Implementation, enrollment, and engagement in an opt-out telehealth pharmacist-assisted tobacco treatment program for patients seen in oncology outpatient clinics.

OBJECTIVE: To describe the workflow, reach, cost, and self-reported quit rates for an opt-out tobacco treatment program (TTP) for patients seen in 43 oncology outpatient clinics. METHODS: Between May 25, 2021, and December 31, 2022, adult patients (≥18 years) visiting clinics affiliated with the Medical University of South Carolina Hollings Cancer Center were screened for smoking status. Those currently smoking were referred to a telehealth pharmacy-assisted TTP. An attempt was made to contact referred patients by phone. Patients reached were offered free smoking cessation counseling and a 2-week starter kit of nicotine replacement medication. A random sample of 420 patients enrolled in the TTP were selected to participate in a telephone survey to assess smoking status 4 to 12 months after enrollment. RESULTS: During the reference period 35,756 patients were screened and 9.3% were identified as currently smoking. Among the 3319 patients referred to the TTP at least once, 2393 (72.1%) were reached by phone, of whom 426 (12.8%) were ineligible for treatment, 458 (13.8%) opted out of treatment, and 1509 (45.5%) received treatment. More than 90% of TTP enrollees smoked daily, with an average of 13.1 cigarettes per day. Follow-up surveys were completed on 167 of 420 patients, of whom 23.4% to 33.5% reported not smoking; if all nonresponders to the survey are counted as smoking, the range of quit rates is 9.3% to 13.3%. CONCLUSION: The findings demonstrate the feasibility of reaching and delivering smoking cessation treatments to patients from a diverse set of geographically dispersed oncology clinics.

Optimizing the Implementation of Tobacco Treatment for People with HIV: A Pilot Study.

People with HIV (PWH) have higher rates of tobacco use compared to their societal counterparts and are disproportionately affected by tobacco-related morbidity and mortality. A needs assessment was conducted to assess provider beliefs and opinions on tobacco treatment barriers and treatment approaches. The results highlighted a disconnect between the known importance of quitting smoking and barriers in linking patients to treatment, such as lack of patient interest and other patient issues being a higher priority. Using this assessment data, a treatment delivery approach, Proactive Outreach with Medication Opt-out for Tobacco Treatment Engagement (PrOMOTE), was devised and piloted. PrOMOTE consisted of an outpatient clinical pharmacist trained in tobacco treatment proactively contacting patients for counseling and to prescribe smoking cessation pharmacotherapy (varenicline or dual nicotine replacement therapy (NRT)) using an opt-out approach. The pilot was conducted with 10 PWH and patient reach and opt-out rates were evaluated. Of the 10 patients contacted, 7 were reached and none opted out of the pharmacotherapy prescription (varenicline = 6; NRT = 1). Providers know the importance of smoking cessation for PWH but encounter several barriers to implementing treatment. Using PrOMOTE methods to deliver tobacco treatment increased the reach and pharmacotherapy acceptance rate of PWH who smoke.

Giving Children a Voice About Their Dental Care.

Purpose: To assess young children's views of their experiences of dental treatment.
Methods: Forty-two four- to seven-year-old children were recruited between August and December 2017. Half were asked to tell the interviewer about their recent dental treatment and the remaining half were asked to draw at the same time they talked about this treatment. Only children's verbal responses were coded, not the content of their drawings.
Results: Drawing while talking increased the amount of neutral information that children verbally reported and helped to overcome limitations in language skills. Children talked primarily about emotionally neutral information. They talked about things that they did and did not like, and provided suggestions about how their experience of dental treatment could be improved.
Conclusion: Drawing during the interview helped children talk about their experiences of dental treatment. Gaining children's insights in this way could be used to optimize their oral health.

Practical Needs in the Home Care of Latino Children With Medical Complexity.

Latino children face barriers to high-quality healthcare. Because children with medical complexity (CMC) have higher healthcare needs, Latino CMC are likely to experience greater effects of these barriers. These vulnerabilities are exacerbated when Latino CMC endure adverse social conditions, such as food insecurity and housing instability. The study objective was to describe the challenges faced by caregivers of Latino CMC in meeting the practical needs of their children when caring for them at home. In this qualitative study, 70 Latino CMC enrolled in a complex care program of a tertiary care children's hospital were followed for a median duration of 45 months. We collected care coordination notes from encounter logs and interviewed bilingual care coordinators regarding their experiences with each child. Using thematic content analysis and an iterative process, we identified recurrent themes related to practical needs. Four themes emerged. Caregivers: 1) faced financial challenges due to many reasons that were exacerbated by children's medical conditions; 2) had challenges meeting basic needs of their families, including food and shelter; 3) experienced difficulties obtaining necessary medical supplies for their children; and 4) relied on care coordinators to navigate the system. We conclude that Latino caregivers of CMC experience many challenges meeting their families' basic needs and obtaining necessary medical supplies to care for their CMC at home. Care coordinators play a major role in addressing the practical needs of Latino CMC. Future studies should determine whether addressing the practical needs of Latino CMC would improve their health outcomes.

Postnatal exposure to MK801 induces selective changes in GAD67 or parvalbumin.

Brain injury during the last trimester to the first 1-4 years in humans is now thought to trigger an array of intellectual and emotional problems later in life, including disorders such as schizophrenia. In adult schizophrenic brains, there is a specific loss of neurons that co-express glutamic acid decarboxylase-parvalbumin (GAD67-PV). Loss of this phenotype is thought to occur in mature animals previously exposed to N-methyl-D: -aspartate receptor (NMDAR) antagonists during late gestation or at postnatal day 7 (P7). However, in similarly treated animals, we have previously shown that GAD67 and PV are unaltered in the first 24 h. To more precisely define when changes in these markers first occur, we exposed rat pups (P7 or P6-P10) to the NMDAR antagonist MK801 and at P11 co-stained brain sections for GAD67 or PV. In the cingulate cortex, we found evidence for a reduction in PV (GAD67 levels were very low to undetectable). In contrast, in the somatosensory cortex, we found that expression of GAD67 was reduced, but PV remained stable. Further, repeated but not single doses of MK801 were necessary to see such changes. Thus, depending on the region, NMDAR antagonism appears to influence expression of PV or GAD67, but not both. These observations could not have been predicted by previous studies and raise important questions as to how the GAD67-PV phenotype is lost once animals reach maturity. More importantly, such differential effects may be of great clinical importance, given that cognitive deficits are seen in children exposed to anesthetics that act by blocking the NMDAR.

Postnatal expression of GAD67.

N-methyl-D-aspartate receptor blockade promotes apoptosis at postnatal day 7 (P7) and is linked to loss of glutamic acid decarboxylase 67 (GAD67) expression in older animals. To more fully appreciate this relationship we must first understand how GAD67 is regulated postnatally. Thus, the brains of P7, P14 and P21 rats were examined for expression of GAD67 protein and we found that levels of this GABAergic marker increased steadily with age, such that by P21 there was as much as a 6-fold increase compared to P7 animals and a 1.5- to 2-fold increase compared to P14 animals, depending on the region sampled. At P7, GAD67 was almost exclusively detected in puncta, with very few cell bodies displaying this marker. In contrast, at P14 and especially P21, both puncta and cell bodies were robustly labeled. Our data indicate that adult-like expression of GAD67 emerges quite late in the postnatal period.

MK801-induced activated caspase-3 exhibits selective co-localization with GAD67.

Blockade of the N-methyl-d-aspartate receptor (NMDAR) in postnatal day 7 (P7) rats can promote rapid and robust induction of the pro-apoptotic marker activated caspase-3 (AC3) and loss of the GABAergic marker GAD67 at P56. Thus, we hypothesized that NMDAR blockade-induced AC3 occurs in GAD67 positive cells at P7. To test this idea, we injected P7 rat pups with vehicle or MK801 and after 8h (peak of AC3 induction) we examined brain sections for both AC3 and GAD67. Compared to vehicle, MK801 profoundly induced AC3 in all brain regions examined but co-expression of GAD67 in the same cells was not observed. However, in brain regions where punctate (synaptic) GAD67 was abundant (for example, layer IV of the somatosensory cortex), AC3 was robust. These data suggest that whereas somatic expression of AC3 and GAD67 may be non-overlapping, areas that exhibit punctate GAD67 (and are high in synaptic turnover) may be more vulnerable to MK801 exposure.

A descriptive study of noise in the neonatal intensive care unit: ambient levels and perceptions of contributing factors.

PURPOSE: To examine the baseline acoustic environment in several mid-Atlantic region neonatal intensive care units (NICUs) and investigate the perceived factors contributing to noise levels in these NICUs. SUBJECTS: Quantitative data were collected from 3 urban, mid-Atlantic level IIIB and level IIIC NICUs. Qualitative data were collected via interview from 2 RNs employed in each of the study NICUs. DESIGN: This was an exploratory descriptive study utilizing a mixed-methods approach. A quantitative method was used for sound-level data collection, and a qualitative method was utilized during interviews with nurses to examine perceptions of factors contributing to noise. METHODS: Ambient sound levels, measured in decibels, were taken at 5-minute intervals over a 2-hour period during both day and night shifts in a central location at each NICU. In addition, nurses were interviewed using a standardized interview questionnaire, and these interviews were then reviewed to determine themes regarding perceived factors contributing to sound levels. MAIN OUTCOME MEASURES: Hourly mean sound levels in each NICU ranged from 53.9 dB to 60.6 dB, with no statistically significant difference between noise levels recorded on day shift versus night shift, and no statistically significant difference among sites. Qualitative data showed that nurses' believed day shift to be louder than night shift and many perceived their own NICU as "pretty quiet." Key contributing factors to increased sound levels were stated as monitors or alarms, performing invasive procedures, presence of family, nurses or doctors giving report or rounds, and ringing phones. PRINCIPAL RESULTS: Noise levels were found to be above the American Academy of Pediatrics-recommended 45-dB level and often louder than the 50-dB level, which should not be exceeded more than 10% of the time. The recommended impulse maximum of 65 dB was also exceeded. Environmental Protection Agency recommendations for hospitals include sound levels no louder than 35 dB on night shift; this standard was also violated. CONCLUSIONS: Elevated sound levels need to be addressed in individual NICUs around the country. Further exploratory studies, as well as research regarding effective methods of decreasing sound levels in the NICU environment, are necessary. NICUs can implement behavioral and structural changes that can decrease the sound levels in the NICU environment and decrease the potential for exposure of patients to the harmful physiological effects of increased sound levels.

A descriptive study of noise in the neonatal intensive care unit. Ambient levels and perceptions of contributing factors.

PURPOSE: To examine the baseline acoustic environment in several mid-Atlantic region neonatal intensive care units (NICUs) and investigate the perceived factors contributing to noise levels in these NICUs. SUBJECTS: Quantitative data were collected from 3 urban, mid-Atlantic level IIIB and level IIIC NICUs. Qualitative data were collected via interview from 2 RNs employed in each of the study NICUs. DESIGN: This was an exploratory descriptive study utilizing a mixed-methods approach. A quantitative method was used for sound-level data collection, and a qualitative method was utilized during interviews with nurses to examine perceptions of factors contributing to noise. METHODS: Ambient sound levels, measured in decibels, were taken at 5-minute intervals over a 2-hour period during both day and night shifts in a central location at each NICU. In addition, nurses were interviewed using a standardized interview questionnaire, and these interviews were then reviewed to determine themes regarding perceived factors contributing to sound levels. MAIN OUTCOME MEASURES: Hourly mean sound levels in each NICU ranged from 53.9 dB to 60.6 dB, with no statistically significant difference between noise levels recorded on day shift versus night shift, and no statistically significant difference among sites. Qualitative data showed that nurses' believed day shift to be louder than night shift and many perceived their own NICU as "pretty quiet." Key contributing factors to increased sound levels were stated as monitors or alarms, performing invasive procedures, presence of family, nurses or doctors giving report or rounds, and ringing phones. PRINCIPAL RESULTS: Noise levels were found to be above the American Academy of Pediatrics--recommended 45-dB level and often louder than the 50-dB level, which should not be exceeded more than 10% of the time. The recommended impulse maximum of 65 dB was also exceeded. Environmental Protection Agency recommendations for hospitals include sound levels no louder than 35 dB on night shift; this standard was also violated. CONCLUSIONS: Elevated sound levels need to be addressed in individual NICUs around the country. Further exploratory studies, as well as research regarding effective methods of decreasing sound levels in the NICU environment, are necessary. NICUs can implement behavioral and structural changes that can decrease the sound levels in the NICU environment and decrease the potential for exposure of patients to the harmful physiological effects of increased sound levels.

An automated approach to salt selection for new unique trazodone salts.

PURPOSE: The purpose of this study was to establish an automated approach to salt selection and to search for unique trazodone salts for new applications. METHODS: Automated procedures were developed on a Biomek 2000 automation workstation with stacker and plate reader capabilities. Trazodone was dispensed into 96-well plates, and an automated method was set up to form 104 trazodone salts. Salts were observed under a polarized light microscope to determine crystallinity. After stepwise eliminations, the remaining salts were scaled-up and subjected to differential scanning calorimetry (DSC), powder x-ray diffraction (PXRD), hygroscopic, pH-solubility, density, surface area, and particle size analyses. RESULTS: Oils formed in several cases resulting in preliminary elimination of mesyl and esyl salts and four crystallizing solvents. Crystallinity was observed in 34 of 44 scaled-up trazodone salts. PXRD, DSC, and hygroscopic analyses indicated a number of new salts that were comparable in physicochemical parameters to the marketed HCl salt. Among them, the tosylate salt showed uniqueness for new applications. CONCLUSIONS: Automated procedures can be developed to increase the efficiency of pharmaceutical salt selection. The new tosylate salt gave a unique pH-solubility profile with low solubility over the entire pH range making it a potential candidate for a suspension or prolonged action formulation.