Overreporting of adherence to hepatitis C direct-acting antiviral therapy and sustained virologic response among people who inject drugs in the HERO study.

BACKGROUND: Self-reported adherence to direct-acting antivirals (DAAs) to treat hepatitis C virus (HCV) among persons who inject drugs (PWID) is often an overreport of objectively measured adherence. The association of such overreporting with sustained virologic response (SVR) is understudied. This study among PWID aimed to determine a threshold of overreporting adherence that optimally predicts lower SVR rates, and to explore correlates of the optimal overreporting threshold. METHODS: This study analyzed per-protocol data of participants with adherence data (N = 493) from the HERO (Hepatitis C Real Options) study. Self-reported and objective adherence to a 12-week DAA regimen were measured using visual analogue scales and electronic blister packs, respectively. The difference (Δ) between self-reported and objectively measured adherence was calculated. We used the Youden index based on receiver operating characteristic (ROC) curve analysis to identify an optimal threshold of overreporting for predicting lower SVR rates. Factors associated with the optimal threshold of overreporting were identified by comparing baseline characteristics between participants at/above versus those below the threshold. RESULTS: The self-reported, objective, and Δ adherence averages were 95.1% (SD = 8.9), 75.9% (SD = 16.3), and 19.2% (SD = 15.2), respectively. The ≥ 25% overreporting threshold was determined to be optimal. The SVR rate was lower for ≥ 25% vs. < 25% overreporting (86.7% vs. 95.8%, p <.001). The factors associated with ≥ 25% Δ adherence were unemployment; higher number of days and times/day of injecting drugs; higher proportion of positive urine drug screening for amphetamine, methamphetamine, and oxycodone, and negative urine screening for THC (tetrahydrocannabinol)/cannabis. CONCLUSIONS: Self-reported DAA adherence was significantly greater than objectively measured adherence among PWID by 19.2%. Having ≥ 25% overreported adherence was associated with optimal prediction of lower SVR rates. PWID with risk factors for high overreporting may need to be more intensively managed to promote actual adherence.

Perinatal Telehealth: Meeting Patients Where They Are.

INTRODUCTION: Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of innovative telehealth perinatal care models showed similar clinical outcomes and perceived quality of care between groups receiving a combination of virtual video and in-person visits. However, these studies included primarily White, English-speaking participants, excluding those who were economically disenfranchised or did not speak English. The purpose of this qualitative study was to describe perinatal patients' and providers' experiences with telehealth during and after the acute phase of the COVID-19 pandemic to inform future utilization of telehealth to drive the delivery of high-quality, accessible, and equitable perinatal care to diverse communities. METHODS: This descriptive qualitative study included a purposive sample of 14 patients and 17 providers who received or provided perinatal care via telehealth in either a certified nurse-midwifery practice or the nurse-family partnership care model between March 2020 and April 2022. Maximum variation sampling offered a diverse population based on race, ethnicity, and rurality. Researchers conducted 2 rounds of semistructured interviews with a focus on understanding social and geographic context. RESULTS: Six themes were identified through inductive analysis: (1) unexpected advantages of telehealth, (2) patient empowerment, (3) providers' fear of adverse outcomes, (4) concern for equitable care, (5) strategies to enhance the telehealth experience, and (6) strategies to address access to perinatal telehealth. Patients appreciated the increased ease and reduced cost of accessing visits, which led to fewer missed appointments. Health care providers saw great opportunity in telehealth but expressed concerns about accessibility for patients with language barriers or limited resources. DISCUSSION: This study provides insight into priorities for continued telehealth utilization focused on providing equitable access to perinatal care. Rather than returning to practices from before the COVID-19 pandemic formed from longstanding routines and perceived limitations, providers are encouraged to capitalize on the rapid innovations in telehealth to build a more effective, equitable, and patient-centered approach to perinatal care.

Contemporary Nurse-Midwifery Care in Colorado: A Survey of Certified Nurse-Midwife Practices in Hospital and Community Settings.

Lack of access to birth facilities and maternity care providers has contributed to rising US maternal mortality and morbidity rates, especially among women in rural areas. Evidence supports the increased use of midwives as a potential solution for access-to-care issues. This observational survey was conducted to identify the practice environment for Certified Nurse-Midwives® in Colorado for the purpose of informing future workforce expansion. Study results indicate that midwives provide services aligned with the midwifery model of care and have mostly autonomous practice in hospitals where midwifery practices are already established. However, there is limited use of midwives, as fewer than half of Colorado's 69 birthing hospitals have midwifery practices, and financial constraint created by low Medicaid reimbursement could be a limiting factor in establishing new midwifery practices. Policy recommendations based on survey results include (a) support for midwifery education and workforce development, (b) removal of hospital-level restrictions for privileges of midwives, and (c) consideration for public payment models that promote expansion of midwifery practices.

Case Commentary: Uncertainty in Evaluating Treatment Outcomes in Carbapenem-Resistant Acinetobacter baumannii Infections.

Carbapenem-resistant Acinetobacter baumannii (CRAB) infections are challenging to treat and associated with poor clinical outcomes. In this issue, sulbactam-durlobactam, a novel ß-lactam-ß-lactamase inhibitor, was used with cefiderocol to successfully treat CRAB pneumonia. While this report and in vitro data are encouraging, determining the impact of treatment regimens on clinical outcomes after CRAB infections is not straightforward. Therefore, careful evaluation in pathogen-directed randomized controlled trials is needed to determine the optimal treatment of CRAB infections.

Meeting the Challenge of Perinatal Care in Rural Communities.

The complexities of providing quality perinatal care within rural communities provide significant challenges to providers and policy makers. Provision of healthcare in rural communities is challenging on individual as well as community-based levels. A quality improvement lens is applied to consider key challenges that pertain to patients, providers, place, and policy. Potential solutions from a provider perspective include nurse-midwifery care and inclusion of advanced practice providers in a variety of specialties in addition to creating care models for registered nurses to practice at the top of their scope. To enhance access in the rural place, telehealth and coordination activities are recommended. Finally, policy approaches such as Perinatal Care Collaboratives, Area Health Education Centers, and enhanced financial resources to eliminate socioeconomic disparities will enhance perinatal care in rural communities.

Assessing uranium and select trace elements associated with breccia pipe uranium deposits in the Colorado River and main tributaries in Grand Canyon, USA.

Assessing chemical loading from streams in remote, difficult-to-access watersheds is challenging. The Grand Canyon area in northern Arizona, an international tourist destination and sacred place for many Native Americans, is characterized by broad plateaus divided by canyons as much as two-thousand meters deep and hosts some of the highest-grade uranium deposits in the U.S. From 2015-2018 major surface waters in Grand Canyon were monitored for select elements associated with breccia-pipe uranium deposits in the area, including uranium, arsenic, cadmium, and lead. Dissolved constituents in the Colorado River were monitored upstream (Lees Ferry), in the middle (Phantom Ranch), and downstream (Diamond Creek) of uranium mining areas. Concentrations of uranium, arsenic, cadmium, and lead at these main-stem sites varied little during the study period and were all well below human health and aquatic life benchmark criteria (30, 10, 5, and 15 µg/L maximum contaminant levels and 15, 150, 0.8, and 3.1 µg/L aquatic life criteria, respectively). Additionally, dissolved and sediment-bound constituents were monitored during a wide range of streamflow conditions at Little Colorado River, Kanab Creek, and Havasu Creek tributaries, whose watersheds have experienced different levels of uranium mining activities over time. Samples from the tributary sites contained ≤3.8 µg/L of dissolved cadmium and lead, and ≤17 µg/L of dissolved uranium. Dissolved arsenic also was mostly below human and aquatic life criteria at Little Colorado River and Kanab Creek; however, 63% of water samples from Havasu Creek were above the maximum contaminant level for arsenic. Arsenic in suspended sediment was greater than sediment quality guidelines in 9%, 35%, and 35% of samples from Little Colorado River, Kanab Creek, and Havasu Creek, respectively. At the concentrations observed during this study, tributaries contributed on average only about 0.12 µg/L of arsenic and 0.03 µg/L of uranium to the main-stem river. This study demonstrates how chemical loading from mined watersheds may be reliably assessed across a wide range of flow conditions in challenging locations.

Pilot Study of Physiologic Partograph Use Among Low-Risk, Nulliparous Women With Spontaneous Labor Onset.

INTRODUCTION: Neal and Lowe developed a physiologic partograph to give clinicians an evidence-based, uniform approach to assessing active labor progress and diagnosing dystocia in high-resource settings. The aim of this pilot study was to examine the feasibility of implementing the Neal and Lowe partograph for in-hospital labor assessment. METHODS: A descriptive study of low-risk, nulliparous women with spontaneous labor onset was performed at an academic medical center. Eight certified nurse-midwives from a single practice used the Neal and Lowe partograph for the assessment of labor progress. Descriptive statistics were used to summarize characteristics, interventions, and outcomes for women with partograph-assessed labors. Labors assessed by nurse-midwives (n = 83) or obstetricians (n = 75) using their usual assessment strategies were also described for the year prior to partograph introduction to contextualize partograph-assessed labor findings. Inferential statistical tests were not performed. RESULTS: Thirty-one of 34 (91.2%) partographs were used correctly. Seventy-one percent (n = 22) of these women progressed to complete dilatation within expected physiologic time frames while the remaining women (n = 9) experienced labor dystocia. Similar proportions of women in the partograph and usual labor assessment groups received oxytocin during labor. The cesarean rate was lower in the partograph group than in the usual care groups. No cesareans were performed for dystocia in active labor for women whose labors were assessed via partograph. DISCUSSION: Implementation of the Neal and Lowe partograph for in-hospital labor assessment is feasible. Incorrect plotting and/or interpretation of the partograph may be further minimized by providing clinicians opportunities for ongoing partograph training after implementation or through partograph software development. The Neal and Lowe partograph may assist clinicians in safely and significantly decreasing primary cesarean births performed for active labor dystocia in high-resource settings. Larger scale, hypothesis-testing studies of partograph implementation are now warranted.

Trends in Practice Patterns and Perspectives of Colorado Certified Nurse-Midwives.

Healthcare resources are stretched perilously thin and the demand for primary healthcare services has never been greater. Despite this demand for service, relatively little is known about the practice environment of primary healthcare providers, particularly certified nurse-midwives (CNMs), where workforce surveys frequently include these specialists within the broader nurse practitioner category. A distinct professional discipline, nurse-midwives are one type of primary care provider recommended to enhance access to services. The objective of this study was to understand the nature of the nurse-midwifery practice environment in the state of Colorado. Online survey of Colorado CNMs (N = 328) found little ethnic/racial diversity and an aging workforce, with most providing care in an urban, hospital/medical center environment. Several key legislative issues were identified though respondents felt ill prepared to engage in legislative change. Overall, CNMs were optimistic about the future of midwifery and were largely satisfied with their practice.