SET) and monitoring strategy for all three conditions, minimal in-person visits, followed by tele-health communication between patients, outreach workers and clinicians. In-person visits occurred only during induction onto methadone and phlebotomy at baseline and phlebotomy 12 weeks post-treatment for HCV to measure sustained virological response (SVR). Patients received supportive texts/calls from outreach workers and clinicians. RESULTS: Overall, 66 actively injecting PWID, all with OUD, underwent bundled laboratory screening; 35 had chronic HCV infection. Participants were 40 years (mean), mostly white (N = 18) men (N = 28) and 12 were unstably housed. Two were lost to-follow-up and 2 were incarcerated, leaving 31 who started pan-genotypic direct-acting antivirals (DAAs). The mean time from referral to initial phlebotomy and initiation of DAAs was 6.9 and 9.9 days, respectively. Fourteen additional patients were newly started on buprenorphine and 6 started on methadone; three and four, respectively, were on treatment at baseline. Overall, 29 (93.5%) PWID who initiated DAAs achieved SVR; among unstably housed persons the SVR was 83.3%. CONCLUSIONS: In response to COVID-19, an innovative differentiated care model for PWID at an SSP evolved that included successful co-treatment for HCV, HIV and OUD using a client-centered approach that reduces treatment demands on patients yet supports ongoing access to evidence-based treatments.