Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons.

BACKGROUND: Many pregnant persons in the United States are receiving messenger RNA (mRNA) coronavirus disease 2019 (Covid-19) vaccines, but data are limited on their safety in pregnancy. METHODS: From December 14, 2020, to February 28, 2021, we used data from the "v-safe after vaccination health checker" surveillance system, the v-safe pregnancy registry, and the Vaccine Adverse Event Reporting System (VAERS) to characterize the initial safety of mRNA Covid-19 vaccines in pregnant persons. RESULTS: A total of 35,691 v-safe participants 16 to 54 years of age identified as pregnant. Injection-site pain was reported more frequently among pregnant persons than among nonpregnant women, whereas headache, myalgia, chills, and fever were reported less frequently. Among 3958 participants enrolled in the v-safe pregnancy registry, 827 had a completed pregnancy, of which 115 (13.9%) resulted in a pregnancy loss and 712 (86.1%) resulted in a live birth (mostly among participants with vaccination in the third trimester). Adverse neonatal outcomes included preterm birth (in 9.4%) and small size for gestational age (in 3.2%); no neonatal deaths were reported. Although not directly comparable, calculated proportions of adverse pregnancy and neonatal outcomes in persons vaccinated against Covid-19 who had a completed pregnancy were similar to incidences reported in studies involving pregnant women that were conducted before the Covid-19 pandemic. Among 221 pregnancy-related adverse events reported to the VAERS, the most frequently reported event was spontaneous abortion (46 cases). CONCLUSIONS: Preliminary findings did not show obvious safety signals among pregnant persons who received mRNA Covid-19 vaccines. However, more longitudinal follow-up, including follow-up of large numbers of women vaccinated earlier in pregnancy, is necessary to inform maternal, pregnancy, and infant outcomes.

Screening and Brief Interventions for Alcohol Use During Pregnancy: Practices Among US Primary Care Clinicians, DocStyles 2019.

INTRODUCTION: Alcohol use during pregnancy can cause birth defects and developmental disabilities. From 2018 through 2020, 13.5% of pregnant women reported current drinking. The US Preventive Services Task Force recommends evidence-based tools (eg, AUDIT-C and SASQ) for implementing screening and brief interventions to reduce excessive alcohol use among adults, including pregnant people, for whom any alcohol use is considered excessive. METHODS: We used DocStyles 2019 data to conduct a cross-sectional analysis to examine current screening and brief intervention practices that primary care clinicians conduct among pregnant patients; clinicians' confidence levels in conducting screening, brief interventions, and referral to treatment; and the documentation of brief interventions in the medical record. RESULTS: A total of 1,500 US adult medicine clinicians completed the entire survey. Among the respondents who conduct screening (N = 1,373) and brief interventions (N = 1,357) in their practice, nearly all reported implementing screening (94.6%) and brief interventions (94.9%) with their pregnant patients for alcohol use, but fewer than half felt confident about conducting their screening practices (46.5%). Two-thirds (64%) reported using a tool that met the criteria recommended by the US Preventive Services Task Force (USPSTF). Over half documented brief interventions in electronic health record notes (51.7%) or designated space (50.7%). CONCLUSION: Pregnancy presents a unique opportunity for clinicians to incorporate screening into routine obstetric care and encourage behavior change among patients. Most providers reported always screening their pregnant patients for alcohol use, but fewer used evidence-based USPSTF-recommended screening tools. Increased clinician confidence in screening and brief intervention, the use of standardized screening tools tailored to pregnant people, and maximal use of electronic health record technology may enhance the benefits of their application to alcohol use, which ultimately can reduce adverse outcomes associated with alcohol use during pregnancy.

A pragmatic review of varenicline prescribing practices.

BACKGROUND: Smoking is the leading preventable cause of illness and premature death worldwide. Most tobacco users desire to quit, but few are successful. Guidelines recommend varenicline as an initial treatment recommendation to support smoking cessation. OBJECTIVES: Determine whether historic warnings preclude the use of varenicline as an initial treatment recommendation in patients with and without certain comorbidities. Appendix 1 shows the questions asked in the survey. METHODS: This study was conducted in 2 parts. Part 1 of this study was a provider survey. Part 2 was a multicenter, retrospective chart review. Survey respondents were primary care providers (PCPs) or internal medicine residents within a large health system. Patients included in the chart review had a PCP appointment between January 1, 2017, and December 31, 2020, and a diagnosis of tobacco dependence or tobacco cessation therapy prescription. RESULTS: In total, 352 providers were included in survey distribution and 56 responses were received, resulting in a response rate of 16%. Most providers (77%) indicated that they would be likely to use varenicline as an initial treatment recommendation in a patient with no comorbidities. Providers indicated they would be unlikely to use varenicline in a patient with certain mental health comorbidities (43%, 43%, and 55% for patients with bipolar disorder, schizophrenia, or history of suicide attempts, respectively, with 25%, 30%, and 27% having no opinion for each group). In addition, chart review yielded data for 25,128 patients. Notably, patients with schizophrenia were found to have an odds ratio of 0.55 (95% confidence interval [CI] 0.39-0.77) to receive varenicline at any point in therapy, and patients with diabetes had an odds ratio of 2.66 (95% CI 2.22-3.19) to receive no treatment. CONCLUSIONS: Historic warnings for neuropsychiatric events with varenicline may still preclude usage in patients with serious psychiatric comorbidities such as schizophrenia. In addition, patients with diabetes were less likely to receive any form of tobacco cessation therapy.

Fiber in the ICU: Should it Be a Regular Part of Feeding?

PURPOSE OF REVIEW: To highlight the controversy of fiber use in the current critical care nutrition guidelines; review the effect of fiber on the gut microbiota in the critically ill; and examine the data on fiber and outcomes in the intensive care setting. RECENT FINDINGS: Fiber is increasingly recognized as a necessary component of colonic health and nutrition support. In critical illness there is a shift toward gut dysbiosis and immune dysregulation. Through fermentation and the generation of short-chain fatty acids, fiber has a role in maintaining intestinal homeostasis, immune function, and supporting commensal bacteria. In contrast to fermentable fiber, recent animal models suggest that non-fermentable fiber can also favorably alter intestinal homeostasis in a mechanism distinct from short chain fatty acids. In the critically ill, RCTs and meta-analyses suggest that soluble and mixed fiber supplemented enteral nutrition can reduce diarrhea and is well tolerated. Based on limited data, there may be benefits in reducing length of hospital stay, certain infections, and glucose metabolism. Nonetheless, the role of fiber enriched nutrition in critically ill patients is controversial as evident in the conflicting guidelines. Despite shortcomings in the literature, soluble and mixed fiber supplemented enteral nutrition is safe and beneficial in most hemodynamically stable intensive care patients. More research is necessary to determine optimal fiber composition.

Does an encounter with the ambulatory clinical pharmacist in the transitional setting play a role in clinic attendance and patient engagement?

BACKGROUND: Patient engagement is an important aspect in improving patient outcomes. However, there is a paucity of literature regarding patient engagement in a nonresearch health care setting and the impacts of ambulatory clinical pharmacist interventions. Patient engagement has several definitions making it challenging to assess, but attendance to initial primary care provider (PCP) visits is an important aspect of patient engagement. OBJECTIVE: The study objective was to assess if improved patient engagement, defined as attendance to an initial PCP visit, was associated with differences in services provided or pharmacist participation during postdischarge clinic appointments. PRACTICE DESCRIPTION: The site of this study was the Johns Hopkins After Care Clinic (JHACC), an interdisciplinary postdischarge, safety net clinic in Baltimore, MD. PRACTICE INNOVATION: Through an interdisciplinary health care team including pharmacists, patients received comprehensive care to assist with postacute disease-state management and transitions of care. EVALUATION METHODS: Initial PCP visit attendance after a postacute visit in a high-risk population was evaluated for differing service delivery factors between groups who attended and did not attend their initial PCP visit. Descriptive statistics and chi-square tests were used for analysis. RESULTS: Patients were statistically significantly more likely to engage in primary care when clinical pharmacy specialists participated in their JHACC appointment (P = 0.02). Medication education and disease-state counseling improved initial PCP visit attendance, both of which are key pharmacist activities. CONCLUSION: This study suggests ambulatory clinical pharmacy specialists' roles in an interdisciplinary clinic model correlates with increased attendance to initial PCP visits, a surrogate for patient engagement. Disease-state education and medication education are both important activities in improving this measure; however, additional research is necessary to determine specific pharmacist interventions associated with patient engagement. As research in patient engagement continues, the positive effects of pharmacist involvement in this area could support their value in ambulatory care services.

Unintentional use of fentanyl attributed to surreptitious cannabis adulteration.

OBJECTIVE: This case addresses the issue of surreptitious adulteration of cannabis. Many with opioid and substance use disorders use cannabis while receiving office-based opioid treatment (OBOT), making it valuable to understand the rationale for its use. Further study of the effects that cannabis use has on OBOT success or failure is necessary. CASE SUMMARY: A 50-year-old man receiving OBOT continually tested positive in urine drug screenings (UDSs) for fentanyl, while abstaining from all opiates, but he endorsed smoking cannabis 2-3 times weekly as a self-reported headache reliever and a sleep aid. After changing the source from which he bought cannabis, his UDS became negative for fentanyl. He was maintained on a stable dose of buprenorphine with a consistent UDS after this intervention and was able to make many positive lifestyle changes as a result (i.e., maintaining a relationship with his girlfriend, continuing attendance at support groups, and pursuing employment opportunities). PRACTICE IMPLICATIONS: The consequences of cannabis use on OBOT success are highly variable and dependent on many factors. Although the concern regarding adulteration of cannabis exists, there is no systematic monitoring or reliable data on its frequency or the magnitude of its effect, which generates a demand for further research and exploration. Depending on state-specific regulations, patients may be able to obtain cannabis from reliable, regulated (nonadulterated) sources. However, providers must thoroughly consider the barriers to patients obtaining medicinal or legalized cannabis.

Non-nutritive sweeteners and their association with the metabolic syndrome and non-alcoholic fatty liver disease: a review of the literature.

PURPOSE: Non-alcoholic fatty liver disease (NAFLD) is increasing in incidence worldwide, paralleling epidemics in obesity and metabolic syndrome. Widely considered the hepatic manifestation of the metabolic syndrome, NAFLD is associated with significant morbidity, mortality, and increased healthcare costs. There is an abundance of data linking sugar-sweetened beverages, and fructose, in particular, to the metabolic syndrome and NAFLD. As a result, non-nutritive sweeteners (NNSs) are frequently substituted for sugar in drinks and a variety of foods. However, despite the widespread consumption of NNSs, there is growing concern about their impact on metabolic health. METHODS: This review examines the experimental and clinical evidence on non-nutritive sweetener (NNS) consumption and features of the metabolic syndrome, including NAFLD. RESULTS: Experimental animal studies show that NNS consumption can induce glucose intolerance, increased food consumption, and weight gain, with proposed mechanisms including altered gut microbiome, inhibition of protective intestinal enzymes, and increased appetite. The evidence from clinical studies is more controversial. Observational studies overwhelmingly show an association between NNS consumption and features of the metabolic syndrome, and this includes NAFLD when analyses are not adjusted for obesity. The evidence from randomized-controlled trials in humans is sparse and conflicting, and primarily evaluates weight-related outcomes. CONCLUSION: Further research is urgently needed to evaluate NNS consumption and its relationship with NAFLD and the gut microbiome in humans.

Nutrition in Cirrhosis.

PURPOSE OF REVIEW: This review discusses the prevalence of malnutrition in cirrhosis, metabolic functions of the liver and alterations in cirrhosis, malnutrition screening tools, and common macronutrient and micronutrient deficiencies encountered in individuals with chronic liver disease and their impact on morbidity and mortality. RECENT FINDINGS: Several meta-analyses and international society guidelines recommend malnutrition screening and nutrition interventions to improve outcomes in all patients with chronic liver disease given their high risk of malnutrition which is often under recognized. Malnutrition is common in individuals with chronic liver disease and has a significant impact on patient outcomes. Thus, it is critical that validated malnutrition screening tools are used routinely in this patient population in order to identify high-risk patients and implement nutrition and exercise interventions early.

Pregnancy Outcomes After Maternal Zika Virus Infection During Pregnancy - U.S. Territories, January 1, 2016-April 25, 2017.

Pregnant women living in or traveling to areas with local mosquito-borne Zika virus transmission are at risk for Zika virus infection, which can lead to severe fetal and infant brain abnormalities and microcephaly (1). In February 2016, CDC recommended 1) routine testing for Zika virus infection of asymptomatic pregnant women living in areas with ongoing local Zika virus transmission at the first prenatal care visit, 2) retesting during the second trimester for women who initially test negative, and 3) testing of pregnant women with signs or symptoms consistent with Zika virus disease (e.g., fever, rash, arthralgia, or conjunctivitis) at any time during pregnancy (2). To collect information about pregnant women with laboratory evidence of recent possible Zika virus infection* and outcomes in their fetuses and infants, CDC established pregnancy and infant registries (3). During January 1, 2016-April 25, 2017, U.S. territories† with local transmission of Zika virus reported 2,549 completed pregnancies§ (live births and pregnancy losses at any gestational age) with laboratory evidence of recent possible Zika virus infection; 5% of fetuses or infants resulting from these pregnancies had birth defects potentially associated with Zika virus infection¶ (4,5). Among completed pregnancies with positive nucleic acid tests confirming Zika infection identified in the first, second, and third trimesters, the percentage of fetuses or infants with possible Zika-associated birth defects was 8%, 5%, and 4%, respectively. Among liveborn infants, 59% had Zika laboratory testing results reported to the pregnancy and infant registries. Identification and follow-up of infants born to women with laboratory evidence of recent possible Zika virus infection during pregnancy permits timely and appropriate clinical intervention services (6).

Supratherapeutic INR During Treatment With Nirmatrelvir/Ritonavir and Warfarin and Acute Illness With COVID-19: A Case Report.

Background: Several studies have examined INR fluctuations using pharmacokinetic (PK) models or post-hoc INR values after completing nirmatrelvir/ritonavir, but further study of the effects of the drug interaction with warfarin during treatment is necessary. Case Summary: Nirmatrelvir/ritonavir is largely utilized in the outpatient setting so data regarding INR trends in hospitalized patients on warfarin is limited. However, many who receive nirmatrelvir/ritonavir outpatient experience difficulty with presenting to clinic for INR checks due to feeling acutely ill along with isolation precautions. We present the case of a patient receiving warfarin and utilizing home INR testing for monitoring. After diagnosis of coronavirus disease of 2019 (COVID-19), she was started on nirmatrelvir/ritonavir on day five after testing positive. Most recent INR prior to the start of therapy was 2.7 and had been stable on the same dose for months prior to infection. On day two of nirmatrelvir/ritonavir, her INR rose to 4.0 on home point of care INR testing. Despite reducing her dose of warfarin by 15%, her INR remained supratherapeutic the day after completing nirmatrelvir/ritonavir (4.0) and for several checks after. One month after completion of therapy, her INR returned to therapeutic levels. Practice Implications: While PK models and case series have hypothesized both potential increases or decreases in INR with the nirmatrelvir/ritonavir and warfarin interaction, COVID-19 infection itself can cause several pharmacodynamic changes which can increase INR, including decreased appetite and, in severe cases, organ dysfunction. This case provides real-world insight into the drug interaction between nirmatrelvir/ritonavir and the drug-disease state interaction between warfarin and COVID-19.

Institutional practices for charitable medication access for uninsured patients.

OBJECTIVES: To identify the most frequently prescribed medications, the location where prescriptions were filled, and whether a voucher was utilized among patients enrolled in a charitable care program within an academic medical center. STUDY DESIGN: This was a retrospective cohort study analyzing electronic health record and pharmacy dispensing information at a medical center's outpatient pharmacies. METHODS: Patients included in this analysis were enrolled in a charitable care program and had at least 1 ambulatory encounter in a primary care clinic from March 1, 2019, to June 30, 2021. The study identified frequently prescribed medications, prescription payment methods, the overall cost of prescriptions if available, and the percentage of patients who filled their prescription at a medical center's outpatient pharmacies vs external outpatient pharmacies. Descriptive statistics were used to describe the results. RESULTS: This study included 511 patients, 87% of whom were Spanish speaking. A total of 8453 prescriptions were identified, and more than half of the prescriptions were sent to external outpatient pharmacies. The most common medications prescribed were for cardiovascular disease, diabetes, and pain treatment. Forty-seven percent of all prescriptions were sent to the medical center's outpatient pharmacies. The medical center's charitable care program covered the costs of 44% of the prescriptions sent to internal pharmacies, assisting 148 unique patients and incurring a cost of $111,052 for the medical center. CONCLUSIONS: Overall, this study was able to characterize patient demographics, historical costs related to charitable care coverage, and the utilization of health care services among this population. This information can be used to support the development and implementation of a charitable medication formulary, with the aims of improving quality of care for this population and reducing medical center costs.

Evaluation of opioid use disorder treatment outcomes in patients receiving split daily versus once daily dosing of buprenorphine-naloxone.

INTRODUCTION: In clinical practice, sublingual (SL) buprenorphine-naloxone is prescribed as once daily or split daily dosing for the management of opioid use disorder (OUD). Evidence is lacking that assesses how split daily buprenorphine-naloxone affects OUD outcomes. This study aims to evaluate how the dosing frequency of SL buprenorphine-naloxone impacts therapy effectiveness when treating patients with OUD. METHODS: This retrospective analysis included adult outpatients prescribed treatment with SL buprenorphine-naloxone for OUD between July 1, 2016, and March 1, 2020. The study excluded patients with sickle cell disease, recent methadone treatment, or pregnancy. We characterized study groups by dosing frequency, either once daily or split dosing. The study compared retention in treatment, medication adherence, adherence to treatment program, and hospital encounters between groups. RESULTS: The study screened eight-hundred and seven patients, and included 250 patients newly prescribed SL buprenorphine-naloxone. Fifty-seven patients (22.8 %) were prescribed once daily dosing and 193 patients (77.2 %) were prescribed split daily dosing. The study found no significant differences noted in 12-month rates of treatment retention (52.6 % vs. 45.6 %, p = .35). These outcomes remained similar when assessed at three and six months. Within a year of buprenorphine-naloxone initiation, the study found no differences in the percentage of patients with hospitalizations (26.3 % vs. 38.3 %, p = .10), median number of hospitalizations (2 vs. 2), or proportion of days covered by a prescription ≥80 % (93.3 % vs. 92.0 %, p = .82). CONCLUSIONS: In this study, patients receiving once daily buprenorphine-naloxone had similar treatment outcomes to patients receiving split dosing. Further controlled studies are necessary to evaluate which patients are more likely to benefit from split dosing.

Synbiotics and Surgery: Can Prebiotics and Probiotics Affect Inflammatory Surgical Outcomes?

PURPOSE OF REVIEW: Prebiotics, probiotics, and synbiotics have received increasing attention over the years for their beneficial impact on the gut microbiome and for their systemic anti-inflammatory effects. They have also been shown to improve surgical outcomes. Here, we review the inflammatory effects of surgery as well as the data which suggests a benefit of prebiotics, probiotics, and synbiotics taken in the perioperative period. RECENT FINDINGS: Synbiotics and fermented foods may have an even greater anti-inflammatory effect than probiotics or prebiotics alone. Recent data suggest that the anti-inflammatory effects and microbiome changes brought on by prebiotics, probiotics, and synbiotics have the potential to improve surgical outcomes. We highlight the potential to alter systemic inflammation, surgical and hospital-acquired infections, colorectal cancer formation, recurrence, and anastomotic leak. Synbiotics could also impact metabolic syndrome. Prebiotics, probiotics, and especially synbiotics may be extremely beneficial when taken in the perioperative period. Even short-term gut microbiome pre-habilitation could alter surgical outcomes significantly.

Novel Virtual Vision Screening Program: Give Kids Sight Day 2020.

PURPOSE: To determine whether a low-technology novel virtual vision screening protocol can reliably screen pediatric visual acuity. METHODS: Give Kids Sight Day (GKSD), an annual out-reach program, aims to provide free vision screening and ophthalmic care to underserved children in Philadelphia, Pennsylvania. Children were screened virtually through the low-technology protocol. Based on screening results, 152 children were provided in-person eye examinations. Data from in-person examinations were compared to data from virtual screenings for 151 children who were seen in-person. RESULTS: Of 475 children screened virtually, 152 children were seen in-person for examination, and 151 children were included in the analysis. Results from 151 children (mean age: 10.7 years, age range: 5 to 18 years, 43% female, 28% speaking a non-English language) were reviewed. There was a moderate correlation (R = .64, P < .0001; n = 100 children) between screening and in-person visual acuity without refractive correction and a strong correlation (R = 0.82, P < .0001; n = 18 children) between screening and in-person visual acuity with refractive correction. Of the 140 children who were seen in-person, 133 children were provided glasses prescriptions. Seventeen children required a referral to a pediatric ophthalmologist for evaluation of ophthalmic conditions, most commonly strabismus (5.3%) and amblyopia (4%). CONCLUSIONS: The GKSD virtual visual acuity testing demonstrated good correlation with in-person visual acuity testing, supporting the virtual screening approach as a useful tool for future applications in widespread community vision outreach programs. Further studies are needed to refine virtual ophthalmic screening to optimize its applications in bridging the gaps in ophthalmic care. [J Pediatr Ophthalmol Strabismus. 2023;60(6):390-395.].

Medication for Opioid Use Disorder During Pregnancy - Maternal and Infant Network to Understand Outcomes Associated with Use of Medication for Opioid Use Disorder During Pregnancy (MAT-LINK), 2014-2021.

Problem: Medication for opioid use disorder (MOUD) is recommended for persons with opioid use disorder (OUD) during pregnancy. However, knowledge gaps exist about best practices for management of OUD during pregnancy and these data are needed to guide clinical care. Period Covered: 2014-2021. Description of the System: Established in 2019, the Maternal and Infant Network to Understand Outcomes Associated with Medication for Opioid Use Disorder During Pregnancy (MAT-LINK) is a surveillance network of seven clinical sites in the United States. Boston Medical Center, Kaiser Permanente Northwest, The Ohio State University, and the University of Utah were the initial clinical sites in 2019. In 2021, three clinical sites were added to the network (the University of New Mexico, the University of Rochester, and the University of South Florida). Persons receiving care at the seven clinical sites are diverse in terms of geography, urbanicity, race and ethnicity, insurance coverage, and type of MOUD received. The goal of MAT-LINK is to capture demographic and clinical information about persons with OUD during pregnancy to better understand the effect of MOUD on outcomes and, ultimately, provide information for clinical care and public health interventions for this population. MAT-LINK maintains strict confidentiality through robust information technology architecture. MAT-LINK surveillance methods, population characteristics, and evaluation findings are described in this inaugural surveillance report. This report is the first to describe the system, presenting detailed information on funding, structure, data elements, and methods as well as findings from a surveillance evaluation. The findings presented in this report are limited to selected demographic characteristics of pregnant persons overall and by MOUD treatment status. Clinical and outcome data are not included because data collection and cleaning have not been completed; initial analyses of clinical and outcome data will begin in 2023. Results: The MAT-LINK surveillance network gathered data on 5,541 reported pregnancies with a known pregnancy outcome during 2014-2021 among persons with OUD from seven clinical sites. The mean maternal age was 29.7 (SD = ±5.1) years. By race and ethnicity, 86.3% of pregnant persons were identified as White, 25.4% as Hispanic or Latino, and 5.8% as Black or African American. Among pregnant persons, 81.6% had public insurance, and 84.4% lived in urban areas. Compared with persons not receiving MOUD during pregnancy, those receiving MOUD during pregnancy were more likely to be older and White and to have public insurance. The evaluation of the surveillance system found that the initial four clinical sites were not representative of demographics of the South or Southwest regions of the United States and had low representation from certain racial and ethnic groups compared with the overall U.S. population; however, the addition of three clinical sites in 2021 made the surveillance network more representative. Automated extraction and processing improved the speed of data collection and analysis. The ability to add new clinical sites and variables demonstrated the flexibility of MAT-LINK. Interpretation: MAT-LINK is the first surveillance system to collect comprehensive, longitudinal data on pregnant person-infant dyads with perinatal outcomes associated with MOUD during pregnancy from multiple clinical sites. Analyses of clinical site data demonstrated different sociodemographic characteristics between the MOUD and non-MOUD treatment groups. Public Health Actions: MAT-LINK is a timely and flexible surveillance system with data on approximately 5,500 pregnancies. Ongoing data collection and analyses of these data will provide information to support clinical and public health guidance to improve health outcomes among pregnant persons with OUD and their children.

Communication experiences of healthcare students whilst managing adults with communication disorders.

BACKGROUND:  Research has found that people with communication disabilities are three times more likely to encounter medical mishaps. Almost a third of patients with speech-language therapy (SLT) diagnoses have other medical conditions across more than one of the burden of disease categories. Fifty per cent of these patients present with communication disorders. Student healthcare curriculums focus on patient dynamics and field-specific diversities. It does not often include the skills and knowledge required to effectively communicate and treat those with communication disorders. OBJECTIVES:  This study aims to describe the communication challenges and strategies employed by a group of final year Nursing, Medicine, Dietetics and Human Nutrition, Physiotherapy and Occupational Therapy students when managing adults with communication disorders. METHOD:  A qualitative, phenomenological study design was used. Questionnaires were electronically distributed, and results were analysed thematically. RESULTS:  The most significant challenges whilst managing adults with communication disorders were patients' receptive and expressive language difficulties. Further challenges included lack of knowledge surrounding communication disorders, lack of training in the use of appropriate communicative assistive devices, factors within the physical environment and gaps in students' clinical performance. Strategies used to facilitate communication included caregiver assistance, gestures and written language. CONCLUSION:  This study revealed that there is a need to develop healthcare students' skills in managing adults with communication disorders. This is because of the challenges faced and inefficiency of the strategies used. Future research should focus on determining solutions for improved communication with adults with communication disorders. The study highlights the need for further education and training to address students' communication needs with patients.

A Case for Comprehensive Transitional Care for Formerly Incarcerated Individuals.

People released from prison are at risk of adverse health outcomes in the weeks after release. This article describes cases that illustrate the complexity of caring for this population. It is important to address medical and psychological needs as well as factors that contribute to social determinants of health.

Community Perspectives on Contraception in the Context of Zika Virus in American Samoa and the Commonwealth of the Northern Mariana Islands.

The prevention of unintended pregnancy was identified as a primary prevention strategy to reduce Zika-related adverse birth outcomes during the 2016-2017 Zika virus outbreak. The Centers for Disease Control and Prevention in partnership with local health agencies conducted formative research to guide the development of culturally appropriate messages and materials to increase awareness of the prevention of unintended pregnancy as a strategy to decrease Zika-related adverse outcomes in American Samoa and the Commonwealth of the Northern Mariana Islands (CNMI). Nine focus groups (N=71) were conducted with women and men aged 18-44 years living in American Samoa and CNMI. Semi-structured interview guides were used to explore participants' knowledge and perceptions of Zika, family planning, and contraception; barriers and facilitators to access contraception and use; and information sources and contraception decision-making. Trained staff from local organizations co-moderated each focus group. Thematic analysis was conducted with NVivo 10. Participants had mixed knowledge about Zika virus and its relation to pregnancy and birth defects. Women and men had varied knowledge of the full range of contraceptive methods available in their jurisdiction and identified barriers to contraceptive access. Social factors including stigma, gender roles, and religion often deterred participants from accessing contraceptive services. Participants highlighted the need for culturally appropriate and clear messaging about contraceptive methods. Results demonstrate the feasibility of conducting formative research as an effective strategy for understanding community perspectives on unintended pregnancy prevention in the context of the Zika virus outbreak to develop health communication materials.

"The Gluten-Free Diet and Its Relationship with Metabolic Syndrome: Dietary Friend or Foe?"

PURPOSE OF REVIEW: Celiac disease (CD) is a prevalent digestive illness as well as a budding area of research in the field of gastroenterology. While investigations are underway to find new and improved pharmacological therapies for CD, the gluten-free diet (GFD) remains the only option to effectively manage the condition. RECENT FINDINGS: While the GFD is recommended for patients diagnosed with CD and other gluten-related conditions, studies show the number of individuals on the GFD surpasses the projected number of patients with these medical indications (1). The implications of widespread adoption of this dietary approach are still being determined, with many patients believing this diet will improve overall health and cardiovascular risk. This review analyzes the relationship between a GFD and metabolic syndrome in both non-celiac and celiac patients, concluding that although the diet may slightly improve overall cardiac risk factors, weight, and/or insulin resistance, its use in the absence of a gluten-related disorder is controversial.