Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study.

BACKGROUND: In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. METHODS: We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. RESULTS: Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. CONCLUSION: Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives.

PURPOSE: As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success. METHODS: Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data. FINDINGS: Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

The effect of NaOCl and heat treatment on static and dynamic mechanical properties and chemical changes of dentine.

OBJECTIVES: To determine the effect of heat on flexural strength (FS), maximum strain (MS), storage modulus (SM), tan delta (TD) and chemical changes through micro-Raman spectroscopy of dentine exposed to 2.5% NaOCl or saline. METHOD: ology: Dentine bars were randomly allocated to 8 test groups. Half (groups 2,4,6,8) were treated with NaOCl for 20 min; the rest (groups 1,3,5,7) remained in saline. FS/MS were measured in groups 1-4 (n = 15) (3/4 were also heated to 200 °C & re-hydrated in saline). Micro-Raman spectroscopy was performed on bars from groups 1-4. SM/TD were measured in 5-8: in 5/6 (n = 10), repeated after heating (200 °C), then following re-hydration; in 7/8 (n = 3) after heating to 25-185 °C. RESULTS: Increase in MS on heat and FS/MS on heat + NaOCl was not significant (P > 0.05). SM increased (P = 0.06) after heat treatment but reduced to initial state after rehydration (P = 0.03). TD did not change (P = 0.4) after heat (200 °C) treatment but rehydration increased it compared with pre-treatment state (P = 0.001). For dentine bars pre-treated with NaOCl, SM did not change (P = 0.6) after heat (200 °C) treatment or rehydration but TD significantly increased (P = 0.02) upon re-hydration compared with pre- (P=0.007), or post- (P = 0.03) heat-treatment states. SM and TD varied between 25-185 °C with no consistent trend amongst the NaOCl pre-treated bars. Micro-Raman only detected chemical changes following NaOCl treatment in the mineral phase. CONCLUSIONS: Exposure of dentine bars to heat and NaOCl produced only moderate changes to quasi-static but marked changes to viscoelastic properties, which may be explained by chemical alterations.

Prognostic value of peripheral leukocyte counts and plasma glucose in intracerebral haemorrhage.

INTRODUCTION: The value of routine blood markers as prognostic indicators is increasingly established in acute ischaemic stroke. The relationship is less well defined in haemorrhagic stroke. In this study, we examined routine admission blood markers and applied a logistic regression model to predict outcome in haemorrhagic stroke. METHOD: A retrospective study was performed between September 2009-2011 in a general admission stroke unit in the UK. 1400 patients were admitted with stroke during this period, of which 117 were haemorrhagic. Admission systolic and diastolic blood pressure, venous blood samples and pre- and post-morbid (i.e. at discharge or death) modified Rankin scores were also recorded. Patients were controlled for age, sex, smoking status, hypertension status and co-morbidities (using Charleson Comorbidity Index scores). Logistic regression models were generated using SPSS. RESULTS: 113 patients were analysed (58 male/55 female). Lower admission blood glucose (p=0.009), lower total leukocyte count (p=0.001) and lower neutrophil count (p=0.021) were found to be significantly associated with survival vs. death. 90 patients with complete glucose, leukocyte count, sex (forced) and pre-morbid Rankin score (forced) data were entered into a logistic regression model. This predicted correct group membership (survived/deceased) in 72.2% of cases (83.9% survivors/52.9% deceased correctly predicted). In females with normal leukocyte count and glucose, survival was predicted with 68% accuracy. CONCLUSION: These results suggest that a logistic regression model using low admission glucose and low total leukocyte count may be markers of better prognosis in acute haemorrhagic stroke with a differential effect between sexes.

Conversion, shrinkage, water sorption, flexural strength and modulus of re-mineralizing dental composites.

OBJECTIVES: Cure, volumetric changes and mechanical properties were assessed for new dental composites containing chlorhexidine (CHX) and reactive calcium phosphate-containing (CaP) to reduce recurrent caries. METHODS: 20wt.% of light curable urethane dimethacrylate based liquid was mixed with 80wt.% glass filler containing 10wt.% CHX and 0-40wt.% CaP. Conversion versus depth with 20 or 40s light exposure was assessed by FTIR. Solidification depth and polymerization shrinkage were determined using ISO 4049 and 17304, respectively. Subsequent volume expansion and biaxial flexural strength and modulus change upon water immersion were determined over 4 weeks. Hydroxyapatite precipitation in simulated body fluid was assessed at 1 week. RESULTS: Conversion decreased linearly with both depth and CaP content. Average solidification depths were 4.5, 3.9, 3.3, 2.9 and 5.0 with 0, 10, 20, and 40% CaP and a commercial composite, Z250, respectively. Conversions at these depths were 53±2% for experimental materials but with Z250 only 32%. With Z250 more than 50% conversion was achieved only below 1.1mm. Shrinkage was 3% and 2.5% for experimental materials and Z250, respectively. Early water sorption increased linearly, whilst strength and modulus decreased exponentially to final values when plotted versus square root of time. Maximum volumetric expansion increased linearly with CaP rise and balanced shrinkage at 10-20wt.% CaP. Strength and modulus for Z250 decreased from 191 to 158MPa and 3.2 to 2.5GPa. Experimental composites initial strength and modulus decreased linearly from 169 to 139MPa and 5.8 to 3.8GPa with increasing CaP. Extrapolated final values decreased from 156 to 84MPa and 4.1 to 1.7GPa. All materials containing CaP promoted hydroxyapatite precipitation. SIGNIFICANCE: The lower surface of composite restorations should both be solid and have greater than 50% conversion. The results, therefore, suggest the experimental composite may be placed in much thicker layers than Z250 and have reduced unbounded cytotoxic monomer. Experimental materials with 10-20wt.% additionally have volumetric expansion to compensate shrinkage, antibacterial and re-mineralizing components and competitive mechanical properties.

From Hospital to Home: Limited Nutritional and Functional Recovery for Older Adults.

BACKGROUND: The post-hospital period may be a vulnerable time for elders recovering from acute illness. Few studies have examined nutrition outcomes of older people at nutrition risk after acute hospitalisation. OBJECTIVES: This study aims to describe a) standard nutrition care received by recently discharged older medical patients, b) change in nutritional and functional status at six weeks post-discharge and c) clinical outcomes at twelve weeks post discharge. DESIGN: Prospective cohort study. SETTING: Two metropolitan teaching hospitals in Brisbane, Australia. PARTICIPANTS: Medical patients aged ≥65 years at risk of malnutrition (Malnutrition Screening Score ≥2) and discharged to independent living in the community. MEASUREMENT: Nutritional status (Mini Nutritional Assessment (MNA), weight, lean body mass), functional status (grip strength, walk speed, activities of daily living) and health-related quality of life assessed on discharge and six weeks post-discharge. Inpatient and post-discharge nutrition intervention was recorded. Death and unplanned admissions were measured at 12 weeks. RESULTS: Of the 42 consented participants, only 14% (n=6) received post-discharge dietitian review and 19% (n=8) received practical nutrition supports at home (meal delivery, shopping assistance) as part of standard care. While there was a small improvement in MNA (18.4±4.0 to 20.1±4.2, p=0.004) and walk speed (0.7±0.3 m/s to 0.9±0.3, p=0.004) at six weeks, there was no difference in mean weight, lean body mass, grip strength or activities of daily living. Five (15%) participants lost ≥5% body weight. By twelve weeks, 17 participants (46%) had at least one unplanned hospital admission and four (10%) had died. CONCLUSIONS: Few patients at nutrition risk received nutrition-focussed care in the post-hospital period, and most did not improve nutritional or functional status at 6 weeks.

Disruption of medial prefrontal synchrony in the subchronic phencyclidine model of schizophrenia in rats.

Subchronic treatment with the N-methyl-D-aspartate (NMDA) antagonist phencyclidine (PCP) produces behavioral abnormalities in rodents which are considered a reliable pharmacological model of neurocognitive deficits in schizophrenia. Alterations in prefrontal neuronal firing after acute PCP administration have been observed, however enduring changes in prefrontal activity after subchronic PCP treatment have not been studied. To address this we have recorded cortical oscillations and unit responses in putative cortical pyramidal cells in subchronic PCP-treated rats (2mg/kg twice daily for 7 days) under urethane anesthesia. We found that this regimen reduced theta oscillations in the medial prefrontal cortex. It further produced abnormal cortical synchronization in putative cortical pyramidal cells. These alterations in prefrontal cortex functioning may contribute to cognitive deficits seen in subchronic NMDA antagonist pre-treated animals in prefrontal-dependent tasks.

Systematic review of behavioural interventions with culturally adapted strategies to improve diet and weight outcomes in African American women.

Behavioural interventions incorporating features that are culturally salient to African American women have emerged as one approach to address the high rates of obesity in this group. Yet, the systematic evaluation of this research is lacking. This review identified culturally adapted strategies reported in behavioural interventions using a prescribed framework and examined the effectiveness of these interventions for diet and weight outcomes among African American women. Publications from 1 January 1990 through 31 December 2012 were retrieved from four databases, yielding 28 interventions. Seventeen of 28 studies reported significant improvements in diet and/or weight change outcomes in treatment over comparison groups. The most commonly identified strategies reported were 'sociocultural' (reflecting a group's values and beliefs) and 'constituent involving' (drawing from a group's experiences). Studies with significant findings commonly reported constituent-involving strategies during the formative phases of the intervention. Involving constituents early on may uncover key attributes of a target group and contribute to a greater understanding of the heterogeneity that exists even within racial/ethnic groups. Available evidence does not, however, explain how culturally adapted strategies specifically influence outcomes. Greater attention to defining and measuring cultural variables and linking them to outcomes or related mediators are important next steps.

Drug users' willingness to encourage social, sexual, and drug network members to receive an HIV vaccine: a social network analysis.

This study examined feasibility of peer-based promotion of HIV vaccination and dyadic correlates to vaccine encouragement in risk- and non-risk networks of drug users (n = 433) in the US. Data were collected on HIV vaccine attitudes, risk compensation intentions, likelihood of encouraging vaccination, and recent (past 6 months) risk (i.e. involving sex and/or injecting drugs) and non-risk (i.e. involving co-usage of noninjected drugs and/or social support) relationships. Willingness to encourage HIV vaccination was reported in 521 and 555 risk- and non-risk relationships, respectively. However, 37 % expressed hesitancy, typically due to fear of side effects or social concerns. Encouragement was often motivated by perceived HIV risk, though 9 % were motivated by risk compensation intentions. In non-risk partnerships, encouragement was associated with drug co-usage, and in risk relationships, with perceived vaccine acceptability and encouragement by the partner. Network-based HIV vaccine promotion may be a successful strategy, but risk compensation intentions should be explored.

Quantifying effects of interactions between polyacrylic acid and chlorhexidine in dicalcium phosphate - forming cements.

The aim of this study was to assess how varying the ratio of aqueous 0.8 M citric acid : 6 M polyacrylic acid (PAA) (3 : 0, 1 or 3 by weight) affected setting chemistry, mechanical properties and chlorhexidine di-acetate (CHX) release of dicalcium phosphate - forming bone cements. Cement powder included ß-tricalcium phosphate (ß-TCP) : monocalcium phosphate monohydrate (MCPM) : CHX at 1 : 1 : (0, 0.08 or 0.16) molar ratio. Powder to liquid ratio was fixed at 3 : 1 by weight. Chemical setting kinetics, reactive intermediate formation and final product homogeneity were assessed by ATR FTIR and Raman mapping. Biaxial flexural strength and modulus were determined after 24 hours setting plus 24 hours in water at 37 °C and analysed using Weibull type equations. CHX release from 1 mm thick set discs was assessed over 4 weeks using UV spectroscopy. FTIR demonstrated that CHX interaction with citric acid inhibited formation of the reactive citrate/dicalcium phosphate intermediate complex that enables delay before snap set. High CHX additionally increased strength variability. Upon partial citric acid substitution with higher levels of PAA, delay before cement set was maintained. Monetite instead of brushite, however, was formed in conjuction with more stable polyacrylate complexes. These formulations had much improved strength but also greater modulus. CHX addition and interaction with PAA encouraged greater brushite instead of monetite formation. These complex interactions enabled formulations with high drug and PAA to have improved strength without increase in modulus. They also had low strength variability and better (slower) controlled release of drug. These properties are beneficial for cement use in a range of orthopaedic and dental applications.

Social networks and HCV viraemia in anti-HCV-positive rural drug users.

Although social networks are known to play an important role in drug-using behaviours associated with hepatitis C virus (HCV) infection, literature on social networks and HCV is inconsistent. This exploratory study examined HCV RNA distribution within a social network of anti-HCV-positive non-medical prescription opioid users (NMPOUs) in rural Appalachia. Participants were tested serologically for HCV RNA, and behavioural, demographic, and network data were collected using interview-administered questionnaires. Multivariate analyses were performed using logistic regression. Behavioural and demographic characteristics did not differ by RNA status. In the multivariate model, recent injecting drug users (IDUs) were more likely to be RNA positive [odds ratio (OR) 4·06, 95% confidence interval (CI) 1·04-15·83], and turnover into an IDU's drug network was significantly protective (OR 0·15, 95% CI 0·03-0·75). This is the first study to date to examine HCV distribution in rural NMPOUs from a network perspective and demonstrates that network characteristics significantly contribute to the epidemiology of HCV in this understudied, high-risk population.

Network structure and the risk for HIV transmission among rural drug users.

Research suggests that structural properties of drug users' social networks can have substantial effects on HIV risk. The purpose of this study was to investigate if the structural properties of Appalachian drug users' risk networks could lend insight into the potential for HIV transmission in this population. Data from 503 drug users recruited through respondent-driven sampling were used to construct a sociometric risk network. Network ties represented relationships in which partners had engaged in unprotected sex and/or shared injection equipment. Compared to 1,000 randomly generated networks, the observed network was found to have a larger main component and exhibit more cohesiveness and centralization than would be expected at random. Thus, the risk network structure in this sample has many structural characteristics shown to be facilitative of HIV transmission. This underscores the importance of primary prevention in this population and prompts further investigation into the epidemiology of HIV in the region.

Disruption of overshadowing and latent inhibition in high schizotypy individuals.

Deficits in selective attention are seen in positively symptomatic schizophrenia sufferers, and in normal people displaying schizotypal traits. We investigated the relationship between selective attention and schizotypy in undergraduate students, by comparing participants' performance in two models of selective attention, overshadowing and latent inhibition, with psychoticism scores derived from the Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE). Using a novel within-subject overshadowing task, we showed that the unusual experiences dimension of schizotypy, but not the other three O-LIFE dimensions, was negatively related to overshadowing score. We also replicated findings that the unusual experiences dimension of schizotypy was negatively related to latent inhibition score. These experiments provide evidence that selective attention is disrupted in normal individuals showing traits relating to positive-like schizophrenic symptoms, and has implications for interpreting selective attention deficits measured in schizophrenia patients.

Audio-induced psychogenic non-epileptic seizures.

A 45-year-old woman presented with vague attacks, which consisted of headaches, confusion and sleepiness. An electroencephalograph was normal, but subsequent scans revealed the presence of a right-sided convexity meningioma. This was excised and complications led to the removal of an infected bone flap in a separate procedure the following year. Various types of 'seizures' resulted from the operation. These were described to involve both tonic-clonic and absence seizures. This continued for 18 years, unaffected by medication, until a specialist diagnosed pseudo-epilepsy, by fortune of a hospital fire alarm. The patient began a psychological intervention programme including cognitive-behavioural therapy, which has significantly reduced episodes. In conclusion, psychogenic non-epileptic seizures may develop after intracranial neurosurgery undertaken for indications other than the control of refractory epileptic seizures. A diagnosis of psychogenic non-epileptic seizures should be considered in patients who develop refractory seizures after neurosurgery and managed appropriately.

Allopregnanolone protects against dopamine-induced striatal damage after in vitro ischaemia via interaction at GABA A receptors.

Sex steroid hormones, such as progesterone, have been shown to display neuroprotective properties after various models of central nervous system injury, including cerebral ischaemia, although the mechanism(s) of action remain largely undetermined. Allopregnanolone, an active progesterone metabolite, may explain some of the protective actions of progesterone. We utilised an in vitro model of ischaemia to evaluate the neuroprotective potential of allopregnanolone and examine its interaction at the GABA(A) receptor, which is hypothesised to be its main neuroprotective mechanism. In adult male mouse coronal caudate slices exposed to oxygen glucose deprivation (OGD), we measured aspects of OGD-induced dopamine release, which is neurotoxic during ischaemia, using fast cyclic voltammetry and also assessed tissue viability. The GABA(A) agonist, muscimol, displayed a neuroprotective profile in terms of delaying the OGD-evoked dopamine efflux (P < 0.05) and reducing the amount of dopamine released after OGD (P < 0.05). Allopregnanolone, at a concentration of 10(-6) m, also displayed a neuroprotective profile because it significantly reduced the amount of dopamine efflux (P < 0.05) and reduced the loss of viable tissue after OGD compared to slices exposed to vehicle during OGD (P < 0.05). However, the effect of 10(-6) m allopregnanolone on dopamine efflux was prevented in the presence of bicuculline, a competitive GABA(A) receptor antagonist. These results describe the use of an in vitro model of ischaemia with respect to determining that allopregnanolone is neuroprotective during the acute phase of ischaemia, and also demonstrate that such actions are dependent, at least in part, upon interaction at the GABA(A) receptor.

Prevalence and correlates of recent vaginal douching among African American adolescent females.

STUDY OBJECTIVE: To describe the prevalence and correlates of vaginal douching among urban African American adolescents and to examine the association between douching and sexually transmitted infection (STI) status. DESIGN: Demographic, psychosocial, and behavioral data were collected through cross-sectional, self-administered surveys. Self-collected vaginal swabs were assayed using nucleic acid amplification tests for trichomoniasis, chlamydia, and gonorrhea. SETTING: Sexual health clinic in a large metropolitan area of the southeastern United States. PARTICIPANTS: African American females (N = 701), ages 14-20, participating in a human immunodeficiency virus prevention intervention. MAIN OUTCOME MEASURE: The outcome of interest was the association between vaginal douching (lifetime, past 90 days, and past 7 days) with demographic characteristics (eg, age, education, and socioeconomic status), physical and mental health status, STI status, sexual behavior (eg, number of vaginal sexual partners, age of sex partners, consistent condom use in the past 90 days, sex while self/partner was high on drugs or alcohol), and psychosocial characteristics (eg, sexual adventurism, social support, peer norms, sexual satisfaction, self-efficacy for sex refusal, self-esteem, relationship power, risk avoidance). RESULTS: Forty-three percent reported ever douching, and 29% reported douching in the past 90 days. In bivariate analyses, recent douching was associated with demographic, behavioral, and psychosocial variables, but not current STI status. In multivariate analyses, recent douching was associated with age (odds ratio [AOR] = 1.13, confidence interval [CI] = 1.02-1.25), lower socioeconomic status (AOR = 1.25, CI = 1.05-1.47), and having sex with much older partners (AOR = 1.87, CI = 1.22-2.86). CONCLUSION: Increased age, lower socioeconomic status, and older partners may be salient risk factors for douching behavior among African American young women.