A case of true vocal fold jaundice.

OBJECTIVES: While jaundice is frequently described in the sclera and skin, there are few reports of true vocal fold jaundice in patients with high bilirubin, and no reports by otolaryngologists in the literature. Here we describe a case of a patient with bilateral true vocal fold jaundice and discuss the potential pathogenesis and implications of this finding. METHODS: A 29-year-old man with history of Dubin-Johnson Syndrome presented with cough and difficulty breathing and was incidentally found to have persistent yellow discoloration of the true vocal folds bilaterally. RESULTS: Videolaryngoscopic exam demonstrated bilateral true vocal fold yellow discoloration with sparing of nearby laryngeal structures on initial presentation and follow-up exam. Direct and total bilirubin levels were found to be elevated. CONCLUSION: A patient with benign Dubin-Johnson Syndrome and elevated total and direct bilirubin was incidentally found to have bilateral vocal fold jaundice. Jaundice and the presence of bilirubin do not appear to cause harm to the function or health of the true vocal folds and may be related to the high concentration of elastin present in the true vocal folds.

Awareness, Utilization, and Preferences of Harm Reduction Interventions among Street-Involved Young Adults in Boston.

OBJECTIVES: This study explores knowledge and utilization of, barriers to, and preferences for harm reduction services among street-involved young adults (YA) in Boston, Massachusetts. METHODS: This cross-sectional survey of YA encountered between November and December 2019 by a longstanding outreach program for street-involved YA. We report descriptive statistics on participant-reported substance use, knowledge and utilization of harm reduction strategies, barriers to harm reduction services and treatment, and preferences for harm reduction service delivery. RESULTS: The 52 YA surveyed were on average 21.4 years old; 63.5% were male, and 44.2% were Black. Participants reported high past-week marijuana (80.8%) and alcohol (51.9%) use, and 15.4% endorsed opioid use and using needles to inject drugs in the past six months. Fifteen (28.8%) YA had heard of "harm reduction", and 17.3% reported participating in harm reduction services. The most common barriers to substance use disorder treatment were waitlists and cost. Participants suggested that harm reduction programs offer peer support (59.6%) and provide a variety of services including pre-exposure prophylaxis (42.3%) and sexually transmitted infection testing (61.5%) at flexible times and in different languages, including Spanish (61.5%) and Portuguese (17.3%). CONCLUSIONS: There is need for comprehensive, YA-oriented harm reduction outreach geared toward marginalized YA and developed with YA input to reduce barriers, address gaps in awareness and knowledge of harm reduction, and make programs more relevant and inviting to YA.

A Novel Text Message Intervention to Improve Adherence to Stimulants in Adults With Attention Deficit/Hyperactivity Disorder.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) is a prevalent neurobiological disorder associated with a wide range of adverse outcomes. Although large data sets document that stimulants decrease the risks for many ADHD-associated adverse outcomes, compliance with stimulants remains very poor. The main aim of this study was to assess the effectiveness of a novel text messaging-based intervention aimed at improving the poor rate of adherence to stimulant medications in adults with ADHD. METHODS: Subjects were adults with ages 18 to 55, prescribed a stimulant medication for ADHD treatment. For comparators, we identified at a 5-to-1 ratio (age and sex matched) adult patients from the Partners HealthCare electronic medical record who had been prescribed stimulant medications over a 1-year period. We determined whether patients had timely prescription refills, defined as refilled within 37 days, using prescriptions documented in their electronic medical record. RESULTS: Our results showed that 68% of the SMS intervention group refilled their prescriptions in a timely manner. In contrast, only 34% of patients receiving treatment as usual refilled their prescriptions in a timely fashion (odds ratio, 4.04; 95% confidence interval, 2.49-6.56; P < 0.001). CONCLUSIONS: These data indicate that an innovative ADHD-centric text messaging intervention significantly improved patient engagement to treatment with stimulants in adults with ADHD. Findings provide strong support for the use of a readily accessible, inexpensive, and widely available technology to improve the poor rate of adherence to stimulant treatment in adults with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for adults with ADHD.

Evaluating mobile harm reduction services for youth and young adults.

The adolescent and young adult (AYA) population has experienced an increase in both emergency room visits and deaths related to substance use. However, AYA are less likely to engage in existing addiction treatment infrastructure. A youth-specific mobile harm reduction program has the potential to reduce substance-related morbidity and mortality including infections, overdose, and death. Launched in 2019, the Community Care in Reach AYA pilot program seeks to address the difference in patterns of substance use between AYA and adults. The results of this evaluation suggest the importance of a youth-oriented program in increasing AYA engagement with harm reduction.

The relationship between safety-net hospital status and outcomes among elderly head and neck cancer patients.

BACKGROUND: The impact of safety-net status, case volume, and outcomes among geriatric head and neck cancer patients is unknown. METHODS: Chi-square tests and Student's t tests to compare head and neck surgery outcomes of elderly patients between safety-net and non-safety-net hospitals. Multivariable linear regressions to determine predictors of outcome variables including mortality index, ICU stays, 30-day readmission, total direct cost, and direct cost index. RESULTS: Compared with non-safety-net hospitals, safety-net hospitals had a higher average mortality index (1.04 vs. 0.32, p = 0.001), higher mortality rate (1% vs. 0.5%, p = 0.002), and higher direct cost index (p = 0.001). A multivariable model of mortality index found the interaction between safety-net status and medium case volume was predictive of higher mortality index (p = 0.006). CONCLUSION: Safety-net status is correlated with higher mortality index and cost in geriatric head and neck cancer patients. The interaction between medium volume and safety-net status is independently predictive of higher mortality index.

Reducing COVID-19 Health Inequities by Identifying Social Needs and Clinical Deterioration of Discharged Emergency Department Patients.

INTRODUCTION: The decision to discharge a patient from the hospital with confirmed or suspected coronavirus 2019 (COVID-19) is fraught with challenges. Patients who are discharged home must be both medically stable and able to safely isolate to prevent disease spread. Socioeconomically disadvantaged patient populations in particular may lack resources to safely quarantine and are at high risk for COVID-19 morbidity. METHODS: We developed a telehealth follow-up program for emergency department (ED) patients who received testing for COVID-19 from April 24-June 29, 2020 and were discharged home. Patients who were discharged with a pending COVID-19 test received follow-up calls on Days 1, 4, and 8. The objective of our program was to screen and provide referrals for health-related social needs (HRSN), conduct clinical screening for worsening symptoms, and deliver risk-reduction strategies for vulnerable individuals. We conducted retrospective chart reviews on all patients in this cohort to collect demographic information, testing results, and outcomes of clinical symptom and HRSN screening. Our primary outcome measurement was the need for clinical reassessment and referral for an unmet HRSN. RESULTS: From April 24-June 29, 2020, we made calls to 1,468 patients tested for COVID-19 and discharged home. On Day 4, we reached 67.0% of the 1,468 patients called. Of these, 15.9% were referred to a physician's assistant (PA) out of concern for clinical worsening and 12.4% were referred to an emergency department (ED) patient navigator for HRSNs. On Day 8, we reached 81.8% of the 122 patients called. Of these, 19.7% were referred to a PA for clinical reassessment and 14.0% were referred to an ED patient navigator for HRSNs. Our intervention reached 1,069 patients, of whom 12.6% required referral for HRSNs and 1.3% (n = 14) were referred to the ED or Respiratory Illness Clinic due to concern for worsening clinical symptoms. CONCLUSION: In this patient population, the demand for interventions to address social needs was as high as the need for clinical reassessment. Similar ED-based programs should be considered to help support patients' interdependent social and health needs beyond those related to COVID-19.

Mind Wandering (Internal Distractibility) in ADHD: A Literature Review.

Objective: Mind wandering, the unintended shifting of attention from a task, has been previously associated with symptoms of ADHD. To this end, we conducted a literature search to investigate the association between mind wandering and ADHD. Method: We conducted a systematic search of the literature of relevant articles assessing mind wandering and ADHD in PubMed, PsycINFO/OVID, and Medline. Included were original articles in English that had operationalized definitions of ADHD and mind wandering, adequate sample size, and reliance on statistical evaluation of findings. Excluded were reviews, opinions, and case reports. Results: Only nine studies met our a priori inclusion and exclusion criteria (N = 8 in adults; N = 1 in pediatrics). Findings suggest that ADHD is frequently associated with spontaneous mind wandering and when present heralds more functional impairments. Conclusion: The limited research on mind wandering in ADHD indicates that it is prevalent and morbid supporting further research on the subject.

An equity-based narrative review of barriers to timely postoperative radiation therapy for patients with head and neck squamous cell carcinoma.

OBJECTIVES: The majority of patients with head and neck squamous cell carcinoma (HNSCC) do not commence postoperative radiation treatment (PORT) within the recommended 6 weeks. We explore how delayed PORT affects survival outcomes, what factors are associated with delayed PORT initiation, and what interventions exist to reduce delays in PORT initiation. METHODS: We conducted a PubMed search to identify articles discussing timely PORT for HNSCC. We performed a narrative review to assess survival outcomes of delayed PORT as well as social determinants of health (SDOH) and clinical factors associated with delayed PORT, using the PROGRESS-Plus health equity framework to guide our analysis. We reviewed interventions designed to reduce delays in PORT. RESULTS: Delayed PORT is associated with reduced overall survival. Delays in PORT disproportionately burden patients of racial/ethnic minority backgrounds, Medicaid or no insurance, low socioeconomic status, limited access to care, more comorbidities, presentation at advanced stages, and those who experience postoperative complications. Delays in PORT initiation tend to occur during transitions in head and neck cancer care. Delays in PORT may be reduced by interventions that identify patients who are most likely to experience delayed PORT, support patients according to their specific needs and barriers to care, and streamline care and referral processes. CONCLUSIONS: Both SDOH and clinical factors are associated with delays in timely PORT. Structural change is needed to reduce health disparities and promote equitable access to care for all. When planning care, providers must consider not only biological factors but also SDOH to maximize care outcomes.

Harm Reduction for Adolescents and Young Adults During the COVID-19 Pandemic: A Case Study of Community Care in Reach.

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of harm reduction programs to provide vital services to adolescents, young adults, and people who use drugs, thereby increasing the risk of overdose, infection, withdrawal, and other complications of drug use. To evaluate the effect of the COVID-19 pandemic on harm reduction services for adolescents and young adults in Boston, we conducted a quantitative assessment of the Community Care in Reach (CCIR) youth pilot program to determine gaps in services created by its closure during the peak of the pandemic (March 19-June 21, 2020). We also conducted semistructured interviews with staff members at 6 harm reduction programs in Boston from April 27 through May 4, 2020, to identify gaps in harm reduction services, changes in substance use practices and patterns of engagement with people who use drugs, and how harm reduction programs adapted to pandemic conditions. During the pandemic, harm reduction programs struggled to maintain staffing, supplies, infection control measures, and regular connection with their participants. During the 3-month suspension of CCIR mobile van services, CCIR missed an estimated 363 contacts, 169 units of naloxone distributed, and 402 syringes distributed. Based on our findings, we propose the following recommendations for sustaining harm reduction services during times of crisis: pursuing high-level policy changes to eliminate political barriers to care and fund harm reduction efforts; enabling and empowering harm reduction programs to innovatively and safely distribute vital resources and build community during a crisis; and providing comprehensive support to people to minimize drug-related harms.

Telemedicine in the Management of ADHD: Literature Review of Telemedicine in ADHD.

Objective: Telemedicine has been used successfully in several medical specialties with favorable patient outcomes, satisfaction, in a cost-effective manner. However, its use in the context of ADHD remains unclear. Our main aim was to investigate what is known about the use of telemedicine in ADHD. Method: We conducted a systematic search of the literature assessing telemedicine in ADHD in PubMed, PsycINFO, and Medline. Included were original articles published in English with the main aim to assess the use of telemedicine in ADHD. Results: Only 11 articles met our inclusion and exclusion criteria, coming from only three systematic trials of telemedicine in ADHD. The studies suggest that telemedicine is valued by its users, is well accepted, and is associated with improved outcomes. Conclusion: The limited research indicates that telemedicine has potential to expand the delivery of clinical services to patients with ADHD. More work is needed to further evaluate this finding.

Further evidence of low adherence to stimulant treatment in adult ADHD: an electronic medical record study examining timely renewal of a stimulant prescription.

RATIONALE: ADHD is a prevalent and morbid neurobiological disorder affecting up to 5% of adults. While stimulants have been documented to be safe and effective in adults with ADHD, uncertainties remain about adherence to these treatments. OBJECTIVES: The main aim of this article was to evaluate contemporaneous rates and correlates of adherence to stimulants in adults with ADHD using data from electronic medical records from a large healthcare organization focusing on timely renewal of an initial prescription. METHODS: Subjects were patients 18 to 44 years of age who had been prescribed a stimulant between January 1, 2015, and December 31, 2016. Prescription and sociodemographic data were extracted from the Partners HealthCare Research Patient Data Registry (RPDR). Our outcome metric was renewal of the index stimulant prescription defined as the first prescription recorded in the electronic record for the period under investigation. RESULTS: We identified 2689 patients with an index prescription for a stimulant medication. Results showed that only 42% of patients renewed their prescriptions in a timely enough fashion to be considered consistently medicated. CONCLUSIONS: Results indicate that adults with ADHD have a low rate of renewal of their initial stimulant prescription indicating poor patient engagement in their treatment for ADHD.

Clinical correlates of mind wandering in adults with ADHD.

The objective of this study was to investigate the prevalence and clinical correlates of ADHD patients with mind wandering. 255 consecutively referred 18- to 55-year-old adults of both sexes with ADHD were assessed. Subjects completed a demographic interview, the Mind Wandering Questionnaire (MWQ), the ADHD Rating Scale (ADHD RS), the Behavior Rating Inventory of Executive Function - Adult Version (BRIEF-A), the Social Responsiveness Scale - Second Edition (SRS-2) Adult Self-Report Form, the Adult Self-Report (ASR), the Barkley Emotional Dysregulation Scale, and the Quality of Life Enjoyment & Satisfaction Questionnaire (Q-LES-Q). We used receiver operator characteristic (ROC) curves to identify the optimal cut-off on the MWQ to categorize patients as having high-versus low-level mind wandering and compared demographic and clinical characteristics between the two groups. Participants were categorized by ROC analysis as having high- (N = 127) and low-level (N = 128) mind wandering based on an MWQ total score ≥ or < than 24, respectively. Compared with low-level mind wandering participants, those with high-level mind wandering had significantly more Inattentive and Hyperactive symptoms (all p < 0001), worse executive functioning as measured by the BRIEF-A, more impaired mean (all p ≤ 0.001) and dichotomized scores (t-score ≥65) (all p < 0.005) on subscales and composite ASR scales, more impaired scores on the Barkley Emotional Dysregulation Scale (p < 0.001), and more impaired quality of life scores. High-level mind wandering is prevalent in adults with ADHD and is associated with more severe ADHD symptoms, more executive function deficits, more emotional dysregulation, higher levels of associated psychopathology, and more impaired quality of life.

Dysregulated protocadherin-pathway activity as an intrinsic defect in induced pluripotent stem cell-derived cortical interneurons from subjects with schizophrenia.

We generated cortical interneurons (cINs) from induced pluripotent stem cells derived from 14 healthy controls and 14 subjects with schizophrenia. Both healthy control cINs and schizophrenia cINs were authentic, fired spontaneously, received functional excitatory inputs from host neurons, and induced GABA-mediated inhibition in host neurons in vivo. However, schizophrenia cINs had dysregulated expression of protocadherin genes, which lie within documented schizophrenia loci. Mice lacking protocadherin-α showed defective arborization and synaptic density of prefrontal cortex cINs and behavioral abnormalities. Schizophrenia cINs similarly showed defects in synaptic density and arborization that were reversed by inhibitors of protein kinase C, a downstream kinase in the protocadherin pathway. These findings reveal an intrinsic abnormality in schizophrenia cINs in the absence of any circuit-driven pathology. They also demonstrate the utility of homogenous and functional populations of a relevant neuronal subtype for probing pathogenesis mechanisms during development.

Does the course of manic symptoms in pediatric bipolar disorder impact the course of conduct disorder? Findings from four prospective datasets.

BACKGROUND: To assess whether the course of pediatric bipolar-I (BP-I) disorder impacts the course of conduct disorder (CD)/antisocial personality disorder (ASPD). We hypothesized that remission of manic symptoms in BP-I youth will be associated with remission of CD/ASPD. METHODS: We used data from four longitudinal datasets of carefully characterized and comprehensively assessed youth with structured diagnostic interview based diagnoses of BP-I disorder and CD/ASPD assessed at baseline in childhood and at follow-up onto adolescent years. The baseline sample consisted of 240 subjects with full BP-I disorder. The average follow-up time was 6.6 ±â€¯2.4 years. RESULTS: Subjects with remitting BP-I disorder in adolescent years had a significantly lower one-year prevalence of CD or ASPD compared to those with persistent BP-I disorder (χ2 = 10.35, p = 0.001). LIMITATIONS: Our inferences were derived from the examination of naturalistic longitudinal follow-up data and not results of a clinical trial. CONCLUSIONS: Results indicate that remission of manic symptoms at the adolescent follow up in youth with BP-I disorder were associated with a significant decrease in rates of CD/ASPD. These results suggest that targeting manic symptoms in youth with BP-I disorder could mitigate the course of CD/ASPD in youth. Considering the high morbidity and disability associated CD/ASPD in youth and the limited treatment options available to address it, if replicated, these findings would have very important clinical and public health significance.

Identification of Risk Factors for Elevated Neonatal Gentamicin Trough Concentrations.

OBJECTIVES: The objective of this study was to identify neonatal and maternal characteristics that may be associated with elevated neonatal gentamicin trough concentrations despite application of a previously published gentamicin dosage strategy. METHODS: Retrospective cohort study of all neonates admitted to University of Vermont Medical Center (562-bed academic teaching hospital, Burlington, VT) receiving gentamicin between June 1, 2009, and August 31, 2013. A total of 205 neonates were included, with 41 cases and 164 controls. RESULTS: Postmenstrual age (PMA, gestational age plus chronological age) and small-for-gestational age (SGA) status were independently associated with elevated neonatal gentamicin trough concentrations. No maternal risk factor evaluated remained significantly associated in the multivariate analysis. CONCLUSIONS: The probability of an elevated gentamicin trough concentration increases with lower PMA and is further accentuated in neonates with SGA status. In contrast, the presence of maternal risk factors did not increase the likelihood of elevated gentamicin trough concentrations. Neonates with lower PMA and SGA status may require an individualized dosage and monitoring strategy.

Training of community health workers to deliver cancer patient navigation to rural African American seniors.

BACKGROUND: Rural African American (AA) seniors may experience significant challenges during cancer treatment. Previous research suggests community health workers (CHWs) can provide effective cancer patient navigation (CPN) support. OBJECTIVES: To develop a Train the Trainers (TTT) program for CHWs in rural Central Virginia who would navigate local AA seniors with cancer and train their support persons to provide similar types of assistance. METHODS: We conducted focus groups with rural AA seniors, consulted with experienced CHW trainers, recruited and trained CHWs through a combination of online learning and distance education, evaluated the TTT via surveys and focus groups, and hired CHWs to the study team. RESULTS/LESSONS LEARNED: Lessons learned from our TTT experience include the value of incorporating CHW trainers and trainees as full members of the research team. CONCLUSIONS: Training should be accessible and flexible, providing trainees community-level resources and enriched educational experiences. Findings have informed a culturally tailored support CHW intervention to address cancer diagnosis and treatment needs for older rural AAs.