Patient experiences with a transitional, low-threshold clinic for the treatment of substance use disorder: A qualitative study of a bridge clinic.

BACKGROUND: A minority of patients with substance use disorder (SUD) receives treatment, indicating the need for innovation in care for individuals with SUD. Transitional and low threshold models of care for SUD are utilized to address this treatment gap, but there is limited evidence about their effectiveness or patient perspectives on these models. METHODS: Patients participated in semi-structured interviews (N = 29) which explored their experience in a transitional, low threshold, Bridge clinic for the treatment of SUD. In order to reach a diverse patient population across age, gender, housing status, type of SUD, length of stay, and patient status in the clinic, researchers employed maximum variation sampling. Interviews were conducted until no new central concepts emerged. Codes were developed and assigned using an inductive as well as a mixed inductive-deductive approach. RESULTS: Patients identified flexibility and accessibility of services, compassionate approach of providers and staff, use of peers in recovery, and the emphasis on harm reduction as positive features of the model. Patients struggled with transitioning out of the clinic. CONCLUSION: Patients reported positive experiences in a transitional, low threshold clinic for SUD, comparing it favorably to other programs. Patients maintained sobriety more consistently and increasing motivation to adhere to treatment. Patients almost universally appreciated the flexible and harm reduction-oriented model of treatment. Future quantitative research is needed to further examine the effects of low threshold programs on treatment outcomes, including ongoing substance use, treatment retention and overdose mortality, as compared to traditional treatment programs.

Racial Disparities in Inhospital Outcomes for Hepatocellular Carcinoma in the United States.

OBJECTIVE: To study racial disparities in therapeutic interventions and hospitalization outcomes for hepatocellular cancer (HCC) in the United States. PATIENTS AND METHODS: Using the 2011 Nationwide Inpatient Sample (comprising hospitalizations between January 1 and December 31, 2011), we identified patients with HCC-related admissions using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. Among these, we also identified those that were procedure-related (associated with liver transplantation, hepatic resection, radiofrequency ablation, or transarterial chemoembolization). Multivariate regression was performed to identify the contribution of race to therapeutic interventions and outcomes. RESULTS: A total of 22,933 HCC-related hospitalizations were included, of which 10,285 were procedure related (45%). Blacks had a smaller proportion (35%) of procedure-related HCC hospitalizations than did whites (46%) (odds ratio [OR], 0.65; 95% CI, 0.49-0.86). Specifically, blacks had lower odds of liver transplantation (OR, 0.43; 95% CI, 0.26-0.71), hepatic resection (OR, 0.57; 95% CI, 0.33-0.98), and ablation (OR, 0.46; 95% CI, 0.29-0.74) (P=.002) than did whites. Overall, 10.9% of HCC-related admissions resulted in death in blacks as compared with 6.4% in whites (OR, 1.58; 95% CI, 1.12-2.24). CONCLUSION: Among patients admitted for HCC-related hospitalizations, blacks were less likely to receive liver transplantation, hepatic resection, and ablation than whites and had higher inhospital mortality. Identifying racial disparities in health care is a necessary first step to appropriately address and eliminate them.

Motivational interviewing with computer assistance as an intervention to empower women to make contraceptive choices while incarcerated: study protocol for randomized controlled trial.

BACKGROUND: Unplanned pregnancies and sexually transmitted infections (STIs) are important and costly public health problems in the United States resulting from unprotected sexual intercourse. Risk factors for unplanned pregnancies and STIs (poverty, low educational attainment, homelessness, substance abuse, lack of health insurance, history of an abusive environment, and practice of commercial sex work) are especially high among women with a history of incarceration. Project CARE (Contraceptive Awareness and Reproductive Education) is designed to evaluate an innovative intervention, motivational interviewing with computer assistance (MICA), aimed at enhancing contraceptive initiation and maintenance among incarcerated women who do not want a pregnancy within the next year and who are anticipated to be released back to the community. This study aims to: (1) increase the initiation of highly effective contraceptives while incarcerated; (2) increase the continuation of highly effective contraceptive use at 3, 6, 9, and 12 months after release; and (3) decrease unsafe sexual activity. METHODS/DESIGN: This randomized controlled trial will recruit 400 women from the Rhode Island Department of Corrections (RI DOC) women's jail at risk for an unplanned pregnancy (that is, sexually active with men and not planning/wanting to become pregnant in the next year). They will be randomized to two interventions: a control group who receive two educational videos (on contraception, STIs, and pre-conception counseling) or a treatment group who receive two sessions of personalized MICA. MICA is based on the principles of the Transtheoretical Model (TTM) and on Motivational Interviewing (MI), an empirically supported counseling technique designed to enhance readiness to change targeted behaviors. Women will be followed at 3, 6, 9, and 12 months post release and assessed for STIs, pregnancy, and reported condom use. DISCUSSION: Results from this study are expected to enhance our understanding of the efficacy of MICA to enhance contraceptive initiation and maintenance and reduce sexual risk-taking behaviors among incarcerated women who have re-entered the community. TRIAL REGISTRATION: NCT01132950.

The use of immune complex vaccines to enhance antibody responses against neutralizing epitopes on HIV-1 envelope gp120.

The capacity of immune complexes to augment antibody (Ab) responses is well established. The enhancing effects of immune complexes have been attributed mainly to Fc-mediated adjuvant activity, while the ability of Abs to induce antigenic alterations of specific epitopes as a result of immune complex formation has been less well studied. Previously we have shown that the interaction of anti-CD4-binding site (CD4bs) Abs with HIV-1 gp120 induces conformation changes that lead to enhanced antigenicity and immunogenicity of neutralizing epitopes in the V3 loop. The present study shows that significant increases in the antigenicity of the V3 and C1 regions of gp120 were attained for several subtype B gp120s and a subtype C gp120 upon immune complex formation with the anti-CD4bs monoclonal Ab (mAb) 654-D. Such enhancement was observed with immune complexes made with other anti-CD4bs mAbs and anti-V2 mAbs, but not with anti-C2 mAbs, indicating this activity is determined by antigen specificity of the mAb that formed the immune complex. When immune complexes of gp120(LAI)/654-D and gp120(JRFL)/654-D were tested as immunogens in mice, serum Abs to gp120 and V3 were generated at significantly higher titers than those induced by the respective uncomplexed gp120s. Notably, the anti-V3 Ab responses had distinct fine specificities; gp120(JRFL)/654-D stimulated more cross-reactive anti-V3 Abs than gp120(LAI)/654-D. Neutralizing activities against viruses with heterologous envelope were also detected in sera of mice immunized with gp120(JRFL)/654-D, although the neutralization breadth was still limited. Overall this study shows the potential use of gp120/Ab complexes to augment the immunogenicity of HIV-1 envelope gp120, but further improvements are needed to elicit virus-neutralizing Ab responses with higher potency and breadth.