Self-injecting non-prescribed substances into vascular access devices: a case study of one health system's ongoing journey from clinical concern to practice and policy response.

BACKGROUND: Overdose-associated deaths and morbidity related to substance use is a global public health emergency with devastating social and economic costs. Complications of substance use are most pronounced among people who inject drugs (PWID), particularly infections, resulting in increased risk of hospitalization. PWID often require intravenous access for medical treatments such as antibiotics; however, vascular access may be limited due to the impacts of long-term self-venipuncture. While vascular access devices including peripherally inserted central catheters (PICCs) allow reliable and sustained routes of administration for indicated therapies, the use of PICCs among PWID presents unique challenges. The incidence and risks associated with self-injecting non-prescribed substances into vascular access devices (SIVAD) is one such concern for which there is limited evidence and absence of formal practice guidance. CASE PRESENTATION: We report the experience of a multidisciplinary team at a health organization in Vancouver, Canada, working to characterize the incidence, patient and healthcare provider perspectives, and overall impact of SIVAD. The case study of SIVAD begins with a patient's perspective, including patient rationale for SIVAD, understanding of risks and the varying responses given by healthcare providers following disclosure of SIVAD. Using the limited literature available on the subject, we summarize the intersection of SIVAD and substance use and outline known and anticipated health risks. The case study is further contextualized by experience from a Vancouver in-hospital Overdose Prevention Site (OPS), where 37% of all individual visits involve SIVAD. The case study concludes by describing the systematic process by which local clinical guidance for SIVAD harm reduction was developed with stakeholder engagement, medical ethics consultation, expert consensus guideline development and implementation with staff education and planned research evaluation. CONCLUSION: SIVAD is encountered with enough frequency in an urban healthcare setting in Vancouver, Canada, to warrant an organizational approach. This case study aims to enhance appreciation of SIVAD as a common and complex clinical issue with anticipated health risks. The authors conclude that using a harm reduction lens for SIVAD policy and research can provide benefit to clinicians and patients by offering a clear and a consistent healthcare response to this common issue.

Dietary ethanol ingestion by free-ranging spider monkeys (Ateles geoffroyi).

Ethanol within ripe and over-ripe fruit is produced naturally through the metabolic activity of fermentative yeasts. As a consequence, frugivorous animals may chronically consume ethanol as part of their routine diet, although direct measurements of such exposure are lacking. Here, we present data on ethanol concentrations within fruits of Spondias mombin (Anacardiaceae) that are eaten by black-handed spider monkeys (Ateles geoffroyi) on Barro Colorado Island, Panama. Of collected fruits that were partially consumed and then dropped by foraging monkeys, pulp-ethanol content was typically in the range of 1-2%; the percentage of pulp for consumed fruits was not significantly correlated with the ethanol concentration of the pulp remaining within each fruit. Urine samples from foraging spider monkeys were also evaluated for the ethanol metabolites ethyl glucuronide and ethyl sulfate; five of six samples tested positive for both compounds. In aggregate, these data indicate natural exposure to fruit-associated ethanol in a wild primate species.

Treatment Dilemmas in Disseminated Nontuberculous Mycobacterial Infections With Interferon-gamma Autoantibodies.

Disseminated Mycobacterium avium complex (dMAC) is typically seen in individuals with impaired cell-mediated immunity and is best described in those with HIV. Recently, cases have been described in otherwise healthy individuals with neutralizing antibodies to interferon-gamma (nIFNγ-autoAb), especially in patients of Southeast Asian descent. Treatment is often refractory to mycobacterial therapies, and the use of rituximab and other immunomodulatory agents has been explored. We report 3 cases of dMAC with nIFN-γ-autoAb and review the available literature on treatment strategies to provide a framework for the management of patients with refractory infections in the context of neutralizing antibodies to interferon-gamma.

Improving patient portal enrolment in an academic resident continuity clinic: quality improvement made simple.

Electronic health record patient portal usage has been associated with improvement in chronic disease parameters, patient functional status and patient satisfaction. Our institution's patient portal is a secure, online health management tool that connects patients to portions of their electronic health record. Our quality improvement project aimed to increase patient portal enrolment significantly in our Internal Medicine resident patient panels. This study was conducted in a large, multisite health system in Kansas City, Kansas that serves a diverse patient population. Our clinic includes 65 resident patient panels. We followed a subset of 16 resident patient panels in this quality improvement project. A baseline audit showed that 35% of the 1628 patients in these panels were enrolled in the patient portal system. A standardised, nurse-initiated portal sign-up process following patient rooming was implemented. Initial results indicated a 9.6% increase in patient portal sign-up at the end of the first 4-week cycle. We then implemented educational sessions for our clinic nurses as well as attending physicians, and achieved a 15.1% increase from baseline to the end of the second 4-week cycle, resulting in 86 patient portal activations (p<0.01). Resident physicians worked with clinic nurse partners in two formats for this project. Nurses assigned to patient rooming for residents during the clinic sessions being studied (rooming nurses) initiated the portal sign-up process. Nurses assigned to partner with the resident for longitudinal patient care management, anchor nurses, worked with residents on items such as phone messages or portal messages. Semi-structured interviews of the four anchor nurses aligned with the 16 residents were conducted at the end of the study and revealed that nursing staff perceived increased patient portal activity to be associated with a decrease in nursing workload and an increase in patient engagement.