Accelerating Solutions for the Overdose Crisis: an Effectiveness-Implementation Hybrid Protocol for the HEAL Prevention Cooperative

Given increasing opioid overdose mortality rates in the USA over the past 20 years, accelerating the implementation of prevention interventions found to be effective is critical. The Helping End Addiction Long-Term (HEAL) Prevention Cooperative (HPC) is a consortium of research projects funded to implement and test interventions designed to prevent the onset or escalation of opioid misuse among youth and young adults. The HPC offers a unique opportunity to synthesize and share lessons learned from participating research projects' varied implementation experiences, which can facilitate quicker integration of effective prevention interventions into practice. This protocol paper describes our hybrid approach to collecting and analyzing information about the implementation experiences of nine of the HPC research projects while they maintain their focus on assessing the effectiveness and cost-effectiveness of prevention interventions. To better understand implementation within this context, we will address five research questions: (1) What were the context and approach for implementing the prevention interventions, and how was the overall implementation experience? (2) How representative of the target population are the participants who were enrolled and retained in the research projects' effectiveness trials? (3) For what purposes and how were stakeholders engaged by the research projects? (4) What are the adaptable components of the prevention interventions? And finally, (5) how might implementation of the prevention interventions vary for non-trial implementation? This work will result in intervention-specific and general practical dissemination resources that can help potential adopters and deliverers of opioid misuse prevention make adoption decisions and prepare for successful implementation.

Individual and Medical Characteristics of Adults Presenting to an Urban Emergency Department in Ghana

BACKGROUND

The aims of this study were to characterize the patients seeking acute care for injury and non-injury complaints in an urban Emergency Department in Ghana in order to 1) inform the curriculum of the newly developed Emergency Medicine resident training program 2) improve treatment processes, and 3) direct future community-wide injury prevention policies.

STUDY DESIGN

A prospective cross-sectional survey of patients 18 years or older seeking care in an urban Accident and Emergency Center (AEC) was conducted between 7/13/2009 and 7/30/2009. Questionnaires were administered by trained research staff and each survey took 10-15 minutes to complete. Patients were asked questions regarding demographics, overall health and chief complaint.

RESULTS

254 patients were included in the sample. Participants' chief complaints were classified as either medical or injury-related. Approximately one third (38%) of patients presented with injuries and 62% presented for medical complaints. The most common injury at presentation was due to a road traffic injury, followed by falls and assault/fight. The most common medical presentation was abdominal pain followed by difficulty breathing and fainting/ blackout. Only 13% arrived to AEC by ambulance and 51% were unable to ambulate at the time of presentation.

CONCLUSION

Approximately one-third of non-fatal adult visits were for acute injury. Future research should focus on developing surveillance systems for both medical and trauma patients. Physicians that are specifically trained to manage both the acutely injured patient and the medical patient will serve this population well given the variety of patients that seek care at the AEC.

Bypassing proximal health care facilities for acute care: a survey of patients in a Ghanaian Accident and Emergency Centre

OBJECTIVE

To characterise the population that presents to the Accident and Emergency Centre (AEC) at Komfo Anokye Teaching Hospital (KATH) and to identify risk factors associated with bypassing proximal care facilities.

METHODS

A structured questionnaire was verbally administered to patients presenting to the AEC over 2 weeks. The questionnaire focused on the use of health care resources and characteristics of current illness or injury. Measures recorded include demographics, socioeconomic status, chief complaint, transportation and mobility, reasons for choosing KATH and health care service utilisation and cost.

RESULTS

The total rate of bypassing proximal care was 33.9%. On multivariate analysis, factors positively associated with bypassing included age older than 38 years (OR: 2.18, P 0.04) and prior visits to facility (OR 2.88, P 0.01). Bypassers were less likely to be insured (OR 0.31, P 0.01), to be seeking care due to injury (OR 0.42, P 0.03) and to have previously sought care for the problem (OR 0.10, P < 0.001).

CONCLUSIONS

Patients who bypass facilities near them to seek care at an urban AEC in Ghana do so for a combination of reasons including familiarity with the facility, chief complaint and insurance status. Understanding bypassing behaviour is important for guiding health care utilisation policy decisions and streamlining cost-effective, appropriate access to care for all patients.

Stimulus induced pH changes in cochlear implants: an in vitro and in vivo study

Large pH changes have been shown to be potentially harmful to tissue. The present study was designed to examine stimulus induced changes in pH for a variety of stimulus parameters both in vitro and in vivo, in order to ensure that stimulation strategies for neural prostheses result in minimal pH change. Stimulation using charge balanced biphasic pulses at intensities both within and well above maximum clinical levels for cochlear implants (0.025-0.68 microC per phase), were delivered to platinum electrodes in vitro [saline, phosphate buffered saline (PBS), or saline with human serum albumin (HSA)], and in vivo (scala tympani). Stimulus rates were typically varied from 62.5 to 1000 pulses per second (pps), although rates of up to 14,500 pps were used in some experiments. The pH level was recorded using a pH indicator (Phenol red) or pH microelectrodes. While electrical stimulation at intensities and rates used clinically showed no evidence of a pH shift, intensities significantly above these levels induced pH changes both in vitro and in vivo. The extent of pH change was related to stimulus rate and intensity. In addition, pH change was closely associated with the residual direct current (dc) level. As expected, stimulation with capacitive coupling induced little dc and a minimal pH shift. Moreover, no pH shift was observed using alternating leading phase pulse trains at intensities up to 0.68 microC per phase and 1000 pps. Saline with HSA or buffered solutions dramatically reduced the extent of pH shift observed following stimulation in unbuffered inorganic saline. Reduced pH shift was also observed following in vivo stimulation. These findings provide an insight into mechanisms of safe change injection in neural prostheses.

Electrical stimulation of the auditory nerve: direct current measurement in vivo

Neural prostheses use charge recovery mechanisms to ensure the electrical stimulus is charge balanced. Nucleus cochlear implants short all stimulating electrodes between pulses in order to achieve charge balance, resulting in a small residual direct current (DC). In the present study we sought to characterize the variation of this residual DC with different charge recovery mechanisms, stimulation modes, and stimulation parameters, and by modeling, to gain insight into the underlying mechanisms. In an acute study with anaesthetised guinea pigs, DC was measured in four platinum intracochlear electrodes stimulated using a Nucleus C124M cochlear implant at moderate to high pulse rates (1200-14,500 pulses/s) and stimulus intensities (0.2-1.75 mA at 26-200 microseconds/phase). Both monopolar and bipolar stimulation modes were used, and the effects of shorting or combining a capacitor with shorting for charge recovery were investigated. Residual DC increased as a function of stimulus rate, stimulus intensity, and pulse width. DC was lower for monopolar than bipolar stimulation, and lower still with capacitively coupled monopolar stimulation. Our model suggests that residual DC is a consequence of Faradaic reactions which allow charge to leak through the electrode tissue interface. Such reactions and charge leakage are still present when capacitors are used to achieve charge recovery, but anodic and cathodic reactions are balanced in such a way that the net charge leakage is zero.

Asthma: the irreversible airways disease

Chronic inflammation of the asthmatic airway leads to epithelial desquamation, goblet cell hyperplasia, mucosal and submucosal inflammation, prominent smooth muscle, and collagen deposition below the basement membrane. The changes in the airway are attributed to chronic inflammation, the healing process and subsequent remodeling. These changes contribute to three predominant mechanisms of increased airway resistance in asthma: decreased elastance of airways; increased smooth muscle in the airway which may cause increased narrowing during bronchospasm; and collagen deposition beneath the basement membrane resulting in airway wall thickening. Destruction and subsequent remodeling of the normal bronchial architecture are manifested by a progressive decline in FEV1. In an attempt to decrease the progressive decline in FEV1, studies on proper therapy have been undertaken. Antiinflammatory medications, such as inhaled corticosteroids, have been shown to decrease this rate of decline in lung function, while the effect of bronchodilators is less conclusive. Beginning treatment with inhaled corticosteroids early produces a better clinical response compared to initiating treatment late, and early treatment may prevent airway remodeling and development of irreversible structural changes.

Cost-effectiveness of cervical cytologic examination during pregnancy

BACKGROUND

We undertook a study to determine the cost-effectiveness of performing routine cervical cytologic examination during pregnancy.

METHODS

The costs generated by doing routine prenatal cervical cytologic examination were calculated based on chart review in a family practice setting. A consecutive sample of 523 patients giving birth during 1990 was used. Analysis was done on 423 of those patients with prenatal Papanicolaou smear results recorded. Cost savings from detection of curable disease and utility of the test in terms of well-years saved were calculated from published statistics using a single-step Markov process to model the population at risk.

RESULTS

For patients of all ages using a discount rate of 5 percent, the cost generated by prenatal cervical cytologic examination was $146,400 per well-year of life saved. Age stratification showed cost per well-year to range from $321,600 for patients aged 15 to 19 years to $48,800 for those aged 35 to 39 years.

CONCLUSIONS

Routine prenatal cervical cytologic examination is significantly less cost-effective than the most commonly done medical procedures. If medical funding is limited, elimination of this test should be considered for women with normal findings on cervical cytologic examinations within the previous 2 to 3 years.

Reduction of psychiatric inpatient stay for older adults by intensive case management

An intensive case management program was offered for a 5-month period to all older persons admitted to a county inpatient unit. A quasiexperimental design was used for program evaluation with comparison to a preintervention baseline period and to younger adults on the inpatient unit during both baseline and intervention periods. Length of stay was reduced from 27 days during baseline to 12 days during intervention. For the younger patient group, length of stay changed from 11 to 12 days. Contrary to expectation, older patients were the young-old, mostly first admissions, and with mostly functional rather than organic diagnoses. This reduction in length of stay would save about $6,750 per geriatric admission.

The Australian reference preparation of human serum immunoglobulins

An Australian Reference Preparation of human serum immunoglobulins was prepared from pooled sera of 240 healthy, adult donors. The preparation was calibrated for IgG, IgA and IgM levels by radial immunodiffusion against the 1st International Reference Preparation of Human Serum Immunoglobulins G, A and M (IgG, IgA and IgM) and for IgE by PRIST against the 1st International Reference Preparation of Human Serum Immunoglobulin E (IgE). The following potency values were assigned to the Australian Reference Preparation designated ASPS 78-1 (Lyoph.): 100 IU/vial for IgG and IgE, 102 IU/vial for IgA and 114 IU/vial for IgM.

Evaluation of the Gambro Lundia Major 1.36 m2 disposable parallel plate dialyzer

The Gambro Lundia Major 1.36 m2 dialyzer was assessed in vivo in ten hemodialysis patients. Urea and creatinine clearances (measured as whole blood values at 60 minutes with a blood flow rate of 200 ml/minute) were 166 +/- 8 m/minute (mean +/- standard error of the mean, n = 9) and 115 +/- 4 ml/minute (n = 11). The creatinine clearance is 15% lower than in vitro data. There was a marked decrease in urea and creatinine clearance with third use of the dialyzer. The ultrafiltration rate was 490 ml/hour/100 mmHg. The priming volume was 125 ml (at a transmembrane pressure of 100 mmHg) and residual blood volume in the dialyzer was 0.57 +/- 0.11 ml (n = 5). The handling, storage and ease of disposal of the dialyzer is better than previous models and its performance characteristics are clinically acceptable.

Protein analyses in myelomatosis

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IgM paraproteins

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Solitary plasmacytoma of the clavicle

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Immune complex disease

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Clinical significance of 7s IgM in monoclonal IgM diseases

The sera from 117 patients with diseases associated with a high production of monoclonal IgM were analysed for the presence of low molecular weight (7s) IgM by using a simple thin-layer Sephadex technique. 7s IgM was found in the sera of patients with myelomata (66%), lymphomata (45%), and Waldenström's macroglobulinaemia (20%), but was absent from the sera of patients with benign monoclonal macroglobulinaemia.This technique provides a cheap and practical test which may be valuable in selecting patients with lymphomata from those with benign lesions.