Multicenter expanded access program for access to investigational products for amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Expanded access (EA) is a Food and Drug Administration-regulated pathway to provide access to investigational products (IPs) to individuals with serious diseases who are ineligible for clinical trials. The aim of this report is to share the design and operations of a multicenter, multidrug EA program for amyotrophic lateral sclerosis (ALS) across nine US centers. METHODS: A central coordination center was established to design and conduct the program. Templated documents and processes were developed to streamline study design, regulatory submissions, and clinical operations across protocols. The program included three protocols and provided access to IPs that were being tested in respective regimens of the HEALEY ALS Platform Trial (verdiperstat, CNM-Au8, and pridopidine). Clinical and safety data were collected in all EA protocols (EAPs). The program cohorts comprised participants who were not eligible for the platform trial, including participants at advanced stages of disease progression and with long disease duration. RESULTS: A total of 85 participants were screened across the 3 EAPs from July 2021 to September 2022. The screen failure rate was 3.5%. Enrollment for the regimens of the platform trial was completed as planned and results informed the duration of the corresponding EAP. The verdiperstat EAP was concluded in December 2022. Mean duration of participation in the verdiperstat EAP was 5.8 ± 4.1 months. The CNM-Au8 and pridopidine EAPs are ongoing. DISCUSSION: Multicenter EAPs conducted in parallel to randomized clinical trials for ALS can successfully enroll participants who do not qualify for clinical trials.

Hypercalcemia Secondary to Elevated PTHrP in an Infant Followed by Progression to Nephrotic Syndrome.

In infants, hypercalcemia from elevated parathyroid hormone-related protein (PTHrP) is rare, often signaling neoplasm or renal or urinary anomalies. We report an infant who presented with failure to thrive and hypercalcemia at 10 months old, with initial evaluation showing elevated PTHrP of unclear etiology with imaging negative for neoplasm and no structural anomalies of the kidneys or ureters on ultrasound. Within 6 months of presentation, the patient developed nephrotic syndrome and by 2 years had progressed to end-stage kidney disease, necessitating kidney transplantation. Genetic testing was inconclusive but suggested congenital nephrotic syndrome. While reports of hypercalcemia secondary to elevated PTHrP exist in children with known structural renal anomalies, this is the first to demonstrate hypercalcemia and PTHrP elevation before detection of renal abnormalities. Experimental models have suggested a role for increased PTHrP expression in renal cells following acute kidney injury from nephrotic syndrome, and clinically detectable PTHrP levels may indicate progression of renal injury. We suggest monitoring of renal function for early detection of nephrotic syndrome in infants and children with elevated PTHrP who otherwise lack anatomical renal anomalies or detectable malignancies.

Age of Dental Apical Closure in Domestic Cats.

Data on the age of apical closure in felines is limited. Moreover, differences in age of apical closure between male and female cats have not been studied. The aim of this study was to determine the timing of apical closure in cats and determine if sex or position in the dental arch affected closure. In this retrospective descriptive study, intraoral radiographs were obtained at monthly or multiple-monthly intervals for 18 cats. Nine were intact females and 9 were neutered males, ranging from 6 to 9.4 months of age at the start of the study which ranged over an 8-month period. Radiographs were evaluated to establish age of apical closure for all canine teeth as well as the mandibular premolar and molar teeth. Mandibular canine tooth apices closed between 10 and 12 months of age and maxillary canine tooth apices closed between 12 and 14 months of age. The mesial and distal root apices of both the mandibular third and fourth premolar teeth closed between 8 and 9 months. The mandibular first molar tooth mesial and distal root apices closed between 8 and 8.5 months. Root apices of canine teeth closed earlier in female cats than in male cats with mandibular canine tooth root apices closing significantly earlier than maxillary canine tooth roots in both sexes. These findings suggest that there are notable differences in age of apical closure between male and female cats and discernible trends in timing of apical closure among teeth in the dental arcade.

Camouflage using three-dimensional surface disruption.

Disruptive markings are common in animal patterns and can provide camouflage benefits by concealing the body's true edges and/or by breaking the surface of the body into multiple depth planes. Disruptive patterns that are accentuated by high contrast borders are most likely to provide false depth cues to enhance camouflage, but studies to date have used visual detection models or humans as predators. We presented three-dimensional-printed moth-like targets to wild bird predators to determine whether: (1) three-dimensional prey with disrupted body surfaces have higher survival than three-dimensional prey with continuous surfaces, (2) two-dimensional prey with disruptive patterns or enhanced edge markings have higher survival than non-patterned two-dimensional prey. We found a survival benefit for three-dimensional prey with disrupted surfaces, and a significant effect of mean wing luminance. There was no evidence that false depth cues provided the same protective benefits as physical surface disruption in three-dimensional prey, perhaps because our treatments did not mimic the complexity of patterns found in natural animal markings. Our findings indicate that disruption of surface continuity is an important strategy for concealing a three-dimensional body shape.

Intraoperative diagnosis of type 1 diabetes and diabetic ketoacidosis during scoliosis surgery.

Diabetic ketoacidosis is the leading cause of morbidity and mortality in children with type 1 diabetes. Management of diabetic ketoacidosis requires meticulous monitoring and treatment of severe dehydration and metabolic derangement. We present an adolescent patient who was diagnosed with diabetic ketoacidosis during spinal fusion for idiopathic scoliosis and discuss the management of this unexpected intraoperative emergency.

Prognostic indicators for feline craniofacial trauma: a retrospective study of 114 cases.

Craniofacial traumatic injuries contribute significantly to the morbidity and mortality of domestic felines. Previous studies focused on feline craniofacial injuries have investigated the origin of injury, injuries sustained, and effectiveness of diagnostic tools. The aim of the study is to identify prognostic indicators for feline craniofacial trauma patients and determine their association with negative and positive outcomes. The Veterinary Committee on Trauma (VetCOT) Trauma Registry and Dentistry and Oral Surgery Case Logs were utilized to identify feline craniofacial trauma cases that were presented to Colorado State University's Veterinary Teaching Hospital between 2014 and 2020. Prognostic indicators evaluated included: etiology of injury, signalment (age and sex), the Modified Glascow Coma Scale (MGCS), Animal Trauma Triage (ATT) scores, craniofacial examination findings, diagnostic imaging technique, and injuries identified via imaging. Outcomes were determined via patient status upon discharge. Outcomes were grouped into the following categories: survival to discharge at initial presentation to CSU Urgent Care (SDIP), survival to discharge after injury treatment/repair by CSU DOSS or another specialty service (SDTX), euthanized due to grave prognosis at initial presentation (EUGP), euthanized due to financial limitations at initial presentation (EUF), and euthanized due to grave prognosis and financial limitations (EUGP + EUF). The continuous data was described using means and standard deviations. To determine the associations of various groupings of clinical signs and imaging findings with outcome a principal component analysis was performed. Patient sex, trauma etiology, cumulative MGCS and ATT scores on initial presentation and clinical signs on initial presentation were identified as prognostic indicators with intact males, vehicular and animal altercations, lower MGCS cumulative scores, higher ATT scores and the presence of altered mentation identified as negative prognostic indicators. Prognostic indicators for feline craniofacial trauma can be associated with outcomes and help guide clinical decision making.

Long-term Continuous Glucose Monitor Use in Very Young Children With Type 1 Diabetes: One-Year Results From the SENCE Study.

OBJECTIVES: Achieving optimal glycemic outcomes in young children with type 1 diabetes (T1D) is challenging. This study examined the durability of continuous glucose monitoring (CGM) coupled with a family behavioral intervention (FBI) to improve glycemia. STUDY DESIGN: This one-year study included an initial 26-week randomized controlled trial of CGM with FBI (CGM+FBI) and CGM alone (Standard-CGM) compared with blood glucose monitoring (BGM), followed by a 26-week extension phase wherein the BGM Group received the CGM+FBI (BGM-Crossover) and both original CGM groups continued this technology. RESULTS: Time in range (70-180 mg/dL) did not improve with CGM use (CGM+FBI: baseline 37%, 52 weeks 41%; Standard-CGM: baseline 41%, 52 weeks 44%; BGM-Crossover: 26 weeks 38%, 52 weeks 40%). All three groups sustained decreases in hypoglycemia (<70 mg/dL) with CGM use (CGM+FBI: baseline 3.4%, 52 weeks 2.0%; Standard-CGM: baseline 4.1%, 52 weeks 2.1%; BGM-Crossover: 26 weeks 4.5%, 52 weeks 1.7%, P-values <.001). Hemoglobin A1c was unchanged with CGM use (CGM+FBI: baseline 8.3%, 52 weeks 8.2%; Standard-CGM: baseline 8.2%, 52 weeks 8.0%; BGM-Crossover: 26 weeks 8.1%, 52 weeks 8.3%). Sensor use remained high (52-week study visit: CGM+FBI 91%, Standard-CGM 92%, BGM-Crossover 88%). CONCLUSION: Over 12 months young children with T1D using newer CGM technology sustained reductions in hypoglycemia and, in contrast to prior studies, persistently wore CGM. However, pervasive hyperglycemia remained unmitigated. This indicates an urgent need for further advances in diabetes technology, behavioral support, and diabetes management educational approaches to optimize glycemia in young children.

Comparative Effectiveness of Postdischarge Smoking Cessation Interventions for Hospital Patients: The Helping HAND 4 Randomized Clinical Trial.

Importance: Smoking cessation interventions for hospitalized patients must continue after discharge to improve long-term tobacco abstinence. How health systems can best deliver postdischarge tobacco treatment is uncertain. Objective: To determine if health system-based tobacco cessation treatment after hospital discharge produces more long-term tobacco abstinence than referral to a community-based quitline. Design, Setting, and Participants: This randomized clinical trial was conducted September 2018 to November 2020 in 3 hospitals in Massachusetts, Pennsylvania, and Tennessee. Cigarette smokers admitted to a study hospital who received brief in-hospital tobacco treatment and wanted to quit smoking were recruited for participation and randomized for postdischarge treatment to health system-based Transitional Tobacco Care Management (TTCM) or electronic referral to a community-based quitline (QL). Both multicomponent interventions offered smoking cessation counseling and nicotine replacement therapy (NRT) for up to 3 months. Data were analyzed from February 1, 2021, to April 25, 2022. Interventions: TTCM provided 8 weeks of NRT at discharge and 7 automated calls with a hospital-based counselor call-back option. The QL intervention sent referrals from the hospital electronic health record to the state quitline, which offered 5 counseling calls and an NRT sample. Main Outcomes and Measures: The main outcome was biochemically verified past 7-day tobacco abstinence at 6 months. Self-reported point-prevalence and continuous tobacco abstinence and tobacco treatment utilization were assessed 1, 3, and 6 months after discharge. Results: A total of 1409 participants (mean [SD] age, 51.7 [12.6] years; 784 [55.6%] women; mean [SD] 16.4 [10.6] cigarettes/day) were recruited, including 706 randomized to TTCM and 703 randomized to QL. Participants were comparable at baseline, including 216 Black participants (15.3%), 82 Hispanic participants (5.8%), and 1089 White participants (77.3%). At 1 and 3 months after discharge, more TTCM participants than QL participants used cessation counseling (1 month: 245 participants [34.7%] vs 154 participants [21.9%]; 3 months: 248 participants [35.1%] vs 123 participants [17.5%]; P < .001) and pharmacotherapy (1 month: 455 participants [64.4%] vs 324 participants [46.1%]; 3 months: 367 participants [52.0%] vs 264 participants [37.6%]; P < .001). More TTCM than QL participants reported continuous abstinence for 3 months (RR, 1.30; 95% CI, 1.06-1.58) and point-prevalence abstinence at 1 month (RR, 1.22; 95% CI, 1.08-1.35) and 3 months (RR, 1.23; 95% CI, 1.09-1.37) but not at 6 months (RR, 1.14; 95% CI, 0.99-1.29). The primary outcome, biochemically verified point-prevalence abstinence at 6 months, was not statistically significantly different between groups (19.9% vs 16.9%; RR, 1.18; 95% CI, 0.92-1.50). Conclusions and Relevance: In this randomized clinical trial, biochemically verified tobacco abstinence rates were not significantly different between groups at the 6-month follow-up. However, the health system-based model was superior to the community-based quitline model throughout the 3 months of active treatment. A longer duration of postdischarge treatment may sustain the superiority of the health system-based model. Trial Registration: ClinicalTrials.gov Identifier: NCT03603496.

3D animal camouflage.

Camouflage is a fundamental way for animals to avoid detection and recognition. While depth information is critical for object detection and recognition, little is known about how camouflage patterns might interfere with the mechanisms of depth perception. We reveal how many common camouflage strategies could exploit 3D visual processing mechanisms.

Clinical Evaluation of Intraoral Suture Patterns Using Poliglecaprone 25 in Greyhound Dogs.

To evaluate healing and complications of extraction sites closed with a simple interrupted pattern (SI) and a simple continuous (SC) suture pattern in a prospective randomized clinical trial. Greyhounds were selected from a rescue with a standardized environment and naturally occurring disease. Surgical extractions were performed (35 sites) and all mucogingival flaps were closed with 4-0 poliglecaprone 25 using either SI or SC randomly assigned by surgical site. Oral healing/dehiscence, suture inflammation, suture loss, accumulation of debris, presence/nature of discharge, necrotic tissue and adjacent contact ulceration were evaluated. Fisher's exact test was used to compare categorical data and two-tail T tests used to compare continuous data. Results showed SC was faster to apply. No new dehiscence events were detected after Recheck 1. There was no significant difference for dehiscence scores between SI and SC. A trend was seen towards more major dehiscence in the SI group. This study concluded SC is an alternative to SI for closure of occlusal surfaces in the mouth. Mandibular canine tooth extraction sites were more likely to have a high dehiscence score than all other sites combined regardless of surgical technique.

Understanding engagement behaviors and rapport building in tobacco cessation telephone counseling: An analysis of audio-recorded counseling calls.

INTRODUCTION: Though telephone counseling is a modality commonly used to promote health behavior change, including tobacco cessation, specific counselor and participant behaviors that indicate engagement and therapeutic alliance remain poorly characterized in the literature. We sought to explore smokers' and counselors' engagement and rapport-building behaviors in telephone counseling for smoking cessation and patterns of these behaviors by smokers' psychiatric symptoms. METHODS: The study team transcribed, audio-recorded tobacco cessation counseling calls for the presence of engagement and rapport-building behaviors among recently hospitalized participants enrolled in a smoking cessation randomized controlled trial (RCT). The study used baseline data from the RCT to explore frequencies of counselors' and smokers' behaviors among smokers who had reported more (vs. fewer) symptoms of depression (PHQ8 ≥ 10) or anxiety (GAD7 ≥ 10) at study entry. RESULTS: Participants (n = 37) were mostly female (23/37), White (26/37), with a median age of 58. At study entry while hospitalized, moderate-to-severe symptoms of depression (18/37) and anxiety (22/37) were common. Participant-led engagement behaviors included referencing past quit attempts, asking questions, elaborating response to yes/no questions, expressing commitment to behavior change, and assigning importance to nonautomated calls. Counselor-led behaviors included building off prior interaction, empathy, normalizing challenges, reframing and summarizing, validating achievements, and expressing shared experience. Both participants and counselors engaged via general discussion and humor. Participant-led engagement behaviors appeared more often in call transcripts among patients with higher baseline depression and anxiety symptoms compared to those with lower symptom scores. CONCLUSIONS: This study classified participant-led, counselor-led, and shared engagement behaviors during tobacco cessation counseling calls. Increased engagement via telephone counseling may be important for individuals with psychiatric symptoms identified at the start of treatment.

Fascia Iliaca Pain Block Results in Lower Overall Opioid Usage and Shorter Hospital Stays than Epidural Anesthesia After Hip Reconstruction in Children With Cerebral Palsy.

INTRODUCTION AND OBJECTIVE: Epidural anesthesia (EA) is often used for pain control in children with cerebral palsy (CP) who undergo hip reconstructions. The purpose of this study is to determine if preoperative fascia iliaca (FI) pain blocks would improve pain scores, decrease opioid use, and result in shorter hospital stays in comparison to the use of EA. METHODS: This is a nonrandomized retrospective cohort study examining 60 consecutive patients with CP who underwent hip reconstruction utilizing either a fascia iliac compartment nerve block (FICNB) (N=37) or continuous lumbar epidural (N=22) from January 2017 to March 2019. Age at surgery was 8.5±4.6 years. We recorded age, weight, operating room (OR) time, FLACC (Face, Legs, Activity, Cry, Consolability scale) scores on postoperative days (PODs) 0, 1, 2, and 3, opioid doses, overall opioid (mg) used, and length of stay. We compared pain scores, opioid usage, OR time, and lengths of stay between our 2 patient groups. RESULTS: Pain scores were similar between groups on POD #0, 2, and 3 but were statistically improved on POD #1 (1.8±1.3 vs. 3.1±1.4, P<0.001). Total number of opiod doses (7.9±4.4 vs. 10.7±2.3, P=0.004), total milligram given (18.3±11.8 vs. 24.7±12.3, P<0.05), and milligram per kilogram given (0.77±0.42 vs. 1.11 mg/kg±0.36 mg/kg, P=0.001) were less for the FI group versus the epidural group. The OR time (which includes time for blocks/epidurals) was lower in the FI group (4.6±1.2 vs. 5.7±1.1 h, P=0.0002). Overall hospital stays were lower in the FI group (3.4±1.5 vs. 4.1±1.0 d, P<0.05). CONCLUSIONS: This study demonstrates that in the setting of hip reconstruction, patients that received preoperative FI blocks used a lower amount of opioids, required fewer rescue doses and ultimately had a shorter hospital length of stay than those undergoing EA.

Stigma and Human Rights: Transgender Discrimination and Its Influence on Patient Health.

PURPOSE/OBJECTIVES: Transgender patients encounter barriers to accessing medical treatment. Although the medical field has made strides to improve transgender patients' health care experiences, programs that provide support in navigating existing obstacles are lacking. As integrated care becomes more prevalent, primary care settings have the potential to become medical havens for vulnerable patient populations. Enlisting support of professional case managers to connect transgender patients to services to meet their physical and behavioral health needs could increase health care utilization and decrease disparities. FINDINGS/CONCLUSIONS: Because of their gender identities, transgender individuals experience high rates of discrimination within health care settings. There are also inequities that limit their access to quality treatment. These, combined with the fear of discrimination, contribute to an avoidance of medical care that negatively impacts the physical and mental health of transgender patients. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Transgender discrimination in health care settings is pervasive and has detrimental effects on patients' well-being. Future research should foster collaboration between health care administrators, professional case managers, primary care providers, behavioral health consultants, and transgender patients to remove existing barriers and increase access to care. Until these changes occur, programs need to be designed for case managers to assist transgender patients in navigating the health care system and connecting to affirming providers. PRIMARY PRACTICE SETTINGS: Health care systems and integrated primary care settings.

Cigarette Smoking and Risk Perceptions During the COVID-19 Pandemic Reported by Recently Hospitalized Participants in a Smoking Cessation Trial.

BACKGROUND: Cigarette smoking is a risk factor for severe COVID-19 disease. Understanding smokers' responses to the pandemic will help assess its public health impact and inform future public health and provider messages to smokers. OBJECTIVE: To assess risk perceptions and change in tobacco use among current and former smokers during the COVID-19 pandemic. DESIGN: Cross-sectional survey conducted in May-July 2020 (55% response rate) PARTICIPANTS: 694 current and former daily smokers (mean age 53, 40% male, 78% white) who had been hospitalized pre-COVID-19 and enrolled into a smoking cessation clinical trial at hospitals in Massachusetts, Pennsylvania, and Tennessee. MAIN MEASURES: Perceived risk of COVID-19 due to tobacco use; changes in tobacco consumption and interest in quitting tobacco use; self-reported quitting and relapse since January 2020. KEY RESULTS: 68% (95% CI, 65-72%) of respondents believed that smoking increases the risk of contracting COVID-19 or having a more severe case. In adjusted analyses, perceived risk was higher in Massachusetts where COVID-19 had already surged than in Pennsylvania and Tennessee which were pre-surge during survey administration (AOR 1.56, 95% CI, 1.07-2.28). Higher perceived COVID-19 risk was associated with increased interest in quitting smoking (AOR 1.72, 95% CI 1.01-2.92). During the pandemic, 32% (95% CI, 27-37%) of smokers increased, 37% (95% CI, 33-42%) decreased, and 31% (95% CI, 26-35%) did not change their cigarette consumption. Increased smoking was associated with higher perceived stress (AOR 1.49, 95% CI 1.16-1.91). Overall, 11% (95% CI, 8-14%) of respondents who smoked in January 2020 (pre-COVID-19) had quit smoking at survey (mean, 6 months later) while 28% (95% CI, 22-34%) of former smokers relapsed. Higher perceived COVID-19 risk was associated with higher odds of quitting and lower odds of relapse. CONCLUSIONS: Most smokers believed that smoking increased COVID-19 risk. Smokers' responses to the pandemic varied, with increased smoking related to stress and increased quitting associated with perceived COVID-19 vulnerability.

A Qualitative Study of the Impact of COVID-19 on Smoking Behavior for Participants in a Post-Hospitalization Smoking Cessation Trial.

(1) Background: COVID-19 has substantially altered individual environments and behaviors. We aim to explore the impact of COVID-19 on the smoking behavior of individuals trying to quit tobacco. (2) Methods: This study presents a qualitative analysis of individual interviews focused on perceived impacts of the COVID-19 pandemic on tobacco use among 39 participants in the Helping HAND 4 (HH4) post-hospitalization smoking cessation trial (NCT03603496). (3) Results: Emergent impacts of COVID-19 included change in routine, isolation, employment changes, and financial challenges; these in turn were associated with boredom, altered cravings and triggers, and increased stress. The availability of effective coping mechanisms instead of smoking to deal with stress heavily influenced subsequent smoking behavior. These results were triangulated with the Transactional Model of Stress, providing a framework to elucidate connections between factors such as perceived control, self-efficacy, and dispositional coping style, and highlighting potential areas for intervention. (4) Conclusions: Results suggest that stress during the COVID-19 pandemic may undermine effective coping skills among individuals enrolled in a post-hospitalization smoking cessation trial. Strengthening effective coping skills (e.g., minimizing the use of tobacco as a default stress response) and increasing perceived control and self-efficacy are promising intervention targets.

Cadaveric Evaluation of Load to Failure in Canine Gingiva Apposed With Varied Suture Patterns Using Poliglecaprone 25.

The purpose of the study was to determine the effect of suture pattern and repair length on the load to failure in an ex vivo canine gingival model. Healthy mandibular gingiva and mucosa were harvested from fresh cadavers euthanized for purposes unrelated to the study. Samples were randomly assigned by length and pattern. Lingual and buccal free gingival margins were apposed using a simple interrupted (SI), cruciate (XT), simple continuous (SC), or unidirectional knotless continuous barbed suture (SF) closure technique with USP 4-0 poliglecaprone 25i, ii applied over 2 lengths (3 cm and 6 cm). A custom template was used to ensure uniform suture bite application. Surgical time was recorded. Using a soft tissue mechanical testing frame, samples were tensioned to failure. Testing was video recorded and reviewed in conjunction with the tension trace data for tension at initial failure (Tfail) and maximum tension sustained (Tmax). Two factor ANOVA by length and pattern was performed followed by individual one way T-tests. Statistically significant findings were XT-SC-SF patterns were quicker to perform than SI. SF was more likely to fail by suture breakage than tissue tearing, and SF withstood less tension at the 3 cm length than SI-XT-SC. No significant difference was detected in Tmax or Tfail between SI and SC or XT. The study demonstrates that SC and XT are comparable to SI in tension resistance and faster to perform suggesting that SC and XT could replace SI for extraction site closure although further in vivo testing is required.

Nurse/Resident Reciprocal Shadowing to Improve Interprofessional Communication.

OBJECTIVES: Poor communication is a major contributor to sentinel events in hospitals. Suboptimal communication between physicians and nurses may be due to poor understanding of team members' roles. We sought to evaluate the impact of a shadowing experience on nurse-resident interprofessional collaboration, bidirectional communication, and role perceptions. METHODS: This mixed-methods study took place at 2 large academic children's hospitals with pediatric residency programs during the 2018-2019 academic year. First-year residents and nurses participated in a reciprocal, structured 4-hour shadowing experience. Participants were surveyed before, immediately after, and 6 months after their shadowing experience by using an anonymous web-based platform containing the 20-item Interprofessional Collaborative Competency Attainment Survey, as well as open-ended qualitative questions. Quantitative data were analyzed via linear mixed models. Qualitative data were thematically analyzed. RESULTS: Participants included 33 nurses and 53 residents from the 2 study sites. The immediate postshadowing survey results revealed statistically significant improvements in 12 Interprofessional Collaborative Competency Attainment Survey question responses for nurses and 19 for residents (P ≤ .01). Subsequently, 6 questions for nurses and 17 for residents revealed sustained improvements 6 months after the intervention. Qualitative analysis identified 5 major themes related to optimal nurse-resident engagement: effective communication, collaboration, role understanding, team process, and patient-centered. CONCLUSIONS: The reciprocal shadowing experience was associated with an increase in participant understanding of contributions from all interprofessional team members. This improved awareness may improve patient care. Future work may be conducted to assess the impact of spread to different clinical areas and elucidate patient outcomes that may be associated with this intervention.

Insulin Bolus Calculator: Lessons Learned from Institutional Experience.

Insulin bolus calculators have proven effective in improving glycemia and patient safety. Insulin calculators are increasingly being implemented for inpatient hospital care. Multidisciplinary teams are often involved in the design and review of the efficacy and utilization for these calculators. At times, unintended consequences and benefits of utilization are found on review. Integration of our insulin calculator into our electronic health record system was a multidisciplinary effort. During implementation, several obstacles to effective care were identified and are discussed in the following manuscript. We describe the barriers to utilization and potential pitfalls in clinical integration. We further describe benefits in patient education, time of insulin administration versus meal delivery, variations in insulin bolus for ketone correction, variation in care, and maximum bolus administration. Sharing lessons learned from experiences using electronic insulin calculator order sets will further our goals of improved patient care in the hospital setting.

Enhancing employer coverage of smoking cessation treatment: A randomized trial of the Partners in Helping You Quit (PiHQ) program.

The workplace is a key channel for delivering tobacco cessation treatment to a population. Employers can provide workplace-based programs and/or financial incentives such as health insurance benefits that cover the cost of treatment accessed outside the workplace. Little is known about the effect of combining these strategies. We tested the benefit of adding a workplace cessation program, Partners in Helping You Quit (PiHQ), to comprehensive health insurance coverage of smoking cessation medications by Partners HealthCare, a large Boston-based healthcare delivery system. PiHQ offers biweekly telephone-based behavioral support, additional automated calls, and medication care coordination for 3 months then monthly telephone monitoring for 9 months. In a pragmatic randomized trial, employees who smoked were informed about the insurance benefit, then randomly assigned (2:1) to PiHQ or to active referral to a free 3-month phone-based community program, Massachusetts Quitline (QL). Outcomes were assessed at 3, 6, and 12 months. During 2015-2018, 106 smokers (n = 73 PiHQ, n = 33 QL) enrolled (64% female; 75% white, 21% black; mean age 46 years, mean cigarettes/day = 13). More PiHQ than QL participants made a quit attempt by 3 months (82 vs. 61%, p < .02) and achieved the primary outcome, verified past 7-day cigarette abstinence at 6 months (31 vs. 12%, odds ratio 3.34, 95% CI, 1.05-10.60). Among participants using behavioral support, PiHQ participants completed more scheduled calls and rated counseling helpfulness higher than did QL participants. These results suggest that employers can enhance the impact of providing comprehensive health insurance coverage of smoking cessation medication by adding a phone-based worksite cessation program.