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Abstract Objectives Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain. Design Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge. Setting Urban academic emergency department (>88,000 annual visits). Subjects Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary. Methods Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis. Results Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] “other”). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1–7]; total MME: median [IQR] = 20 [10–50]); patients with back pain used the most (total pills: median [IQR] = 12 [7–16]; total MME: median [IQR] = 65 [47.5–100]); 92.5% of patients had leftover pills. Conclusions In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit.

Abstract Objective To better understand patients’ reasoning for keeping unused opioid pills. Methods As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as “dispose,” “keep,” and “don’t know.” Baseline characteristics were compared between the “keep” and “dispose” groups. Verbatim responses categorized as “keep” were analyzed qualitatively using a team-based inductive approach with constant comparison across cases. Results One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills “just in case,” with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills “just in case” without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids. Conclusions This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.

Background Approximately one in five HIV infections in the United States occurs among cisgender women, those whose gender identity matches their sex assigned at birth. Pre-exposure prophylaxis (PrEP) is a highly effective preventive option for all genders, yet lack of awareness and stigma have hindered uptake. To address this gap, we sought to develop and pilot test an electronic health record-based strategy among cisgender women in primary care. Methods Our strategy, informed by prior work, identified cisgender women in primary care who might benefit from PrEP, provided them with person-centered PrEP educational materials via the patient portal, and offered an opportunity to electronically request a dedicated PrEP visit with a PrEP champion – a female primary care physician – if desired. We conducted two sequential patient-randomized pilot studies to test: (1) the efficacy of the materials compared to usual care, and (2) the preliminary effectiveness of our strategy compared to usual care. The primary outcomes for the efficacy study included PrEP knowledge and PrEP stigma, while the primary outcome for the preliminary effectiveness study was PrEP uptake over a three-month period. Results In total, we enrolled 200 women. The efficacy study ( n  = 100, n  = 50 per arm) revealed our PrEP educational materials significantly increased PrEP knowledge scores among women who were directly shown the materials, compared to those who were not (9.4 (standard deviation (SD) 0.9) vs. 5.8 (SD 1.8) out of 10, p -value < 0.01, respectively). However, the preliminary effectiveness study ( n  = 100, n  = 50 per arm) resulted in no significant differences, other than PrEP awareness, between women randomized to our strategy and those randomized to usual care. Conclusions PrEP educational materials have the potential to increase PrEP knowledge among cisgender women. For the patient portal to be an effective delivery channel, additional support efforts should be considered. Trial registration The study was registered at ClinicalTrials.Gov, Clinical Trial number NCT05709860 registered on 2023-01-17.

IntroductionThe lack of definitive means to prevent or treat cognitive impairment or dementia is driving intense efforts to identify causal mechanisms. Recent evidence suggests clinically meaningful declines in cognition might present as early as middle age. Studying cognitive changes in middle adulthood could elucidate modifiable factors affecting later cognitive and health outcomes, yet few cognitive ageing studies include this age group. The purpose of the MidCog study is to begin investigations of less-studied and potentially modifiable midlife determinants of later life cognitive outcomes.Methods and analysisMidCog is a prospective cohort study of adults ages 35–64, with two in-person interviews 2.5 years apart. Data will be collected from interviews, electronic health records and pharmacy fill data. Measurements will include health literacy, self-management skills, cognitive function, lifestyle and health behaviours, healthcare use, health status and chronic disease outcomes. Associations of health literacy and self-management skills with health behaviours and cognitive/health outcomes will be examined in a series of regression models, and moderating effects of modifiable psychosocial factors.Finally, MidCog data will be linked to an ongoing, parallel cohort study of older adults recruited at ages 55–74 in 2008 (‘LitCog’; ages 70–90 in 2023), to explore associations between age, health literacy, self-management skills, chronic diseases, health status and cognitive function among adults ages 35–90.Ethics and disseminationThe Institutional Review Board at Northwestern University has approved the MidCog study protocol (STU00214736). Results will be published in peer-reviewed journals and summaries will be provided to the funders of the study as well as patients.

Inadequate adherence to prescribed immunosuppressive medication regimens among kidney transplant recipients is common, yet interventions are needed to support patients in sustaining adequate adherence to prescribed regimens and achieving optimal transplant outcomes. We examined the preliminary fidelity of a transplant center-based, multifaceted adherence monitoring strategy known as TAKE IT. The TAKE IT strategy includes: (1) routine, online, monthly patient self-report adherence assessments; (2) care alerts directed to nurses; (3) quarterly reports monitoring tacrolimus values and adherence trends; (4) support tools tailored to specific adherence concerns. A 2-arm, patient-randomized trial is underway at two large transplant centers (N=449). To evaluate the initial fidelity of TAKE IT, we investigated patient uptake of monthly adherence assessments during the course of a 3-month period, whether any disparities emerged, and the nature of any reported adherence concerns. Among 202 patients randomized and exposed to TAKE IT for 3-months or more, 81% (164/202) completed an adherence assessment, 73% (148/202) completed at least two, and 57% (116/202) completed all monthly assessments. Overall, 50% (82/164) of kidney transplant recipients reported at least one adherence concern over the 3-month assessment period. The most common barriers were classified as regimen-related (eg, regimen complexity), cognitive (eg, forgetfulness), and medical (eg, side effects). Higher-income participants were more likely to complete all surveys compared to lower-income participants (P=.01). TAKE IT demonstrated 81% (164/202) completion of an adherence assessment, 73% (148/202) completion of at least two, and 57% (116/202) completion of all monthly assessments during this brief, initial observation period. Among those that did respond to the online assessments, the majority demonstrated sustained engagement. Additional monitoring modalities could also be offered to meet patient preferences to ensure all patients' medication use can be properly monitored. ClinicalTrials.gov NCT03104868; https://clinicaltrials.gov/ct2/show/NCT03104868.

Objective To evaluate patient-reported experiences of telehealth and disparities in access, use, and satisfaction with telehealth during the COVID-19 pandemic. Materials and methods We examined data from the fifth wave of the COVID-19 & Chronic Conditions (C3) study conducted between December 2020 and March 2021. Results Of the 718 participants, 342 (47.6%) reported having a telehealth visit within the past 4 months. Participants who had a recent telehealth visit were younger, reported worse overall health and chronic illness burden, and living below poverty level. Among participants who had a telehealth visit, 66.7% reported telephone visits and most participants (57.6%) rated telehealth quality as better-or-equal-to in-person visits. Inadequate health literacy was associated with lower likelihood of reporting telehealth quality and usefulness. In multivariable analyses, lower patient activation (adjusted odds ratio (AOR) 0.19, 95% CI, 0.05-0.59) and limited English proficiency (AOR 0.12, 95% CI, 0.03-0.47) were less likely to report telehealth as being better than in-person visits; lower patient activation (AOR 0.06, 95% CI, 0.003-0.41) and income below poverty level (AOR 0.36, 95% CI, 0.13-0.98) were associated with difficulty remembering telehealth visit information. Discussion Most participants reported usefulness and ease of navigating telehealth. Lower socioeconomic status, limited English proficiency, inadequate health literacy, lower educational attainment, and low patient activation are risks for poorer quality telehealth. Conclusion The COVID pandemic has accelerated the adoption of telehealth, however, disparities in access and self-reported visit quality persist. Since telemedicine is here to stay, we identify vulnerable populations and discuss potential solutions to reduce healthcare disparities in telehealth use. Lay Summary Telehealth provided continued access to healthcare during the COVID-19 pandemic. We sought to understand how patients with chronic illness used and experienced telehealth during the pandemic, including self-reported quality and usefulness of telehealth visits, and whether there were patient-differences in telehealth experiences. This study found that most patients who had a recent telehealth visit were typically younger, less healthy (eg, self-reported worse overall health or chronic illness burden), and living below poverty level. Though majority of patients reported high satisfaction and usefulness of telehealth, patients who had lower socioeconomic status, lower education, limited English proficiency, more difficulty understanding health information, and less motivation in participating in their healthcare were more likely to report having poorer quality telehealth. These findings highlight that not all patients find telehealth useful or meaningful and certain patient populations might be more vulnerable to poor-quality telehealth visits. These may be important considerations, as telehealth continues to be a part of the healthcare system postpandemic. We offer potential solutions to address this gap in telehealth use and experiences.

Statins, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, which are approved for cholesterol reduction, may also be beneficial in the treatment of inflammatory diseases 1 , 2 , 3 . Atorvastatin (Lipitor) was tested in chronic and relapsing experimental autoimmune encephalomyelitis, a CD4 + Th1-mediated central nervous system (CNS) demyelinating disease model of multiple sclerosis 4 , 5 . Here we show that oral atorvastatin prevented or reversed chronic and relapsing paralysis. Atorvastatin induced STAT6 phosphorylation and secretion of Th2 cytokines (interleukin (IL)-4, IL-5 and IL-10) and transforming growth factor (TGF)-β. Conversely, STAT4 phosphorylation was inhibited and secretion of Th1 cytokines (IL-2, IL-12, interferon (IFN)-γ and tumour necrosis factor (TNF)-α) was suppressed. Atorvastatin promoted differentiation of Th0 cells into Th2 cells. In adoptive transfer, these Th2 cells protected recipient mice from EAE induction. Atorvastatin reduced CNS infiltration and major histocompatibility complex (MHC) class II expression. Treatment of microglia inhibited IFN-γ-inducible transcription at multiple MHC class II transactivator (CIITA) promoters and suppressed class II upregulation. Atorvastatin suppressed IFN-γ-inducible expression of CD40, CD80 and CD86 co-stimulatory molecules. l -Mevalonate, the product of HMG-CoA reductase, reversed atorvastatin's effects on antigen-presenting cells (APC) and T cells. Atorvastatin treatment of either APC or T cells suppressed antigen-specific T-cell activation. Thus, atorvastatin has pleiotropic immunomodulatory effects involving both APC and T-cell compartments. Statins may be beneficial for multiple sclerosis and other Th1-mediated autoimmune diseases.

Direct assessment of patient samples holds unprecedented potential in the treatment of cancer. Circulating tumor cells (CTCs) in liquid biopsies are a rapidly evolving source of primary cells in the clinic and are ideal candidates for functional assays to uncover real-time tumor information in real-time. However, a lack of routines allowing direct and active interrogation of CTCs directly from liquid biopsy samples represents a bottleneck for the translational use of liquid biopsies in clinical settings. To address this, we present a workflow for using a microfluidic vortex-assisted electroporation system designed for the functional assessment of CTCs purified from blood. Validation of this approach was assessed through drug response assays on wild-type (HCC827 wt) and gefitinib-resistant (HCC827 GR6) non-small cell lung cancer (NSCLC) cells. HCC827 cells trapped within microscale vortices were electroporated to sequentially deliver drug agents into the cytosol. Electroporation conditions facilitating multi-agent delivery were characterized for both cell lines using an automatic single-cell image fluorescence intensity algorithm. HCC827 GR6 cells spiked into the blood to emulate drug-resistant CTCs were able to be collected with high purity, demonstrating the ability of the device to minimize background cell impact for downstream sensitive cell assays. Using our proposed workflow, drug agent combinations to restore gefitinib sensitivity reflected the anticipated cytotoxic response. Taken together, these results represent a microfluidics multi-drug screening panel workflow that can enable functional interrogation of patient CTCs in situ , thereby accelerating the clinical standardization of liquid biopsies.

Background Patients with fibrotic interstitial lung disease (ILD) are frequently physically inactive and many ILD subtypes are characterized by risk factors for myopathy; however, the importance of body composition, muscle strength, and physical performance in this population is largely unknown. Methods Patients were prospectively recruited from a specialized ILD clinic, baseline characteristics were collected from the clinical record, pulmonary function tests were performed per established protocols, and dyspnea was measured using the University of California San Diego Shortness of Breath Questionnaire. Dual-energy X-ray absorptiometry (DXA) was used to assess body composition; handgrip strength to determine muscle strength, and 4-m gait speed to measure physical performance. Results One hundred and fifteen patients with fibrotic ILD including 40 patients with idiopathic pulmonary fibrosis were recruited. The mean age was 69+/− 10 years in men (62% of the cohort), and 66+/− 9 years in women, with mild and moderate reduction in FVC and DLCO, respectively, for both sexes. ILD severity (measured by FVC %-predicted, DLCO %-predicted, or the Composite Physiologic Index in separate models) significantly predicted muscle mass and percent body fat including with adjustment for age, sex, and weight. ILD severity was associated with grip strength and gait speed independent from body composition. Conclusions ILD severity has an important impact on body composition, particularly in men. Future studies are needed to confirm and further explore the possibility of additional pathways through which ILD directly impacts limb muscle function and physical performance.

Converting rice husk to biochar is one of the solutions to manage crop residues by transforming waste into a value-added material that has broad benefits to the environment when biochar is applied to the soil. This study investigated the impact of the application of rice husk and its biochar at different doses (i.e., 0, 10, and 30 t ha−1) on soil carbon stability, the property of water-soluble soil organic matter, and the abundance and diversity of microbial communities in a Lei bamboo (Phyllostachys praecox) forest soil 262 days after their application. The application of rice husk, especially at 30 t ha−1, increased dissolved organic carbon due to the high labile carbon (C) (e.g., cellulose, hemicellulose, polysaccharides) content in the rice husk. The biochar treatments stimulated the release of humic-like substances (e.g., (poly) phenols) into the soil solution, increased the aromatic C content by 412–557%, and increased the relative abundance of Chloroflexi, Planctomycetota, and Proteobacteria compared to the control. This study shows that biochar application, particularly at 30 t ha−1, enhanced the C stability by turning organic C into recalcitrant forms in the soil, demonstrating the merit of converting rice husk into biochar before its application to the soil.