Using a Fitbit-based Walking Game to Improve Physical Activity Among U.S. Veterans.

INTRODUCTION: Physical inactivity, hereafter inactivity, is a serious health problem among U.S. veterans, hereafter veterans. Inactive adults are at risk for adverse cardiac events and premature mortality. Specifically, among veterans, inactivity has been associated with a 23% increase in mortality. In order to increase physical activity among veterans, we developed Veterans Affairs (VA) MapTrek, a mobile-phone-based web app that allows users to take a virtual walk in interesting locations around the world while tracking their progress against that of others like themselves on an interactive map. Steps are counted by a commercially available Fitbit triaxial accelerometer, and users see their progress along a predefined scenic path overlaid on Google Maps. The objective of this study was to determine the effectiveness of VA MapTrek to increase physical activity in a population of veterans at risk for obesity-related morbidity. MATERIALS AND METHODS: We recruited overweight and obese veterans obtaining care at the Iowa City Veterans Affairs Health Center. Half of the veterans were assigned to participate in VA MapTrek. Each week, participants were assigned virtual walking races (Monday through Saturday), which followed a predetermined route that is displayed on Google Maps. The participant's position on the map is automatically updated each time their Fitbit syncs to their phone. In addition, challenges were issued periodically. Veterans in the control group were only given a Fitbit. We regressed daily step counts on the days of the week, the days since the start of the intervention period, whether the user was in the VA MapTrek or Control group, and an interaction between the study group and the days since the start of the intervention period. We included subject-specific random intercepts and subject-specific random slopes. This model was estimated using Bayesian Hamiltonian Monte Carlo using Stan's No-U-Turns sampler. We set vague, uniform priors on all the parameters. RESULTS: We enrolled 276 participants, but only 251 (102 in the control group and 149 in the VA MapTrek group) contributed data during the intervention period. Our analysis suggests an 86.8% likelihood that the VA MapTrek intervention led to a minimum increase of 1,000 daily steps over the 8-week period, compared to the control group. Throughout the 8-week intervention, we project that VA MapTrek participants would have taken an extra 96,627 steps, equivalent to 77.8 additional kilometers (km) (48.3 additional miles), assuming an average of 1,242 steps per km (2,000 steps per mile). CONCLUSIONS: Our study underscores the potential of VA MapTrek as an intervention for promoting walking among veterans who face elevated risks of obesity and cardiac issues. Rural veterans are a high-risk population, and new interventions like VA MapTrek are needed to improve veterans' health.

Impact of Outpatient Pharmacist Dispensing in an Opioid Use Disorder Clinic.

BACKGROUND: Medications for opioid use disorder (MOUD) are effective in reducing opioid deaths, but access can be an issue. Relocating an outpatient pharmacist for weekly buprenorphine dispensing in an outpatient clinic may facilitate coverage for buprenorphine and mitigate access and counseling barriers. OBJECTIVES: To evaluate if staffing an outpatient resident pharmacist to dispense in the buprenorphine clinic had a positive impact on 1) mean cost-per-prescription charged to charity care and 2) basic elements of patient satisfaction with the on-site pharmacist. METHODS: Patient demographics, buprenorphine formulation, insurance type, and uncovered costs were abstracted from dispensing records in the 16 weeks before the pharmacist clinic presence and 16 weeks with the pharmacist present. The difference in insurance types across the two periods was tested using a Chi-square test and the mean uncovered prescription costs charged to charity care for the two periods was compared using an independent samples t-test. A brief survey was administered while the pharmacist was on site to evaluate satisfaction which was analyzed with frequencies of "yes" responses and free-text comments. RESULTS: A total of 38 patients received buprenorphine during both the pre- and post-periods. Once the pharmacist was on-site, more patients used Medicaid or private insurance, decreasing the mean uncovered cost per prescription from $55.00 (sd 68.7) to $36.97 (sd 60.1) p=.002. Patients reported high levels of satisfaction with most reporting they were more likely to ask questions, pick up their prescriptions, and take their medicine with the pharmacist in clinic. CONCLUSIONS: The pharmacist successfully transitioned a portion of prescriptions previously covered by charity care to Medicaid or private insurance. This shift led to a decrease in charity care costs by $2,950.20 and a reduction in the average uncovered cost per prescription. The pharmacist's presence in the clinic appeared to reduce barriers especially related to inconvenience.

Association between household opioid prescriptions and risk for overdose among family members not prescribed opioids.

BACKGROUND: Prescription opioids have contributed to the rise in opioid-related overdoses and deaths. The presence of opioids within households may increase the risk of overdose among family members who were not prescribed an opioid themselves. Larger quantities of opioids may further increase risk. OBJECTIVES: To determine the risk of opioid overdose among individuals who were not prescribed an opioid but were exposed to opioids prescribed to other family members in the household, and evaluate the risk in relation to the total morphine milligram equivalents (MMEs) present in the household. METHODS: We conducted a cohort study using a large database of commercial insurance claims from 2001 to 2021. For inclusion in the cohort, we identified individuals not prescribed an opioid in the prior 90 days from households with two or more family members, and determined the total MMEs prescribed to other family members. Individuals were stratified into monthly enrollment strata defined by household opioid exposure and other confounders. A generalized linear model was used to estimate incidence rate ratios (IRRs) for overdose. RESULTS: Overall, the incidence of overdose among enrollees in households where a family member was prescribed an opioid was 1.73 (95% confidence interval [CI]: 1.67-1.78) times greater than households without opioid prescriptions. The risk of overdose increased continuously with the level of potential MMEs in the household from an IRR of 1.23 (95% CI: 1.16-1.32) for 1-100 MMEs to 4.67 (95% CI: 4.18-5.22) for >12,000 MMEs. The risk of overdose associated with household opioid exposure was greatest for ages 1-2 years (IRR: 3.46 [95% CI: 2.98-4.01]) and 3-5 years (IRR: 3.31 [95% CI: 2.75-3.99]). CONCLUSIONS: The presence of opioids in a household significantly increases the risk of overdose among other family members who were not prescribed an opioid. Higher levels of MMEs, either in terms of opioid strength or quantity, were associated with increased levels of risk. Risk estimates may reflect accidental poisonings among younger family members.

Predicting use of a gait-stabilizing device using a Wii Balance Board.

Gait-stabilizing devices (GSDs) are effective at preventing falls, but people are often reluctant to use them until after experiencing a fall. Inexpensive, convenient, and effective methods for predicting which patients need GSDs could help improve adoption. The purpose of this study was to determine if a Wii Balance Board (WBB) can be used to determine whether or not patients use a GSD. We prospectively recruited participants ages 70-100, some who used GSDs and some who did not. Participants first answered questions from the Modified Vulnerable Elders Survey, and then completed a grip-strength test using a handgrip dynamometer. Finally, they were asked to complete a series of four 30-second balance tests on a WBB in random order: (1) eyes open, feet apart; (2) eyes open, feet together; (3) eyes closed, feet apart; and (4) eyes closed, feet together. The four-test series was repeated a second time in the same random order. The resulting data, represented as 25 features extracted from the questionnaires and the grip test, and data from the eight balance tests, were used to predict a subject's GSD use using generalized functional linear models based on the Bernoulli distribution. 268 participants were consented; 62 were missing data elements and were removed from analysis; 109 were not GSD users and 97 were GSD users. The use of velocity and acceleration information from the WBB improved upon predictions based solely on grip strength, demographic, and survey variables. The WBB is a convenient, inexpensive, and easy-to-use device that can be used to recommend whether or not patients should be using a GSD.

Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial.

BACKGROUND: Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity. METHODS: We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration. RESULTS: Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity. CONCLUSIONS: Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity. REGISTRATION DETAILS: www. CLINICALTRIALS: gov Identifier: NCT05488795.

Using Thermal Imaging to Track Cellulitis.

Background: Cellulitis is a common soft tissue infection and a major cause of morbidity. The diagnosis is based almost exclusively on clinical history and physical exam. To improve the diagnosis of cellulitis, we used a thermal camera to track how skin temperature of the affected area changed during a hospital stay for patients with cellulitis. Methods: We recruited 120 patients admitted with a diagnosis of cellulitis. Daily thermal images of the affected limb were taken. Temperature intensity and area were analyzed from the images. Highest daily body temperature and antibiotics administered were also collected.We estimated a longitudinal linear mixed-effects model with a random intercept for the affected body area. All observations on a given day were included, and we used an integer time indicator indexed to the initial day (ie, t = 1 for the first day the patient was observed, etc.). We then analyzed the effect of this time trend on both severity (ie, normalized temperature) and scale (ie, area of skin with elevated temperature). Results: We analyzed thermal images from the 41 patients with a confirmed case of cellulitis who had at least 3 days of photos. For each day that the patient was observed, the severity decreased by 1.63 (95% CI, -13.45 to 10.32) units on average, and the scale decreased by 0.63 (95% CI, -1.08 to -0.17) points on average. Also, patients' body temperatures decreased by 0.28°F each day (95% CI, -0.40 to -0.17). Conclusions: Thermal imaging could be used to help diagnose cellulitis and track clinical progress.

Hepatitis C screening in a community pharmacy setting: Patient perspective.

BACKGROUND: Hepatitis C virus (HCV) is an infection of the liver, which contributes to over 15,000 deaths in the United States annually. When treated, HCV has a 90% or greater cure rate, however testing for HCV remains low. OBJECTIVES: To assess patient perspectives on HCV screenings in the community pharmacy setting including awareness of screening, willingness to be screened, barriers to screening, and willingness to pay for HCV screening. METHODS: This study used a cross-sectional survey design. The surveys were distributed by staff at an independent community pharmacy participating in an HCV screening initiative through the state department of public health. Eligible patients were born between 1945 and 1965. Descriptive statistics were calculated for survey variables. Open-ended responses were analyzed for additional context. RESULTS: Fifty-seven surveys were returned and analyzed. The majority of the respondents were White (94%), female (56%), and had some college education (26%). Only 7% were aware that a finger-stick point-of-care test was available and 67% were unaware of the Centers for Disease Control and Prevention (CDC) recommendation for testing. The most frequently reported barrier or hesitation to screening was the patient not thinking they were at risk (29%) followed by uncertainty about cost (14%). Over half of respondents (63%) were either somewhat interested or very interested in testing in a community pharmacy, however, the majority (71%) were not willing to pay or only willing to pay less than $20. CONCLUSIONS: Survey respondents were largely unaware of the recommendations and availability of finger-stick HCV screenings at community pharmacies but many were willing to be tested if low-cost. Providing patient education on the importance of HCV screenings and CDC recommendations may bolster interest in screening.

Association of Appendicitis Incidence With Warmer Weather Independent of Season.

Importance: Acute appendicitis is a common cause of abdominal pain and the most common reason for emergency surgery in several countries. Increased cases during summer months have been reported. Objective: To investigate the incidence of acute appendicitis by considering local temperature patterns in geographic regions with different climate over several years. Design, Setting, and Participants: This cohort study used insurance claims data from the MarketScan Commercial Claims and Encounters Database and the Medicare Supplemental and Coordination of Benefits Database from January 1, 2001, to December 31, 2017. The cohort included individuals at risk for appendicitis who were enrolled in US insurance plans that contribute data to the MarketScan databases. Cases of appendicitis in the inpatient, outpatient, and emergency department settings were identified using International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. Local weather data were obtained for individuals living in a metropolitan statistical area (MSA) from the Integrated Surface Database. Associations were characterized using a fixed-effects generalized linear model based on a negative binomial distribution. The model was adjusted for age, sex, and day of week and included fixed effects for year and MSA. The generalized linear model was fit with a piecewise linear model by searching each 0.56 °C in temperature for change points. To further isolate the role of temperature, observed temperature was replaced with the expected temperature and the deviation of the observed temperature from the expected temperature for a given city on a given day of year. Data were analyzed from October 1, 2021, to July 31, 2022. Main Outcomes and Measures: The primary outcome was the daily number of appendicitis cases in a given city stratified by age and sex, with mean temperature in the MSA over the previous 7 days as the independent variable. Results: A total of 450 723 744 person-years at risk and 689 917 patients with appendicitis (mean [SD] age, 35 [18] years; 347 473 male [50.4%] individuals) were included. Every 5.56 °C increase in temperature was associated with a 1.3% increase in the incidence of appendicitis (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) when temperatures were 10.56 °C or lower and a 2.9% increase in incidence (IRR, 1.03; 95% CI, 1.03-1.03) for temperatures higher than 10.56 °C. In terms of temperature deviations, a higher-than-expected temperature increase greater than 5.56 °C was associated with a 3.3% (95% CI, 1.0%-5.7%) increase in the incidence of appendicitis compared with days with near-0 deviations. Conclusions and Relevance: Results of this cohort study observed seasonality in the incidence of appendicitis and found an association between increased incidence and warmer weather. These results could help elucidate the mechanism of appendicitis.

Machine learning approaches to predict the 1-year-after-initial-AMI survival of elderly patients.

BACKGROUND: While multiple randomized controlled trials (RCTs) are available, their results may not be generalizable to older, unhealthier or less-adherent patients. Observational data can be used to predict outcomes and evaluate treatments; however, exactly which strategy should be used to analyze the outcomes of treatment using observational data is currently unclear. This study aimed to determine the most accurate machine learning technique to predict 1-year-after-initial-acute-myocardial-infarction (AMI) survival of elderly patients and to identify the association of angiotensin-converting- enzyme inhibitors and angiotensin-receptor blockers (ACEi/ARBs) with survival. METHODS: We built a cohort of 124,031 Medicare beneficiaries who experienced an AMI in 2007 or 2008. For analytical purposes, all variables were categorized into nine different groups: ACEi/ARB use, demographics, cardiac events, comorbidities, complications, procedures, medications, insurance, and healthcare utilization. Our outcome of interest was 1-year-post-AMI survival. To solve this classification task, we used lasso logistic regression (LLR) and random forest (RF), and compared their performance depending on category selection, sampling methods, and hyper-parameter selection. Nested 10-fold cross-validation was implemented to obtain an unbiased estimate of performance evaluation. We used the area under the receiver operating curve (AUC) as our primary measure for evaluating the performance of predictive algorithms. RESULTS: LLR consistently showed best AUC results throughout the experiments, closely followed by RF. The best prediction was yielded with LLR based on the combination of demographics, comorbidities, procedures, and utilization. The coefficients from the final LLR model showed that AMI patients with many comorbidities, older ages, or living in a low-income area have a higher risk of mortality 1-year after an AMI. In addition, treating the AMI patients with ACEi/ARBs increases the 1-year-after-initial-AMI survival rate of the patients. CONCLUSIONS: Given the many features we examined, ACEi/ARBs were associated with increased 1-year survival among elderly patients after an AMI. We found LLR to be the best-performing model over RF to predict 1-year survival after an AMI. LLR greatly improved the generalization of the model by feature selection, which implicitly indicates the association between AMI-related variables and survival can be defined by a relatively simple model with a small number of features. Some comorbidities were associated with a greater risk of mortality, such as heart failure and chronic kidney disease, but others were associated with survival such as hypertension, hyperlipidemia, and diabetes. In addition, patients who live in urban areas and areas with large numbers of immigrants have a higher probability of survival. Machine learning methods are helpful to determine outcomes when RCT results are not available.

Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension.

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

Gamifying accelerometer use increases physical activity levels of individuals pre-disposed to type II diabetes.

Physical activity is important for preventing obesity and diabetes, but most obese and pre-diabetic patients are not physically active. We developed a Fitbit-based game called MapTrek that promotes walking. We recruited obese and pre-diabetic patients. Half were randomly assigned to the control group and given a Fitbit alone. The others were given a Fitbit plus MapTrek. The MapTrek group participated in 6 months of weekly virtual races. Each week, participants were placed in a race with 9 others who achieved a similar number of steps in the previous week's race. Participants moved along the virtual route by the steps recorded on their Fitbit and received daily walking challenges via text message. Text messages also had links to the race map and leaderboard. We used a Bayesian mixed effects model to analyze the number of steps taken during the intervention. A total of 192 (89%) participants in the control group and 196 (91%) in the MapTrek group were included in the analyses. MapTrek significantly increased step counts when it began: MapTrek participants walked almost 1,700 steps more than the control group on the first day of the intervention. We estimate that there is a 97% probability that the effect of MapTrek is at least 1,000 additional steps per day throughout the course of the 6-month intervention and that MapTrek participants would have walked an additional 81 miles, on average, before the effect ended. Our MapTrek intervention led to significant extra walking by the MapTrek participants.

Multilevel mHealth Intervention Increases Physical Activity of Older Adults Living in Retirement Community.

BACKGROUND: Regular physical activity is crucial for healthy aging, but older adults are the least active age group. This study explored the feasibility, acceptability, and efficacy of a multilevel mHealth intervention for increasing physical activity of older adults living in a retirement community. METHODS: Participants included 54 older adults (mean age = 81.2 y, 77.8% female, 98.1% white) living in a retirement community. Participants received a Fitbit Zip and access to a multilevel mHealth physical activity intervention (MapTrek Residential) for 8 weeks. Physical activity (in steps per day) and intervention compliance (days worn) were measured objectively with the Fitbit for 12 weeks (8-wk intervention plus 4-wk follow-up). Psychosocial outcomes (social support, self-efficacy, and outcome expectations) were assessed at baseline and 8 weeks. Acceptability outcomes were assessed with an open-ended process evaluation survey and focus groups. Descriptive statistics and linear mixed models were used to examine intervention effects. RESULTS: Participants increased daily steps from 5438 steps per day at baseline (95% CI, 4620 to 6256) to 6201 steps per day (95% CI, 5359 to 7042) at week 8 (P < .0001) but this was not maintained at 12 weeks (P = .92). CONCLUSIONS: Our multilevel mHealth physical activity intervention was effective for increasing physical activity older adults over 8 weeks. Additional research focused on maintaining physical activity gains with this approach is warranted.

Warmer Weather and the Risk of Urinary Tract Infections in Women.

PURPOSE: The incidence of urinary tract infections is seasonal, peaking in summer months. One possible mechanism for the observed seasonality of urinary tract infections is warmer weather. MATERIALS AND METHODS: We identified all urinary tract infection cases located in approximately 400 metropolitan statistical areas in the contiguous United States between 2001 and 2015 using the Truven Health MarketScan® databases. A total of 167,078,882 person-years were included in this data set and a total of 15,876,030 urinary tract infection events were identified by ICD-9 code 599.0. Weather data for each metropolitan statistical area and date were obtained from the National Centers for Environmental Information. We computed the mean temperature during the period 0 to 7 days prior to the urinary tract infection diagnosis. We used a quasi-Poisson generalized linear model. The primary outcome was the number of urinary tract infections each day in a metropolitan statistical area in each age group. Covariates considered included age group, day of week, year and the temperature during the previous 7 days. RESULTS: Warmer weather increases the risk of urinary tract infections among women treated in outpatient settings in a dose-response fashion. On days when the prior week's average temperature was between 25 and 30C, the incidence of urinary tract infections was increased by 20% to 30% relative to when the prior week's temperature was 5 to 7.5C. CONCLUSIONS: The incidence of urinary tract infections increases with the prior week's temperature. Our results indicate that warmer weather is a risk factor for urinary tract infections. Furthermore, as temperatures rise, the morbidity attributable to urinary tract infections may increase.

A cluster randomized trial to evaluate a centralized remote clinical pharmacy service in large, health system primary care clinics.

Background: We developed a remote cardiovascular risk service (CVRS) managed by clinical pharmacists to support primary care teams. The purpose of this study was to examine whether the CVRS could improve guideline adherence in primary care clinics with diverse geographic and patient characteristics. Methods: This study was a cluster-randomized trial initiated in 20 primary care clinics across the US. Clinics were stratified as high or low minority and then randomized to receive the intervention or maintain usual care for 12 months. The primary outcome was adherence to relevant The Guideline Advantage (TGA) criteria met. TGA is a compilation of criteria from practice guidelines intended to improve the quality of primary care. Post-hoc outcomes included changes in individual TGA measures. Results: A total of 401 study subjects were included in the analysis. Mean TGA scores remained the same in the intervention group (n=193, 0.72) and slightly decreased in the usual care group (n=208, 0.67 to 0.66) over the 12-month study period. There was no significant difference between the mean TGA scores in intervention and usual care groups for the overall population at 12 months (0.72 versus 0.66 respectively, p=0.10). For under-represented minority subjects, there was no significant difference between TGA scores at 12 months (n=186; 0.70 versus 0.67, respectively, p=0.50). In a post-hoc analysis of subjects uncontrolled at baseline, there was a significant improvement in systolic BP at 12 months in the intervention group versus usual care (model-based difference of -8.03mmHg, p=0.03). Conclusions: Improvements in individual TGA measures were limited, in part, due to higher than expected baseline TGA scores. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02215408; https://clinicaltrials.gov/ct2/show/NCT02215408?id=NCT02215408.

Predictors of HIV Preexposure Prophylaxis Initiation Among Public Health Clients in Rural and Small Urban Areas in Iowa.

OBJECTIVE: Preexposure prophylaxis (PrEP) is a safe and effective method for HIV prevention, but little is known about PrEP uptake in rural and small urban areas. We described rates and predictors of HIV PrEP initiation among public health clients in rural and small urban areas in Iowa. METHODS: This was a prospective cohort study of clients with PrEP indications served by HIV testing and disease intervention specialist/partner services (DIS/PS) programs in public health departments in Iowa from February 1, 2018, through February 28, 2019. Eligible participants were aged 18-70 and referred for PrEP by public health personnel. Participants completed surveys at enrollment addressing demographic characteristics; sexual history; previous drug use; PrEP experiences; and knowledge, attitudes, and beliefs about PrEP. A follow-up survey assessed PrEP initiation at 30 days. We compared baseline characteristics of PrEP initiators and non-initiators. RESULTS: Two hundred thirty-four public health clients consented to participate in the study; 189 completed the baseline survey, and 117 (61.9%) completed the follow-up survey. The mean age of participants in the baseline survey was 30 (range, 18-68); 109 (57.7%) were male, 127 (67.2%) were White, and 169 (89.4%) lived in a rural or small urban area. Of 117 participants in the follow-up survey, those who initiated PrEP were significantly more likely than those who did not initiate PrEP to be referred by DIS/PS programs (46.7% vs 7.8%, P < .001) and to recognize that PrEP was ≥90% effective (86.7% vs 35.3%, P = .001). No PrEP initiators and 8 PrEP non-initiators agreed that PrEP is for promiscuous people (0% vs 7.8%, P = .04). Perceived PrEP stigma was low and not associated with PrEP initiation. CONCLUSIONS: PrEP initiation rates were low among rural and small urban health department clients. Interventions are needed to improve linkage to PrEP among rural and small urban public health clients.

Opioid abuse surveillance in patients with endocarditis.

BACKGROUND: Opioid abuse is a significant cause of morbidity and mortality in the United States, and injection drug use (IDU) is a common form of opioid abuse. IDU is a major risk factor for infections including infective endocarditis (IE). OBJECTIVES: To determine the prevalence of opioid abuse among patients with IE in both patient problem lists and diagnostic codes and describe underlying patient characteristics. METHODS: A retrospective chart review from 1-1-2010 to 11-19-2018 of a large academic medical center's patients with documented IE was performed. Demographic, comorbidity, opioid prescription data and records of drug abuse in both the patient's problem list and ICD9/10 codes were recorded. RESULTS: Of the 796 patients with documented IE, 105 patients (13.2%) had opioid abuse or related IDU in their problem list, but only 22 received an ICD-9/10 code associated with drug abuse. IE patients with opioid abuse were generally younger (43.6 vs 61.7 years [P < 0.001]), had fewer chronic comorbidities, and were prescribed opioids more often (86.7% vs 53.8% [P < 0.001]). CONCLUSIONS: Opioid abuse and IDU are commonly recorded in the problem list of patients with IE, but opioid abuse is frequently not listed as a diagnosis in administrative billing codes.

A pharmacist intervention for monitoring and treating hypertension using bidirectional texting: PharmText BP.

BACKGROUND: New approaches are needed to better monitor blood pressure (BP) between physician visits, especially for patients in rural areas or for those who lack transportation. We have developed a custom-built bi-directional texting platform for home BP measurements that can then be managed by clinical pharmacists located remotely. The purpose of this study is to evaluate whether the BP texting approach combined with a pharmacist-based intervention improves BP management and to determine if the approach is cost effective. METHODS: This study is a randomized, prospective trial in four primary care offices that serve patients in rural areas. Subjects will receive standardized research BP measurements at baseline, 6 and 12 months. The primary outcome will be differences between the intervention and control group in mean systolic BP at 12 months. Secondary outcomes will include systolic BP at 6 months; diastolic BP at 6 and 12 months, number of medication changes and costs. CONCLUSIONS: This study plans to enroll subjects through 2022, follow-up will be completed in 2023 and results will be available in 2024. This study will provide information on whether a combined approach using texting of home BP values and a pharmacist-based telehealth services can improve BP control.

Diabetic Foot Surveillance Using Mobile Phones and Automated Software Messaging, a Randomized Observational Trial.

Background: Early detection of diabetic foot ulcers can improve outcomes. However, patients do not always monitor their feet or seek medical attention when ulcers worsen. New approaches for diabetic-foot surveillance are needed. The goal of this study was to determine if patients would be willing and able to regularly photograph their feet; evaluate different foot-imaging approaches; and determine clinical adequacy of the resulting pictures. Methods: We recruited adults with diabetes and assigned them to Self Photo (SP), Assistive Device (AD), or Other Party (OP) groups. The SP group photographed their own feet, while the AD group used a selfie stick; the OP group required another adult to photograph the patient's foot. For 8 weeks, we texted all patients requesting that they text us a photo of each foot. The collected images were evaluated for clinical adequacy. Numbers of (i) submitted and (ii) clinically useful images were compared among groups using generalized linear models and generalized linear mixed models. Results: A total of 96 patients consented and 88 participated. There were 30 patients in SP, 29 in AD, and 29 in OP. The completion rate was 77%, with no significant differences among groups. However, 74.1% of photographs in SC, 83.7% in AD, 92.6% in OP were determined to be clinically adequate, and these differed statistically significantly. Conclusions: Patients with diabetes are willing and able to take photographs of their feet, but using selfie sticks or having another adult take the photographs increases the clinical adequacy of the photographs.Level of Evidence: II.

The Cardiovascular Effects of Treatment with Hydroxychloroquine and Azithromycin.

Hydroxychloroquine combined with azithromycin has been investigated for activity against coronavirus disease 2019 (COVID-19), but concerns about adverse cardiovascular (CV) effects have been raised. This study evaluated claims data to determine if risks for CV events were increased with hydroxychloroquine alone or combined with azithromycin. We identified data from 43,752 enrollees that qualified for analysis. The number of CV events increased by 25 (95% confidence interval [CI]: 8, 42, p=0.005) per 1000 people per year of treatment with hydroxychloroquine alone compared with pretreatment levels and by 201 (95% CI: 145, 256, p<0.001) events per 1000 people per year when individuals took hydroxychloroquine and azithromycin. These rates translate to an additional 0.34 (95% CI: 0.11, 0.58) CV events per 1000 patients placed on a 5-day treatment with hydroxychloroquine monotherapy and 2.75 (95% CI: 1.99, 3.51) per 1000 patients on a 5-day treatment with both hydroxychloroquine and azithromycin. The rate of adverse events increased with age following exposure to hydroxychloroquine alone and combined with azithromycin. For females aged 60 to 79 years prescribed hydroxychloroquine, the rate of adverse CV events was 0.92 per 1000 patients on 5 days of therapy, but it increased to 4.78 per 1000 patients when azithromycin was added. The rate of adverse CV events did not differ significantly from zero for patients 60 years of age or younger. These data suggest that hydroxychloroquine with or without azithromycin is likely safe in individuals under 60 years of age if they do not have additional CV risks. However, the combination of hydroxychloroquine and azithromycin should be used with extreme caution in older patients.