A Novel Inpatient Buprenorphine Induction Program for Adolescents With Opioid Use Disorder.

BACKGROUND: Morbidity and mortality from nonprescribed opioid use and opioid use disorder (OUD) in adolescents have risen dramatically. Medication for opioid use disorder (MOUD) with buprenorphine reduces nonprescribed opioid use and prevents overdoses, though <5% of adolescents with OUD have timely access, partly because of barriers associated with buprenorphine induction. Induction in an inpatient pediatric setting has the potential to address such barriers and improve adolescent MOUD access. METHODS: We developed and implemented a protocol for inpatient buprenorphine induction and linkage to MOUD care within a safety-net health system. After 1 year, we conducted descriptive analysis of participant characteristics, rates of induction completion and treatment linkage, and adverse events. We analyzed field notes from multidisciplinary huddles to identify implementation facilitators and barriers. RESULTS: During May 2021 to July 2022, we completed 46 admissions for 36 patients aged 12 to 21 years. All used fentanyl and no other opioids. Forty of 46 (87%) admissions resulted in completed induction, and 3 additional patients never developed withdrawal symptoms and were discharged with maintenance buprenorphine. Linkage to ongoing treatment occurred within 2 weeks for 31 of 43 (72%) admissions for which buprenorphine was started. We identified facilitators and barriers to program implementation and maintenance. CONCLUSION: These results provide promising preliminary evidence of the feasibility of inpatient buprenorphine induction for adolescents with OUD. Given the public health urgency and severe shortage of adolescent access to MOUD, these results prompt consideration of broader clinical implementation and research to facilitate rapid expansion of access to evidence-based OUD care.

Meeting the Needs of Postpartum Women: Provider Perspectives on Maternal Contraceptive Care in Pediatric Settings.

OBJECTIVE: Closely spaced, mistimed, and unwanted pregnancies are common among postpartum women and can lead to adverse maternal and perinatal outcomes. Women inconsistently attend postpartum obstetric visits, though they reliably interface with pediatric providers during the postpartum months, presenting novel opportunities to identify and address unmet family planning needs. METHODS: We conducted a qualitative study to explore pediatric provider perspectives on addressing maternal family planning in three settings: a neonatal intensive care unit, a primary care clinic, and a high-risk infant follow-up clinic. RESULTS: Pediatric providers were generally open to incorporating postpartum family planning screening and counseling into a pediatric encounter, if given appropriate training and implementation support. Providers largely agreed that contraceptive provision to women was not feasible in their practices, and they shared ideas for utilizing the pediatric encounter to connect women with comprehensive contraceptive care. CONCLUSION: Pediatric providers perceived postpartum family planning screening and counseling, and not contraceptive provision, as potentially acceptable and feasible in their practice settings. These exploratory findings justify further investigation to assess their generalizability and to develop postpartum family planning interventions for pediatrics.

Righting the Autonomy-Supervision Pendulum: Understanding the Impact of Independent Rounds on Medical Students, Residents, and Faculty.

PURPOSE: To explore trainee and faculty perspectives on an independent rounding intervention on general pediatrics wards at 2 institutions. METHOD: In July 2018, the authors introduced independent rounds 1 to 2 times a week at 2 training sites. In this qualitative study, the authors conducted semistructured focus groups with a purposive sample of junior trainees (clerkship medical students and postgraduate year [PGY] 1 residents), senior trainees (PGY-2 and PGY 3-5 residents), and hospital medicine faculty between October 2018 and May 2019. Focus groups were audio-recorded, transcribed verbatim, and analyzed for themes using the constant comparative approach associated with grounded theory. RESULTS: Focus groups included 27 junior trainees, 20 senior trainees, and 18 faculty. Six themes emerged: (1) Independent rounds contributed to all trainees' development; (2) Senior residents described increased motivation to take full ownership of their patients and educational needs of the team; (3) Faculty expressed concerns about decreased opportunities for teaching and feedback; however, all trainees reported unique learning from having faculty both present and absent from rounds; (4) No significant patient safety events were reported; (5) All participants identified communication and patient progression concerns; and (6) A tension emerged between decreased faculty and enhanced trainee career satisfaction. Participants identified solutions to identified barriers to further improve this educational intervention. CONCLUSIONS: As a result of independent rounding, trainees described increased motivation to take ownership of their patients and team. Both rounding experiences contributed to their development as physicians in different ways. Further studies should explore patient and caregiver perspectives and concerns about communication and patient care progression when designing future interventions to promote resident autonomy.

Meeting the Needs of Postpartum Women With and Without a Recent Preterm Birth: Perceptions of Maternal Family Planning in Pediatrics.

OBJECTIVES: Women face distinct barriers to meeting their reproductive health needs postpartum, especially women who deliver preterm. Pediatric encounters present unique opportunities to address women's family planning, particularly within 18 months of a prior pregnancy, when pregnancy has an elevated risk of an adverse outcome, such as preterm birth. To ensure maternal family planning initiatives are designed in a patient-centered manner, we explored perspectives on addressing reproductive health in a pediatric setting among women with and without a recent preterm delivery. METHODS: We conducted semi-structured, qualitative interviews with 41 women (66% delivered preterm). Women who delivered at any gestational age were interviewed at a pediatric primary care clinic. We also interviewed women whose infants were either in a level II intensive care nursery or attending a high-risk infant follow-up clinic, all of whom had delivered preterm. Data were analyzed using team-based coding and theme analysis. RESULTS: While women's preferred timing and setting for addressing peripartum contraception varied, they largely considered pediatric settings to be an acceptable place to discuss family planning. A few women felt family planning fell outside of the pediatric scope or distracted from the child focus. Women discussed various barriers to accessing family planning care postpartum, including circumstances unique to women who delivered preterm. CONCLUSIONS FOR PRACTICE: Family planning interventions in pediatric settings were overall an acceptable approach to reducing barriers to care among our sample of women who predominantly delivered preterm. These exploratory findings justify further investigation to assess their generalizability and to develop maternal family planning interventions for pediatric settings.

Reaching beyond pregnant women to eliminate mother-to-child transmission of syphilis in Africa.

Congenital syphilis is a devastating disease that can be prevented by screening and treatment of infected pregnant women. The WHO is leading a global initiative to eliminate mother-to-child-transmission of syphilis with a goal of ≤50 congenital syphilis cases per 100,000 live births and targets of 95% antenatal care, 95% syphilis testing, and 95% treatment coverage. We estimated current congenital syphilis rates for 43 African countries, and additional scenarios in a subset of 9 countries. Our analysis suggested that only 4 of 43 countries are likely to currently have a congenital syphilis rate ≤50 per 100,000 live births, and none of the 9 countries could reach this goal even in 5 different scenarios with improved services. To achieve the eliminate mother-to-child-transmission goal, it appears necessary to intervene beyond services for pregnant women, and decrease prevalence of syphilis in the general population as well.

Feasibility of community-based careHPV for cervical cancer prevention in rural Thailand.

OBJECTIVE: This study aimed to assess the safety, acceptability and feasibility of primary human papillomavirus (HPV) testing for cervical cancer prevention at the community level in a low-resource setting. MATERIALS AND METHODS: After training a technician to run specimens on the careHPV unit, the study team traveled to a different village each day in rural Roi-et Province, Thailand. Women were tested for HPV using self-swab, followed by careHPV testing. Those with positive result were assessed immediately by visual inspection with acetic acid. Women positive for HPV and visual inspection with acetic acid were offered cryotherapy. Safety was determined by monitoring adverse events. Exit surveys assessed acceptability and feasibility. Feasibility was also assessed by measuring testing and triage throughputs. RESULTS: Technician training required 2.5 days to achieve competency. A total of 431 women were screened in 14 days, with an average of 31 women screened daily. No adverse events were reported. Women deemed the program overwhelmingly acceptable: 90.5% reported that they would take the self-swab again, 71.3% preferred the self-swab to a clinician swab. The program was also feasible: 99.8% of eligible women agreed to testing, 94.8% returned for same-day follow-up, and women only spent 30 to 50 minutes of their total time with the program from screening to results. CONCLUSIONS: Cervical cancer prevention programs based on self-swab HPV testing could be safe, acceptable, feasible, and effective at the community level in low-resource settings.

Preventing cervical cancer: stakeholder attitudes toward CareHPV-focused screening programs in Roi-et Province, Thailand.

OBJECTIVE: To assess which of the 5 CareHPV-inclusive protocols stakeholders in Roi-et Province, Thailand found (1) most preferable and (2) most beneficial to the overall goal of reducing cervical cancer. DESIGN: Five CareHPV-inclusive cancer prevention approaches were presented to a convenience sample of colposcopists, trainers, health care providers, district medical directors, and district health officers. Participants ranked their preference for each plan (A-E) compared with the current screening protocol and also the perceived comparative benefit of the plans. Plans differed in whether every patient was screened using both the human papillomavirus (HPV) test and visual inspection with acetic acid (VIA) or only HPV-positive women were screened with VIA; in clinician versus self-swab and in hospital/clinic-based or village-based screening. RESULTS: Overall, participants supported an innovative plan in which women would be screened in their homes and villages using the self-swab version of the CareHPV DNA test, and only those who screened positive for HPV are screened with VIA. When results were stratified by provider type (physician vs nonphysician) and/or practice concentration (hospital-oriented vs field-oriented), preference and perceived benefit for the plans differed significantly with physician/hospital-oriented participants and are more likely to be skeptical of the self-swab version of the CareHPV test. CONCLUSIONS: Providers in Thailand recognize the potential value of a rapid HPV test as part of a cervical cancer prevention program and, overall, support a patient-administered self-swab followed by visual confirmation and treatment as the most practical CareHPV-inclusive approach largely because of the likely increase in coverage. Future studies will further define the clinical benefits and limitations of this test.