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Coordinated specialty care (CSC) is widely accepted as an evidence-based treatment for first episode psychosis (FEP). The NAVIGATE intervention from the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study is a CSC intervention which offers a suite of evidence-based treatments shown to improve engagement and clinical outcomes, especially in those with shorter duration of untreated psychosis (DUP). Coincident with the publication of this study, legislation was passed by the United States Congress in 2014–15 to fund CSC for FEP via a Substance Abuse and Mental Health Services Administration (SAMHSA) block grant set-aside for each state. In Michigan (MI) the management of this grant was delegated to Network180, the community mental health authority in Kent County, with the goal of making CSC more widely available to the 10 million people in MI. Limited research describes the outcomes of implementation of CSC into community practices with no published accounts evaluating the use of the NAVIGATE intervention in a naturalistic setting. We describe the outcomes of NAVIGATE implementation in the state of MI.
In 2014, 3 centers in MI were selected and trained to provide NAVIGATE CSC for FEP. In 2016 a 4th center was added, and 2 existing centers were expanded to provide additional access to NAVIGATE. Inclusion: age 18–31, served in 1 of 4 FEP centers in MI. Data collection began in 2015 for basic demographics, global illness (CGI q3 mo), hospital/ED use and work/school (SURF q3 mo) and was expanded in 2016 to include further demographics, diagnosis, DUP, vital signs; and in 2018 for clinical symptoms with the modified Colorado Symptom Inventory (mCSI q6 mo), reported via an online portal. This analysis used data until 12/31/19. Mixed effects models adjusted by age, sex and race were used to account for correlated data within patients.
N=283 had useable demographic information and were included in the analysis. Age at enrollment was 21.6 ± 3.0 yrs; 74.2% male; 53.4% Caucasian, 34.6% African American; 12.9 ± 1.7 yrs of education (N=195). 18 mo retention was 67% with no difference by sex or race. CGI scores decreased 20% from baseline (BL) to 18 mo (BL=3.5, N=134; 15–18 mo=2.8, N=60). Service utilization via the SURF was measured at BL (N=172) and 18 mo (N=72): psychiatric hospitalizations occurred in 37% at BL and 6% at 18 mo (p<0.01); ER visits occurred in 40% at BL and 13% at 18 mo (p<0.01). 44% were working or in school at BL and 68% at 18 mo (p<0.01). 21% were on antipsychotics (AP) at BL (N=178) and 85% at 18 mo (N=13) with 8% and 54% on long acting injectable-AP at BL and 18 mo, respectively. Limitations include missing data and lack of a control group.
The implementation of the NAVIGATE CSC program for FEP in MI resulted in meaningful clinical improvement for enrollees. Further support could make this evidence-based intervention available to more people with FEP.
Supported by funds from the SAMHSA Medicaid State Block Grant set-aside awarded to Network180 (Achtyes, Kempema). The funders had no role in the design of the study, the analysis or the decision to publish the results.
Psychiatric prescribers typically assess adherence by patient or caregiver self-report. A new digital medicine (DM) technology provides objective data on adherence by using an ingestible event monitoring (IEM) sensor embedded within oral medication to track ingestion. Despite likely clinical benefit, adoption by prescribers will in part depend on attitudes toward and experience with digital health technology, learning style preference (LSP), and how the technology s utility and value are described.
is to identify attitudes, experiences, and proclivities toward DM platforms that may affect adoption of the IEM platform and provide direction on tailoring educational materials to maximize adoption. Methods A survey of prescribers treating seriously mentally ill patients was conducted to assess drivers/barriers to IEM adoption. Factor analysis was performed on 13 items representing prior experience with and attitudes toward DM. Factor scores were correlated with prescriber characteristics including attitude and experience with digital technologies, LSP, and level of focus on healthcare cost.
A total of 127 prescribers (56% female, 76% physicians, mean age 48.1yrs.) completed the survey. Over 90% agreed medication adherence is important, visits allow enough time to monitor adherence (84.1%), and tailoring treatment to level of adherence would be beneficial (92.9%). The majority (65.9%) preferred relying upon outcomes data as their learning style while 15.9% preferred opinion leader recommendations and 18.3% information about how the technology would affect practice efficiency. Factor analysis revealed four dimensions: Level of comfort with EHR; Concern over current ability to monitor medication adherence; Attitudes about value of DM applications; and Benefits vs cost of DM for payers. Women scored higher on attitudes about the value of digital applications (p<0.01). Providers who perceive non-adherence as costly, and those who believe DM could benefit providers and patients scored higher on the value of DM (p<.05). Those whose LSP focuses on improving efficiency and prescribers with a higher proportion of Medicaid/ uninsured patients displayed concern about their ability to monitor adherence (p<0.05). Willingness to be a Beta Test site for DM applications was positively correlated with concern about their ability to monitor adherence and attitudes about the value of DM (p <0.01).
Prescriber characteristics including LSP, focus on healthcare costs, and attitudes toward DM may be related to adoption of the IEM platform. Those with more Medicaid/ uninsured patients were more concerned about ability to monitor adherence while those focused-on cost and benefit to providers and patients viewed DM as part of a solution for managing outcomes and cost. Overall, LSP, patient panel size by payer type, and focus on healthcare cost containment should be considered when developing IEM provider training materials.
Otsuka Pharmaceutical Development & Commercialization, Inc.
Few studies have derived data-driven dietary patterns in youth in the USA. This study examined data-driven dietary patterns and their associations with BMI measures in predominantly low-income, racial/ethnic minority US youth. Data were from baseline assessments of the four Childhood Obesity Prevention and Treatment Research (COPTR) Consortium trials: NET-Works (534 2–4-year-olds), GROW (610 3–5-year-olds), GOALS (241 7–11-year-olds) and IMPACT (360 10–13-year-olds). Weight and height were measured. Children/adult proxies completed three 24-h dietary recalls. Dietary patterns were derived for each site from twenty-four food/beverage groups using k-means cluster analysis. Multivariable linear regression models examined associations of dietary patterns with BMI and percentage of the 95th BMI percentile. Healthy (produce and whole grains) and Unhealthy (fried food, savoury snacks and desserts) patterns were found in NET-Works and GROW. GROW additionally had a dairy- and sugar-sweetened beverage-based pattern. GOALS had a similar Healthy pattern and a pattern resembling a traditional Mexican diet. Associations between dietary patterns and BMI were only observed in IMPACT. In IMPACT, youth in the Sandwich (cold cuts, refined grains, cheese and miscellaneous) compared with Mixed (whole grains and desserts) cluster had significantly higher BMI (β = 0·99 (95 % CI 0·01, 1·97)) and percentage of the 95th BMI percentile (β = 4·17 (95 % CI 0·11, 8·24)). Healthy and Unhealthy patterns were the most common dietary patterns in COPTR youth, but diets may differ according to age, race/ethnicity or geographic location. Public health messages focused on healthy dietary substitutions may help youth mimic a dietary pattern associated with lower BMI.
Raw milk cheeses are commonly consumed in France and are also a common source of foodborne outbreaks (FBOs). Both an FBO surveillance system and a laboratory-based surveillance system aim to detect Salmonella outbreaks. In early August 2018, five familial FBOs due to Salmonella spp. were reported to a regional health authority. Investigation identified common exposure to a raw goats' milk cheese, from which Salmonella spp. were also isolated, leading to an international product recall. Three weeks later, on 22 August, a national increase in Salmonella Newport ST118 was detected through laboratory surveillance. Concomitantly isolates from the earlier familial clusters were confirmed as S. Newport ST118. Interviews with a selection of the laboratory-identified cases revealed exposure to the same cheese, including exposure to batches not included in the previous recall, leading to an expansion of the recall. The outbreak affected 153 cases, including six cases in Scotland. S. Newport was detected in the cheese and in the milk of one of the producer's goats. The difference in the two alerts generated by this outbreak highlight the timeliness of the FBO system and the precision of the laboratory-based surveillance system. It is also a reminder of the risks associated with raw milk cheeses.
Introduction: Competency based medical education (CBME) has triggered widespread utilization of workplace-based assessment (WBA) tools in postgraduate training programs. These WBAs predominately use rating scales with entrustment anchors, such as the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). However, little is known about the factors that influence a supervising physician's decision to assign a particular rating on scales using entrustment anchors. This study aimed to identify the factors that influence supervisors’ ratings of trainees using WBA tools with entrustment anchors at the time of assessment and to explore the experiences with and challenges of using entrustment anchors in the emergency department (ED). Methods: A convenience sample of full-time emergency medicine (EM) faculty were recruited from two sites within a single academic Canadian EM hospital system. Fifty semi-structured interviews were conducted with EM physicians within two hours of completing a WBA for an EM trainee. Interviews were audio-recorded, transcribed verbatim, and independently analyzed by two members of the research team. Themes were stratified by trainee level, rating and task. Results: Interviews involved 73% (27/37) of all EM staff and captured assessments completed on 83% (37/50) of EM trainees. The mean WBA rating of studied samples was 4.34 ± 0.77 (2 to 5), which was similar to the mean rating of all WBAs completed during the study period. Overall, six major factors were identified that influenced staff WBA ratings: amount of guidance required, perceived competence through discussion and questioning, trainee experience, clinical context, past experience working with the trainee, and perceived confidence. The majority of staff denied struggling to assign ratings. However, when they did struggle, it involved the interpretation of WBA anchors and their application to the clinical context in the ED. Conclusion: Several factors appear to be taken into account by clinical supervisors when they make decisions regarding the particular rating that they will assign a trainee on a WBA that uses entrustment anchors. Not all of these factors are specific to that particular clinical encounter. The results from this study further our understanding on the use of entrustment anchors within the ED and may facilitate faculty development regarding WBA completion as we move forward in CBME.
Shiga toxin-producing Escherichia coli (STEC) infection can cause serious illness including haemolytic uraemic syndrome. The role of socio-economic status (SES) in differential clinical presentation and exposure to potential risk factors amongst STEC cases has not previously been reported in England. We conducted an observational study using a dataset of all STEC cases identified in England, 2010–2015. Odds ratios for clinical characteristics of cases and foodborne, waterborne and environmental risk factors were estimated using logistic regression, stratified by SES, adjusting for baseline demographic factors. Incidence was higher in the highest SES group compared to the lowest (RR 1.54, 95% CI 1.19–2.00). Odds of Accident and Emergency attendance (OR 1.35, 95% CI 1.10–1.75) and hospitalisation (OR 1.71, 95% CI 1.36–2.15) because of illness were higher in the most disadvantaged compared to the least, suggesting potential lower ascertainment of milder cases or delayed care-seeking behaviour in disadvantaged groups. Advantaged individuals were significantly more likely to report salad/fruit/vegetable/herb consumption (OR 1.59, 95% CI 1.16–2.17), non-UK or UK travel (OR 1.76, 95% CI 1.40–2.27; OR 1.85, 95% CI 1.35–2.56) and environmental exposures (walking in a paddock, OR 1.82, 95% CI 1.22–2.70; soil contact, OR 1.52, 95% CI 2.13–1.09) suggesting other unmeasured risks, such as person-to-person transmission, could be more important in the most disadvantaged group.
To describe snacking characteristics and patterns in children and examine associations with diet quality and BMI.
Children’s weight and height were measured. Participants/adult proxies completed multiple 24 h dietary recalls. Snack occasions were self-identified. Snack patterns were derived for each sample using exploratory factor analysis. Associations of snacking characteristics and patterns with Healthy Eating Index-2010 (HEI-2010) score and BMI were examined using multivariable linear regression models.
Childhood Obesity Prevention and Treatment Research (COPTR) Consortium, USA: NET-Works, GROW, GOALS and IMPACT studies.
Two snack patterns were derived for three studies: a meal-like pattern and a beverage pattern. The IMPACT study had a similar meal-like pattern and a dairy/grains pattern. A positive association was observed between meal-like pattern adherence and HEI-2010 score (P for trend < 0⋅01) and snack occasion frequency and HEI-2010 score (β coefficient (95 % CI): NET-Works, 0⋅14 (0⋅04, 0⋅23); GROW, 0⋅12 (0⋅02, 0⋅21)) among younger children. A preference for snacking while using a screen was inversely associated with HEI-2010 score in all studies except IMPACT (β coefficient (95 % CI): NET-Works, −3⋅15 (−5⋅37, −0⋅92); GROW, −2⋅44 (−4⋅27, −0⋅61); GOALS, −5⋅80 (−8⋅74, −2⋅86)). Associations with BMI were almost all null.
Meal-like and beverage patterns described most children’s snack intake, although patterns for non-Hispanic Blacks or adolescents may differ. Diets of 2–5-year-olds may benefit from frequent meal-like pattern snack consumption and diets of all children may benefit from decreasing screen use during eating occasions.
OBJECTIVES/SPECIFIC AIMS: To examine maternal morbidity and its related social determinants among women experiencing homelessness during pregnancy. METHODS/STUDY POPULATION: This study will use an exploratory sequential mixed method design to explore and examine the structural, interpersonal and individual factors contributing to maternal morbidity among a convenience sample of 150 English speaking women experiencing homelessness during a pregnancy within the last 3 years in Baltimore. In the qualitative phase of the study, we will conduct semi-structured interviews with 15 women purposively sampled to refine the relationships between resilience, social determinants of health and multilevel factors that impact maternal morbidities. Factors of interest include prenatal care received, barriers and facilitators to receiving prenatal care, maternal morbidities, social support, and strategies used to manage their condition during this time. Using the findings from the qualitative phase, a quantitative survey will be developed to gather data on topics that emerged in the interviews. In addition, the Housing Instability Index will be used to measure the degree of homelessness as defined by the degree of housing instability in a 6-month period. Using the 25-item Connor-Davidson Resilience Scale, resilience levels among women in the sample will be assessed as a moderating factor in the examination of the relationship between a pregnant woman’s homeless status and maternal morbidity. Descriptive statistics and logistical regression tests will be used to analyze these relationships while controlling for other structural, interpersonal, and individual factors that may be associated with maternal morbidity. RESULTS/ANTICIPATED RESULTS: Qualitatively we expect to gain insight into the relationship between the extrinsic and intrinsic factors impacting maternal morbidities and the health behaviors and practices used by women to manage their pregnancy while homeless. These findings will inform the quantitative survey development and help generalize the quantitative findings. We expect to identify the common morbidities in this population we anticipate that there will be differences in maternal morbidity among the different types of homelessness. Maternal morbidity will be higher among women with a greater degree of homelessness. Resilience will have a moderating effect on the relationship between homelessness and maternal morbidity. DISCUSSION/SIGNIFICANCE OF IMPACT: This study, to our knowledge, is the first to look at maternal morbidity in this population. Additionally, this study seeks to move current research from examining infant outcomes at birth among mothers experiencing homelessness to understanding the maternal morbidities during this period. Long term, good maternal health has significant implications for the health of a mother’s future pregnancies and a risk reduction of adverse chronic conditions. Study results will provide the preliminary knowledge needed to guide further research leading to clinical approaches that promote better maternal health in this population. Lastly, the study findings will inform policy by characterizing the quality and strength of evidence of the adverse maternal health effects associated with the experience of homelessness.
Infection preventionists at Minnesota hospitals were surveyed to determine whether they had Legionella water management plans. Of 137 hospitals, 84 (61%) responded. Among them, 27% hospitals had a water management plan, 21% regularly sampled for Legionella, and 51% had knowledge of ASHRAE Legionella prevention standards. Significant changes are needed to protect patients from nosocomial infection.
A controversy at the 2016 IUCN World Conservation Congress on the topic of closing domestic ivory markets (the 007, or so-called James Bond, motion) has given rise to a debate on IUCN's value proposition. A cross-section of authors who are engaged in IUCN but not employed by the organization, and with diverse perspectives and opinions, here argue for the importance of safeguarding and strengthening the unique technical and convening roles of IUCN, providing examples of what has and has not worked. Recommendations for protecting and enhancing IUCN's contribution to global conservation debates and policy formulation are given.
The availability of genome-wide genetic data on hundreds of thousands of people has led to an equally rapid growth in methodologies available to analyse these data. While the motivation for undertaking genome-wide association studies (GWAS) is identification of genetic markers associated with complex traits, once generated these data can be used for many other analyses. GWAS have demonstrated that complex traits exhibit a highly polygenic genetic architecture, often with shared genetic risk factors across traits. New methods to analyse data from GWAS are increasingly being used to address a diverse set of questions about the aetiology of complex traits and diseases, including psychiatric disorders. Here, we give an overview of some of these methods and present examples of how they have contributed to our understanding of psychiatric disorders. We consider: (i) estimation of the extent of genetic influence on traits, (ii) uncovering of shared genetic control between traits, (iii) predictions of genetic risk for individuals, (iv) uncovering of causal relationships between traits, (v) identifying causal single-nucleotide polymorphisms and genes or (vi) the detection of genetic heterogeneity. This classification helps organise the large number of recently developed methods, although some could be placed in more than one category. While some methods require GWAS data on individual people, others simply use GWAS summary statistics data, allowing novel well-powered analyses to be conducted at a low computational burden.