Impacts of Skin Color and Hypoxemia on Noninvasive Assessment of Peripheral Blood Oxygen Saturation: A Scoping Review.

Standard pulse oximeters estimate arterial blood saturation (SaO2) non-invasively by emitting and detecting light of a specific wavelength through a cutaneous vascular bed, such as a digit or the ear lobe. The quantity measured at these peripheral sites is designated as oxygen saturation (SpO2). Most reliable pulse oximeters are calibrated from measurements of healthy volunteers using some form of oxygen desaturation method. As the degree of inducible hypoxemia is limited, the calibration below achievable desaturation levels is usually extrapolated, leading to potential measurement error at low SaO2 values, especially in highly pigmented skin. Such skin color-related errors (SCRE) are the topic of this scoping review. Specifically, this study aimed to identify the combined impact of skin color and reduced SaO2 on the non-invasive assessment of SpO2 and report the consequences of potential inaccuracies. Three databases were searched (Cumulated Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Web of Science) for peer-reviewed prospective and retrospective studies published in English between 2000 and 2022 involving human patients with hypoxemia that included a measure of skin color (Fitzpatrick scale or race/ethnicity). Ten studies met the criteria and were included in the final review. Eight of these studies reported statistically significant higher pulse oximeter readings in darker-skinned patients with hypoxia compared to their arterial blood gas measurements. Occult hypoxia was more prevalent in Black and Hispanic patients than in White patients. Minority patients overall (Black, Asian, and American Indian) were more likely to have a SaO2 < 88% that was not detected by pulse oximetry (occult hypoxemia) during hospitalization. With greater levels of hypoxemia, the differences between SpO2 and SaO2 were greater. If SaO2 was < 90%, then SpO2 was overestimated in all ethnicities but worse in minorities. In conclusion, the bias found in pulse oximeter readings in the skin of color broadly impacts patients with hypoxemia. The failure of SpO2 measuring devices to detect occult hypoxemia can delay the delivery of life-saving treatment to critically ill patients requiring respiratory rehabilitation and supplemental oxygen therapy. This may lead to adverse health outcomes, increased in-hospital mortality, and complications such as organ dysfunction. An improvement in pulse oximeter detection mechanisms that would include all skin pigmentations is therefore much desired to optimize individual healthcare status and minimize disparities in treatment.

Initiation of HIV pre-exposure prophylaxis among youth in the United States, 2015-2018.

Adolescents and young adults ("youth") account for one-fifth of new HIV diagnoses in the U.S. HIV pre-exposure prophylaxis (PrEP), which became FDA approved in adolescents in May 2018, is highly effective at preventing HIV infection though there are limited data for PrEP initiation in youth. We aimed to quantify PrEP initiation and identify factors associated with PrEP initiation among youth at risk for HIV. We conducted a retrospective cohort study of youth aged 13-26 years who had an indication for PrEP between 1 January 2015, and 31 December 2018. We used data on commercially insured US individuals from the IBM MarketScan Commercial Database. We compared factors among youth who did and did not receive PrEP. We developed a multivariable logistic regression model to identify the association of all study covariates with receipt of PrEP. Among potentially PrEP eligible youth, only 2171 (1.6%) received a PrEP prescription in the year following their PrEP eligible claim. In multivariable models, youth who received PrEP were more likely to be older (adjusted odd ratio [aOR] for 18-20 year olds = 5.11; 95% CI = 3.35-7.77; aOR for 21-26 year olds = 16.90; 95% CI = 11.0-24.7), male (aOR = 92.42; 95% CI = 68.24-125), have sexual activity with elevated risk (aOR = 7.47; 95% CI = 6.50-8.60), or be diagnosed with gonorrhea or syphilis than youth who did not receive PrEP. Our findings highlight an opportunity to improve HIV prevention early in the life course.

Attitudes and training related to substance use in pediatric emergency departments.

BACKGROUND: In recent years, pediatric emergency departments (PED) have seen an increase in presentations related to substance use among their adolescent patient population. We aimed to examine pediatric emergency medicine (PEM) physicians' knowledge, attitudes, and beliefs on caring for adolescents with substance use. METHODS: We conducted a cross-sectional online survey of PEM physicians through the American Academy of Pediatrics Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC) listserv. The 41-item survey contained the following domains: demographics, current protocols and education for managing adolescent substance use, and attitudes about treatment of substance use. We calculated descriptive statistics for each variable within the domains. RESULTS: Of 177 respondents (38.2% response rate), 55.4% were female, 45.2% aged ≥ 50 years, 78% worked in a children's hospital, and 50.8% had > 15 years clinical practice. Overall, 77.8% reported caring for adolescents with a chief complaint related to non-opioid substance use and 26.0% opioid use at least once a month. Most (80.9%) reported feeling comfortable treating major medical complications of substance use, while less than half were comfortable treating withdrawal symptoms. 73% said that they were not interested in prescribing buprenorphine. CONCLUSIONS: Among this national sample of PEM physicians, 3 of 4 physicians managed substance-related visits monthly, but 52% lacked comfort in managing withdrawal symptoms and 73.1% were not interested in prescribing buprenorphine. Almost all PEM physician identified substance use-related education is important but lacked access to faculty expertise or educational content. Expanded access to education and training for PEM physicians related to substance use is needed.

Prevalence of HIV Preexposure Prophylaxis Prescribing Among Persons With Commercial Insurance and Likely Injection Drug Use.

Importance: Although HIV preexposure prophylaxis (PrEP) implementation among persons who inject drugs has been inadequate, national HIV monitoring programs do not include data on PrEP, and specific trends in PrEP use are not well understood. Objective: To estimate HIV PrEP uptake among commercially insured persons with opioid or stimulant use disorder by injection drug use (IDU) status. Design, Setting, and Participants: This cross-sectional study used deidentified data from the MarketScan Commercial Claims and Encounters Database to identify a sample of 547 709 commercially insured persons without HIV but with opioid and/or stimulant use disorder, including 110 592 with evidence of IDU between January 1, 2010, and December 31, 2019. Data were analyzed from November 1, 2020, to July 1, 2021. Exposures: Persons with opioid and/or stimulant use disorder and evidence of IDU were identified through claims data. Main Outcomes and Measures: The outcome was receipt of tenofovir disoproxil fumarate and emtricitabine for PrEP as identified from filled pharmacy claims. Multivariable logistic regression was used to assess the association of demographic and clinical characteristics with receipt of PrEP. Results: The study cohort included 211 609 (28.6%) females and 336 100 (61.4%) males with a combined mean (SD) age of 34.8 (13.1) years, including 110 592 individuals with evidence of IDU. During the study period, 508 (0.09%) persons with opioid and/or stimulant use disorder, including 170 (0.15%) with evidence of IDU, received PrEP. Receipt of PrEP increased from 0.001 to 0.243 per 100 person-years from 2010 through 2019 among the entire cohort and from 0.000 to 0.295 per 100 person-years among those with IDU. In multivariable analysis, PrEP use was more likely among males (adjusted odds ratio [aOR] 8.72; 95% CI, 6.39-11.89), persons with evidence of IDU (aOR, 1.47; 95% CI, 1.21-1.79), and persons with evidence of sexual risk indications for PrEP (aOR, 23.68; 95% CI, 19.57-28.66). Conclusions and Relevance: In this cross-sectional study of commercially insured persons with opioid and/or stimulant use disorder, HIV PrEP delivery remained low, including among those with evidence of IDU. PrEP should be consistently offered alongside substance use disorder treatment and other harm reduction and HIV prevention services.

Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use-Associated Infective Endocarditis.

IMPORTANCE: Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. OBJECTIVE: To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. DESIGN, SETTING, AND PARTICIPANTS: This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. INTERVENTIONS: The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). MAIN OUTCOMES AND MEASURES: Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). RESULTS: All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30% to 2.65% per week, the partial oral antibiotic strategy was cost-effective compared with OPAT at the $100 000 per LY threshold. CONCLUSIONS AND RELEVANCE: In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone.

Crisis stabilization units for jail diversion: A preliminary assessment of patient characteristics and outcomes.

Crisis stabilization units (CSUs), which offer a range of short-term psychiatric and psychological services, are one of several treatment programs that may create "alternative to arrest" options for law enforcement. Here, we examined the characteristics of the population who was referred to a newly established CSU in its first year of operation and examined the impact of the CSU on regional jail bookings. Administrative medical records and regional jail booking data were merged to form our study sample. Adults who had at least one jail booking and/or one CSU admission during our study period were included. We found that from September 1, 2018 to August 30, 2019, 458 people were admitted into the CSU. Approximately one-third (33.8%) had a jail booking during the study period. In the 3 months following CSU admission, 4.1% had an increase in jail bookings, 11.1% had a decrease, and 66.2% had no change. CSU patients self-reported high depressive and posttraumatic stress disorder symptoms, while also reporting low quality of life scores overall. We conclude that CSUs may be promising components of jail diversion efforts, providing critical services to populations experiencing significant mental health symptoms and who are at risk for incarceration. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Integrating substance use care into primary care for adolescents and young adults: Lessons learned.

BACKGROUND: Substance use disorders are common chronic conditions that often begin and develop during adolescence and young adulthood, yet the delivery of primary care is not developmentally tailored for youth who use substances. Very few primary care-based substance use treatment programs exist in the United States for adolescents and young adults and no clear guidance is available about how to provide substance use treatment in primary care. METHODS: We conducted a retrospective evaluation from July 2016 to December 2018 of a newly established primary care-based, multidisciplinary, outpatient program for youth who use substances. Components of the program include primary care, addiction treatment, harm reduction, naloxone distribution, psychotherapy, recovery support, and navigation addressing social determinants of health. We report the following patient characteristics and outcomes: demographics; proportion with substance use and mental health diagnoses; receipt of medications for opioid use disorder; retention in care at three, six, nine, and 12 months; and re-engagement in medical care. RESULTS: From July 2016 through December 2018, 148 patients had at least one visit. Demographic characteristics included: median age 21 years; 40.5% female; 94.0% spoke primarily English; 18.3% Black, 14.9% Hispanic, and 60.8% white. One-third of patients (33.8%) were homeless or housing insecure. The most common substance use disorder was opioid use disorder (60.8%), followed by nicotine (37.2%), cannabis (20.9%), and alcohol (18.2%). Overall, 29.7% of patients had depression, 32.4% had anxiety disorder, and 18.9% had post-traumatic stress disorder. Retention in care was 29.7% at six months and 12.2% at 12 months. Among the 90 patients with OUD, 90.0% received medication for OUD, and 35.5% and 15.5% of patients with OUD were retained at six and 12 months, respectively. For patients lost to follow-up (no contact during a three-month period), the median time to re-engagement was 4.8 months, and 33.3% (37/111) of patients re-engaged. The most common reason for re-engagement was to access mental health treatment (59.5%) and primary care (51.4%). CONCLUSIONS: Youth who sought care in a primary care-based substance use program presented most commonly with opioid, nicotine, cannabis, and alcohol use disorders. Co-morbid mental health diagnoses were common. While continuous retention at 12 months was low, one in three of the patients who fell out of care re-engaged. For youth receiving substance use care integrated into primary care, key components for pursing optimal retention in substance use treatment are a flexible model that anticipates the need for the treatment of mental health disorders and the use of re-engagement strategies.

Opioid use disorder and overdose among youth following an initial opioid prescription.

BACKGROUND AND AIMS: Some adolescents and young adults (termed "youth") prescribed an opioid will develop opioid use disorder or experience overdose. This study aimed to identify patient and prescription characteristics associated with subsequent risk of opioid use disorder or overdose during the year after an opioid is first dispensed. DESIGN: Retrospective cohort study. SETTING: Commercial health insurance claims in a large United States (US) database from 2006 to 2016. PARTICIPANTS: Youth age 11 to 25 years filling an initial opioid prescription (n = 3 278 990). MEASUREMENTS: The primary outcome was development of an 'opioid-related complication' (a diagnosis of opioid use disorder or opioid-related overdose) during the subsequent 12 months. Exposures of interest were patient (sociodemographic information, and physical and mental health diagnoses) and prescription characteristics (opioid formulation, dose, and duration). FINDINGS: Among youth filling an initial opioid prescription, median age was 18 years (interquartile range [IQR] = 16-21) and 56.1% were female. During the subsequent 12 months, 10 405 (0.3%) youth experienced an opioid-related complication. Conditions associated with increased risk included mood/anxiety disorders (adjusted relative risk [aRR] = 4.45; 95% CI = 4.25-4.66) and substance use (aRR = 20.77; 95% CI = 19.74-21.84). Comorbid substance use disorders were present among 72.8% of youth experiencing an opioid-related complication and included alcohol (33.4%), cannabis (33.0%), nicotine (43.2%), and other substance use disorders (75.5%). Long-acting opioids (aRR = 2.59; 95% CI = 2.18-3.09) and longer durations were associated with increased risk (7-14 days: aRR = 1.15; 95% CI = 1.08-1.22; ≥15 days: aRR = 1.96; 95% CI = 1.80-2.12) compared with short-acting formulations and durations ≤3 days, respectively. CONCLUSIONS: Among United States youth, complications after an initial opioid prescription appear to be relatively rare and appear to be associated with mood/anxiety disorders, substance use, comorbid substance use disorders, and prescriptions involving long-acting opioids or long durations.

Incidence and Characteristics of Nonfatal Opioid Overdose Among Youths Aged 11 to 24 Years by Sex.

Importance: Opioid-related overdose has substantially increased among adolescents and young adults in recent years. How overdose differs by age and sex among youths and the factors associated with overdose by sex remain poorly described. Objective: To compare the sociodemographic and clinical characteristics of female and male youths who have experienced a nonfatal opioid overdose (NFOD) and compare the incidence of NFOD by sex. Design, Setting, and Participants: This retrospective cohort study used data on US individuals aged 11 to 24 years with a diagnosis of NFOD from the IBM MarketScan Commercial Database from January 1, 2006, through December 31, 2017. Exposure: Sex. Main Outcomes and Measures: The primary outcome was NFOD stratified by sex; covariates included sociodemographic and clinical characteristics. Results: Among 20 312 youths aged 11 to 24 years who had a history of NFOD and met study eligibility criteria, the median age was 20 years (interquartile range, 18-22 years; mean [SD] age, 20.0 [2.9] years) and 56.7% were male. Compared with male youths, female youths had a higher baseline prevalence of mood or anxiety disorder (65.5% vs 51.9%, P < .001), trauma and stress-related disorders (16.4% vs 10.1%, P < .001), and history of suicide attempt or self-harm (14.6% vs 9.9%, P < .001). Male youths had a higher prevalence of opioid use disorder (44.7% vs 29.2%, P < .001), cannabis use disorder (18.3% vs 11.3%, P < .001), and alcohol use disorder (20.3% vs 14.4%, P < .001). The incidence rate ratio of NFODs in females vs males was greater than 1 for ages 11 to 16 years and was less than or equal to 1 after age 17 years. Conclusions and Relevance: This cohort study found differences between female and male youths in sociodemographic and clinical characteristics and incidence of NFOD. Although female and male youths who experience overdose appear to have different risk factors, many of these risk factors may be amenable to early detection through screening and intervention.

Impact of medications for opioid use disorder among persons hospitalized for drug use-associated skin and soft tissue infections.

BACKGROUND: Skin and soft tissue infections (SSTI) are common complications of injection drug use. We aimed to determine if rehospitalization and recurrent SSTI differ among persons with opioid use disorder (OUD) hospitalized for SSTI who are initiated on MOUD within 30 days of discharge and those who are not. METHODS: We performed a retrospective analysis of commercially insured adults aged 18 years and older in the U.S. with OUD and hospitalization for injection-related SSTI from 2010-2017. The primary exposure was initiation of MOUD in the 30 days following hospitalization for SSTI. The primary outcomes included 30-day and 1-year 1) all-cause rehospitalization and 2) recurrent SSTI. We calculated the incidence rates for the two groups: MOUD group and no MOUD group for the primary outcomes. We developed Cox models to determine if rehospitalization and recurrent SSTI differ between the two groups. RESULTS: Only 5.5 % (357/6538) of people received MOUD in the month following their index SSTI hospitalization. 30-day rehospitalization incidence was higher in the MOUD group compared to no MOUD (35.9 vs 27.5 per 100 person-30 days) and one-year SSTI recurrence was lower (10.3 vs 18.7 per 100 person-years). In multivariable modeling, the MOUD group remained at significantly higher risk of 30-day rehospitalization compared to the no MOUD group and at lower risk for one-year SSTI recurrence. CONCLUSIONS: MOUD receipt following SSTI hospitalization decreases risk of recurrent SSTI among persons with OUD. Further expansion of these in-hospital services could provide an effective tool in the U.S. response to the opioid epidemic.