Coordinating Outpatient Care for Pregnant and Postpartum Women with Opioid Use Disorder: Implications from the COACHH Program.

Purpose With the rise of opioid use disorder (OUD) among women of childbearing age, effective care models must address the complex needs of pregnant and postpartum women with OUD. This paper describes promising practices and implementation challenges from the Collaborative Outreach and Adaptable Care at Hallmark Health (COACHH) program, which utilizes a collaborative care team to coordinate outpatient care for pregnant and postpartum women with OUD. Description Semi-structured interviews were conducted with members of the COACHH team to discuss program logistics and takeaways. Interviews were coded to analyze themes. Assessment The COACHH team identified the need for specialized, time-intensive care coordination to address the unique needs of pregnant and postpartum women with OUD. First, the team prioritizes forming trusting relationships with patients to holistically understand patients' needs, improve patient engagement, and connect patients with resources. Second, the wide range of patient needs necessitates a team with diverse professional skills, whose members share an understanding of addiction and pregnancy. Third, finding the right quantitative outcome measurements is difficult; instead, success is measured in qualitative terms, stressing relationships and engagement as signals of change. Finally, the team encounters challenges with low referral rates, lack of provider awareness, and fragmented services. Conclusion We identified care delivery and program design considerations that may inform others who wish to coordinate care for pregnant and postpartum women with OUD. The program continues to face challenges enrolling patients and measuring outcomes, reflecting the need for tailored approaches and metrics for this population.

Skin Sodium and Hypertension: a Paradigm Shift?

PURPOSE OF REVIEW: Dietary sodium is an important trigger for hypertension and humans show a heterogeneous blood pressure response to salt intake. The precise mechanisms for this have not been fully explained although renal sodium handling has traditionally been considered to play a central role. RECENT FINDINGS: Animal studies have shown that dietary salt loading results in non-osmotic sodium accumulation via glycosaminoglycans and lymphangiogenesis in skin mediated by vascular endothelial growth factor-C, both processes attenuating the rise in BP. Studies in humans have shown that skin could be a buffer for sodium and that skin sodium could be a marker of hypertension and salt sensitivity. Skin sodium storage could represent an additional system influencing the response to salt load and blood pressure in humans.

Historical Inequities in Medical Education - Commitment to Opportunity, Diversity, and Equity at the University of Hawai'i School of Medicine.

Medical education in the US has contributed to institutionalized racism through historically exclusionary practices, which has led to health disparities and inequities in health care today. The 1910 Flexner report, which favored schools with greater resources, led to the closure of nearly half of medical schools in the Us, which were mostly small schools located in rural communities that served economically disadvantaged, ethnic minority, and female populations. Closing these schools ultimately limited the availability of physicians willing to serve disadvantaged and minority populations in impoverished and underserved communities. In order to transform medical education to be more equitable, medical schools must be proactive in opportunity, diversity, and equity efforts. This not only includes efforts in admissions and faculty hiring, but also curricula related to social and health disparities, interracial interactions between students and faculty, and service learning activities that engage and work with marginalized communities. The University of Hawai'i John A. Burns School of Medicine has a longstanding commitment to diversity, which is integral to the school's mission. Providing opportunities to underserved populations has been a priority since establishment of the school. As one of the most diverse univeristies in the US, the school of medicine continues to focus on opportunity, diversity, and equity priorities in both its strategic planning and overall mission.

Novel Relaxin Receptor RXFP1 Agonist AZD3427 in the Treatment of Heart Failure: A Phase 1a/b, First-in-Human, Randomized, Single-Blind, Placebo-Controlled Study.

BACKGROUND: Heart failure mortality remains high despite recent progress in pharmacological treatment. AZD3427 is a selective long-acting analog of relaxin, a vasodilatory hormone with antifibrotic effects. We assessed the safety, pharmacokinetics, and pharmacodynamics of AZD3427 in healthy volunteers and patients with heart failure on standard-of-care therapy. METHODS AND RESULTS: In this first-in-human, phase 1a/b, randomized, single-blind, placebo-controlled study, healthy volunteers were randomized 6:2 to receive a single dose of AZD3427 or placebo by subcutaneous injection in 5 mixed-ethnicity cohorts (5, 10, 30, 90, or 270 mg) and 1 Japanese-descent cohort (270 mg), or by intravenous injection in 1 cohort (15 mg). After confirming safety and tolerability in healthy volunteers, 3 cohorts of patients with heart failure and left ventricular ejection fraction ≤40% and 3 cohorts with ejection fraction ≥41% were randomized 6:2 to receive 5 weekly doses of AZD3427 (5, 15, or 45 mg) or placebo by subcutaneous injection. In total, 56 healthy volunteers and 48 patients with heart failure were randomized. AZD3427 was well tolerated at all doses. After subcutaneous administration, AZD3427 was absorbed slowly, and exposure was approximately linear across the dose range. In patients with heart failure, AZD3427 terminal half-life was 13 to 14 days and there were numerical increases in stroke volume and estimated glomerular filtration rate. No treatment-emergent antidrug antibodies were detected. CONCLUSIONS: AZD3427 had favorable safety and pharmacokinetic profiles. Hemodynamic changes in patients with heart failure were consistent with the anticipated effects of a relaxin analog. These findings support further development of AZD3427 as a novel long-term treatment for patients with heart failure. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04630067.

Medical School Faculty and Staff Well-being in Fall 2020 during the COVID-19 Pandemic.

The COVID-19 pandemic increased stress and worry among faculty and staff members at universities across the US. To assess the well-being of university faculty and staff, a survey was administered at a medical school in the state of Hawai'i during early fall 2020. The purpose of the exploratory study was to assess and gauge faculty and staff members' well-being regarding the school's response to COVID-19. Participants in this study represented a convenience sample of compensated teaching, research, and administrative faculty and staff members. A total of 80 faculty and 73 staff members participated. Overall, faculty and staff reported relatively low levels of worries and stress. Staff members reported greater levels of worry and stress than faculty members in 8 of the 11 questions. Statistical differences were detected in 3 questions, with staff reporting higher levels of worry and stress in their health and well-being of themselves (P < .001), paying bills (P < .001), and losing their jobs (P < .001). Both faculty and staff reported good overall satisfaction on the timeliness and clarity of messages that they received, support from leadership and the school, and support to adjust to changes in response to COVID-19. For both faculty and staff, the greatest worry or concern for the open-ended question on worry and stress was related to financial and economic issues. Data from this survey and can contribute to an understanding of medical school employee well-being during a major operational disruption and may help develop policies and programs to assist employees in different employment categories during future disruptions.

Time-course of the human thoracic aorta ageing process assessed using uniaxial mechanical testing and constitutive modelling.

Age-related remodelling of the arterial wall shifts the load bearing from the compliant elastin network to the stiffer collagen fibres. While this phenomenon has been widely investigated in animal models, human studies are lacking due to shortage of donors' arteries. This work aimed to characterise the effect of ageing on the mechanical properties of the human aortic wall in the circumferential direction. N = 127 thoracic aortic rings (age 18-81 years) were subjected to circumferential tensile testing. The tangential elastic modulus (Kθθθθ) was calculated at pressure-equivalent stresses ranging 60-100 mmHg. Further, the mechanical data were fitted using the Holzpafel-Gasser-Ogden hyperelastic strain energy function (HGO-SEF), modelling the superimposed response of an isotropic matrix (elastin) reinforced by collagen fibres. Kθθθθ increased with age across at all considered pressures (p < 0.001), although more strongly at higher pressures. Indeed, the slope of the linear Kθθθθ-pressure relationship increased by 300% from donors <30 to ≥70 years (4.72± 2.95 to 19.06± 6.82 kPa/mmHg, p < 0.001). The HGO-SEF elastin stiffness-like parameter dropped by 31% between 30 and 40 years (p < 0.05) with non-significant changes thereafter. Conversely, changes in HGO-SEF collagen parameters were observed later at age>60 years, with the exponential constant increasing by ∼20-50 times in the investigated age range (p < 0.001). The results provided evidence that the human thoracic aorta undergoes stiffening during its life-course. Constitutive modelling suggested that these changes in arterial mechanics are related to the different degeneration time-courses of elastin and collagen; likely due to considerable fragmentation of elastin first, with the load bearing shifting from the compliant elastin to the stiffer collagen fibres. This process leads to a gradual impairment of the aortic elastic function with age.

Nonadherence to antihypertensive medications amongst patients with uncontrolled hypertension: A retrospective study.

ABSTRACT: Medication nonadherence represents a modifiable risk factor for patients with hypertension. Identification of nonadherent patients could have significant clinical and economic implications in the management of uncontrolled hypertension.We analysed the results of 174 urinary adherence screens from patients referred to Addenbrooke's Hospital, Cambridge, for uncontrolled hypertension. Cases were identified for evaluation by results of liquid chromatography-tandem mass spectrometry of urine samples (males: 91; females: 83; age range: 17-87). We performed a binary logistic regression analysis for nonadherence using age, sex, and number of medications prescribed (both antihypertensives and non-antihypertensives separately) as independent predictors. Rates of nonadherence for individual antihypertensive drugs were calculated if prescribed to ≥10 patients.The overall rate of nonadherence to one or more prescribed antihypertensive medications was 40.3%. 14.4% of all patients were nonadherent to all prescribed antihypertensive medications (complete nonadherence), whereas 25.9% of all patients were nonadherent to at least 1, (but not all) prescribed antihypertensive medications (partial nonadherence). 72% of patients were prescribed ≥3 antihypertensives And for every increase in the number of antihypertensive medications prescribed, nonadherence increased with adjusted odds ratios of 2.9 (P < .001). Logistic regression showed that women were 3.3 times more likely to be nonadherent (P = .004). Polypharmacy (≥6 medications prescribed for hypertension and/or concomitant comorbidities) was prevalent in 52%. Bendroflumethiazide and chlortalidone demonstrated the highest and lowest nonadherences respectively (45.5% and 11.8%).Rate of nonadherence in patients with hypertension was significantly impacted by sex and number of antihypertensive medications prescribed. Understanding these factors is crucial in identifying and managing nonadherence.

Design of FLAIR: a Phase 2b Study of the 5-Lipoxygenase Activating Protein Inhibitor AZD5718 in Patients With Proteinuric CKD.

INTRODUCTION: Patients with chronic kidney disease (CKD) remain at risk for kidney and cardiovascular events resulting from residual albuminuria, despite available treatments. Leukotrienes are proinflammatory and vasoconstrictive lipid mediators implicated in the etiology of chronic inflammatory diseases. AZD5718 is a potent, selective, and reversible 5-lipoxygenase activating protein (FLAP) inhibitor that suppresses leukotriene production. METHODS: FLAIR (FLAP Inhibition in Renal disease) is an ongoing phase 2b, randomized, double-blind, placebo-controlled, multicenter study to evaluate the efficacy and safety of AZD5718 in patients with proteinuric CKD with or without type 2 diabetes. Participants receive AZD5718 at 3 different doses or placebo once daily for 12 weeks, followed by an 8-week extension in which they also receive dapagliflozin (10 mg/d) as anticipated future standard of care. The planned sample size is 632 participants, providing 91% power to detect 30% reduction in urinary albumin-to-creatinine ratio (UACR) between the maximum dose of AZD5718 and placebo. The dose-response effect of AZD5718 on UACR after the dapagliflozin extension is the primary efficacy objective. Key secondary objectives are the dose-response effect of AZD5718 plus current standard of care on UACR and acute effects of treatment on the estimated glomerular filtration rate. Safety, tolerability, AZD5718 pharmacokinetics, and analyses of biomarkers that may predict or reflect response to AZD5718 are additional objectives. CONCLUSION: FLAIR will provide data on the effects of 5-lipoxygenase pathway inhibition in patients with proteinuric CKD with or without type 2 diabetes, and will form the basis for future clinical trials (ClinicalTrials.gov: NCT04492722).

Teaching mass casualty triage skills using iterative multimanikin simulations.

OBJECTIVE: Effective mass casualty triage requires rapid and accurate decision making. First responders need to be trained, but opportunities to practice triage and receive individualized feedback during traditional mass casualty (MC) exercises are uncommon. It was hypothesized that novice learners would improve in speed, accuracy, and self-efficacy after deliberate practice triaging multiple simulated casualties in a MC exercise using high-fidelity manikins. METHODS: Learners initially developed baseline knowledge of MC triage by listening to four short podcasts and passing a written examination. They then experienced three sequential MC scenarios (A, B, and C) consisting of five manikin simulations each, coupled with individual feedback after each scenario. Students served as their own controls. A triage score (TS) and intervention score (IS) were recorded. For the TS, one point was awarded for each correctly identified main problem, required intervention, and triage category. For the IS, one point was awarded for each correctly applied intervention. Before-and-after surveys measured self-efficacy and reaction to the training. RESULTS: Twenty-one medical students were enrolled and 20 students passed the examination. The TS and IS improved significantly during scenario B (p < 0.001). Time to complete each scenario decreased significantly from scenario A (8 min 27 sec) to scenario B (6 min 19 sec) (p < 0.001), but not from scenario B to scenario C (5 min 40 sec). Self-efficacy improved significantly after scenario C for prioritizing treatment and resources, identifying high-risk casualties, and learning to be an effective first responder. CONCLUSION: Novice learners demonstrated improved triage and intervention scores, speed, and self-efficacy during an iterative, multimanikin MC training experience.

Comparison of outcomes in a traditional versus accelerated nursing curriculum.

In this descriptive study, graduates of a traditional baccalaureate nursing program were compared with graduates of an accelerated baccalaureate program at the same university between 1991 and 2006. A survey was sent to a random sample of two groups: traditional baccalaureate graduates and graduates of the accelerated program who had previous degrees in another major and completed the nursing curriculum in a shorter time frame than the traditional students, resulting in a total sample of 73 graduates. Outcome variables included demographics, NCLEX passing rates, transitioning to the professional role, employment, professional development, certifications and self-reported reasons the respondents entered the nursing profession and why they remained. There were no statistically significant differences between the two groups on these variables. Results of a t-test revealed that the GPA of the accelerated group was significantly higher than the traditional group. Future considerations include the impact that accelerated program development may have on both the current and projected nursing shortage.

Complex care models to achieve accountable care readiness: Lessons from two community hospitals.

Massachusetts' community hospitals face the challenge of achieving accountable care readiness with fewer financial and operational resources and a higher share of publicly-insured patients than their academic medical center counterparts. They are thus doubly constrained to make the investments necessary to perform in a value-based payment environment. Hallmark Health System and Lowell General Hospital are among 25 community hospital awardees engaged with the Massachusetts Health Policy Commission's Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program to implement clinical transformation programs to reduce unnecessary hospital utilization; enhance care for individuals with social, behavioral, and medical complexity; and improve post-acute community-based care, as means to advance accountable care readiness. The programs are payer-blind and designed to operate at-scale based on clinical and/or utilization criteria. Using examples from Hallmark Health System and Lowell General Hospital, we report on early lessons learned, representative of experiences from across the Phase 2 cohort: 1) locally-derived data enables hospitals to plan and implement action-oriented initiatives that are tailored to their communities; 2) investments in appropriate technologies facilitate near real-time patient engagement upon presentation to the acute care setting and/or immediately post-discharge; 3) non-medical providers are a cost-effective and high-value addition to complex care teams serving individuals with complex needs; and 4) collaboration with community partners improves care continuity and promotes stability outside the hospital-a promising approach to cost-effective population health management.

Artificial Lithium Toxicity: A Case Report and Review of the Literature.

Lithium toxicity results in a range of gastrointestinal and neurologic signs and symptoms and can ultimately be fatal. Serum lithium levels may be unreliable when evaluating patients for toxicity, since levels may not be elevated in patients on chronic lithium therapy. Serum lithium levels may also be artificially elevated if blood is collected in a tube containing lithium heparin. We present a case of a woman on chronic lithium therapy whose lithium level was artificially elevated due to blood collection in an incorrect tube.

Planning for assessment of student learning outcomes: a process within your grasp.

Assessment in educational institutions is mandated by the public and by accrediting organizations. Faculty must plan for program assessment within the context of the college or university goals and assessment projects. Within the department or college of nursing, student learning outcomes must be assessed at the total program level and at the course and classroom levels. Faculty who are motivated to plan assessments and use outcome data should take leadership in the process. The process consists of determining the outcomes to be assessed, the measures to be used, and the standards to be reached. When data has been collected, it must be evaluated and used to make improvements. Finally, the assessment process itself should be assessed. This article gives examples of assessment methods for all levels of assessment at the institution, but especially at the program and course levels. A departmental assessment blueprint is included. The end result of implementation of an assessment plan is that at every level of the institution, excellence should be enhanced.

Examining e-Health literacy and the digital divide in an underserved population in Hawai'i.

Seeking health information is one of the leading uses for the Internet and World Wide Web (WWW). Research has found the amount one benefits from e-Health information (health information from electronic sources) is directly related to the level of e-Health literacy. e-Health literacy is defined as "the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem." In order to gain a further understanding of the effects and use of technology, the digital divide, and the relationship between technology utilization and health outcomes, focus group interviews were conducted with participants diagnosed with diabetes and currently residing in a Medically Underserved Area. Overall, 25 volunteers participated in the four focus group meetings. Based on the focus group discussions, a general low e-Health literacy rate was identified. This was demonstrated by the lack of access to the Internet and the skills needed to retrieve health information. Of the 25 participants, 64% reported having Internet access at some level, but, only one reported going on the Internet every day. When the barriers to using the Internet were discussed, many participants expressed a lack of knowledge in how to retrieve information. Results of this study further show that having access to technology is not necessarily associated with usage. This dynamic is evolving into a new form of digital divide, gap in information retrieval and usage, versus gap in access. This is the first known study to examine e-Health literacy in an underserved population in Hawai'i. With the proliferation of information and communication technology and the transformation of information retrieval to be mobile and "on demand", a multi-pronged communication and education strategy is needed to explore how technology can improve e-Health literacy and health outcomes among underserved populations.

Medical school hotline: A History of the University of Hawai'i Postgraduate Medical Education Program at Okinawa Chubu Hospital, 1966-2012.

The University of Hawai'i (UH) has been collaborating with Okinawa Prefectural Chubu Hospital for over 46 years. This collaboration started as a post-World War II effort to increase the physician workforce. At the initiation of the US Army and State Department, the University of Hawai'i was recruited, in cooperation with the government of the Ryukyus and USCAR, to initiate a US style postgraduate clinical training program. The Postgraduate Medical Training Program of University of Hawai'i at Okinawa Chubu Hospital introduced a style of training similar to that in the US by offering a rotating internship. The initial contract had UH establish and run the Postgraduate Medical Training Program of University of Hawaii at Okinawa Central Hospital. After Okinawa's reversion to Japan, under a new contract, UH physicians participated as consultants by providing lectures at "grand rounds" and guidance to faculty, staff, and students. To date, 895 physicians have completed the University of Hawai'i Postgraduate Medical Training Program with 74 currently training. Approximately 662 (74%) of the trainees have remained in Okinawa Prefecture to practice medicine. As a result, the program has enhanced the physician workforce for the islands of Okinawa and neighbor archipelagos of Miyako and Yaeyama Islands.