Evaluation of contingency management as a strategy to improve HCV linkage to care and treatment in persons attending needle and syringe programs: A pilot study.

BACKGROUND: A greater proportion of HCV-infected people who inject drugs (PWID) need to be linked to care for HCV antiviral treatment. This study sets out to evaluate the efficacy of contingency management (CM) for improving HCV linkage to care, treatment initiation, adherence, and cure for PWID recruited from a needle and syringe program. METHODS: Between March 2015 and April 2016, 20 participants were enrolled into the CM arm, and then subsequently enrolled 20 participants in the enhanced standard of care (eSOC) arm. Participants in the eSOC arm received an expedited appointment and a round-trip transit card. Participants enrolled in the CM arm received eSOC plus $25 for up to ten HCV clinical visits and $10 for each returned weekly medication blister pack. Adherence was measured via electronic blister packs. RESULTS: Overall the median age was 47 years; most were men (67%) and Hispanic (69%). There were no significant differences in demographic characteristics between participants in the study arms. In the CM arm 74% were linked to HCV care, compared to 30% in the eSOC arm (p = 0.01). In the CM arm, 75% (9/12) of treatment eligible participants initiated treatment, compared to 100%(4/4) in the eSOC arm (p = 0.53). All patients (9/9) achieved cure in the CM arm, as compared to 75% (3/4) of patients in the eSOC arm. There were no differences in adherence between study arms. CONCLUSIONS: In this pilot study, contingency management led to higher rates of HCV linkage to care for PWID, as compared to standard of care. CM should be considered as a possible intervention to improve the HCV treatment cascade for PWID.

Retention in buprenorphine treatment is associated with improved HCV care outcomes.

Persons who inject drugs, most of whom are opioid dependent, comprise the majority of the HCV infected in the United States. As the national opioid epidemic unfolds, increasing numbers of people are entering the medical system to access treatment for opioid use disorder, specifically with buprenorphine. Yet little is known about HCV care in patients accessing buprenorphine-based opioid treatment. We sought to determine the HCV prevalence, cascade of care, and the association between patient characteristics and completion of HCV cascade of care milestones for patients initiating buprenorphine treatment. We reviewed electronic health records of all patients who initiated buprenorphine treatment at a primary-care clinic in the Bronx, NY between January 2009 and January 2014. Of the 390 patients who initiated buprenorphine treatment, 123 were confirmed to have chronic HCV infection. The only patient characteristic associated with achieving HCV care milestones was retention in opioid treatment. Patients retained (vs. not retained) in buprenorphine treatment were more likely to be referred for HCV specialty care (63.1% vs. 34.0%, p<0.01), achieve an HCV-specific evaluation (40.8% vs. 21.3%, p<0.05), be offered HCV treatment (22.4% vs. 8.5%, p<0.05), and initiate HCV treatment (9.2% vs. 6.4%, p=0.6). Given the current opioid epidemic in the US and the growing number of people receiving buprenorphine treatment, there is an unprecedented opportunity to access and treat persons with HCV, reducing HCV transmission, morbidity and mortality. Retention in opioid treatment may improve linkage and retention in HCV care; innovative models of care that integrate opioid drug treatment with HCV treatment are essential.

The Hepatitis C virus treatment cascade at an urban postincarceration transitions clinic.

Transitions clinics, which provide medical care to individuals who have been released from incarceration, reach a population at high risk for hepatitis C Virus (HCV) infection. We used the HCV treatment cascade to describe HCV care at an urban postincarceration transitions clinic, identifying gaps in care and determining reasons for lapses in care. In this retrospective cohort study, we reviewed electronic health records for all formerly incarcerated individuals receiving care at the Bronx Transitions Clinic. HCV treatment cascade measures included the following: detection of HCV antibodies, confirmation of chronic infection, specialist referral, specialist evaluation, initiation of treatment, completion of treatment and achievement of SVR. We recorded reasons for lapses in care. Of 451 patients accessing care, 317 (70%) were screened for HCV antibodies, and 106 (33%) tested positive. Of the 106 antibody-positive patients, 93 (88%) were evaluated for HCV viremia and 84 (79%) were confirmed to have chronic HCV infection; 19% of the total sample had chronic HCV infection. Of these 84 with chronic HCV, 48 (57%) received specialist referral, 30 (36%) were evaluated, 8 (10%) initiated treatment, and 5 (6%) completed treatment and achieved SVR. Some treatment lapses occurred because patients were deemed unstable for treatment (12%) or were re-incarcerated (5%). Chronic HCV infection was common among transitions clinic patients. Few were treated and cured. Patients lost contact with providers before consideration for antiviral therapy. Referral to specialty providers was a gap in care. Increasing HCV treatment in this population will likely require intensive delivery models.

Aspergillus niger: an unusual cause of invasive pulmonary aspergillosis.

Infections due to Aspergillus species cause significant morbidity and mortality. Most are attributed to Aspergillus fumigatus, followed by Aspergillus flavus and Aspergillus terreus. Aspergillus niger is a mould that is rarely reported as a cause of pneumonia. A 72-year-old female with chronic obstructive pulmonary disease and temporal arteritis being treated with steroids long term presented with haemoptysis and pleuritic chest pain. Chest radiography revealed areas of heterogeneous consolidation with cavitation in the right upper lobe of the lung. Induced bacterial sputum cultures, and acid-fast smears and cultures were negative. Fungal sputum cultures grew A. niger. The patient clinically improved on a combination therapy of empiric antibacterials and voriconazole, followed by voriconazole monotherapy. After 4 weeks of voriconazole therapy, however, repeat chest computed tomography scanning showed a significant progression of the infection and near-complete necrosis of the right upper lobe of the lung. Serum voriconazole levels were low-normal (1.0 microg ml(-1), normal range for the assay 0.5-6.0 microg ml(-1)). A. niger was again recovered from bronchoalveolar lavage specimens. A right upper lobectomy was performed, and lung tissue cultures grew A. niger. Furthermore, the lung histopathology showed acute and organizing pneumonia, fungal hyphae and oxalate crystallosis, confirming the diagnosis of invasive A. niger infection. A. niger, unlike A. fumigatus and A. flavus, is less commonly considered a cause of invasive aspergillosis (IA). The finding of calcium oxalate crystals in histopathology specimens is classic for A. niger infection and can be helpful in making a diagnosis even in the absence of conidia. Therapeutic drug monitoring may be useful in optimizing the treatment of IA given the wide variations in the oral bioavailability of voriconazole.

Creation and piloting of a new hospital capacity assessment tool in a major urban area.

OBJECTIVES: Crowded hospital emergency departments (EDs) can undermine the ability of a region's safety net to provide safe, timely care. However, data to measure hospital capacity community-wide is generally unavailable. This study aimed to assess hospital crowding, capacity and patient flow in an urban community using the newly developed hospital capacity assessment tool (HCAT). STUDY DESIGN: A survey of the eight acute care hospitals in the District of Columbia (DC) with active EDs. METHODS: Existing emergency care assessment tools were reviewed. Eighteen of the 57 questions on the HCAT were adapted from existing hospital surveys, while the remaining 39 questions were constructed de novo for use in this assessment. Hospitals were provided with paper and electronic versions of the HCAT. RESULTS: All eight DC hospitals completed the HCAT; however, three hospitals were unable to answer many of the questions due to a lack of regular data collection. The HCAT data shows throughput times in DC hospitals that are substantially longer than national averages. CONCLUSIONS: The HCAT is a promising tool for evaluating community-wide emergency care. Findings from the HCAT allowed for the introduction of new ED performance data into the local decision-making process.

Achieving a "Broad view of health": findings from the California Healthy Cities and Communities Evaluation

Promoting a "broad view of health" is an important objective of the healthy cities movement, including recognition of the powerful role that social relations and living conditions play in the health of community members. This article presents a quantitative approach to assessing consensus and change in ideas about health determinants among local coalition members. A ranking of five determinants of health in the form of paired comparisons was included in a survey of coalition members of 20 local healthy communities projects in California. Findings revealed conflicting views among members in the planning year, with some respondents emphasizing the role of social factors and living conditions and others emphasizing the role of health care and lifestyle decisions. Data collected at the end of the funded intervention showed movement toward a broader view of health, with greater consensus on this view in select communities. (AU)

Age-related changes in auditory evoked potentials of gerbils. I. Response amplitudes.

Auditory brainstem responses (ABRs) were recorded in young (6-10 month) and aged (36 month) Mongolian gerbils. For each subject, ABR thresholds and response amplitudes were measured at octave intervals from 1 through 16 kHz. Data from the young animals served as the baselines for comparison to aged animals which were categorized on the basis of auditory brainstem response (ABR) thresholds. The aged groups included subjects with thresholds (a) at the mean of a pool of 50 aged gerbils, (b) one standard deviation (SD) lower than the mean, (c) one sd higher than the mean, and (d) near normal for young gerbils. The amplitudes of ABR waveforms for the aged gerbils were reduced compared to the young subjects, particularly at high sound pressure levels. This was true even for aged subjects with thresholds similar to those for younger subjects. The slopes of the amplitude-intensity (I/O) functions were shallower in all aged subjects compared to young subjects. The results suggest that ABR amplitudes and I/O slopes decrease as a function of age and that the decreases are not a direct result of loss of auditory sensitivity. The reductions in ABR amplitudes from aged gerbils presumably reflect age-related pathology in the auditory periphery, as previous studies have shown reductions in amplitudes of the compound action potential of aged gerbils.

Age-related changes in auditory evoked potentials of gerbils. II. Response latencies.

Auditory brainstem responses (ABR) were recorded in young (6-10 month) and aged (36 month) Mongolian gerbils. Data from the young animals served as the baselines for comparison to aged animals which were categorized on the basis of ABR thresholds. Aged gerbils with normal thresholds (re young controls) had wave i and ii latencies of the ABR which were relatively normal at 1-4 kHz and slightly reduced at 8 and 16 kHz. Wave iv latencies in the aged gerbils with normal thresholds were reduced at all frequencies. Aged gerbils with 10-30 dB of hearing loss had wave i, ii, and iv latencies which were prolonged at low sound pressure levels and normal at high stimulus levels. Aged gerbils with 30 dB or greater losses had prolonged wave i, ii, and iv latencies at most levels. Slopes of latency-intensity (L/I) functions were steeper at 1-4 kHz than controls in aged subjects with hearing losses of 10 dB or greater. Slopes of L/I functions for wave iv were normal in aged subjects. The wave i-iv interval was shorter than normal in aged subjects with no hearing loss, normal in aged subjects with 10-30 dB of loss, and prolonged in subjects with greater than 30 dB of loss.