The Massachusetts Department of Public Health Post Overdose Support Team Initiative: A Public Health-Centered Co-Response Model for Post-Overdose Outreach.

CONTEXT: Post-overdose outreach programs have emerged in response to surging overdose deaths amid fentanyl contamination of the illicit opioid supply. Predominantly centered in police departments in collaboration with public health providers, these programs conduct home-based outreach with survivors and their social networks following an overdose. APPROACH: We describe implementation of the Post Overdose Support Team (POST) initiative, an ongoing public health funded and centered approach. Post Overdose Support Team is a person-centered model led by harm reductionists in health and human services agencies in collaboration with municipal first responders. The goal of POST is to engage overdose survivors and their social network to improve general health, connect people to services (including access to treatment, if desired), and reduce risk of subsequent overdose. IMPLEMENTATION: Nine agencies in Massachusetts that are part of the state's overdose education and naloxone distribution network implemented POST programs, covering 28 municipalities. The POST teams conduct home-based outreach with individuals who experienced an opioid-related overdose to provide a menu of services, including naloxone rescue kits, overdose response and risk reduction planning, referral to treatment for substance use disorders, including medication for opioid use disorder, and referral to recovery and family supports. EVALUATION: From October 2017 to October 2021, the POST teams attempted to reach 5634 overdose survivors via 10 536 outreach visits. Teams successfully engaged 3014 survivors, either directly or through contact with their social network (53.5% success rate). Using data from a real-time encounter-level database, monthly peer-sharing calls with program sites, and annual site visits, we describe the implementation of the POST initiative and provide practice-based recommendations and lessons learned. DISCUSSION: Early evidence suggests that the POST initiative is meeting its goal to engage overdose survivors, improve general health, and reduce subsequent overdose risk. Future evaluations should examine long-term outcomes among participants, including service linkages and incremental behavior change.

Implementation and Uptake of the Massachusetts Drug Supply Data Stream: A Statewide Public Health-Public Safety Partnership Drug Checking Program.

CONTEXT: The illicit drug supply is rapidly evolving. Equally important to gathering drug supply data for monitoring is timely sharing of information with people who use drugs, the providers who care for them, law enforcement partners, and public health stakeholders so that efforts to avoid harmful substances, take preventive actions, and better target interventions can occur. PROGRAM: The Massachusetts Drug Supply Data Stream (MADDS) is the country's first statewide community drug checking program. Founded on public health-public safety partnerships, MADDS collects remnant drug packaging and paraphernalia with residue from people who use drugs and noncriminal samples from partnering police departments. MADDS tests samples using simultaneous immunoassay fentanyl test strips, Fourier-transform infrared spectrometry (FTIR), and off-site laboratory testing by gas chromatography-mass spectrometry (GC/MS). Results are accessible to community programs and municipalities, while trend analyses inform public health for cross-site alerts and informational bulletins. IMPLEMENTATION: MADDS was launched statewide in 2020 and rapidly expanded to a multisite program. Program staff approached communities and met with municipal police and community partners to secure written agreements to host drug checking. Community partners designed sample collection consistent with their pandemic era workflows. Consultations with stakeholders gathered feedback on design and deliverables. EVALUATION: The program tests sample donations on-site from community agencies and police departments, incorporates review by a medical toxicologist for health and safety concerns, crafts stakeholder-specific communications, and disseminates English, Spanish, and Portuguese language materials. For 2020, a total of 427 samples were tested, of which 47.1% were positive for fentanyl. By early 2021, MADDS detected shifts in cocaine purity, alerted communities of a new toxic fentanyl analogue and a synthetic cannabinoid contaminant, and confirmed the increase of xylazine (a veterinary sedative) in Massachusetts. DISCUSSION: Community drug checking programs can be collaboratively designed with public health and public safety to generate critical health and safety information for people who use drugs and the communities where they live.

Monitoring Cognitive Health Status in Homebound Older Adults: Insights from a Nationwide Request for Information.

The COVID-19 pandemic has fueled growing concerns about the long-term impacts on outcomes in older adults including social isolation and declines in cognitive health. Prior to the pandemic, the Administration for Community Living (ACL) released a nationwide request for information to understand how community-based organizations monitor changes in cognitive status for homebound older adults. This Perspective describes strategies reported by community-based organizations to monitor cognitive status in homebound older adults and notes the potential for technology to mitigate the risk of social isolation and delays in observing cognitive decline, considerations that are especially relevant during COVID-19 amid social distancing requirements.

Emotion socialization in mothers with mood disorders: Affective modeling and recollected responses to childhood emotion.

Growing evidence suggests that emotion socialization may be disrupted by maternal depression. However, little is known about emotion-related parenting by mothers with bipolar disorder or whether affective modeling in early childhood is linked to young adults' recollections of emotion socialization practices. The current study investigates emotion socialization by mothers with histories of major depression, bipolar disorder, or no mood disorder. Affective modeling was coded from parent-child interactions in early childhood and maternal responses to negative emotions were recollected by young adult offspring (n = 131, 59.5% female, M age = 22.16, SD = 2.58). Multilevel models revealed that maternal bipolar disorder was associated with more neglecting, punishing, and magnifying responses to children's emotions, whereas maternal major depression was associated with more magnifying responses; links between maternal diagnosis and magnifying responses were robust to covariates. Young adult recollections of maternal responses to emotion were predicted by affective modeling in early childhood, providing preliminary validity evidence for the Emotions as a Child Scale. Findings provide novel evidence that major depression and bipolar disorder are associated with altered emotion socialization and that maternal affective modeling in early childhood prospectively predicts young adults' recollections of emotion socialization in families with and without mood disorder.

Children's secure base script knowledge as a mediator between early life stress and later behavior problems.

Attachment theory posits that children's interactions with caregivers contribute to internalized representations that reflects the common and recurring elements of sensitive caregiving interactions (i.e. the secure base script). These internalized representations are theorized to influence later adaptation, including the development of psychopathology. Given prior research suggesting that stress exposure may undermine secure base script knowledge (SBSK), this study evaluated SBSK development in early childhood as a mechanism by which childhood stress exposure may influence later adaptation. We hypothesized that children's (N = 230; Mage = 73.30 months, SD = 2.51, 50% girls; 45.7% Latinx) stress exposure would be associated with lower levels of SBSK at age 6, which, in turn, would contribute to increased internalizing and externalizing symptoms at age 8. SBSK emerged as a significant mechanism by which early life stress may contribute to later externalizing, but not internalizing, child behavior problems. These findings highlight the role of SBSK as a profitable focus for both risk identification and intervention efforts aimed at reducing behavioral maladaptation among stress-exposed children.

A Framework for Rigorous Qualitative Research as a Component of Mixed Method Rapid-Cycle Evaluation.

As federal, state, and local governments continue to test innovative approaches to health care delivery, the ability to produce timely and reliable evidence of what works and why it works is crucial. There is limited literature on methodological approaches to rapid-cycle qualitative research. The purpose of this article is to describe the advantages and limitations of a broadly applicable framework for in-depth qualitative analysis placed within a larger rapid-cycle, multisite, mixed-method evaluation. This evaluation included multiple cycles of primary qualitative data collection and quarterly and annual reporting. Several strategies allowed us to be adaptable while remaining rigorous; these included planning for multiple waves of qualitative coding, a hybrid inductive/deductive approach informed by a cross-program evaluation framework, and use of a large team with specific program expertise. Lessons from this evaluation can inform researchers and evaluators functioning in rapid assessment or rapid-cycle evaluation contexts.

The Role of Lysosomes in a Broad Disease-Modifying Approach Evaluated across Transgenic Mouse Models of Alzheimer's Disease and Parkinson's Disease and Models of Mild Cognitive Impairment.

Many neurodegenerative disorders have lysosomal impediments, and the list of proposed treatments targeting lysosomes is growing. We investigated the role of lysosomes in Alzheimer's disease (AD) and other age-related disorders, as well as in a strategy to compensate for lysosomal disturbances. Comprehensive immunostaining was used to analyze brains from wild-type mice vs. amyloid precursor protein/presenilin-1 (APP/PS1) mice that express mutant proteins linked to familial AD. Also, lysosomal modulation was evaluated for inducing synaptic and behavioral improvements in transgenic models of AD and Parkinson's disease, and in models of mild cognitive impairment (MCI). Amyloid plaques were surrounded by swollen organelles positive for the lysosome-associated membrane protein 1 (LAMP1) in the APP/PS1 cortex and hippocampus, regions with robust synaptic deterioration. Within neurons, lysosomes contain the amyloid ß 42 (Aß42) degradation product Aß38, and this indicator of Aß42 detoxification was augmented by Z-Phe-Ala-diazomethylketone (PADK; also known as ZFAD) as it enhanced the lysosomal hydrolase cathepsin B (CatB). PADK promoted Aß42 colocalization with CatB in lysosomes that formed clusters in neurons, while reducing Aß deposits as well. PADK also reduced amyloidogenic peptides and α-synuclein in correspondence with restored synaptic markers, and both synaptic and cognitive measures were improved in the APP/PS1 and MCI models. These findings indicate that lysosomal perturbation contributes to synaptic and cognitive decay, whereas safely enhancing protein clearance through modulated CatB ameliorates the compromised synapses and cognition, thus supporting early CatB upregulation as a disease-modifying therapy that may also slow the MCI to dementia continuum.

Practical Strategies to Improve Your Writing: Lessons Learned From Public Health Practitioners Participating in a Writing Group.

Many public health professionals (researchers and practitioners) do not regularly spend time writing. We often receive no formal training in the practices that lead one to become a productive writer. In addition, many internal (mental/emotional) and external (schedules/distractions) barriers make writing consistently even less appealing and may lead to a cycle of avoidance followed by binge writing. This commentary demonstrates how one writing group became an effective means of providing career and professional development. Each week for 9 months we held a 1-hour writing group meeting designed around a commitment to ground rules, accountability, training opportunities, and feedback. Our experiences suggest that engaging in a writing group can help us develop as writers by allowing us to learn new practices and skills. Adopting new practices like writing regularly for short blocks of time, in turn, led to benefits like reduced anxiety and increased productivity. In the process, we became better writers, reviewers, and mentors. We provide recommendations and resources for groups and individuals who are interested in improving their writing as an essential component of their continuing education and professional development. Whatever your professional role, using a writing group to become a more powerful and productive writer will make you more effective.

Two Innovative Cancer Care Programs Have Potential to Reduce Utilization and Spending.

BACKGROUND: Cancer patients often present to the emergency department (ED) and hospital for symptom management, but many of these visits are avoidable and costly. OBJECTIVE: We assessed the impact of 2 Health Care Innovation Awards that used an oncology medical home model [Community Oncology Medical Home (COME HOME)] or patient navigation model [Patient Care Connect Program (PCCP)] on utilization and spending. METHODS: Participants in COME HOME and PCCP models were matched to similar comparators using propensity scores. We analyzed utilization and spending outcomes using Medicare fee-for-service claims with unadjusted and adjusted difference-in-differences models. RESULTS: In the adjusted models, both COME HOME and PCCP were associated with fewer ED visits than a comparison group (15 and 22 per 1000 patients/quarter, respectively; P<0.01). In addition, COME HOME had lower spending ($675 per patient/quarter; P<0.01), and PCCP had fewer hospitalizations (11 per 1000 patients/quarter; P<0.05), relative to the comparison group. Among patients undergoing chemotherapy, fewer COME HOME and PCCP patients had ED visits (18 and 28 per 1000 patients/quarter, respectively; P<0.01) and fewer PCCP patients had hospitalizations (13 per 1000 patients/quarter; P<0.05), than comparison patients. CONCLUSIONS: The oncology medical home and patient navigator programs both showed reductions in spending or utilization. Adoption of such programs holds promise for improving cancer care.

Characteristics of Fentanyl Overdose - Massachusetts, 2014-2016.

Opioid overdose deaths in Massachusetts increased 150% from 2012 to 2015 (1). The proportion of opioid overdose deaths in the state involving fentanyl, a synthetic, short-acting opioid with 50-100 times the potency of morphine, increased from 32% during 2013-2014 to 74% in the first half of 2016 (1-3). In April 2015, the Drug Enforcement Agency (DEA) and CDC reported an increase in law enforcement fentanyl seizures in Massachusetts, much of which was believed to be illicitly manufactured fentanyl (IMF) (4). To guide overdose prevention and response activities, in April 2016, the Massachusetts Department of Public Health and the Office of the Chief Medical Examiner collaborated with CDC to investigate the characteristics of fentanyl overdose in three Massachusetts counties with high opioid overdose death rates. In these counties, medical examiner charts of opioid overdose decedents who died during October 1, 2014-March 31, 2015 were reviewed, and during April 2016, interviews were conducted with persons who used illicit opioids and witnessed or experienced an opioid overdose. Approximately two thirds of opioid overdose decedents tested positive for fentanyl on postmortem toxicology. Evidence for rapid progression of fentanyl overdose was common among both fatal and nonfatal overdoses. A majority of interview respondents reported successfully using multiple doses of naloxone, the antidote to opioid overdose, to reverse suspected fentanyl overdoses. Expanding and enhancing existing opioid overdose education and prevention programs to include fentanyl-specific messaging and practices could help public health authorities mitigate adverse effects associated with overdoses, especially in communities affected by IMF.

Origins of Secure Base Script Knowledge and the Developmental Construction of Attachment Representations.

Increasing evidence suggests that attachment representations take at least two forms: a secure base script and an autobiographical narrative of childhood caregiving experiences. This study presents data from the first 26 years of the Minnesota Longitudinal Study of Risk and Adaptation (N = 169), examining the developmental origins of secure base script knowledge in a high-risk sample and testing alternative models of the developmental sequencing of the construction of attachment representations. Results demonstrated that secure base script knowledge was predicted by observations of maternal sensitivity across childhood and adolescence. Furthermore, findings suggest that the construction of a secure base script supports the development of a coherent autobiographical representation of childhood attachment experiences with primary caregivers by early adulthood.

Transactional processes in the development of adult personality disorder symptoms.

The development of adult personality disorder symptoms, including transactional processes of relationship representational and behavioral experience from infancy to early adolescence, was examined using longitudinal data from a risk sample (N = 162). Significant preliminary correlations were found between early caregiving experience and adult personality disorder symptoms and between representational and behavioral indices across time and adult symptomatology. Significant correlations were also found among diverse representational assessments (e.g., interview, drawing, and projective narrative) and between concurrent representational and observational measures of relationship functioning. Path models were analyzed to investigate the combined relations of caregiving experience in infancy; relationship representation and experience in early childhood, middle childhood, and early adolescence; and personality disorder symptoms in adulthood. The hypothesized model representing interactive contributions of representational and behavioral experience represented the data significantly better than competing models representing noninteractive contributions. Representational and behavioral indicators mediated the link between early caregiving quality and personality disorder symptoms. The findings extend previous studies of normative development and support an organizational developmental view that early relationship experiences contribute to socioemotional maladaptation as well as adaptation through the progressive transaction of mutually informing expectations and experience.

Expectancy bias mediates the link between social anxiety and memory bias for social evaluation.

Social anxiety (SA) involves a multitude of cognitive symptoms related to fear of evaluation, including expectancy and memory biases. We examined whether memory biases are influenced by expectancy biases for social feedback in SA. We hypothesised that, faced with a socially evaluative event, people with higher SA would show a negative expectancy bias for future feedback. Furthermore, we predicted that memory bias for feedback in SA would be mediated by expectancy bias. Ninety-four undergraduate students (55 women, mean age = 19.76 years) underwent a two-visit task that measured expectations about (Visit 1) and memory of (Visit 2) feedback from unknown peers. Results showed that higher levels of SA were associated with negative expectancy bias. An indirect relationship was found between SA and memory bias that was mediated by expectancy bias. The results suggest that expectancy biases are in the causal path from SA to negative memory biases for social evaluation.

Expanded access to naloxone among firefighters, police officers, and emergency medical technicians in Massachusetts.

Naloxone is a medication that reverses respiratory depression from opioid overdose if given in time. Paramedics routinely administer naloxone to opioid overdose victims in the prehospital setting, and many states are moving to increase access to the medication. Several jurisdictions have expanded naloxone administration authority to nonparamedic first responders, and others are considering that step. We report here on policy change in Massachusetts, where several communities have equipped emergency medical technicians, law enforcement officers, and firefighters with naloxone.

Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters.

PURPOSE: An isolated focus on 1 disease at a time is insufficient to generate the scientific evidence needed to improve the health of persons living with more than 1 chronic condition. This article explores how to bring context into research efforts to improve the health of persons living with multiple chronic conditions (MCC). METHODS: Forty-five experts, including persons with MCC, family and friend caregivers, researchers, policy makers, funders, and clinicians met to critically consider 4 aspects of incorporating context into research on MCC: key contextual factors, needed research, essential research methods for understanding important contextual factors, and necessary partnerships for catalyzing collaborative action in conducting and applying research. RESULTS: Key contextual factors involve complementary perspectives across multiple levels: public policy, community, health care systems, family, and person, as well as the cellular and molecular levels where most research currently is focused. Needed research involves moving from a disease focus toward a person-driven, goal-directed research agenda. Relevant research methods are participatory, flexible, multilevel, quantitative and qualitative, conducive to longitudinal dynamic measurement from diverse data sources, sufficiently detailed to consider what works for whom in which situation, and generative of ongoing communities of learning, living and practice. Important partnerships for collaborative action include cooperation among members of the research enterprise, health care providers, community-based support, persons with MCC and their family and friend caregivers, policy makers, and payers, including government, public health, philanthropic organizations, and the business community. CONCLUSION: Consistent attention to contextual factors is needed to enhance health research for persons with MCC. Rigorous, integrated, participatory, multimethod approaches to generate new knowledge and diverse partnerships can be used to increase the relevance of research to make health care more sustainable, safe, equitable and effective, to reduce suffering, and to improve quality of life.

Chronic condition self-management surveillance: what is and what should be measured?

INTRODUCTION: The rapid growth in chronic disease prevalence, in particular the prevalence of multiple chronic conditions, poses a significant and increasing burden on the health of Americans. Maximizing the use of proven self-management (SM) strategies is a core goal of the US Department of Health and Human Services. Yet, there is no systematic way to assess how much SM or self-management support (SMS) is occurring in the United States. The purpose of this project was to identify appropriate concepts or measures to incorporate into national SM and SMS surveillance. METHODS: A multistep process was used to identify candidate concepts, assess existing measures, and select high-priority concepts for further development. A stakeholder survey, an environmental scan, subject matter expert feedback, and a stakeholder priority-setting exercise were all used to select the high-priority concepts for development. RESULTS: The stakeholder survey gathered feedback on 32 candidate concepts; 9 concepts were endorsed by more than 66% of respondents. The environmental scan indicated few existing measures that adequately reflected the candidate concepts, and those that were identified were generally specific to a defined condition and not gathered on a population basis. On the basis of the priority setting exercises and environmental scan, we selected 1 concept from each of 5 levels of behavioral influence for immediate development as an SM or SMS indicator. CONCLUSION: The absence of any available measures to assess SM or SMS across the population highlights the need to develop chronic condition SM surveillance that uses national surveys and other data sources to measure national progress in SM and SMS.

Bis[2,6-bis-(benzimidazol-2-yl)pyridine-κ3N,N',N'']nickel(II) bis-(tri-fluoro-methane-sulfonate) diethyl ether monosolvate.

In the title complex, [Ni(C19H13N5)2](CF3SO3)2·(CH3CH2)2O, the central NiII atom is sixfold coordinated by three nitro-gen atoms of each 2,6-bis-(2-benzimidazol-yl)pyridine ligand in a distorted octa-hedral geometry with two tri-fluoro-methane-sulfonate ions and a mol-ecule of diethyl ether completing the outer coordination sphere of the complex. Hydrogen bonding contributes to the organization of the asymmetric units in columns along the a axis generating a porous supra-molecular structure. The structure was refined as a two-component twin with a refined BASF value of 0.4104 (13).

Linguistic indicators of wives' attachment security and communal orientation during military deployment.

Military deployment affects thousands of families each year, yet little is known about its impact on nondeployed spouses (NDSs) and romantic relationships. This report examines two factors-attachment security and a communal orientation with respect to the deployment-that may be crucial to successful dyadic adjustment by the NDS. Thirty-seven female NDSs reported on their relationship satisfaction before and during their partner's deployment, and 20 also did so 2 weeks following their partner's return. Participants provided a stream-of-consciousness speech sample regarding their relationship during the deployment; linguistic coding of sample transcripts provided measures of each participant's (a) narrative coherence, hypothesized to reflect attachment security with respect to their deployed spouse; and (b) frequency of first person plural pronoun use (we-talk), hypothesized to reflect a communal orientation to coping. More frequent first person plural pronounuse-we-talk-was uniquely associated with higher relationship satisfaction during the deployment, and greater narrative coherence was uniquely associated with higher relationship satisfaction during postdeployment. Discussion centers on the value of relationship security and communal orientations in predicting how couples cope with deployment and other types of relationship stressors.

Discretizing continuous variables in nutrition and obesity research: a practice that needs to be cut short.

BACKGROUND/OBJECTIVES: Nutrition and obesity researchers often dichotomize or discretize continuous independent variables to conduct an analysis of variance to examine group differences. We describe consequences associated with dichotomizing and discretizing continuous variables using two cross-sectional studies related to nutrition. SUBJECTS/METHODS: Study 1 investigated the effects of health literacy and nutrition knowledge on nutrition label accuracy (n = 612). Study 2 investigated the effects of cognitive restraint and BMI on fruit and vegetable (F/V) intake (n = 586). We compare analytic approaches where continuous independent variables were either discretized/dichotomized or analyzed as continuous variables. RESULTS: In Study 1, dichotomization of health literacy and nutrition knowledge for 2 × 2 ANOVA revealed health literacy had an effect on nutrition label accuracy. Nutrition knowledge has an effect on nutrition label accuracy, but the health literacy by nutrition knowledge interaction was not significant. When analyzed using regression, the nutrition knowledge effect was significant. The simple effect of health literacy was also significant when health literacy equals zero. Finally, the quadratic effect of health literacy was negative and significant. In Study 2, dichotomization and discretization of cognitive restraint and BMI were used for three ANOVAs, which discretized BMI in three ways. For all ANOVAs, the BMI main effect for predicting fruit and vegetable intake was significant, the interaction between BMI and cognitive restraint was non-significant, and cognitive restraint was only significant when both variables were dichotomized. When analyzed using regression, the continuous mean-centered variables, and their interaction each significantly predicted F/V intake. CONCLUSIONS: Dichotomizing continuous independent variables resulted in distortions of effect sizes across studies, an inability to assess the quadratic effect of health literacy, and an inability to detect the moderating effect of BMI. We discourage researchers from dichotomizing and discretizing continuous independent variables and instead use multiple regression to examine relationships between continuous independent and dependent variables.

Indicators of a balanced long-term service and support system: examining the impact on individuals aging with a lifelong disability.

This article explores how rebalancing efforts can support the needs of individuals aging with a lifelong disability. The National Balancing Indicator project examined the overall long-term supports and services system (LTSS) progress in five indicators within the Sustainability, Coordination and Transparency, and Prevention principles toward a balanced LTSS system for those aging with a lifelong disability. In assessing state efforts to create a balanced participant-directed LTSS system with the National Balancing Indicators, the findings suggest states are better equipping the system to handle a burgeoning population of individuals aging with a lifelong disability, but more progress is still needed. Overall, states need to continue to create a seamless system that allows individuals with lifelong disabilities to transition smoothly through the life course.