Changes in Use of Hepatitis C Direct-Acting Antivirals After Access Restrictions Were Eased by State Medicaid Programs.

Importance: Direct-acting antivirals (DAAs) are safe and highly effective for curing hepatitis C virus (HCV) infection, but their high cost led certain state Medicaid programs to impose coverage restrictions. Since 2015, many of these restrictions have been lifted voluntarily in response to advocacy or because of litigation. Objective: To estimate how the prescribing of DAAs to Medicaid patients changed after states eased access restrictions. Design, Setting, and Participants: This modified difference-in-differences analysis of 39 state Medicaid programs included Medicaid beneficiaries who were prescribed a DAA from January 1, 2015, to December 31, 2019. DAA coverage restrictions were measured based on a series of cross-sectional assessments performed from 2014 through 2022 by the US National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation. Exposure: Calendar quarter when states eased or eliminated 3 types of DAA coverage restrictions: limiting treatment to patients with severe liver disease, restricting use among patients with active substance use, and requiring prescriptions to be written by or in consultation with specialists. States with none of these restrictions at baseline were excluded. Main Outcomes and Measures: Quarterly number of HCV DAA treatment courses per 100 000 Medicaid beneficiaries. Results: Of 39 states, 7 (18%) eliminated coverage restrictions, 25 (64%) eased restrictions, and 7 (18%) maintained the same restrictions from 2015 to 2019. During this period, the average quarterly use of DAAs increased from 669 to 3601 treatment courses per 100 000 Medicaid beneficiaries. After states eased or eliminated restrictions, the use of DAAs increased by 966 (95% CI, 409-1523) treatment courses per 100 000 Medicaid beneficiaries each quarter compared with states that did not ease or eliminate restrictions. Conclusions and Relevance: The results of this study suggest that there was greater use of DAAs after states relaxed coverage restrictions related to liver disease severity, sobriety, or prescriber specialty. Further reductions or elimination of these rules may improve access to a highly effective public health intervention for patients with HCV.

Human lower leg muscles grow asynchronously.

Muscle volume must increase substantially during childhood growth to generate the power required to propel the growing body. One unresolved but fundamental question about childhood muscle growth is whether muscles grow at equal rates; that is, if muscles grow in synchrony with each other. In this study, we used magnetic resonance imaging (MRI) and advances in artificial intelligence methods (deep learning) for medical image segmentation to investigate whether human lower leg muscles grow in synchrony. Muscle volumes were measured in 10 lower leg muscles in 208 typically developing children (eight infants aged less than 3 months and 200 children aged 5 to 15 years). We tested the hypothesis that human lower leg muscles grow synchronously by investigating whether the volume of individual lower leg muscles, expressed as a proportion of total lower leg muscle volume, remains constant with age. There were substantial age-related changes in the relative volume of most muscles in both boys and girls (p < 0.001). This was most evident between birth and five years of age but was still evident after five years. The medial gastrocnemius and soleus muscles, the largest muscles in infancy, grew faster than other muscles in the first five years. The findings demonstrate that muscles in the human lower leg grow asynchronously. This finding may assist early detection of atypical growth and allow targeted muscle-specific interventions to improve the quality of life, particularly for children with neuromotor conditions such as cerebral palsy.

Three-dimensional skeletal muscle architecture in the lower legs of living human infants.

Little is known about the skeletal muscle architecture of living humans at birth. In this study, we used magnetic resonance imaging (MRI) to measure the volumes of ten muscle groups in the lower legs of eight human infants aged less than three months. We then combined MRI and diffusion tensor imaging (DTI) to provide detailed, high-resolution reconstructions and measurements of moment arms, fascicle lengths, physiological cross-sectional areas (PCSAs), pennation angles and diffusion parameters of the medial (MG) and lateral gastrocnemius (LG) muscles. On average, the total lower leg muscle volume was 29.2 cm3. The largest muscle was the soleus muscle with a mean volume of 6.5 cm3. Compared to the LG muscles, the MG muscles had, on average, greater volumes (by ∼35%) and greater PCSAs (by ∼63%) but similar ankle-to-knee moment arm ratios (∼0.1 difference), fascicle lengths (∼5.7 mm difference) and pennation angles (∼2.7° difference). The MG data were compared with data previously collected from adults. The MG muscles of adults had, on average, a 63-fold greater volume, a 36-fold greater PCSA, and 1.7-fold greater fascicle length. This study demonstrates the feasibility of using MRI and DTI to reconstruct the three-dimensional architecture of skeletal muscles in living human infants. It is shown that, between infancy and adulthood, MG muscle fascicles grow primarily in cross-section rather than in length.

Establishing therapeutic and supportive relationships throughout delivery of a school-based group parenting program via telehealth: Exploring causal pathways.

Background: Access to specialised early intervention mental health services for children, including group counselling for parents/carers, is still a challenge in non-metropolitan areas of Australia. Aim: To gain understanding of the acceptability of a school-based targeted parenting group program delivered via telehealth by exploring the experiences of parents/carers, clinicians and school staff, and asking what works, how, why and in what circumstances. Methods: Caregivers, clinicians and school staff involved in the delivery of a mental health program via telehealth into primary schools in two rural Local Health Districts (LHDs) in southern New South Wales (NSW) were invited to participate in interviews and/or focus group discussions. Thematic analysis of the data was conducted with reference to realist theory. Findings: We conducted semi-structured interviews with 12 caregivers, five semi-structured interviews and two focus group discussions with school staff from six participating schools, and three focus groups with seven clinicians who delivered the intervention. We found that the intervention and micro contexts interacted to influence acceptability by initiating or enhancing cohesion among caregivers, establishing channels of communication between caregivers and teachers, and connection between caregivers and clinicians despite geographic distance. Several adaptations were made to strengthen the therapeutic alliance between caregivers and clinicians. Conclusion: Relationships crucial to the success of delivering psychological group counselling were established. Regional community contexts can facilitate acceptability of parenting group counselling delivered into schools via telehealth. Implementation of the program was flexible enough to allow clinicians to adjust their approach and materials to better suit the telehealth modality.

Therapist-assisted online treatment for child conduct problems in rural and urban families: Two randomized controlled trials.

OBJECTIVE: We examined the relative efficacy of an online versus face-to-face (FTF) parenting intervention for reducing the severity of child conduct problems and related parent and child outcomes in 2 randomized controlled trials. METHOD: In Study 1, rural families (n = 133) with a child 3-9 years of age with a full or subclinical primary diagnosis of oppositional defiant or conduct disorder traveled to Sydney, Australia for a comprehensive assessment and randomization to receive either AccessEI, a 6-10 week online therapist-assisted parenting program, or FTF treatment, whereby they received the same program presented FTF during a 1-week treatment. To control for unavoidable treatment dosage differences in the first study, Study 2 was conducted in which urban families (n = 73) with a child aged 3 to 14 years meeting similar criteria as Study 1 were randomized to receive AccessEI versus FTF treatment. RESULTS: In both studies, improvements in severity of child diagnoses and maternal measures of child behavior showed very large effect sizes for both treatments at posttreatment and 3-month follow-up and did not differ across treatment conditions. There were moderate effect sizes for improvements in parent mental health and no differences across treatment conditions. CONCLUSIONS: It is concluded that the effects of the therapist-assisted online parenting interventions for the treatment of child conduct problems were similar to a FTF intervention, providing evidence for the effectiveness of an accessible treatment for rural and remote families. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

On the same page: Co-designing the logic model of a telehealth service for children in rural and remote Australia.

The value of programme logic models as a tool for planning, evaluation, and communication is well recognised. However, the value of its development process is less discussed. In this paper, we describe how we used a combination of literature review and organisational stakeholder consultations to develop a logic model for a telehealth programme for children in rural and remote Australia. Our aim was to use this process to further embed the programme within its implementing organisation, and by so doing to promote its sustainability and scale-up; a major challenge of telehealth programmes, especially those involving reorganisation of processes. Our efforts to describe the components of this complex intervention on the one-page logic model allowed for debates and discussions within the implementing organisation which then facilitated an improved cross-organisational understanding of the telehealth programme; a real time face-to-face (video-link) service which requires the reorganisation of existing service delivery platforms. The process helped to embed the telehealth programme within existing services. We conclude that stakeholder engagement in developing logic models can transform them from being only a tool that provides the picture of why and how a programme works, to one that plays a role in embedding programmes within implementing organisations.

The use of gastrointestinal cocktail for differentiating gastro-oesophageal reflux disease and acute coronary syndrome in the emergency setting: a systematic review.

BACKGROUND: Differentiating acute chest pain caused by myocardial ischaemia from other, potentially more benign causes of chest pain is a frequent diagnostic challenge faced by Emergency Department (ED) clinicians. Only 30% of patients presenting with chest pain will have a cardiac origin for the pain, and gastro-oesophageal disorders are one of the common sources of non-cardiac chest pain, yet remain clinically difficult to differentiate from cardiac pain. AIM: A systematic review of the literature was conducted to locate and evaluate clinical trials comparing the use of an oral gastrointestinal (GI) cocktail (oral viscous lidocaine/ antacid ± anticholinergic) to standard diagnostic protocols (serial electrocardiograms (ECGs), serial biomarkers, imaging and/ or provocative testing) to differentiate emergency patients presenting with acute chest pain caused by gastro-oesophageal disease from those with other aetiologies. METHODS: Studies were identified by searching electronic databases, scanning reference lists of articles, and searching clinical trial databases for relevantly currently registered trials. The search included PubMed (1966 - present), Embase (1980 - present) and Cochrane Central Register of Controlled Trials (CENTRAL). The identified studies were evaluated with a modified QUADAS tool. RESULTS: A total of four studies were identified for inclusion in the review. Studies were of low methodological quality with heterogeneous results. There were no adequately powered and appropriately designed studies identified. DISCUSSION: Current diagnostic protocols for Acute Coronary Syndrome (ACS) revolve around early and serial ECG monitoring and cardiac biomarker testing, imaging and careful clinical examination. In patients with chest pain and suspected ACS, the use of a GI cocktail compared with standard diagnostic protocols (serial ECG and biomarkers and provocative testing or imaging) is not proven to improve accuracy of diagnosis, and cannot reliably exclude myocardial ischaemia.

Clinical research priorities in emergency medicine: results of a consensus meeting and development of a weighting method for assessment of clinical research priorities.

INTRODUCTION: There is limited evidence regarding clinical research priorities in emergency medicine outside of some special interest groups. The ACEM Clinical Trials Group undertook a consensus meeting with the aim of developing a reproducible weighting matrix for assessing clinical research priorities. METHODS: A session at the ACEM annual scientific meeting was dedicated to this meeting. Results from a survey of the ACEM researcher database were presented, along with a proposed weighting matrix. After discussion and adjustment, consensus was achieved on the matrix. RESULTS: It was agreed that the following criteria be used in the matrix: research category and sub-category priority ranking from the ACEM researcher database survey, frequency of presentation of potentially eligible participants, the level of pre-existing evidence regarding the proposed research question and the likely clinical impact of the research. Each criterion was given a weighting, with clinical impact given the heaviest weighting. The weighting matrix was subsequently applied to the list of research questions that resulted from the researcher database survey and a list of research priorities determined. CONCLUSION: The weighting matrix allows reproducible comparison of research questions. The resultant list of research priorities will act as a guide for the ACEM Clinical Trials Group in determining future projects.

A comparison of survival following out-of-hospital cardiac arrest in Sydney, Australia, between 2004-2005 and 2009-2010.

OBJECTIVE: To determine whether survival following out-of- hospital cardiac arrest (OHCA) in Sydney, Australia, improved between 2004-2005 and 2009-2010, and whether there was a change in incidence of OHCA. DESIGN: Retrospective study using the Ambulance Service of New South Wales and NSW Registry of Births, Deaths and Marriages databases. PARTICIPANTS AND SETTING: All patients who had an OHCA in the Sydney metropolitan area and who used the Ambulance Service of NSW between June 2009 and May 2010 (2009-2010), and between June 2004 and May 2005 (2004-2005). MAIN OUTCOME MEASURES: Survival to 90 days. Other outcome measures included the incidence of OHCA and survival to the day following OHCA, 28 days and 1 year following OHCA. Survival and incidence were also calculated according to initial electrocardiograph rhythm. RESULTS: Survival to 90 days was 12.3% in 2004-2005 and 10.2% in 2009-2010 (P = 0.015). In 2004-2005, the age standardised incidence of OHCA was 52.6 events per 100 000 person-years (95% CI, 51.6-53.6 events per 100 000 person-years), and in 2009-2010 it was 48.4 events per 100 000 person-years (95% CI, 46.3-50.4 events per 100 000 person-years). In 2004-2005, the incidence of ventricular fibrillation (VF) was 31.3% (95% CI, 28.4%- 33.9%) and in 2009-2010 it was 22.1% (95% CI, 20.0%- 24.3%). CONCLUSION: There was no improvement in survival following OHCA in Sydney between 2004-2005 and 2009- 2010. There has been a decrease in overall survival from OHCA and a decrease in the overall age-standardised incidence of OHCA. The decrease in overall survival may be due to a decline in the incidence of VF.

Review article: management of cyanide poisoning.

Cyanide poisoning is uncommon, but generates interest because of the presumed utility of an antidote immediately available in those areas with a high risk of cyanide exposure. As part of its regular review of guidelines, the Australian Resuscitation Council conducted a systematic review of the human evidence for the use of various proposed cyanide antidotes, and a narrative review of the relevant pharmacological and animal studies. There have been no relevant comparative or placebo-controlled human trials. Nine case series were identified. Treatment with hydroxocobalamin was reported in a total of 361 cases. No serious adverse effects of hydroxocobalamin were reported, and many patients with otherwise presumably fatal poisoning survived. Sodium thiosulphate use was reported in two case series, similarly with no adverse effects. Treatment with a combination of sodium nitrite, amyl nitrite and sodium thiosulphate was reported in 74 patients, with results indistinguishable from those of hydroxocobalamin and sodium thiosulphate. No case series using dicobalt edetate or 4-dimethylaminophenol were identified, but successful use in single cases has been reported. Hydroxocobalamin and sodium thiosulphate differ from alternatives in having negligible adverse effects, and on the basis of current evidence are the antidotes of choice. The indications for the use of an antidote, the requirements for supportive care and a recommended approach for workplaces where there is a risk of cyanide poisoning are presented.

The quality of life of spouse dementia caregivers: changes associated with yielding to formal care and widowhood.

The focus of the study was the effect on spouse dementia caregivers of relinquishing care. The study used a longitudinal design, in which a group of 150 dementia caregivers were interviewed 2 years apart (designated Time 1 and Time 2), with data collected from both continuing caregivers and those who had relinquished care. The aims were to determine the extent to which changes over time in quality of life differed between continuing caregivers, those who had yielded to formal care, and those who had been widowed; and to examine whether change in quality of life variables was associated with time since yielding to formal care and time since death of the spouse. Quality of life was defined in terms of health status, psychological well-being, and activity participation. All participants were interviewed in their own homes. Three groups of participants were identified at Time 2: those who continued to provide care for their spouses (n=60); those who had yielded their caregiver role by admitting their spouses to permanent residential care (n=53); and those who had admitted their spouses to permanent institutional care, but whose spouse had then died (n=37). Different patterns of quality of life changes were observed between the three groups, with both positives and negatives associated with disengagement from the caregiving role. Positive changes were particularly evident in psychological well-being and activity participation. These findings were discussed in terms of their relevance for a life transitions approach to the relinquishment of caregiving.