No Patient Left Behind: A Novel Paradigm to Fulfill Hepatitis C Virus Treatment for Rural Patients.

Background: This study evaluates a novel multidisciplinary program providing expanded access to hepatitis C virus (HCV) treatment for rural Appalachian patients in South Carolina. This program identified patients via an opt-out emergency department screening program, and it aimed to achieve HCV cure by using community paramedics (CPs) to link and monitor patients from treatment initiation through 12-week sustained virologic response (SVR). Methods: Patients aged ≥18 years who were HCV RNA positive were eligible for enrollment if they failed to appear for a scheduled HCV appointment or reported barriers to accessing office-based treatment. CPs provided home visits (initial and 4, 12, and 24 weeks) using a mobile Wi-Fi hotspot to support telemedicine appointments (compliant with the Health Insurance Portability and Accountability Act) and perform focused physical assessments, venipuncture, and coordinated home delivery of medications. Statistics described participant characteristics, prevalence of SVR, and patient satisfaction results at 12 weeks posttreatment. Results: Thirty-four patients were eligible for SVR laboratory tests by 31 August 2023; the majority were male (61.7%) and White (64.7%) with an average age of 56 years (SD, 11.7). Twenty-eight (82.4%) completed treatment and achieved 12-week SVR. Six (17.6%) were lost to follow-up. Two-thirds strongly agreed that they were satisfied with the overall care that they received, and half strongly agreed that their overall health had improved. Conclusions: This CP-augmented treatment program demonstrated success curing HCV for rural patients who lacked access to office-based treatment. Other health care systems may consider this novel delivery model to treat hard-to-reach individuals who are HCV positive.

Using Community Paramedicine to Treat Hepatitis C Virus in Upstate South Carolina.

OBJECTIVES: Hepatitis C virus (HCV) is an infection of the liver that can lead to significant liver damage and hepatocellular carcinoma. Individuals born between 1945 and 1965 and individuals with intravenous drug use represent the largest HCV demographics and often experience barriers to treatment. In this case series, we discuss a novel partnership between community paramedics (CPs), HCV care coordinators, and an infectious disease physician to provide HCV treatment to individuals with barriers accessing care. METHODS: Three patients tested positive for HCV within a large hospital system in the upstate region of South Carolina. All of the patients were contacted to discuss their results and scheduled for treatment by the hospital's HCV care coordination team. Patients who expressed barriers to attending in-person appointments or were lost to follow-up were offered a telehealth appointment facilitated by CPs performing a home visit with the added ability to draw blood and perform a physical assessment guided by the infectious disease physician. All of the patients were eligible for and prescribed treatment. The CPs assisted with follow-up visits, blood draws, and other patient needs. RESULTS: Two of the three patients connected to care had an undetectable HCV viral load following 4 weeks of treatment, whereas the third was undetectable after 8 weeks. Only one patient reported a mild headache that was potentially linked to the medication, whereas the others did not report any adverse effects. CONCLUSIONS: This case series highlights the barriers experienced by some HCV-positive patients and a distinctive plan to address impediments to access for HCV treatment.

Emergency Department Alternatives to Opioids: Adapting and Implementing Proven Therapies in Practice.

The use of opioids to treat pain can increase the risk of long-term opioid dependency and is associated with negative patient outcomes. The objective of this study was to present the initial results following the implementation of Emergency-Department Alternatives to Opioids (ED-ALTO), a program that encourages the use of non-narcotic medications and procedures to treat pain in the Emergency Department (ED). We used a pre- and post-implementation study design to compare in-ED opioid utilization, as well as ED-ALTO medication and procedure use in the year before and after the program's implementation. After ED-ALTO's implementation, there was a decrease in opioid utilization in the ED and an increase in ED-ALTO medication use. Additionally, there was an increase in ED-ALTO procedure utilization and the complexity of conditions treated with ED-ALTO procedures, including the use of regional nerve blocks for shoulder dislocations and hip and rib fractures. In 8 of the 12 months following ED-ALTO's implementation, a lower proportion of patients receiving ED-ALTO procedures received an opioid, and the opioid dosage was lower compared to patients with the same diagnoses who received standard care. The continued expansion of ED-ALTO programs across the US may serve as a mechanism to reduce opioid utilization and safely and successfully treat pain in ED settings.

Leveraging Public and Private Funding to Implement Opt-out HIV Screening Programs in Rural and Urban Emergency Departments in South Carolina Discovered a High Rate of Human Immunodeficiency Virus (HIV) Infection in Black Patients.

The new epicenter of the ongoing HIV epidemic in the United States is the South. Specifically, South Carolina (SC) is listed a priority state as part of the CDC's Ending the Epidemic Plan for America. A novel opt-out HIV screening program was implemented in one rural and one urban Emergency Department (ED) within a large SC health system. Leveraging both public and private funding sources, which made both the testing and linkage processes cost neutral, ED based screening was provided for 2304 Black patients which represents an 44% increase. As part of this screening program a total of 50 individuals were linked to care of which 29 were Black. The rate of HIV positivity for Black patients using this ED based screening program was nearly double that of the baseline health system screening. This program's utilization of the health system electronic health record (EHR) and funding from various sources may provide a model for legislative and public health entities to combat the HIV epidemic in the South.

Feasibility of a Low-Fidelity Pediatric Simulation-Based Continuing Education Curriculum in Rural Alaska.

Introduction Simulation-based continuing education (SBCE) is a widely used tool to improve healthcare workforce performance. Healthcare providers working in geographically remote and resource-limited settings face many challenges, including the development and application of SBCE. Here, we describe the development, trial, and evaluation of an SBCE curriculum in an Alaska Native healthcare system with the aim to understand SBCE feasibility and specific limitations. Methods The perceived feasibility and efficacy of incorporating a low-fidelity medical simulation curriculum into this Native Alaskan healthcare system was evaluated by analyzing semi-structured interviews, focus groups, and surveys over a 15-month period (August 2018 - October 2019). Subjects were identified via both convenience and purposive sampling. Included were 40 healthcare workers who participated in the simulation curriculum, three local educators who were trained in and subsequently facilitated simulations, and seven institutional leaders identified as "key informants." Data included surveys with the Likert scale and dichotomous positive or negative data, as well as a thematic analysis of the qualitative portion of participant survey responses, focus group interviews of educators, and semi-structured interviews of key informants. Based on these data, feasibility was assessed in four domains: acceptability, demand, practicality, and implementation. Results Stakeholders and participants had positive buy-in for SBCE, recognizing the potential to improve provider confidence, standardize medical care, and improve teamwork and communication, all factors identified to optimize patient safety. The strengths listed support feasibility in terms of acceptability and demand. A number of challenges in the realms of practicality and implementation were identified, including institutional buy-in, need for a program champion in a setting of staff high turnover, and practicalities of scheduling and accessing participants working in one system across a vast and remote geographic region. Participants perceived the simulations to be effective and feasible. Conclusion While simulation participants valued an SBCE program, institutional leaders and educators identified veritable obstacles to the practical implementation of a structured program. Given the inherent challenges of this setting, a traditional simulation curriculum is unlikely to be fully feasibly integrated. However, due to the overall demand and social acceptability expressed by the participants, innovative ways to deliver simulation should be developed, trialed, and evaluated in the future.

Movement behavior of red flour beetle: response to habitat cues and patch boundaries.

Movement behavior determines the success or failure of insects in finding important resources such as food, mates, reproductive sites, and shelter. We examined the response of female red flour beetles (Tribolium castaneum Herbst: Coleoptera: Tenebrionidae) to habitat cues by quantifying the number of individuals that located a patch (either with or without flour) in response to the distance released from the patch, air movement over the arena, and food-deprivation status. We also investigated how patch characteristics, such as resource amount and presence of cover, influenced time taken to find a flour patch, the frequency of entering or leaving, and residence time within the patch. Although the proportion of beetles successfully locating the patch decreased as a function of release distance, the probability that beetles reached the patch was ultimately unaffected by whether flour was present or not, suggesting that search behavior in red flour beetles may exhibit a simple distance-decay function. Significantly more beetles reached the patch when they had not been food deprived and air was flowing over the arena, which indicates that walking beetles may orient to airflow, exhibiting anemotaxis. Results of the second experiment showed that, on first encounter, fewer beetles entered patches with a greater amount of flour; but once they had entered, they left them less frequently than patches with less resource. Beetles entered covered patches more quickly than uncovered patches irrespective of resource amount, which indicates that shelter is perhaps more important to red flour beetles than resource levels in determining whether to enter patches.

Maximizing collection and minimizing risk: does vacuum suction sampling increase the likelihood for misinterpretation of food web connections?

Molecular tools that characterize the structure of complex food webs and identify trophic connectedness in the field have become widely adopted in recent years. However, characterizing the intensity of predator-prey interactions can be prone to error. Maximizing collection success of small, fast-moving predators with vacuum suction samplers has the potential to increase the likelihood of prey DNA detection either through surface-level contamination with damaged prey or direct consumption within the sampling device. In this study, we used PCR to test the hypothesis that vacuum suction sampling will not cause an erroneous increase in the detection of 'predation', thereby incorrectly assigning trophic linkages when evaluating food web structure. We utilized general (1) Aphidoidea and (2) Collembola primers to measure the predation rates of Glenognatha foxi (Araneae: Tetragnathidae) on these prey collected by hand versus those sampled with a vacuum suction device. With both primer pairs, there was no significant increase in predators screening positive for prey DNA when sampled by vacuum suction versus those predators collected, in parallel, by hand. These results clearly validate the application of vacuum suction sampling during molecular gut-content analysis of predator-prey feeding linkages in the field. Furthermore, we found no evidence that predation was occurring inside the suction sampler because specimens collected were never observed to be feeding nor did they screen positive at greater frequencies than hand-collected individuals. Therefore, it can be concluded that the use of vacuum suction sampling devices (in this case a Modified CDC Backpack Aspirator Model 1412) is suitable for molecular gut-content analysis.

The genetic architecture of maize flowering time.

Flowering time is a complex trait that controls adaptation of plants to their local environment in the outcrossing species Zea mays (maize). We dissected variation for flowering time with a set of 5000 recombinant inbred lines (maize Nested Association Mapping population, NAM). Nearly a million plants were assayed in eight environments but showed no evidence for any single large-effect quantitative trait loci (QTLs). Instead, we identified evidence for numerous small-effect QTLs shared among families; however, allelic effects differ across founder lines. We identified no individual QTLs at which allelic effects are determined by geographic origin or large effects for epistasis or environmental interactions. Thus, a simple additive model accurately predicts flowering time for maize, in contrast to the genetic architecture observed in the selfing plant species rice and Arabidopsis.

Genetic properties of the maize nested association mapping population.

Maize genetic diversity has been used to understand the molecular basis of phenotypic variation and to improve agricultural efficiency and sustainability. We crossed 25 diverse inbred maize lines to the B73 reference line, capturing a total of 136,000 recombination events. Variation for recombination frequencies was observed among families, influenced by local (cis) genetic variation. We identified evidence for numerous minor single-locus effects but little two-locus linkage disequilibrium or segregation distortion, which indicated a limited role for genes with large effects and epistatic interactions on fitness. We observed excess residual heterozygosity in pericentromeric regions, which suggested that selection in inbred lines has been less efficient in these regions because of reduced recombination frequency. This implies that pericentromeric regions may contribute disproportionally to heterosis.

Maize association population: a high-resolution platform for quantitative trait locus dissection.

Crop improvement and the dissection of complex genetic traits require germplasm diversity. Although this necessary phenotypic variability exists in diverse maize, most research is conducted using a small subset of inbred lines. An association population of 302 lines is now available--a valuable research tool that captures a large proportion of the alleles in cultivated maize. Provided that appropriate statistical models correcting for population structure are included, this tool can be used in association analyses to provide high-resolution evaluation of multiple alleles. This study describes the population structure of the 302 lines, and investigates the relationship between population structure and various measures of phenotypic and breeding value. On average, our estimates of population structure account for 9.3% of phenotypic variation, roughly equivalent to a major quantitative trait locus (QTL), with a high of 35%. Inclusion of population structure in association models is critical to meaningful analyses. This new association population has the potential to identify QTL with small effects, which will aid in dissecting complex traits and in planning future projects to exploit the rich diversity present in maize.