Direct and Indirect Care of Patients With Multiple Sclerosis: Burden on Providers and Impact of Portal Messages.

BACKGROUND: Multiple sclerosis (MS) indirect patient-care time is often underreported and uncompensated. Data on time spent on indirect and direct care by MS providers is lacking. METHODS: A survey was designed to understand the practice patterns among MS providers in the United States, including time spent on direct and indirect patient care, as well as managing electronic medical record portal messages. The National MS Society and the American Academy of Neurology facilitated the distribution of the survey to MS providers. RESULTS: Most providers spent at least 1 hour on new and at least 30 minutes on follow-up direct patient care. For indirect patient care, 77% of providers spent more than 1 hour and 57% spent more than 2 hours per day. While some providers have support staff to help with portal messages, many do not have protected time or compensation for portal messages. CONCLUSIONS: Multiple sclerosis providers spent a higher-than-average time on direct and indirect patient care tasks, including portal messages, and most lack protected time or compensation for portal messages. These results highlight the potential impact of indirect patient care (notably portal messages) on provider workload and burnout. Better support, protected time and/or compensation for indirect patient care can help ease physician burden and decrease burnout.

Awareness of Preeclampsia among Antenatal Clinic Attendees in Northwestern Nigeria.

Background Preeclampsia (PE) is among the five main causes of maternal mortality in low resource countries. This study was designed to assess PE awareness and its socioeconomic determinants among antenatal clinic attendees in northwestern Nigeria. Methods Two hundred twenty-one antenatal clinic attendees in northwestern Nigeria were selected through systematic random sampling for this quantitative study. Women who were 9 months pregnant and had consented to participate were included; those with chronic illnesses such as diabetes mellitus were excluded. Data on respondents' sociodemographic variables, and PE awareness were collected using a validated questionnaire. Associations between variables were tested using chi-square test and multiple regression analysis. Results Ninety-one percent of respondents were aged 20 to 40 years, 53.9% were multiparous, 27% had no or low level of formal education, and 52% had attended antenatal care (ANC) at least four times in the index pregnancy. Only 37% ( N = 83) were aware of PE. Women with formal education were 3.8 times more likely (odds ratio [OR] = 3.8, 95% confidence interval [CI] = 1.4-10.3) to be aware of PE compared with those with no formal education ( p < 0.05). Also, women who experienced hypertension in their previous pregnancies were 2.8 times more likely (OR = 2.8, 95% CI = 1.37-5.71) to be aware of PE than those women who had not ( p < 0.05). Conclusion There was a low level of PE awareness among pregnant women in this study; being formally educated and having had hypertension in a previous pregnancy were positively associated with PE awareness. PE education should be part of ANC.

Psychological inflexibility processes and nonsuicidal self-injury: Concurrent and prospective associations.

OBJECTIVE: The aim of this study was to examine concurrent and 3-month prospective associations between a multidimensional measure of psychological inflexibility and nonsuicidal self-injury (NSSI) among participants with a self-harm history. METHOD: Participants completed measures of NSSI, psychological inflexibility, negative urgency, and depression at baseline (N = 106, Mage = 34.70, SD = 9.43, 66% women), and were again assessed at follow-up (N = 86). RESULTS: Participants currently engaging in NSSI reported significantly higher psychological inflexibility as compared to those who have ceased NSSI. After controlling for covariates, psychological inflexibility was concurrently associated with NSSI recency and longitudinally predicted perceived likelihood of future NSSI. Psychological inflexibility was not associated with new NSSI acts after including baseline covariates. Finally, psychological inflexibility subscales demonstrated differential relationships with various NSSI functions. CONCLUSION: Results highlight the psychological inflexibility model's utility in understanding NSSI and have implications for future research that may inform clinical practice.

Patient and health worker experiences of differentiated models of care for stable HIV patients in Malawi: A qualitative study.

INTRODUCTION: Several models of differentiated care for stable HIV patients on antiretroviral therapy (ART) in Malawi have been introduced to ensure that care is efficient and patient-centered. Three models have been prioritized by the government for a deeper and broader understanding: adjusted appointment spacing through multi-month scripting (MMS); fast-track drug refills (FTRs) on alternating visits; and community ART groups (CAGs) where rotating group members collect medications at the facility for all members. This qualitative study aimed to understand the challenges and successes of implementing these models of care and of the process of patient differentiation. METHODS: A qualitative study was conducted as a part of a broader process evaluation in 30 purposefully selected ART facilities between February and May 2016. Semi-structured, in-depth interviews with 32 health workers that managed and coordinated ART clinics and 30 focus groups were held with 216 ART patients. Interviews and focus groups were audio recorded, transcribed, and coded thematically. RESULTS: Participants reported that the models of differentiated care have yielded key benefits, including: reduced patients' travel and visit time, decongestion of facilities, and enhanced social support. Participants suggested that these benefits could lead to improved HIV treatment outcomes for patients. At the same time, some challenges were reported, such as inconsistent stocks of drugs, which can inhibit implementation of MMS. For CAGs, the group-based nature of the model presented some unique problems, such as conflicts within groups or concerns about privacy. Health workers also described some of the reasons why eligible patients may not receive the models or conversely why ineligible patients sometimes get the models. CONCLUSIONS: Documenting patient and health worker perspectives on models of differentiated care is critical to understanding and improving these models. While these models can offer important benefits, the models may not be appropriate for all sites or patients, and patient status and needs may change over time. Key challenges should be recognized and addressed for optimal utilization of the models.

Multi-month prescriptions, fast-track refills, and community ART groups: results from a process evaluation in Malawi on using differentiated models of care to achieve national HIV treatment goals.

INTRODUCTION: In order to facilitate scale-up of antiretroviral therapy (ART) in Malawi, innovative and pragmatic models have been developed to optimize the efficiency of HIV service delivery. In particular, three models of differentiated care have emerged for stable patients: adjusted appointment spacing through multi-month scripting (MMS); fast-track drug refills (FTRs) on alternating visits; and community ART groups (CAGs) where group members rotate in collecting medications at the facility for all members. This study aimed to assess the extent to which ART patients in Malawi are differentiated based on clinical stability and describe the characteristics and costs associated with the models of differentiated care offered. METHODS: A mixed methods process evaluation was conducted from 30 purposefully selected ART facilities. Cross-sectional data for this evaluation was collected between February and May 2016. The following forms of data collection are reported here: structured surveys with 136 health care workers; reviews of 75,364 patient clinical records; 714 observations of visit time and flow; and 30 questionnaires on facility characteristics. RESULTS: Among ART patients, 77.5% (95% confidence interval [CI] 74.1-80.6) were eligible for differentiated models of care based on criteria for clinical stability from national guidelines. Across all facilities, 69% of patients were receiving MMS. In facilities offering FTRs and CAGs, 67% and 6% of patients were enrolled in the models, respectively. However, eligibility criteria were used inconsistently: 72.9% (95% CI 66.3-78.6) of eligible patients and 42.3% (95% CI 33.1-52.0) ineligible patients received MMS. Results indicated that patient travel and time costs were reduced by 67%, and the unit costs of ART service delivery through the MMS, FTR and CAG models were similar, representing a reduction of approximately 10% in the annual unit cost of providing care to stable patients that receive no model. CONCLUSIONS: MMS is being implemented nationally and has already generated cost savings and efficiencies in Malawi for patients and the health system, but could be improved by more accurate patient differentiation. While expanding FTRs and CAGs may not offer significant further cost savings in Malawi, future studies should investigate if such alternative models lead to improvements in patient satisfaction or clinical outcomes that might justify their implementation.

Identifying Zn-bound histidine residues in metalloproteins using hydrogen-deuterium exchange mass spectrometry.

In this work, we have developed a method that uses hydrogen-deuterium exchange (HDX) of C2-hydrogens of histidines coupled with mass spectrometry (MS) to identify Zn-bound histidines in metalloproteins. This method relies on differences in HDX reaction rates of Zn-bound and Zn-free His residues. Using several model peptides and proteins, we find that all Zn-bound His residues have substantially lower HDX reaction rates in the presence of the metal. The vast majority of non-Zn-binding His residues undergo no significant changes in HDX reaction rates when their reactivity is compared in the presence and absence of Zn. Using this new approach, we then determined the Zn binding site of ß-2-microglobulin, a protein associated with metal-induced amyloidosis. Together, these results suggest that HDX-MS of His C2-hydrogens is a promising new method for identifying Zn-bound histidines in metalloproteins.

A novel locus for body mass index on 5p15.2: a meta-analysis of two genome-wide association studies.

OBJECTIVE: Genetic factors play an important role in modulating the vulnerability to body mass index (BMI). The purpose of this study is to identify novel genetic variants for BMI using genome-wide association (GWA) meta-analysis. METHODS: PLINK software was used to perform meta-analysis of two GWA studies (the FUSION and Marshfield samples) of 5218 Caucasian individuals with BMI. A replication study was conducted using the SAGE sample with 762 individuals. RESULTS: Through meta-analysis we identified 33 SNPs associated with BMI with p<10(-4). The most significant association was observed with rs2967951 (p=1.19×10(-6)) at 5p15.2 within ROPN1L gene. Two additional SNPs within ROPN1L and 5 SNPs within MARCH6 (the top SNP was rs2607292 with 4.27×10(-6)) further supported the association with BMI on 5p15.2 (p<1.8×10(-5)). Conditional analysis on 5p15.2 could not distinguish the effects of ROPN1L and MARCH6. Several SNPs within MARCH6 and ROPN1L were replicated in the SAGE sample (p<0.05). CONCLUSION: We identified a novel locus for BMI. These findings offer the potential for new insights into the pathogenesis of BMI and obesity and will serve as a resource for replication in other populations to elucidate the potential role of these genetic variants in BMI and obesity.

Where there is no anesthetist--increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors.

OBJECTIVE: The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs' experience of the program, and identified factors leading to post-training performance. METHODS: The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n=14). Data on facility preparedness and monthly case load were also collected. RESULTS: Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures. CONCLUSION: Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program.