Challenges and Facilitators in Implementing Remote Patient Monitoring Programs in Primary Care.

BACKGROUND: The COVID-19 pandemic resulted in greater use of remote patient monitoring (RPM). However, the use of RPM has been modest compared to other forms of telehealth. OBJECTIVE: To identify and describe barriers to the implementation of RPM among primary care physicians (PCPs) that may be constraining its growth. DESIGN: We conducted 20 semi-structured interviews with PCPs across the USA who adopted RPM. Interview questions focused on implementation facilitators and barriers and RPM's impact on quality. We conducted thematic analysis of semi-structured interviews using both inductive and deductive approaches. The analysis was informed by the NASSS (non-adoption and abandonment and challenges to scale-up, spread, and sustainability) framework. PARTICIPANTS: PCPs who practiced at least 10 h per week in an outpatient setting, served adults, and monitored blood pressure and/or blood glucose levels with automatic transmission of data with at least 3 patients. KEY RESULTS: While PCPs generally agreed that RPM improved quality of care for their patients, many identified barriers to adoption and maintenance of RPM programs. Challenges included difficulties handling the influx of data and establishing a manageable workflow, along with digital and health literacy barriers. In addition to these barriers, many PCPs did not believe RPM was profitable. CONCLUSIONS: To encourage ongoing growth of RPM, it will be necessary to address implementation barriers through changes in payment policy, training and education in digital and health literacy, improvements in staff roles and workflows, and new strategies to ensure equitable access.

Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making.

PURPOSE: Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care. METHODS: We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior. RESULTS: Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD. CONCLUSIONS: There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.

Suggestion for a new bacteriophage genus for the Klebsiella pneumoniae phage vB_KpnS-Carvaje.

This work describes the newly isolated Klebsiella pneumoniae phage vB_KpnS-Carvaje that presents unique features in relation to other phages reported to date. These findings provide new insights into the diversity and evolutionary pathways of Klebsiella phages. The genome characterization of the Carvaje phage revealed that its genome length is approximately 57 kb with 99 open reading frames (ORFs), 33 of which have assigned functions while 66 are unknown. This phage differs from other sequenced Klebsiella phages, showing the closest resemblance (up to 65.32%) with Salmonella phages belonging to the Nonanavirus and Sashavirus genera. Comparisons at the amino acid level and phylogeny analysis among homologous genomes indicate that the Klebsiella Carvaje phage forms a novel sister taxon within the node of the Nonanaviruses and Sashaviruses cluster. Due to the unique features of the Carvaje phage, we propose the constitution of a new genus within the Caudoviricetes class. Further studies include the exploitation of this phage and its identified proteins for the control of Klebsiella infections and as recognition molecules in diagnostic methods.

Evaluating culturally and linguistically integrated care for Latinx adults with mental and substance use disorders.

Objective: To evaluate changes in health and health care utilization outcomes for Latinx adults with substance use and mental disorders receiving integrated behavioral and primary health care.Design: Study sample included enrollees who completed baseline, 6-month and 12-month assessments (n = 107). Study outcomes were depression symptom severity, anxiety symptom severity, illicit drug use, emergency department utilization and homelessness status. Pre-post analyses were conducted using paired t-test and McNemar test to examine changes in study outcomes. Multivariable regression model estimated through generalized estimating equations explored the influence of the intervention on study outcomes. Results were presented in adjusted odds ratios (AOR) and 95% confidence intervals (CI).Results: Participants were less likely to report depressive symptoms (AOR: 0.496, 95%CI: 0.296-0.832), less likely to report anxiety symptoms (AOR: 0.539, 95%CI: 0.329-0.884), and less likely to experience homelessness (AOR: 0.556, 95%CI: 0.328-0.943) at 6-month assessment compared to baseline. Participants were also less likely to report depressive symptoms (AOR: 0.378, 95%CI: 0.209-0.684), less likely to report anxiety symptoms (AOR: 0.471, 95%CI: 0.270-0.821), less likely to experience homelessness (AOR: 0.333, 95%CI: 0.189-0.587), and less likely to utilize the emergency department in the past 30 days (AOR: 0.397, 95%CI: 0.188-0.837) at 12-month assessment compared to baseline.Conclusions: Integrating culturally responsive behavioral and primary health care services is critical for addressing the needs of Latinx adults with mental and substance use disorders, and other chronic diseases. This initiative has the potential to reduce disparities in access to and engagement in care for Latinx adults.

Cashew apple (Anacardium occidentale L.) extract from a by-product of juice processing: assessment of its toxicity, antiproliferative and antimicrobial activities.

Cashew apple extract (CAE) is a product with intense yellow color obtained from residual fibers of juice processing. Although CAE is known to be rich in carotenoids and anacardic acids, the biological activities of this potential natural food colorant remain unexplored. The present study is the first to investigate the toxicity, antiproliferative and antimicrobial activities of the lyophilized CAE (L-CAE) and its encapsulated products, using maltodextrin (M-CAE) or cashew gum (CG-CAE) as carriers. In addition to their high carotenoid content, the phenolic contents in all materials was determined using UPLC-QTOF-MSE. The acute toxicity was performed using adult zebrafish (Danio rerio); antiproliferative activity was assessed using seven different human tumor cell lines [U-251 (glioblastoma), MCF-7 (breast, adenocarcinoma), NCI-ADR/RES (multidrug-resistant ovarian adenocarcinoma), NCI-H-460 (lung, large cell carcinoma), PC-3 (prostate, adenocarcinoma), OVCAR-3 (ovarian adenocarcinoma), and HT-29 (colon, adenocarcinoma)] and an immortalized human keratinocyte (HaCaT) while the antimicrobioal activity was evaluated on Staphylococcus aureus ATCC 25923, Listeria monocytogenes ATCC 19115, Escherichia coli ATCC 25922 and Salmonella Typhimurium ATCC 51812 microorganisms. Both lyophilized and encapsulated CAE samples did not exert acute toxicity against zebrafish neither antiproliferative effect against human tumor and non-tumor cell lines. Further, L-CAE showed potential antimicrobial activity against Listeria monocytogenes, which was confirmed using electron microscopy. The current findings demonstrated that CAE is a potential source of bioactive compounds to use as an additive in the food industry.

What Drives Greater Assimilation of Telestroke in Emergency Departments?

OBJECTIVE: Although many emergency departments (EDs) have telestroke capacity, it is unclear why some EDs consistently use telestroke and others do not. We compared the characteristics and practices of EDs with robust and low assimilation of telestroke. METHODS: We conducted semi-structured interviews with representatives of EDs that received telestroke services from 10 different networks and had used telestroke for a minimum of two years. We used maximum diversity sampling to select EDs for inclusion and applied a positive deviance approach, comparing programs with robust and low assimilation. Data collection was informed by the Consolidated Framework for Implementation Research. For the qualitative analysis, we created site summaries and conducted a supplemental matrix analysis to identify themes. RESULTS: Representatives from 21 EDs with telestroke, including 11 with robust assimilation and 10 with low assimilation, participated. In EDs with robust assimilation, telestroke workflow was highly protocolized, programs had the support of leadership, telestroke use and outcomes were measured, and individual providers received feedback about their telestroke use. In EDs with low assimilation, telestroke was perceived to increase complexity, and ED physicians felt telestroke did not add value or had little value beyond a telephone consult. EDs with robust assimilation identified four sets of strategies to improve assimilation: strengthening relationships between stroke experts and ED providers, improving and standardizing processes, addressing resistant providers, and expanding the goals and role of the program. CONCLUSION: Greater assimilation of telestroke is observed in EDs with standardized workflow, leadership support, ongoing evaluation and quality improvement efforts, and mechanisms to address resistant providers.

Impact of Project ECHO Models of Medical Tele-Education: a Systematic Review.

BACKGROUND: Extension for Community Healthcare Outcomes (ECHO) and related models of medical tele-education are rapidly expanding; however, their effectiveness remains unclear. This systematic review examines the effectiveness of ECHO and ECHO-like medical tele-education models of healthcare delivery in terms of improved provider- and patient-related outcomes. METHODS: We searched English-language studies in PubMed, Embase, and PsycINFO databases from 1 January 2007 to 1 December 2018 as well as bibliography review. Two reviewers independently screened citations for peer-reviewed publications reporting provider- and/or patient-related outcomes of technology-enabled collaborative learning models that satisfied six criteria of the ECHO framework. Reviewers then independently abstracted data, assessed study quality, and rated strength of evidence (SOE) based on Cochrane GRADE criteria. RESULTS: Data from 52 peer-reviewed articles were included. Forty-three reported provider-related outcomes; 15 reported patient-related outcomes. Studies on provider-related outcomes suggested favorable results across three domains: satisfaction, increased knowledge, and increased clinical confidence. However, SOE was low, relying primarily on self-reports and surveys with low response rates. One randomized trial has been conducted. For patient-related outcomes, 11 of 15 studies incorporated a comparison group; none involved randomization. Four studies reported care outcomes, while 11 reported changes in care processes. Evidence suggested effectiveness at improving outcomes for patients with hepatitis C, chronic pain, dementia, and type 2 diabetes. Evidence is generally low-quality, retrospective, non-experimental, and subject to social desirability bias and low survey response rates. DISCUSSION: The number of studies examining ECHO and ECHO-like models of medical tele-education has been modest compared with the scope and scale of implementation throughout the USA and internationally. Given the potential of ECHO to broaden access to healthcare in rural, remote, and underserved communities, more studies are needed to evaluate effectiveness. This need for evidence follows similar patterns to other service delivery models in the literature.

Correction to: Use and retention of long-lasting insecticidal nets (LLINs) in a malaria risk area in the Brazilian Amazon: a 5-year follow-up intervention.

Following publication of the original article [1], the corresponding author flagged that the particle 'de' in their name had been placed incorrectly.

Use and retention of long-lasting insecticidal nets (LLINs) in a malaria risk area in the Brazilian Amazon: a 5-year follow-up intervention.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are one of the main vector control strategies recommended by the World Health Organization for the control and elimination of malaria. This study aimed to evaluate the use and retention of LLINs during the 5 years of implementing an integrated control strategy in a malaria-endemic area in the Brazilian Amazon. METHODS: This intervention study was conducted in localities of the municipality of Barcelos, Amazonas, from 2008 to 2014. Four rural localities situated along the Padauiri River were the object of this study. Two localities (Bacabal-rio Aracá and the São Sebastião district) were used as controls. LLINs were distributed to all residents of the Padauiri River; assessments were made regarding their use and retention via a semistructured questionnaire, a household register, and direct observation during 5 years. RESULTS: Overall, 208 individuals participated in the study. In the baseline pilot study (2008), 9.9% of the subjects in the intervention group had slept with mosquito nets the previous night compared with 37.8% of the subjects in the control group. In 2010, this percentage was 43.2% in the intervention group and 50.9% in the control group. Therefore, 1 year after the implementation of the strategy, although there was an increase in the use of mosquito nets in both groups, this increase was significantly higher in the intervention group. This increase in LLINs use did not persist after 5 years of intervention. The households' evaluation in 2014 showed that 80% of the houses in the intervention group owned at least one LLIN compared with 66% in the control group (p = 0.11); 76% of households in the intervention group owned sufficient LLINs for all family members compared with 50% in the control group (p = 0.007). CONCLUSIONS: High ownership and retention of the LLINs was observed in the intervention group. At 1 year after the distribution of these LLINs, there was a significant increase in their use that was not maintained over the long term. Control strategies must be permanent; however, exploring new strategies is necessary to ensure that the knowledge acquired further modifies the attitudes and behaviours.

Changes in In-Person, Audio-Only, and Video Visits in California's Federally Qualified Health Centers, 2019-2022.

This study assesses telehealth visit trends among California federally qualified health centers from 2019 to 2022.

Assessment of mechanisms involved in antinociception produced by the alkaloid caulerpine.

In previous works we showed that oral administration of caulerpine, a bisindole alkaloid isolated from algae of the genus Caulerpa, produced antinociception when assessed in chemical and thermal models of nociception. In this study, we evaluated the possible mechanism of action of this alkaloid in mice, using the writhing test. The antinociceptive effect of caulerpine was not affected by intraperitoneal (i.p.) pretreatment of mice with naloxone, flumazenil, l-arginine or atropine, thus discounting the involvement of the opioid, GABAergic, l-arginine-nitric oxide and (muscarinic) cholinergic pathways, respectively. In contrast, i.p. pretreatment with yohimbine, an α2-adrenoceptor antagonist, or tropisetron, a 5-HT3 antagonist, significantly blocked caulerpine-induced antinociception. These results suggest that caulerpine exerts its antinociceptive effect in the writhing test via pathways involving α2-adrenoceptors and 5-HT3 receptors. In summary, this alkaloid could be of interest in the development of new dual-action analgesic drugs.

Perceptions of stimulant and buprenorphine diversion and strategies to address it.

There is ongoing policy debate on the prescribing of controlled substances such as buprenorphine and stimulants via telemedicine. The goal of federal and state policymakers is to ensure access to care while limiting diversion risk. However, there is little evidence on how clinicians view and address diversion and on telemedicine's role in diversion. From December 2023 to January 2024, we conducted semi-structured interviews with 21 psychiatrists and primary care physicians engaged in hybrid (telemedicine and in-person) care models in which we explored perceptions of diversion and strategies used to monitor for diversion. Most physicians reported monitoring for diversion, but there was little consistency on how monitoring was done and reported strategies did not differ between telemedicine vs in-person care. When physicians suspected diversion, there was also wide variation in responses: some clinicians did not immediately take any action while others imposed more requirements on patients (e.g., more frequent visits), no longer prescribed the controlled substance, or terminated the patient from their practice. Few physicians had ever reported a case of suspected diversion to law enforcement. Our findings suggest that the Drug Enforcement Administration could clarify reporting requirements and professional societies could provide additional guidance on how to respond to suspected diversion, given the current variation in practice across clinicians could be exploited by individuals who want to divert.

Necrotizing mesenteric vasculitis in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder which may affect the gastrointestinal system. Half of the patients with SLE experience gastrointestinal symptoms, with the most common being nausea, vomiting, anorexia, and abdominal pain. Mesenteric vasculitis is a severe and rare complication of SLE and one of the most frequent causes of severe acute abdominal pain. The authors present a case of a 57-year-old woman with SLE who was diagnosed with necrotizing mesenteric vasculitis following a urinary septic shock. The patient was treated with high-dose corticosteroid therapy and cyclophosphamide, with resolution of the clinical picture.

Translation and Validation of the Nutrition for Sport Knowledge Questionnaire in Brazil (NSKQ-BR).

This study aimed to translate, culturally adapt, and validate "The Nutrition for Sport Knowledge Questionnaire (NSKQ)" for Brazilian athletes. The NSKQ is an Australian instrument composed of 87 questions divided into six subsections (weight control, macronutrients, micronutrients, sports nutrition, supplementation, and alcohol) designed to assess the nutritional knowledge (NK) of athletes. The translation process followed the recommendations of the World Health Organization for translating and adapting instruments. Semantic validation involved a panel of specialists (n = 21), followed by an assessment performed by a group of adult Brazilian athletes from various sports (n = 17). The reproducibility and internal consistency of the questionnaire were evaluated via a test-retest approach in a sample of adult Brazilian athletes (n = 29) from diverse sports, who completed the Brazilian version of the NSKQ (NSKQ-BR). Overall, the NSKQ-BR presented good internal consistency (α = 0.95) and reproducibility (intraclass correlation coefficient (ICC) = 0.85). The factors "sports nutrition" and "alcohol" showed moderate reproducibility (ICC = 0.74 (0.46-0.88) and ICC = 0.68 (0.33-0.85), respectively). Most athletes (n = 17; 58.6%) presented a medium NK score (50-65%). The NSKQ-BR is available to evaluate the NK levels of Brazilian athletes. The NSKQ-BR presented high internal consistency and reproducibility, validating its applicability among adult athletes across diverse sports.

Spasmolytic effect of caulerpine involves blockade of Ca²âº influx on guinea pig ileum.

In this work, we investigated the spasmolytic effect of caulerpine, a bisindole alkaloid isolated from marine algae of the Caulerpa genus, on guinea pig ileum. Our findings indicated that caulerpine inhibited phasic contractions induced by carbachol (IC50 = 7.0 ± 1.9 × 10⁻5 M), histamine (IC50 = 1.3 ± 0.3 × 10⁻4 M) and serotonin (IC50 = 8.0 ± 1.4 × 10⁻5 M) in a non-selective manner. Furthermore, caulerpine concentration-dependently inhibited serotonin-induced cumulative contractions (pD'2 = 4.48 ± 0.08), shifting the curves to the right with Emax reduction and slope of 2.44 ± 0.21, suggesting a noncompetitive antagonism pseudo-irreversible. The alkaloid also relaxed the ileum pre-contracted by KCl (EC50 = 9.0 ± 0.9 × 10⁻5 M) and carbachol (EC50 = 4.6 ± 0.7 × 10⁻5 M) in a concentration-dependent manner. This effect was probably due to inhibition of Ca²âº influx through voltage-gated calcium channels (CaV), since caulerpine slightly inhibited the CaCl2-induced contractions in depolarizing medium without Ca²âº, shifting the curves to the right and with Emax reduction. According to these results, the spasmolytic effect of caulerpine on guinea pig ileum seems to involve inhibition of Ca²âº influx through CaV. However, other mechanisms are not discarded.

Incidental Adrenal Masses: A Case Report of an Adrenal Oncocytoma.

A 59-year-old woman underwent an abdominal and pelvic computed tomography (CT) scan to rule out non-obstructive urolithiasis. The patient was asymptomatic, with the exception of occasional bilateral low back pain. A physical examination did not reveal any notable findings. The CT scan revealed the presence of an incidental solid left adrenal lesion, which displaced the body of the pancreas and the left kidney. The lesion measured 7 cm × 6.5 cm and exhibited a rounded morphology with well-defined margins. It showed progressive and heterogeneous contrast uptake. Additionally, magnetic resonance imaging (MRI) was performed, confirming the presence of an adrenal lesion with intense and heterogeneous hypersignal on T2. The lesion also demonstrated heterogeneous and persistent enhancement in a dynamic study. Furthermore, there were some indistinct and non-specific hypointense areas identified on both T1 and T2 sequences. The lesion exhibited moderately restricted diffusion. Although the imaging features were non-specific, there were no indications of invasion or distant metastasis, which made a benign large adrenal mass the most likely diagnosis. Non-functioning pheochromocytoma, lipid-poor adrenal adenoma, as well as metastasis or primary adrenal carcinoma, were considered differential diagnoses. The patient underwent an elective adrenalectomy, during which the identified lesion was completely resected. The patient's postoperative recovery was uneventful, and she was discharged three days after the procedure. Subsequent histopathological evaluation revealed an oncocytic neoplasm of the adrenal cortex - specifically, an oncocytoma.

Blunt Trauma and Right Diaphragmatic Rupture: Unveiling the Impact.

Traumatic diaphragmatic ruptures are rare, yet blunt injuries tend to be more easily overlooked compared to penetrating trauma. The minimal evidence of external injuries makes a high index of suspicion key for diagnosis. We report the case of a right-sided thoracoabdominal blunt trauma that resulted in a diaphragmatic rupture and fractured rib. Although often approached through a midline laparotomy, a definitive right thoracotomy repair was exceptionally performed since the adjacent peritoneum remained uninjured.

Solving urban water microplastics with bacterial cellulose hydrogels: Leveraging predictive computational models.

The prevalence of microplastics (MPs) in both urban and aquatic ecosystems is concerning, with wastewater treatment plants being considered one of the major sources of the issue. As the focus on developing sustainable solutions increases, unused remnants from bacterial cellulose (BC) membranes were ground to form BC hydrogels as potential bioflocculants of MPs. The influence of operational parameters such as BC:MPs ratio, hydrogel grinding, immersion and mixing time, temperature, pH, ionic strength, and metal cations on MPs flocculation and dispersion were evaluated. A response surface methodology based on experimental data sets was computed to understand how these parameters influence the flocculation process. Further, both the BC hydrogel and the hetero-aggregation of MPs were characterised by UV-Vis, ATR-FTIR, IGC, water uptake assays, fluorescence, and scanning electron microscopy. These highlights that the BC hydrogel would be fully effective at hetero-aggregating MPs in naturally-occurring concentrations, thereby not constituting a limiting performance factor for MPs' optimal flocculation and aggregation. Even considering exceptionally high concentrations of MPs (2 g/L) that far exceed naturally-occurring concentrations, the BC hydrogel was shown to have elevated MPs flocculation activity (reaching 88.6%: 1.77 g/L). The computation of bioflocculation activity showed high reliability in predicting flocculation performance, unveiling that the BC:MPs ratio and grinding times were the most critical variables modulating flocculation rates. Also, short exposure times (5 min) were sufficient to drive robust particle aggregation. The microporous nature of the hydrogel revealed by electron microscopy is the likely driver of strong MPs bioflocculant activity, far outperforming dispersive commercial bioflocculants like xanthan gum and alginate. This pilot study provides convincing evidence that even BC remainings can be used to produce highly potent and circular bioflocculators of MPs, with prospective application in the wastewater treatment industry.

Anterior Penetrating Neck Injury: A Path to the Cervical Spine.

While rare in incidence, penetrating neck injuries are often life-threatening. When a patient's physiological status is appropriate, the first step in treatment should be a detailed preoperative imaging assessment. Formulating a treatment plan that includes computed tomography (CT) imaging and discussing the surgical approach with a multidisciplinary team before operating allows for a successful selective surgical approach. The authors report the case of a Zone II penetrating injury with a right laterocervical entry wound in which an impaled blade with an inferomedial oblique path pierced deeply into the cervical spine. The blade missed multiple vital structures in the neck, such as the common carotid artery, jugular vein, trachea, and esophagus. The patient underwent a formal neck exploration, and controlled extraction of the blade under direct vision was achieved. Therefore, the author's recommendation for implementing any management algorithm for penetrating neck injuries should rely primarily on a multidisciplinary selective approach.