Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD).

BACKGROUND: Low rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized. METHODS: We performed a retrospective analysis involving deidentified data from Philadelphia's Medicaid beneficiaries ages 16-29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling. RESULTS: We identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06-6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24-0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services. CONCLUSIONS: Co-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

Confirmatory factor analysis of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS-2.0) within the clubhouse model of psychosocial rehabilitation for serious mental illness.

OBJECTIVE: The Clubhouse model (CM) for serious mental illness is a recovery-oriented and member-driven program that aims to facilitate functional recovery. Efficacy evaluation of the CM is limited by lack of uniform functional disability assessment. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS-2.0) is a widely accepted measure of functional disability, but its psychometric properties have yet to be examined within the CM. METHOD: This research sought to confirm the generic six-factor structure of the 12-item WHODAS-2.0 using retrospective administrative data from 339 adults with serious mental illness from an accredited Clubhouse. A second-order confirmatory factor analysis was conducted, followed by secondary known-groups analyses to examine whether the WHODAS-2.0 differentiates between subgroups with varying degrees of disability. RESULTS: The WHODAS-2.0 demonstrated good overall reliability. The generic six-factor structure produced nonsignificant loadings due to lack of independence between the "participation" and "getting along" factors. The items of these two factors were combined into a five-factor model, which displayed excellent fit, with all significant paths and adequate-to-strong loadings, and no correlation among errors. The WHODAS-2.0 significantly differentiated members by receipt of public assistance, employment status, and number of medical comorbidities, supporting construct validity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results provide initial support for the use of the 12-item WHODAS-2.0 as a CM-related outcome measure and encourage future research of the full 36-item version. The intentional community approach of the CM is unique and may require adjustments to the factor structure of the WHODAS-2.0 by merging the "participation" and "getting along" domains. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessment of Small Paediatric Burns: A Coin-Based System.

A review of paediatric burns in our burns facility in the United Kingdom demonstrated variable accuracy of size, and a majority documented as <1% total body surface area (TBSA). Accurate assessment is important for medical records, clinical management and non-accidental injuries. We propose to assess burn size with a coin-based system, where small burns are described by single/multiple sterling coins. Participants were asked about their confidence in evaluating small paediatric burns. Participants were given ten scenarios which included photographs of paediatric patients with small burns. They were asked to assess burn size in their normal manner (TBSA, measurement) and with a coin-based system. The 'burns' were drawn on children based on a given coin size and percentage so that the accuracy of the participant's answer was quantifiable. Participants provided qualitative feedback in a questionnaire on the coin-based system. Thirty nurses and medical staff of varying seniority actively involved in referral/management of paediatric burns took part, creating over 300 responses. In preliminary questions, 66% of participants did not feel confident in estimating paediatric burns and 83% needed to refer to a paediatric burns chart. Accuracy of burn size using TBSA and the coin-based system was 45% and 67%, respectively. The majority (97%) stated estimating size was easier, and 93% found it more accurate. A total of 87% found communication between colleagues easier. Results highlight the improved assessment of small burns in our hospital using a coin-based approach in comparison to TBSA, and could facilitate accurate communication between health care professionals.

En revoyant les évaluations de SB des brûlures pédiatrique dans notre centre du Royaume Uni, nous avons constaté une grande variabilité quant à leur exactitude, avec une majorité d'entre elles touchant moins de 1%. Hors, une évaluation exacte est nécessaire pour la stratégie thérapeutique, la bonne tenue du dossier et sur le plan légal (en particulier après brûlure non accidentelle). Nous proposons, pour ces petites brûlures, une évaluation utilisant la taille d'une pièce de monnaie. Les volontaires à cette étude se sont vus remettre 10 scenarii de petites brûlures, photos à l'appui. Il leur était demandé d'évaluer la SB comme à leur habitude et en utilisant le système de taille de pièce (avec multiples si nécessaire), et d'estimer l'intérêt de l'évaluation « à la pièce ¼. Trente personnels (médecins et infirmières) expérimentés ont participé, générant réponses. En préambule, 66% des participants s'estimaient peu fiables quand à l'évaluation des SB de l'enfant et 83% utilisaient des tables spécifiques. L'exactitude de l'évaluation était de 45% avec les techniques habituelles et 67% à la pièce. La grande majorité estimait que la mesure à la pièce facilitait l'évaluation (97%), la rendait plus précise (93%) et facilitait les transmissions (87%). L'évaluation à la pièce des brûlures pédiatriques pourrait la rendre plus précise et faciliter la communication entre professionnels.

MR imaging for the quantitative assessment of brain iron in aceruloplasminemia: A postmortem validation study.

AIMS: Non-invasive measures of brain iron content would be of great benefit in neurodegeneration with brain iron accumulation (NBIA) to serve as a biomarker for disease progression and evaluation of iron chelation therapy. Although magnetic resonance imaging (MRI) provides several quantitative measures of brain iron content, none of these have been validated for patients with a severely increased cerebral iron burden. We aimed to validate R2* as a quantitative measure of brain iron content in aceruloplasminemia, the most severely iron-loaded NBIA phenotype. METHODS: Tissue samples from 50 gray- and white matter regions of a postmortem aceruloplasminemia brain and control subject were scanned at 1.5 T to obtain R2*, and biochemically analyzed with inductively coupled plasma mass spectrometry. For gray matter samples of the aceruloplasminemia brain, sample R2* values were compared with postmortem in situ MRI data that had been obtained from the same subject at 3 T - in situ R2*. Relationships between R2* and tissue iron concentration were determined by linear regression analyses. RESULTS: Median iron concentrations throughout the whole aceruloplasminemia brain were 10 to 15 times higher than in the control subject, and R2* was linearly associated with iron concentration. For gray matter samples of the aceruloplasminemia subject with an iron concentration up to 1000 mg/kg, 91% of variation in R2* could be explained by iron, and in situ R2* at 3 T and sample R2* at 1.5 T were highly correlated. For white matter regions of the aceruloplasminemia brain, 85% of variation in R2* could be explained by iron. CONCLUSIONS: R2* is highly sensitive to variations in iron concentration in the severely iron-loaded brain, and might be used as a non-invasive measure of brain iron content in aceruloplasminemia and potentially other NBIA disorders.

Development of an intervention to manage knee osteoarthritis risk and symptoms following anterior cruciate ligament injury.

INTRODUCTION: Anterior cruciate ligament (ACL) injury is a risk factor for developing knee osteoarthritis (OA). We developed an intervention to support people manage risk factors for OA. METHODS: We conducted one-on-one interviews with 20 individuals with OA symptoms 6-15 years post ACL injury and used a nominal group process during a workshop with 40 patients and healthcare professionals (HCPs) to elicit information on the intervention content and delivery characteristics (timing, HCPs, and methods). Interview data were analyzed using content analysis. Nominal group ideas with importance ratings ≥5 of 7 met criteria for inclusion. Results were integrated, considering similarities and differences. RESULTS: Eight content categories were identified: 1. understanding knee injury and expectations about recovery; 2. understanding OA risk; 3. understanding OA signs and symptoms; 4. managing OA risk; 5. managing knee OA symptoms; 6. information for influencers; 7. credible sources; and, 8. updates on new evidence and treatments. Delivery timing reflected a lifespan approach from time of injury through symptomatic knee OA management. Although multiple media for delivery were identified, introductory face-to-face discussions and opportunity for re-accessing HCPs were critical. All HCPs who treat people with ACL should be familiar with and able to deliver the intervention. CONCLUSIONS: This co-development approach identified that an intervention to support people with ACL injury to limit and manage knee OA requires content embedded within an easily accessible, multi-media delivery model with capacity for check-back with HCPs that is appealing to different age groups and personal preferences over the lifespan post injury.

Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes.

Policy Points Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources. Current payment mechanisms for health care services do not adequately support critical up-front investments in infrastructure to address medical and social needs, nor provide sufficient incentives to make addressing social needs a priority. Alternative payment models and value-based payment should provide up-front funding for personnel and infrastructure to address social needs and should incentivize care that addresses social needs and outcomes sensitive to social risk. CONTEXT: Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models. METHODS: Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources. FINDINGS: Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions. CONCLUSIONS: Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future.

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

Trajectories of Opioid Use Following First Opioid Prescription in Opioid-Naive Youths and Young Adults.

Importance: Although prescription opioids are the most common way adolescents and young adults initiate opioid use, many studies examine population-level risks following the first opioid prescription. There is currently a lack of understanding regarding how patterns of opioid prescribing following the first opioid exposure may be associated with long-term risks. Objective: To identify distinct patterns of opioid prescribing following the first prescription using group-based trajectory modeling and examine the patient-, clinician-, and prescription-level factors that may be associated with trajectory membership during the first year. Design, Setting, and Participants: This cohort study examined Pennsylvania Medicaid enrollees' claims data from 2010 through 2016. Participants were aged 10 to 21 years at time of first opioid prescription. Data analysis was performed in March 2020. Main Outcomes and Measures: This study used group-based trajectory modeling and defined trajectory status by opioid fill. Results: Among the 189 477 youths who received an initial opioid prescription, 107 562 were female (56.8%), 81 915 were non-Latinx White (59.6%), and the median age was 16.9 (interquartile range [IQR], 14.6-18.8) years. During the subsequent year, 47 477 (25.1%) received at least one additional prescription. Among the models considered, the 2-group trajectory model had the best fit. Of those in the high-risk trajectory, 65.3% (n = 901) filled opioid prescriptions at month 12, in contrast to 13.1% (n = 6031) in the low-risk trajectory. Median age among the high-risk trajectory was 19.0 years (IQR, 17.1-20.0 years) compared with the low-risk trajectory (17.8 years [IQR, 15.8-19.4 years]). The high-risk trajectory received more potent prescriptions compared with the low-risk trajectory (median dosage of the index month for high-risk trajectory group: 10.0 MME/d [IQR, 5.0-21.2 MME/d] vs the low-risk trajectory group: 4.7 MME/d [IQR, 2.5-7.8 MME/d]; P < .001). The trajectories showed persistent differences with more youths in the high-risk trajectory going on to receive a diagnosis of opioid use disorder (30.0%; n = 412) compared with the low-risk group (10.1%; n = 4638) (P < .001). Conclusions and Relevance: This study's results identified 2 trajectories associated with elevated risk for persistent opioid receipt within 12 months following first opioid prescription. The high-risk trajectory was characterized by older age at time of first prescription, and longer and more potent first prescriptions. These findings suggest even short and low-dose opioid prescriptions can be associated with risks of persistent use for youths.

A System-Wide Population Health Value Approach to Reduce Hospitalization Among Chronic Kidney Disease Patients: an Observational Study.

BACKGROUND: Chronic kidney disease (CKD) is a leading cause of healthcare morbidity, utilization, and expenditures nationally, and caring for late-stage CKD populations is complex. Improving health system efficiency could mitigate these outcomes and, in the COVID-19 era, reduce risks of viral exposure. OBJECTIVE: As part of a system-wide transformation to improve healthcare value among populations with high healthcare utilization and morbidity, UCLA Health evaluated a new patient-centered approach that we hypothesized would reduce inpatient utilization for CKD patients. DESIGN: For 18 months in 2015-2016 and 12 months in 2017, we conducted an interrupted time series regression analysis to evaluate the intervention's impact on inpatient utilization. We used internal electronic health records and claims data across six payers. PARTICIPANTS: A total of 1442 stage 4-5 CKD patients at a large academic medical center. INTERVENTION: Between October and December 2016, the organization implemented a Population Health Value CKD intervention for the CKD stages 4-5 population. A multispecialty leadership team risk stratified the population and identified improvement opportunities, redesigned multispecialty care coordination pathways across settings, and developed greater ambulatory infrastructure to support care needs. MAIN MEASURES: Outcomes included utilization of hospitalizations, emergency department (ED) visits, inpatient bed days, and 30-day all-cause readmissions. KEY RESULTS: During the 12 months following intervention implementation, the monthly estimated rate of decline for hospitalizations was 5.4% (95% CI: 3.4-7.4%), which was 3.4 percentage points faster than the 18-month pre-intervention decline of 2.0% (95% CI: 1.0-2.2%) per month (p = 0.004). Medicare CKD patients' monthly ED visit rate of decline was 3.0% (95% CI: 1.2-4.8%) after intervention, which was 2.6 percentage points faster than the pre-intervention decline of 0.4% (95% CI: - 0.8 to 1.6%) per month (p = 0.02). CONCLUSIONS: By creating care pathways that link primary and specialty care teams across settings with increased ambulatory infrastructure, healthcare systems have potential to reduce inpatient healthcare utilization.

FLT3 inhibitors in acute myeloid leukaemia: assessment of clinical effectiveness, adverse events and future research-a systematic review and meta-analysis.

BACKGROUND: FMS-like tyrosine kinase 3 (FLT3) is the most frequent mutation in AML. With two FLT3 inhibitors recently approved by the FDA (midostaurin and gilteritinib), there is a need to evaluate these targeted agents. PURPOSE: To assess the clinical effectiveness of FLT3 inhibitors in AML patients. METHODS: Standard systematic review methods were utilised. Searches were conducted to July 2020 for completed and in-progress randomised controlled trials of FLT3 inhibitors in AML. A fixed-effect meta-analysis was undertaken. RESULTS: Eight completed trials involving 2656 patients and assessing five different FLT3 inhibitors (sorafenib, lestaurtinib, midostaurin, gilteritinib and quizartinib) were included. The pooled results were as follows (FLT3 inhibitor/control): overall survival hazard ratio (HR) = 0.83 (95% confidence interval [CI] 0.75 to 0.92, p = 0.0005), event-free survival HR = 0.85 (95% CI 0.77 to 0.94, p = 0.002), relapse-free survival HR = 0.76 (95% CI 0.64 to 0.90, p = 0.001), complete remission relative risk (RR) = 1.11 (95% CI 1.00 to 1.22. p = 0.05) and 60-day mortality RR = 1.04 (95% CI 0.77 to 1.40, p = 0.79). Relative risk of grade 3 and above vascular, dermatological, respiratory and hepatobiliary adverse events were found to be statistically significantly higher in the FLT3 inhibitor group compared to control, but the actual numbers of events were relatively small. Nineteen ongoing trials are still in progress, only one of which specifically targets older patients with AML. CONCLUSIONS: There is evidence to support the use of FLT3 inhibitors in patients with AML, but more data is needed to verify the optimum use of the drugs regarding type of inhibitor, disease stage and patient characteristics, not only in relation to disease control, but adverse events and quality of life. There are a large number of ongoing trials; therefore, the results of this review are not a fait accompli; thus, is it recommended that the review be updated in a couple of years' time. Given the challenges in extracting the complete data set required to assess clinical effectiveness, it is highly recommended that ongoing and future trials improve transparency and consistency of reporting of all trial outcomes, particularly disease control and adverse events, to enable a global clinical effectiveness assessment. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017055581.

Implementation Science to Address Health Disparities During the Coronavirus Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is disproportionally affecting racial and ethnic minorities. In the United States, data show African American, Hispanic, and Native American populations are overrepresented among COVID-19 cases and deaths. As we speed through the discovery and translation of approaches to fight COVID-19, these disparities are likely to increase. Implementation science can help address disparities by guiding the equitable development and deployment of preventive interventions, testing, and, eventually, treatment and vaccines. In this study, we discuss three ways in which implementation science can inform these efforts: (1) quantify and understand disparities; (2) design equitable interventions; and (3) test, refine, and retest interventions.

Effects of the Serber first step in 3DHZETRN-v2.1.

3DHZETRN-v2 includes a detailed three dimensional (3D) treatment of neutron/light-ion transport based on a quasi-elastic/multiple production assumption allowing improved agreement of the neutron/light-ion fluence compared with results of three Monte Carlo (MC) codes in the sense that the variance with respect to the individual MC results is less than the variance among the MC code results. The current numerical methods are no longer the main limitation to HZETRN code development and further changes in the nuclear model are required. In a prior study, an improved quasi-elastic spectrum based on a solution of the transport approximation to nuclear media effects showed promise, but the remaining multiple-production spectrum was based on a database derived from the Ranft model that used Bertini multiplicities. In the present paper, we will implement a more complete Serber first step into the 3DHZETRN-v2 code, but we retain the Bertini-Ranft branching ratios and evaporation multiplicities. It is shown that the new Serber model in the 3HZETRN-v2 code reduces the variance with individual MC codes, which are largely due to nuclear cross section model differences. The code will be available through the software system, OLTARIS, for shield design and validation and provides a basis for personal computer software capable of space shield analysis and optimization.

Updated deterministic radiation transport for future deep space missions.

NASA's deterministic transport code HZETRN, and its three-dimensional (3D) counterpart, 3DHZETRN, are being used to characterize the space radiation environment over a wide range of scenarios, including future planned missions to the moon or Mars. Combined with available spaceflight measurements, these tools provide the fundamental input for risk models used to quantify possible astronaut health decrements and satisfy agency limits in support of exploration initiatives. Further research is therefore needed to improve radiation transport and nuclear physics models while at the same time continuing to expand the available measurement database (ground-based and spaceflight) to validate such efforts. In this work, significant updates to the deterministic radiation transport models are presented. Charged muons and pions are fully coupled with the existing solutions developed for neutron and light ion (Z ≤ 2) transport. This update includes the 3D nature of pion production as well as the pion interactions, resulting in further production of energetic nucleons within shielding. Additional updates related to low energy proton recoils in hydrogenous materials and capture/decay processes associated with charged pions at rest are also described. Included in this work is the coupling of single and double-differential cross sections from Geant4 into HZETRN and 3DHZETRN. This enables a direct comparison of deterministic and Monte Carlo transport methodologies using the same nuclear databases for specific interactions. Comparisons between Geant4 and 3DHZETRN are shown and establish that the transport methodologies are in excellent agreement when the same cross sections are used. The deterministic codes are also compared to ISS data, and it is found that the updated 3D procedures are within measurement uncertainty (±5%) at cutoff rigidities below 1 GV, which approaches free space conditions.

Higher Rates of Preventive Health Care With Commercial Insurance Compared With Medicaid: Findings From the Arkansas Health Care Independence "Private Option" Program.

BACKGROUND: A requirement of the Arkansas Medicaid Section 1115 demonstration waiver was to evaluate the level of care received for Medicaid expansion eligible beneficiaries enrolled in commercial Qualified Health Plans (QHPs) in the Health Care Independence "Private Option" Program. This allowed for a direct comparison of Medicaid and commercial system performance serving similar newly covered adults. RESEARCH DESIGN: In 2014, assignment to either Medicaid or a QHP was made based upon a psychometrically derived continuous composite score to exceptional health care needs assessment screener using a sharp a priori threshold cutpoint. Using a regression discontinuity design we compared preventive care (flu vaccination and screening rates) services in the 2 programs over 3 years. RESULTS: Compared with Medicaid enrollees, a higher percentage of QHP enrollees consistently received eligible preventive care screenings with 15.3, and 6.9% more receiving at least 1 or all eligible screenings, respectively. For individual preventive care outcomes and compared with Medicaid enrollees over the 3 years under study, a higher percentage of eligible QHP enrollees received a flu shot, cholesterol screenings, glycated hemoglobin assessment, and cervical and breast cancer periodic assessments. No differences were found for colorectal periodic assessments. CONCLUSIONS: These findings suggest that at least for preventive services, the Medicaid federal equal access requirement is not being met for those within Medicaid fee-for-service coverage. This persisted across all 3 years of the program. Differential payment rates for services between Medicaid and QHPs are likely a major contributing factor.

Application of multi-criteria decision analysis to assess sampling strategies in eutrophic urbanized waterbodies.

Different water quality sampling practices such as location selection or frequency can inform future watershed management strategies. The objective of this work was to compare water quality sampling strategies based on different weighted criteria to determine the optimal sampling frequency and sampling location for an urbanized, eutrophic, freshwater system. Weekly water sampling was conducted over a 2-year period at five locations for six water quality parameters. This high frequency (HF) dataset was then deconstructed into a lower frequency (LF) dataset to simulate a monthly sampling strategy. Statistical analyses conducted showed that for all sampling locations the LF datasets were not significantly different from the HF datasets, suggesting monthly sampling is sufficient to capture the overall water quality conditions in this system. A multi-criteria decision analysis was constructed for statistical and operational criteria to determine the optimal sampling locations given different criteria weights. Results showed that the optimal sampling location changed depending on the criteria weighting, suggesting that statistical analyses alone would not be sufficient to determine optimal sampling locations in this system. This analysis was then used if optimal sampling location depended on specific water quality monitoring goals. Results showed that the optimal location depends on the particular water quality monitoring goals and that this effect should also be considered in the design of future sampling programs.

Using Post-discharge Home Visitation to Improve Cultural Sensitivity and Patient-centered Discharge Planning by Internal Medicine Trainees.

BACKGROUND: Patient-centered discharge planning improves transitional care and health outcomes for vulnerable adults. The HOME Initiative was an educational intervention aiming to improve trainees' patient-centered discharge planning skills. METHODS: Using a quasi-experimental design, 52 internal medicine residents at an academic medical center were randomized to intervention or control in 2014-2015. Intervention interns visited recently discharged patients during inpatient rotations. Interns addressed patient deficits in understanding, rectified medication errors, and provided health education. RESULTS: Over three-quarters (77%) of intervention interns completed pre-and post-tests. Intervention interns reported significant improvements in patient-centered discharge planning skills and delivery of culturally sensitive care. Through improved communication skills, residents more effectively elicited patients' illness narratives and assessed their patients' safety (0.65; p=.05), functional status (0.79; p=.02) and health literacy (0.70; p=.01). CONCLUSION: Structured home visitation with recently discharged patients is a valuable tool for medical residents to learn patient-centered discharge planning and improve delivery of culturally sensitive care.

The cost of Mycobacterium avium complex lung disease in Canada, France, Germany, and the United Kingdom: a nationally representative observational study.

BACKGROUND: Management of nontuberculous mycobacterial lung disease (NTMLD) consists of a long-term multi-drug antibiotic regimen, yet many patients do not achieve culture conversion. We estimated the NTMLD-related direct medical costs in Canada, France, Germany, and the United Kingdom (UK) among refractory patients who were infected with Mycobacterium avium complex (MAC), without concomitant cystic fibrosis, tuberculosis, or HIV. METHODS: We conducted a retrospective observational physician survey of nationally representative samples. The survey captured anonymized information about patients' treatment histories for NTMLD-related health care resource utilization over a 24-month period. We summarized NTMLD-related resource use and estimated the total economic burden, from each country's health care payer perspective. RESULTS: In total, 59 physicians provided data on 157 patients. The average person time observed during the 24-month period was 1.7 years (SD: 0.4); 17% of patients died by the end of the study period. The major components of NTMLD-related direct medical costs among refractory patients were hospitalizations (varying from 29% of total annual costs in the UK to 69% in France), outpatient visits (8% in Canada to 51% in the UK), and outpatient testing such as post-diagnostic sputum testing, bronchial wash/lavage, spirometry, biopsies, imaging, and electrocardiograms (5% in France to 35% in Canada). In this patient cohort, the average direct medical costs per person-year, in local currencies, were approximately $16,200 (Canada), €11,600 (Germany), €17,900 (France) and £9,700 (UK). CONCLUSIONS: Based on this study's findings, we conclude that managing patients with refractory NTMLD caused by MAC is associated with a substantial economic burden.

Correction to: Medical and financial burden of acute intermittent porphyria.

Due to a typesetting error the wrong figure 2 was used.

Medical and financial burden of acute intermittent porphyria.

INTRODUCTION: A small proportion of patients with acute intermittent porphyria (AIP) suffer from recurrent porphyric attacks, with a severely diminished quality of life. In this retrospective case-control study, the burden of disease is quantified and compared among three AIP patient subgroups: cases with recurrent attacks, cases with one or occasional attacks and asymptomatic carriers. METHODS: Data from patient records and questionnaires were collected in patients between 1960 and 2016 at the Erasmus Medical Center, Rotterdam, the Netherlands. We collected symptoms related to porphyria, porphyria related complications, attack frequency, hospitalisation frequency, hospitalisation days related to acute porphyric attacks, frequency of heme infusions and medical healthcare costs based on hospitalisations and heme therapy. RESULTS: In total 11 recurrent AIP cases, 24 symptomatic AIP cases and 53 AIP carriers as controls were included. All recurrent patients reported porphyria related symptoms, such as pain, neurological and/or psychiatric disorders, and nearly all developed complications, such as hypertension and chronic kidney disease. In the recurrent cases group, the median lifelong number of hospitalisation days related to porphyric attacks was 82 days per patient (range 10-374), and they spent a median of 346 days (range 34-945) at a day-care facility for prophylactic heme therapy; total follow-up time was 243 person-years (PYRS). In the symptomatic non-recurrent group the median lifelong number of hospitalisation days related to porphyric attacks was 7 days per patient (range 1-78), total follow-up time was 528 PYRS. The calculated total medical healthcare cost for recurrent cases group was €5.8 million versus €0.3 million for the symptomatic cases group.