Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines.

Background: Acupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported. Methods: ACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity. Results: Across 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2-22), needle retention time (M = 23.5 min, range 4-52), session length (M = 40.3 min, range 20-66), whether general recommendations were provided and completion of the session form. Conclusion: To the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs. Protocol registration: The protocol of this study is registered at clinicaltrials.gov: NCT04880733.

Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care-a Randomized Trial.

BACKGROUND: Acupuncture has been shown to be effective for the treatment of chronic musculoskeletal back, neck, and osteoarthritis pain. However, access to acupuncture treatment has been limited in medically underserved and low-income populations. OBJECTIVE: Acupuncture therapy delivered in groups could reduce cost and expand access. We compared the effectiveness of group versus individual acupuncture for pain and function among ethnically diverse, low-income primary care patients with chronic musculoskeletal pain. DESIGN: This was a randomized comparative effectiveness non-inferiority trial in 6 Bronx primary care community health centers. Participants with chronic (> 3 months) back, neck, or osteoarthritis pain were randomly assigned to individual or group acupuncture therapy for 12 weeks. PARTICIPANTS: Seven hundred seventy-nine participants were randomized. Mean age was 54.8 years. 35.3% of participants identified as black and 56.9% identified as Latino. Seventy-six percent were Medicaid insured, 60% reported poor/fair health, and 37% were unable to work due to disability. INTERVENTIONS: Participants received weekly acupuncture treatment in either group or individual setting for 12 weeks. MAIN MEASURES: Primary outcome was pain interference on the Brief Pain Inventory at 12 weeks; secondary outcomes were pain severity (BPI), physical and mental well-being (PROMIS-10), and opiate use. Outcome measures were collected at baseline, 12 and 24 weeks. KEY RESULTS: 37.5% of individual arm and 30.3% in group had > 30% improvement in pain interference (d = 7.2%, 95% CI - 0.6%, 15.1%). Non-inferiority of group acupuncture was not demonstrated for the primary outcome assuming a margin of 10%. In the responder analysis of physical well-being, 63.1% of individual participants and 59.5% of group had clinically important improvement at 12 weeks (d = 3.6%, 95% CI - 4.2%, 11.4%). CONCLUSIONS: Both individual and group acupuncture therapy delivered in primary care settings reduced chronic pain and improved physical function at 12 weeks; non-inferiority of group was not shown. TRIAL REGISTRATION: Clinicaltrials.gov # NCT02456727.

A Learning Collaborative Approach to Improve Primary Care STI Screening.

The Bronx Ongoing Pediatric Screening (BOPS) project sought to improve screening for sexual activity and sexually transmitted infections (gonorrhea and chlamydia [GCC] and HIV) in a primary care network, employing a modified learning collaborative, real-time clinical data feedback to practices, improvement coaching, and a pay-for-quality monetary incentive. Outcomes are compared for 11 BOPS-participating sites and 10 non-participating sites. The quarterly median rate for documenting sexual activity status increased from 55% to 88% (BOPS sites) and from 13% to 74% (non-BOPS sites). GCC screening of sexually active youth increased at BOPS and non-BOPS sites. Screening at non-health care maintenance visits improved more at BOPS than non-BOPS sites. Data from nonparticipating sites suggests that introduction of an adolescent EMR template or other factors improved screening rates regardless of BOPS participation; BOPS activities appear to promote additional improvement of screening during non-health maintenance visits.

Pediatricians Transitioning Practices, Youth With Special Health Care Needs in New York State.

OBJECTIVE: To assess current practices of New York State pediatricians as they transition youth with special health care needs to adult-oriented medical care. METHODS: A survey of New York State pediatricians included 6 critical steps from 2002 consensus statement, 11 essential steps adapted from recent literature, and questions targeting age of starting transition and availability of transition policy. RESULTS: Of 181 respondents, only 11% have a transition policy. Most assist patients in transition process; identify an adult provider (92%); and create portable medical summary (57%). Only 3% start planning process at recommended age. No respondents are compliant with all 6 critical steps; subspecialists were more likely to report compliance to more than 4 steps. CONCLUSIONS: Participating pediatricians are making gains, yet effort is needed, to incorporate the essential steps into practice for transitioning youth with special health care needs. Recognition of barriers, use of electronic tools, and clarifying subspecialist's approach, may improve compliance with transition recommendations.

Do primary care patient experiences vary by teaching versus nonteaching facility?

BACKGROUND: Patient experiences are important components of the patient-centered medical home. Competing demands of primary care and resident education contribute to inefficiencies at teaching sites, which may contribute to poor patient experiences. Educational commitments of residencies may also produce positive experiences. The objective of this study was to compare patient experiences in teaching versus nonteaching sites. METHODS: Patients across 6 primary care sites (3 teaching and 3 nonteaching) completed surveys. Patient experiences assessed using (1) Consumer Assessment of Health care Providers and Systems (CAHPS) across 3 domains: access to care, communication, clerk/receptionist courtesy (scores range from 1 [worst] to 6 [best]) and (2) Patient Assessment of Chronic Illness Care, measuring chronic care experiences (scores range from 1 [worst] to 5 [best]). RESULTS: Approximately 70% of participants were female and >40% were Latino. The adjusted mean score for patient-reported access at teaching sites was 4.35; at nonteaching sites it was 5.14 (P = .01). The total mean score for chronic disease was 4.02 for teaching sites and 3.79 for nonteaching sites (P = .01). Four of the 5 Patient Assessment of Chronic Illness Care subscale scores were better at teaching sites. CONCLUSIONS: Worse access scores among teaching sites may reflect the complexities of residencies. Better chronic care scores are encouraging and potentially indicate focused training. Residencies might continue chronic disease training while considering efforts to improve access.

Teaching family in family medicine residency programs: results of a national survey.

BACKGROUND AND OBJECTIVES: Integrating family into family medicine has been recognized as important for the discipline, yet there is little known about how family-oriented care is taught in training environments. This paper presents results of a national survey assessing the status of teaching family concepts/skills in family medicine residency programs. METHODS: We sought to survey the program director (PD), a behavioral science faculty (BSF), and a chief resident (CR) from all 454 Accreditation Council for Graduate Medical Education (ACGME) family medicine residency programs. RESULTS: Respondents (n=489) were PDs (29%), CRs (34%), and BSF (36%). Of all respondents, 47% to 66% believe that integrating family concepts/skills into family medicine training is very important (highest level of importance). However, only 19%--23% believe their own programs place this level of importance on this curricular area. Less weight is given to family topics when compared with other behavior science subjects. Behavioral scientists who reported inclusion of (1) family concepts/skills in the formulation of ACGME competencies, (2) evaluation of residents on these skills, or (3) the presence of a family champion or scholar in the program, all reported teaching significantly more family-oriented skills compared to those that did not, respectively, 1 (6.96 versus 4.48), 2 (6.55 versus 4.97), and 3 (6.62 versus 4.54). CONCLUSIONS: Teaching about the family in family medicine continues to be highly valued among educators and their trainees; however, it is not perceived to be similarly valued in residency programs. Current changes in health care offer opportunities to promote and affirm family-oriented care. New curricular strategies are needed so that family-oriented care continues to define the uniqueness of family medicine.

Secretion by the nasal salt glands of two insectivorous lizard species is initiated by an ecologically relevant dietary ion, chloride.

Salt glands are used by some vertebrates to excrete hyperosmotic NaCl or KCl solutions in response to dietary salt loads. Control of secretion varies across taxa; some secrete in response to osmotic challenges while others secrete in response to specific dietary ions. We hypothesized that differences in control could be related to different diet-related selective pressures on herbivorous, marine, and insectivorous species. We studied control of secretion and flexibility of cation (sodium or potassium) and anion (chloride or bicarbonate) secretion in two insectivorous lizard species, Schneider's skinks (Eumeces schneideri, Scincidae) and green anoles (Anolis carolinensis, Polychrotidae). Lizards were injected daily for four days with combinations of cations (potassium, sodium, and histidine control) and anions (chloride and acetate control), isoosmotic saline, or sham injection. Secretions were collected daily and analyzed for sodium, potassium, and chloride. Both species secreted only in response to chloride; sodium appeared to have a slight inhibitory effect. Regardless of cation load, skinks secreted a combination of potassium and sodium, while anoles secreted solely potassium. In both species, total cation secretion was matched closely by chloride; very little bicarbonate was secreted. As predicted, secretion in insectivorous lizards was initiated by the dietary ion ecologically most important for these species, chloride, which otherwise cannot be excreted without significant water loss (unlike the cations, which may be excreted as insoluble urate salts). This gives further support to the hypothesis that ecological factors drive the evolution of control mechanisms in lizard salt glands.

[Predictive value of fetal fibronectin for preterm labor]. / Valor predictivo de la fibronectina fetal en amenaza de parto pretérmino.

OBJECTIVE: We evaluated fetal fibronectin levels for the diagnosis of preterm labor. MATERIAL AND METHODS: We included 74 randomized patients who were admitted with the diagnosis of preterm labor. Cervical and vaginal fluid samples were washed in buffer solution prior to the introduction of a reactive strip. Results were interpreted after 10 sec. Patients with negative tests were admitted and followed up. Patients who tested positive were treated according to the protocols of each hospital. Finally, the specificity, sensitivity, predictive value, and odds ratio were determined. RESULTS: Results showed specificity, 90%; sensitivity, 70%; positive predictive value, 64%; negative predictive value, 78%; and odds ratio, 22; 50% were first pregnancies with gestational ages between 22 and 34 weeks. CONCLUSIONS: We consider that a positive fibronectin test is a useful, low-cost, and reliable tool for diagnosing preterm labor.