Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial.

BACKGROUND: Chronic pain is prevalent among people living with human immunodeficiency virus (PLWH); managing pain with chronic opioid therapy (COT) is common. Human immunodeficiency virus (HIV) providers often diverge from prescribing guidelines. METHODS: This 2-arm, unblinded, cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015 to 2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing, and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences. RESULTS: At 12 months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs 20%; adjusted odds ratio [AOR], 13.38 [95% confidence interval {CI}, 5.85-30.60]; P < .0001). We did not detect a statistically significant difference in early refills (22% vs 30%; AOR, 0.55 [95% CI, .26-1.15]; P = .11), pain severity (6.30 vs 5.76; adjusted mean difference, 0.10 [95% CI, -1.56 to 1.75]; P = .91), or HIV viral load suppression (86.9% vs 82.1%; AOR, 1.21 [95% CI, .47-3.09]; P = .69). CONCLUSIONS: TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.

Breast Cancer Treatment Delays at an Urban Safety Net Hospital Among Women Experiencing Homelessness.

Disparities in outcomes for vulnerable women is an ongoing problem. Homelessness and breast cancer treatment outcomes is understudied. This is a descriptive study exploring types of homelessness and treatment delays at an urban safety net hospital providing care to a vulnerable patient population.This study is a retrospective chart review of homeless female patients diagnosed with breast cancer between January 1, 2000 and December 31, 2014. Data for this study were acquired from the hospital cancer registry and electronic medical record. All demographic characteristics, time to treatment and factors related to delays to treatment were analyzed descriptively, reporting frequencies and proportions. The total number of individuals analyzed was 24. All except two subjects were delayed to treatment (≥ 30 days from diagnosis to treatment). Most women in this cohort were categorized as chronically homeless (46%) with the rest categorized as transitionally (29%) or episodically (12%) homeless. The majority of subjects (70%) were Black, non-Hispanic. All except one subject were publicly insured (71% Medicaid; 12% Medicare) or uninsured (8%). Regardless of type of homelessness, most subjects were either 30-60 or 60-90 days delayed. Those who were chronically homeless experienced significantly more delays to first treatment (56% of those who were delayed 30-60 days and 57% of those who were delayed 60-90 days; p value 0.006) than those who were episodically or transitionally homeless. Significant delays and barriers to breast cancer treatment exist among women experiencing homelessness. Further studies to improve breast cancer care for homeless women are warranted.

Provider opioid prescribing practices and the belief that opioids keep people living with HIV engaged in care: a cross-sectional study.

We describe HIV providers' opioid prescribing practices and assess whether belief that chronic opioid therapy (COT) keeps people living with HIV (PLWH) engaged in care is associated with differences in these practices among providers from two HIV clinics. We conducted logistic regression to evaluate the association between the belief that COT keeps PLWH engaged in care and at least one component of guideline-recommended care (i.e., urine drug tests, treatment agreements, and/or prescription monitoring program use). The sample included 41 providers with a median age of 42 years, 63% female, 37% non-white. Routine adherence to guideline-recommended practices was: 34% urine drug tests, 27% treatment agreements, and 17% prescription monitoring program. Over half [54%] agreed that COT keeps PLWH engaged in care. There was no significant association between belief that COT keeps PLWH engaged in care and routinely providing any recommended COT care component (aOR 2.38; 95% CI 0.65-8.73). Most HIV providers do not routinely follow guidelines for opioid prescribing. We observed a positive association between belief that COT keeps PLWH engaged in care and following any guideline-recommended prescribing practices, although the result was not statistically significant. Interventions are needed to improve guideline-concordant care for COT by HIV providers.

Intravenously administered nanoparticles increase survival following blast trauma.

Explosions account for 79% of combat-related injuries, leading to multiorgan hemorrhage and uncontrolled bleeding. Uncontrolled bleeding is the leading cause of death in battlefield traumas as well as in civilian life. We need to stop the bleeding quickly to save lives, but, shockingly, there are no treatments to stop internal bleeding. A therapy that halts bleeding in a site-specific manner and is safe, stable at room temperature, and easily administered is critical for the advancement of trauma care. To address this need, we have developed hemostatic nanoparticles that are administered intravenously. When tested in a model of blast trauma with multiorgan hemorrhaging, i.v. administration of the hemostatic nanoparticles led to a significant improvement in survival over the short term (1 h postblast). No complications from this treatment were apparent out to 3 wk. This work demonstrates that these particles have the potential to save lives and fundamentally change trauma care.

Pregnancy Care Utilization, Experiences, and Outcomes Among Undocumented Immigrants in the United States: A Scoping Review.

BACKGROUND: Undocumented immigrants face many barriers in accessing pregnancy care, including language differences, implicit and explicit bias, limited or no insurance coverage, and fear about accessing services. With the national spotlight on maternal health inequities, the current literature on undocumented immigrants during pregnancy requires synthesis. OBJECTIVE: We aimed to describe the literature on pregnancy care utilization, experiences, and outcomes of undocumented individuals in the United States. METHODS: We performed a scoping review of original research studies in the United States that described the undocumented population specifically and examined pregnancy care utilization, experiences, and outcomes. Studies underwent title, abstract, and full-text review by two investigators. Data were extracted and synthesized using descriptive statistics and content analysis. RESULTS: A total of 5,940 articles were retrieved and 3,949 remained after de-duplication. After two investigators screened and reviewed the articles, 29 studies met inclusion criteria. The definition of undocumented individuals varied widely across studies. Of the 29 articles, 24 showed that undocumented status and anti-immigrant policies and rhetoric are associated with decreased care utilization and worse pregnancy outcomes, while inclusive health care and immigration policies are associated with increased prenatal and postnatal care utilization as well as improved pregnancy outcomes. CONCLUSIONS: The small, heterogeneous literature on undocumented immigrants and pregnancy care is fraught with inconsistent definitions, precluding comparisons across studies. Despite areas in need of further research, the signal among published studies is that undocumented individuals experience variable access to pregnancy care, heightened fear and stress regarding their status during pregnancy, and worse outcomes compared with other groups, including documented immigrants.

Trends in facility-based childbirth and barriers to care at a birth center and community hospital in rural Chiapas, Mexico: A mixed-methods study.

OBJECTIVE: To assess trends in childbirth at a hospital-birth center among women living in Compañeros En Salud (CES)-affiliated communities in Chiapas, Mexico and explore barriers to childbirth care. Our hypothesis was that despite interventions to support and incentivize childbirth at the hospital-birth center, the proportion of births at the hospital-birth center among women from Compañeros En Salud-affiliated communities has not significantly changed after two years. We suspected that this may be due to structural factors impacting access to care and/or perceptions of care impacting desire to deliver at the birth center. DESIGN: This explanatory mixed-methods study included a retrospective Compañeros En Salud maternal health census review followed by quantitative surveys and semi-structured qualitative interviews. PARTICIPANTS AND SETTING: Participants were women living in municipalities in the mountainous Sierra Madre region of Chiapas, Mexico who received prenatal care in one of 10 community clinics served by Compañeros En Salud. Participants were recruited if they gave birth anywhere other than the primary-level rural hospital and adjacent birth center supported by Compañeros En Salud, either at home or at other facilities. MEASUREMENTS: We compared rates of birth at the hospital-birth center, other health facilities, and at home from 2017-2018. We conducted surveys and interviews with women who gave birth between January 2017-July 2018 at home or at facilities other than the hospital-birth center to understand perceptions of care and decision-making surrounding childbirth location. FINDINGS: We found no significant difference in rates of overall number of women birthing at the hospital-birth center from Compañeros En Salud-affiliated communities between 2017 and 2018 (p=0.36). Analysis of 158 surveys revealed distance (30.4%), time (27.8%), and costs (25.9%) as reasons for not birthing at the hospital-birth center. From 27 interviews, negative perceptions and experiences of the hospital included low-quality and disrespectful care, low threshold for medical interventions, and harm and suffering. Partners or family members influenced most decisions about childbirth location. KEY CONCLUSIONS: Interventions to minimize logistical barriers may not be sufficient to overcome distance and perceptions of low-quality, disrespectful care. IMPLICATIONS FOR PRACTICE: Better understanding of complex decision-making around childbirth will guide Compañeros En Salud in developing interventions to further meet the needs and preferences of birthing women in rural Chiapas.

Establishing Academic Homes for Homelessness: A Call to Action.

Although homelessness ranks as one of society's most pressing and visible health equity challenges, the academic community has not actively addressed its health impacts, root causes, and potential solutions. Few schools and programs of public health even offer a basic course for students. In the COVID-19 pandemic era, academia must demonstrate urgency to address homelessness and educate learners, motivate fledgling researchers, inform policy makers, offer community-engaged and evidence-based studies, and join in the growing national debate about best approaches. At a minimum, every public health student should understand the interdisciplinary challenges of homelessness, its implications for health equity, and opportunities to address the crisis. We call for academia, particularly schools and programs of public health, to engage more fully in national partnerships to care for members of society who are most marginalized, in terms of health and behavioral health outcomes, quality of life, and connectedness.

Intravenous hemostatic nanoparticles increase survival following blunt trauma injury.

Trauma is the leading cause of death for people ages 1-44, with blood loss comprising 60-70% of mortality in the absence of lethal CNS or cardiac injury. Immediate intervention is critical to improving chances of survival. While there are several products to control bleeding for external and compressible wounds, including pressure dressings, tourniquets, or topical materials (e.g., QuikClot, HemCon), there are no products that can be administered in the field for internal bleeding. There is a tremendous unmet need for a hemostatic agent to address internal bleeding in the field. We have developed hemostatic nanoparticles (GRGDS-NPs) that reduce bleeding times by ~50% in a rat femoral artery injury model. Here, we investigated their impact on survival following administration in a lethal liver resection injury in rats. Administration of these hemostatic nanoparticles reduced blood loss following the liver injury and dramatically and significantly increased 1 h survival from 40 and 47% in controls (inactive nanoparticles and saline, respectively) to 80%. Furthermore, we saw no complications following administration of these nanoparticles. We further characterized the nanoparticles' effect on clotting time (CT) and maximum clot firmness (MCF) using rotational thromboelastometry (ROTEM), a clinical measurement of whole-blood coagulation. Clotting time is significantly reduced, with no change in MCF. Administration of these hemostatic nanoparticles after massive trauma may help staunch bleeding and improve survival in the critical window following injury, and this could fundamentally change trauma care.

Colorectal cancer screening practices in Alabama: a survey of primary care physicians.

In order to inform efforts to increase screening rates for colorectal cancer (CRC), we conducted a survey of Alabama primary care physicians regarding CRC screening practices, educational preferences, and perceptions of obstacles to screening. A mail survey of 2,378 Alabama physicians in Family Medicine, Internal Medicine, and Obstetrics & Gynecology was conducted. Many physicians are not fully up-to-date with current CRC screening practices that could improve patient compliance with screening guidelines. One example is the potential use of high-sensitivity stool tests, such as the fecal immunochemical test, instead of the no longer recommended low-sensitivity guaiac fecal occult blood tests. In addition, enhanced multimedia and web-based approaches to educating physicians and patients could be more fully utilized. Further, greater use of health information technologies could increase screening rates. Enhancing primary care physicians' knowledge of screening modalities and increasing their use of electronic technology could significantly improve colorectal cancer screening outcomes.

Validation and Use of the Measure of Effective Attributes of Trainers in School-Based Implementation of Proactive Classroom Management Strategies.

In-service training is a critical and frequently utilized implementation strategy to support the adoption and delivery of evidence-based practice (EBP) across service settings, but is characteristically ineffective in producing provider behavior changes, particularly when delivered in single exposure didactic events. EBP trainers are in a strategic position to leverage their trainee-perceived characteristics to influence trainees' attitudes, motivation, and intentions to implement, and ultimately increase the likelihood of successful uptake of skills. The purpose of this study was to extend research on the measure of effective attributes of trainers (MEAT) by examining its underlying factor structure and reliability in the context of in-service EBP training for teachers (i.e., structural validity). This study also examined the predictive validity of the MEAT by examining relationships with a measure of teacher intentions to implement EBPs following a standardized training experience (i.e., predictive validity). An exploratory factor analysis (EFA) was employed to determine the latent factors (i.e., subscales of characteristics) that underlie the data. Additionally, a forward selection, stepwise regression was conducted to determine the extent to which trainer attributes could explain variance in intentions to implement. Results indicated that the MEAT was a valid and reliable measure to examine trainer attributes in school settings. Moreover, findings suggested that trainer attributes, particularly those related to trainee perceptions of the trainers' welcoming disposition (i.e., related to trainers' warm, positive temperament and internal character traits), were significantly associated with trainees' intentions to implement the trained upon EBP.

Investigating strategies to increase general education teachers' adherence to evidence-based social-emotional behavior practices: A meta-analysis of the single-case literature.

Educational researchers have produced a variety of evidence-based practices (EBP) to address social, emotional, and behavioral (SEB) needs among students. Yet, these practices are often insufficiently adopted and implemented with fidelity by teachers to produce the beneficial outcomes associated with the EBP, leaving students at risk for developing SEB problems. If ignored, SEB problems can lead to other negative outcomes, such as academic failure. Therefore, implementation strategies (i.e., methods and procedures designed to promote implementation outcomes) are needed to improve teachers' uptake and delivery of EBPs with fidelity. This meta-analysis sought to examine the types and magnitude of effect of implementation strategies that have been designed and tested to improve teacher adherence to SEB EBPs. Included studies (a) used single case experimental designs, (b) employed at least one implementation strategy, (c) targeted general education teachers, and (d) evaluated adherence as a core dimension of fidelity related to the delivery of EBPs. In total, this study included 28 articles and evaluated 122 effect sizes. A total of 15 unique implementation strategies were categorized. Results indicated that, on average, implementation strategies were associated with increases in teacher adherence to EBPs above baseline and group-based pre-implementation trainings alone (g = 2.32, tau = 0.77). Moderator analysis also indicated that larger effects were associated with implementation strategies that used a greater number of unique behavior change techniques (p < .001). Implications and future directions for research and practice regarding use of implementation strategies for general education teachers are discussed.

Training Clinicians to Care for Patients Where They Are.

Homelessness remains a pervasive, long-standing problem in the United States and is poised to increase as a result of the COVID-19 pandemic. Individuals experiencing homelessness bear a higher burden of complex medical and mental health illnesses and often struggle to obtain quality and timely health care. The United States desperately needs to train a workforce to confront this large and growing crisis, but few health professional schools currently devote curricula to the clinical needs of people experiencing homelessness. This article discusses educational and curricular strategies for health professional students. Understanding the health needs of-and the social influences on the lives of-people experiencing homelessness is crucial for addressing this health equity challenge.

Screening for Colorectal Cancer at the Worksite.

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the United States. To increase statewide CRC screening rates, the Alabama Department of Public Health (through a Centers for Disease Control and Prevention [CDC] Colorectal Cancer Control Program grant) partnered with The University of Alabama in Huntsville (UAH) and The University of South Alabama (USA) to provide free CRC screening opportunities to eligible University employees and dependents. Resources were invested at both universities to ensure participant education, tracking, and monitoring. In total, 86 fecal immunochemical tests (FITs) were distributed at the UAH campus and 62 were returned for testing; 146 FITs were distributed on the USA campus with 111 returned. Fecal immunochemical test return rates were over 70% at each site. Most notably, 21 positive FITs were identified among UAH participants and 25 at USA. Findings from both efforts suggest that employer-based screening initiatives are a systematic and replicable means of improving CRC screening.

A Community-Based Approach to Cervical Cancer Prevention: Lessons Learned in Rural Guatemala.

BACKGROUND: One international and three local organizations developed the Santa Ana Women's Health Partnership (SAWHP) to address cervical cancer in Santa Ana Huista, Huehuetenango, Guatemala. This paper describes the structure, outcomes, and lessons learned from our community partnership and program. METHODS: The community partnership developed a singlevisit approach (SVA) program that guided medically underserved women through screening and treatment of cervical cancer. LESSONS LEARNED: The program promoted acceptability of SVA among rural women by engaging local female leaders and improving access to screening services. The program's approach focused on maximizing access and generated interest beyond the coverage area. Distrust among the community partners and weak financial management contributed to the program's cessation after 4 years. CONCLUSIONS: The SAWHP design may guide future implementation of cervical cancer screening programs to reach medically underserved women. Open, ongoing dialogue among leaders in each partner institution is paramount to success.

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

PURPOSE: The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients. METHODS: This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service. RESULTS: Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending. CONCLUSION: Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.

Mental health of undocumented Mexican immigrants: a review of the literature.

The Latino population in the United States, the majority of whom are Mexican, is one of the fastest growing. Similarly, the number of undocumented Mexican immigrants (UMIs) continues to swell. However, little is known about UMIs living in the United States, and much less is known about their mental health status. This interdisciplinary review of the literature aims to outline the current state of knowledge regarding the mental health of UMIs in the United States. Themes isolated from the literature include failure to succeed in the country of origin; dangerous border crossings; limited resources; restricted mobility; marginalization/isolation; blame/stigmatization and guilt/shame; vulnerability/exploitability; fear/fear-based behaviors; and stress, depression, and health implications.

Steroid-Loaded Hemostatic Nanoparticles Combat Lung Injury after Blast Trauma.

In response to the lack of therapeutics for internal bleeding following a traumatic event, we synthesized hemostatic dexamethasone nanoparticles (hDNP) to help alleviate internal hemorrhaging. hDNP consist of a block copolymer, poly(lactic-co-glycolic acid)-poly(l-lysine)-poly(ethylene glycol) conjugated to a peptide, glycine-arginine-glycine-aspartic acid-serine (GRGDS). These particles were evaluated as treatment for primary blast lung injury in a rodent model. Animals were randomly placed into test and control groups, exposed to blast and given immediate injection. Recovery was assessed using physiological parameters and immunohistochemistry. We found that dexamethasone-loaded hemostatic nanoparticles alleviate physiological deprivation caused by blast injury and reduce lung injury damage.