"Intraosseous Administration of Tenecteplase for Thrombolysis of an Acute Ischemic Stroke".

INTRO: Current guidelines for acute ischemic stroke recommend timely administration of intravascular thrombolytic therapy to promote functional and neurologic outcomes. Tenecteplase is an emerging off-label therapy for this indication and being utilized by various institutions due to its simpler administration strategy. In emergent situations in which intravenous access cannot be obtained, intraosseous access is a viable option for medication administration. However, there has been minimal published cases to support the efficacy and safety of intraosseous administration of tenecteplase for acute ischemic stroke. CASE: We describe the case of a 51-year-old woman who developed acute ischemic stroke within our institution. Due to difficulty achieving intravenous access and time-dependent efficacy of thrombolytic therapy, the decision was made to administer tenecteplase by the intraosseous route. Stroke symptoms improved within 48 hours following administration without complication. CONCLUSION: Intraosseous administration of tenecteplase may be considered for treatment of acute ischemic stroke if intravenous access is unattainable.

A Comparison of Currently Available and Investigational Fecal Microbiota Transplant Products for Recurrent Clostridioides difficile Infection.

Clostridioides difficile infection (CDI) is an intestinal infection that causes morbidity and mortality and places significant burden and cost on the healthcare system, especially in recurrent cases. Antibiotic overuse is well recognized as the leading cause of CDI in high-risk patients, and studies have demonstrated that even short-term antibiotic exposure can cause a large and persistent disturbance to human colonic microbiota. The recovery and sustainability of the gut microbiome after dysbiosis have been associated with fewer CDI recurrences. Fecal microbiota transplantation (FMT) refers to the procedure in which human donor stool is processed and transplanted to a patient with CDI. It has been historically used in patients with pseudomembranous colitis even before the discovery of Clostridioides difficile. More recent research supports the use of FMT as part of the standard therapy of recurrent CDI. This article will be an in-depth review of five microbiome therapeutic products that are either under investigation or currently commercially available: Rebyota (fecal microbiota, live-jslm, formerly RBX2660), Vowst (fecal microbiota spores, live-brpk, formerly SER109), VE303, CP101, and RBX7455. Included in this review is a comparison of the products' composition and dosage forms, available safety and efficacy data, and investigational status.

Management and Outcomes of Patients at a Specialty Clinic for Clostridioides difficile Infection.

Vancomycin and fidaxomicin taper regimens were the most common treatment strategies employed but nearly half of patients (40/83) referred to our Clostridioides difficile infection (CDI) clinic did not require further treatment. The overall 60-day CDI recurrence rate was 16.9% (11/65). CDI management at a dedicated clinic may improve clinical outcomes.

A review of fecal microbiota, live-jslm for the prevention of recurrent Clostridioides difficile infection.

PURPOSE: To review the composition, preparation, proposed mechanism of action, safety, efficacy, and current place in therapy of Rebyota (fecal microbiota, live-jslm). SUMMARY: As the first agent in a new class of drugs, live biotherapeutic products (LBPs), fecal microbiota, live-jslm offers another therapeutic approach for the prevention of recurrent Clostridioides difficile infection (rCDI). LBPs are given following antibiotic therapy for C. difficile to reintroduce certain bacteria present in the normal microbiome, as a means to reconstitute the microbiome of infected individuals. This review provides a summary of phase 2 and 3 clinical trials, product information, discussion of data limitations, and recommendations for place in therapy. High efficacy rates compared to placebo with sustained response up to 24 months after administration have been reported. The majority of adverse events identified were mild to moderate without significant safety signals. CONCLUSION: Fecal microbiota, live-jslm has consistently been shown in randomized trials to be safe and effective in reducing rCDI. Its approval marks the culmination of decades of work to identify, characterize, and refine the intestinal microbiome to create pharmaceutical products.

Impact of a syndrome-based stewardship intervention on antipseudomonal beta-lactam use, antimicrobial resistance, C. difficile rates, and cost in a safety-net community hospital.

Broad-spectrum antimicrobials are commonly used without indication and contribute to antimicrobial resistance (AMR). We implemented a syndrome-based stewardship intervention in a community hospital that targeted common infectious syndromes and antipseudomonal beta-lactam (APBL) use. Our intervention successfully reduced AMR, C. difficile rates, use of APBLs, and cost.

Belief in vaccine myths and vaccine uptake in Utah during the COVID-19 pandemic.

Introduction: Since its emergence in December 2019, COVID-19 has caused millions of deaths worldwide. While vaccines are largely available in most places, including the United States (U.S.), vaccine uptake is lower than is desirable from a public health perspective. Objective: The objective of this paper is to examine belief in vaccine myths, including what individual and place characteristics underpin such beliefs, and uptake of vaccines - as well as the role of belief in myths in obtaining the COVID-19 vaccine. Methods: We use weighted survey data from an online panel of 529 Utah adult residents. Results: Sixty-nine percent of our sample was fully vaccinated at the time of taking the survey. We find that belief in vaccine myths varies among Utahns, with the highest percentage seeing the vaccines as unsafe because of their rapid development. Those who are older, are more religious (including members of The Church of Jesus Christ of Latter-day Saints), have less formal education, and are more conservative were more likely to have medium and/or higher levels of belief in vaccine myths. We find that belief in vaccine myths is associated with lower COVID-19 vaccine uptake, even when controlling for other factors. Conclusion: Understanding what drives vaccination uptake, including the role of belief in emerging vaccine myths, is important for public health measures in this and future outbreaks.

Promoting harm reduction in rural South Dakota using an interdisciplinary consortium.

BACKGROUND: Deaths from drug-related overdoses are increasing. Rural areas continue to have fewer accessible resources than urban areas. The START-SD (Stigma, Treatment, Avoidance, and Recover in Time - South Dakota) project is funded by the Health Resources and Services Administration and aims to address needs surrounding substance use disorder (SUD) in South Dakota. Pharmacists can play a key role in these efforts. OBJECTIVE: Describe harm reduction and prevention activities implemented through START-SD to reduce the impact of SUD in South Dakota. PRACTICE DESCRIPTION: The interdisciplinary team at South Dakota State University, including pharmacists and student pharmacist researchers, partnered with collaborating organizations to provide improved access to prevention, treatment, and recovery services for those impacted by SUD. PRACTICE INNOVATION: Given the rural and conservative nature of the state, the START-SD team used an innovative framework to implement harm reduction and prevention programs that other states could adopt. EVALUATION METHODS: Because the START-SD project uses evidence-based programs, evaluation focuses on the number of programs implemented and the number of people subsequently served. Data are collected and reported biannually by the team. RESULTS: The core team established and expanded an interdisciplinary consortium and advisory board. A variety of harm reduction and prevention strategies were implemented: establishing and developing partnerships with key organizations, working to increase access to harm reduction programs, facilitating educational activities and trainings, and working to reduce stigma related to SUD and harm reduction. DISCUSSION: Reducing the impact of SUD requires a broad, multifaceted approach, as well as overcoming many environmental barriers. Pharmacists and pharmacy staff are uniquely positioned to positively affect harm reduction for patients. CONCLUSION: More work to decrease the impact of SUD is needed, particularly in rural areas. Pharmacists can play a key role in projects to increase the reach and impact of prevention, treatment, and recovery efforts.

Impact of a Public Health Awareness Campaign on Patients' Perceptions of Expanded Pharmacy Services in South Dakota Using the Theory of Planned Behavior.

Background: Pharmacists can offer medication expertise to help better control diabetes and cardiovascular disease (CVD) and improve patient outcomes, particularly in rural communities. This project evaluated the impact of an awareness campaign on perceptions of expanded pharmacy services. Methods: The "Your Pharmacists Knows" campaign included a 30-s commercial, print material, and media announcements. A non-randomized pre-post study was completed using a modified theory of planned behavior (mTPB) to assess knowledge, attitude, perceived benefits and norms, and perceived control. A 73-item survey was administered to a convenience sample (n = 172) across South Dakota. Regression models to assess intent and utilization were conducted using age, gender, race, education, population, and insurance status as predictors for mTPB constructs. Results: Most common predictors were female gender and higher education level (p < 0.001). All mTPB constructs were significant predictors of intent to use services (p < 0.001). Knowledge and perceived control had the largest influence on intent. Additionally, there was significant improvement in post-campaign service utilization (p < 0.001). Conclusions: This campaign positively influenced intent to seek and utilize services in rural communities where pharmacies may be the only healthcare option for miles. Through targeted campaigns, patients with diabetes or CVD may find access to services to better manage their conditions.

Insurance Adjudication Simulation Across Multiple Institutions and Levels of Learners.

Objective. A virtual educational innovation was designed and implemented to have student pharmacists simulate insurance processing. This article describes the impact of this third-party payer simulation on student knowledge and confidence and reports student perceptions of the activity.Methods. First-, second-, and third-year pharmacy students (P1, P2, and P3 students, respectively) at four institutions completed the self-paced simulation. Knowledge was assessed by comparing results of multiple-choice questions on the pre- and post-assessments and evaluated by the Wilcoxon signed rank test. Confidence was assessed by students' change in self-reported confidence scale measurements and compared using the chi-square test.Results. The simulation had a significant impact on student knowledge. The largest improvement was in P1 students, with a pre- to post-assessment average score difference (scale 0-100) of 16.6 compared to 7.2 for P2 and 10.2 for P3 students. Significant improvement was seen on most of the knowledge questions, with variations for certain questions between groups. All groups had significantly improved self-rated confidence in their abilities. Most students agreed that they would recommend this activity to other students (91.7%) and that it encouraged them to think about the material in a new way (85%).Conclusions. Through an innovative simulation on prescription insurance processing, positive results were seen across all three levels of learners. Knowledge assessments significantly improved, and student confidence increased across all groups and all confidence items. Participants would recommend this activity to other students and felt it was an effective way to learn about insurance adjudication.

Appointment attendance and patient perception of drive-up INR testing in a rural anticoagulation clinic during the COVID-19 pandemic.

Introduction: The Anticoagulation Forum and Centers for Disease Control and Prevention (CDC) recommend drive-up international normalized ratio (INR) testing to combat INR non-adherence and increase safety during the coronavirus disease 2019 (COVID-19) pandemic. Patient perceptions and impact on attendance have not been studied. Objective: To assess appointment volume and patient perception after initiation of drive-up INR testing in a rural pharmacist-managed anticoagulation clinic. Methods: This cross-sectional cohort survey study offered each patient attending the anticoagulation clinic via drive-up or in-office visit a survey between May 27 and July 2, 2020. Patients testing off-site were excluded. Study end points included monthly patient volume, visit type preference, testing barriers, desired drive-up duration, and overall clinic satisfaction. Clinic appointment volume from October 2019 to June 2020 was collected retrospectively through a schedule review. Results: Sixty-four (80%) of 80 surveys offered were completed: 46.6% of respondents preferred drive-up testing, 26.7% indifferent, and 26.7% preferred in-office visits; 38.7% of respondents indicated a greater likelihood of continuing routine INR monitoring via drive-up testing. Of the respondents completing the survey curbside, 46% and 27% of respondents identified reduced COVID-19 transmission risk and ease of transportation as benefits of drive-up INR testing, respectively. March and April clinic volumes were 19% and 22% below average, respectively, returning to baseline after drive-up testing was implemented. Clinic rating before and after drive-up testing remained high at 2.75 on a scale of 0-3. While infection risk was identified as the biggest barrier to care by 32.8% of respondents, 59.3% of all respondents wanted drive-up testing to continue indefinitely. Conclusions: Drive-up INR testing improves patient attendance during the COVID-19 pandemic. Patient perception of drive-up testing is positive. About 46% of respondents preferred drive-up INR testing with telehealth follow-up and 59.3% of respondents want drive-up testing to continue indefinitely, which suggests this approach to INR testing as a potential method to allay barriers to routine monitoring beyond the scope of the pandemic.

Perception of Unmet Need after Seeking Treatment for a Past Year Major Depressive Episode: Results from the 2018 National Survey of Drug Use and Health.

Depression, a leading cause of disability and mortality world-wide that one in five U.S. adults are estimated to experience in their lifetime, presents special complications in treatment. While it is well-recognized that there are several barriers to even obtaining treatment for depression, once an individual obtains treatment they may not receive the type of care that they need. In order to examine common factors of those who experienced an unmet treatment need for depression despite seeking mental health treatment, we examined data from the 2018 National Survey of Drug Use and Health (NSDUH). We cross-sectionally compared two groups of individuals who both met criteria for a past year Major Depressive Episode (MDE) and sought mental health treatment, however one group reported an unmet treatment need and the other did not. Results indicate a variety of personal identity and social factors associated with perceiving an unmet treatment need, including age, race/ethnicity, sexual attraction, marital status, poverty level, health insurance, substance misuse, global health, and role impairment. This study contributes to the literature by providing further support for disparities in depression treatment at the consumer, provider, and systemic levels that have downstream effects for health equity policy and public health promotion.

Learning to Speak Up for Patient Safety: Interprofessional Scenarios for Training Future Healthcare Professionals.

BACKGROUND: Preventable medical errors represent a leading cause of death in the United States. Effective undergraduate medical education (UME) strategies are needed to train medical students in error prevention, early identification of potential errors, and proactive communication. To address this need, a team of faculty from A.T. Still University's School of Osteopathic Medicine in Arizona developed four digital patient safety case scenarios for second-year medical students. These scenarios were designed to integrate interprofessional collaboration and patient safety principles, increase student ability to identify potential errors, and promote proactive communication skills. METHODS: Faculty used Qualtrics to create four digital case scenarios on patient safety covering the following domains: communicating about potential drug-to-drug interactions; effective handoffs; human factors errors, such as fatigue, illness, and stress; and conflicts with supervising resident. In fall 2018, 97 second-year medical students completed the entire safety module in dyad or triad teams. As they worked through each case study, student teams completed 11 assessment questions with instant feedback, and participated in short case debrief discussions. Next, each individual student took a 12-question post-test to assess learning. Descriptive statistics were reviewed for the assessment questions, and case critical thinking discussion answers were reviewed to evaluate student comprehension. RESULTS: The mean score for the module was 95.5% (SD= 6.36%, range = 75%-100%). Seventy-eight students completed the post-test, which had a mean score of 96.5% (SD = 6.51%, range = 66.7%-100%). Student written responses to the four case critical thinking discussion prompts indicated a high level of comprehension. CONCLUSION: Our results demonstrated that digital case studies can provide an innovative mechanism to introduce key patient safety concepts and experiential practice of interprofessional communication in early UME. Our design and implementation of these engaging interprofessional patient safety training modules provided an opportunity for students to learn key communication and safety concepts in small teams. This training method was cost-effective and could be replicated in other online learning or blended learning environments for a wide range of health professions.

Uptake of permanent contraception among women in sub-Saharan Africa: a literature review of barriers and facilitators.

OBJECTIVE: Uptake of permanent contraception among women remains low in sub-Saharan Africa compared to other regions. We aimed to synthesize available evidence on barriers to, and facilitators of permanent contraception with regards to tubal ligation among women in sub-Saharan Africa. STUDY DESIGN: We reviewed literature on tubal ligation among African women published between January 1, 2000 and October 30, 2017. We searched PubMed, Global health, EMBASE, Web of science, and Google scholar for quantitative, qualitative, and mixed methods studies which reported on barriers and/or facilitators to uptake of tubal ligation in sub-Saharan Africa. Finally, we conducted a narrative synthesis and categorized our findings using a framework based on the social ecological model. RESULTS: We included 48 articles in the review. Identified barriers to tubal ligation among women included individual-level (myths and misconceptions, fear of surgery, irreversibility of procedure, religious beliefs), interpersonal-level (male partner disapproval), and organizational-level (lack of healthcare worker expertise and equipment) factors. Facilitating factors included achievement of desired family size and perceived effectiveness (individual-level), supportive male partners and knowing other women with permanent contraception experience (interpersonal-level), and finally, subsidized cost of the procedure and task-sharing with lower cadre healthcare workers (organizational-level). CONCLUSIONS: Barriers to, and facilitators of permanent contraception among women in sub-Saharan Africa are multilevel in nature. Strategies countering these barriers should be prioritized, as effective contraception can promote women's health and economic development in sub-Saharan Africa. In addition to these strategies, more quantitative research is needed to further understand patient-level factors associated with uptake of permanent contraception among women.

Timely reminder interventions to improve annual Papanicolaou (Pap) smear rates among HIV-infected women in an outpatient center of southern Nevada: a short report.

Current guidelines recommend annual Papanicolaou (Pap) smears for human immunodeficiency virus (HIV)-infected women for cervical cancer screening. Rates for such screening in Nevada are below the national rate. Our cohort includes 485 eligible HIV-infected adult women from an outpatient center in Southern Nevada of which only 12 women had obtained a Pap smear in the past year. An intervention was conducted from June 2015 to September 2015, in which reminders to schedule a Pap smear were sent to the remaining cohort of 473 women via sequential text messaging, followed by phone call attempts. Of all subjects, 94% contacted by text messages and 41% contacted by phone calls were successfully reached. There was an increase in the rate of completed Pap smears from 2.5% (12/485) at baseline to 11.8% (56/473) after interventions (p < 0.0001) in a period of three months. Out of the 68 Pap smear results, 20 (29.4%) were abnormal. Our intervention, utilizing methods of communication such as text messaging and phone calls, markedly increased the rate of completed Pap smear screening in our population.

What do You Need to Get Male Partners of Pregnant Women Tested for HIV in Resource Limited Settings? The Baby Shower Cluster Randomized Trial.

Male partner involvement has the potential to increase uptake of interventions to prevent mother-to-child transmission of HIV (PMTCT). Finding cultural appropriate strategies to promote male partner involvement in PMTCT programs remains an abiding public health challenge. We assessed whether a congregation-based intervention, the Healthy Beginning Initiative (HBI), would lead to increased uptake of HIV testing among male partners of pregnant women during pregnancy. A cluster-randomized controlled trial of forty churches in Southeastern Nigeria randomly assigned to either the HBI (intervention group; IG) or standard of care referral to a health facility (control group; CG) was conducted. Participants in the IG received education and were offered onsite HIV testing. Overall, 2498 male partners enrolled and participated, a participation rate of 88.9%. Results showed that male partners in the IG were 12 times more likely to have had an HIV test compared to male partners of pregnant women in the CG (CG = 37.71% vs. IG = 84.00%; adjusted odds ratio = 11.9; p < .01). Culturally appropriate and community-based interventions can be effective in increasing HIV testing and counseling among male partners of pregnant women.

Using a Cultural Framework to Understand Factors Influencing HIV Testing in Nigeria.

With support from the U.S. President's Emergency Plan for AIDS Relief and the global fund for HIV, tuberculosis, and malaria, Nigeria offers free services for prevention of mother-to-child transmission of HIV. However, uptake of these services is low, and pediatric transmission of HIV remains a significant public health challenge. Using the PEN-3 cultural model as the theoretical framework, we examined social, cultural, and contextual factors that influenced uptake of HIV counseling and testing among pregnant women and their male partners. This was a qualitative study of participants in the Healthy Beginning Initiative (HBI), a congregation-based program to prevent mother-to-child transmission of HIV in Enugu, southeast Nigeria. We conducted eight focus group discussion sessions with 83 pregnant women and their male partners. Participants' perspectives on why they did or did not test for HIV were obtained. The most cited reasons for getting tested for HIV included the following: "the need to know one's status", "the role of prenatal testing" (positive perceptions); "the role of the church", "personal rapport with healthcare worker" (positive enablers); and the "influence of marriage" (positive nurturer). The most cited reason for not testing were: "fear of HIV test", "shame associated with HIV+ test results", "conspiratorial beliefs about HIV testing" (negative perceptions); "lack of confidentiality with HIV testing", (negative enabler); and "HIV-related stigma from family and community systems" (negative nurturer). Overall, numerous facilitators and barriers influence uptake of HIV testing in the study setting. Public health practitioners and policymakers need to consider how sociocultural and religious factors unique to specific local contexts may promote or hinder uptake of available HIV/AIDS prevention and care interventions.

Prevalence of Sickle Cell Trait and Reliability of Self-Reported Status among Expectant Parents in Nigeria: Implications for Targeted Newborn Screening.

BACKGROUND/AIMS: Sickle cell disease (SCD) is a life-threatening, autosomal recessive blood disorder prevalent in sub-Saharan Africa. We identified the prevalence of sickle cell trait (SCT) among pregnant women and their male partners in Enugu State, Nigeria, and determined the accuracy of self-reported sickle cell status and its reliability for identifying high-risk newborns for targeted screening. METHODS: We conducted a nested cohort study of expectant parents enrolled in the Healthy Beginning Initiative (HBI). The HBI is a cluster-randomized trial of a congregation-based approach designed to increase HIV testing. Participants completed a survey regarding self-awareness of their sickle cell genotype and consented to genotype screening by cellulose acetate electrophoresis. RESULTS: SCT prevalence (HbAS) was 22% (746/3,371). Only 50% of participants provided an accurate self-report. Self-report accuracy was significantly different (p < 0.0001) between individuals who reported having SCT or SCD (61% accuracy) versus those who reported not having SCT or SCD (86% accuracy). Demographic variables including gender, age, household size, employment, education, and home location were significantly associated with providing an accurate self-report. CONCLUSIONS: Low numbers of accurate parental self-reports, coupled with a high SCT prevalence in Nigeria, could limit the efficacy of targeted newborn screening. However, our data indicate that it is feasible to integrate sickle cell screening for pregnant women with existing, community-based health care programs developed by the President's Emergency Plan for AIDS Relief (PEPFAR), such as the HBI. Expanding screening programs could enable the development of targeted newborn screening based on maternal genotype that could identify all newborns with SCD in resource-limited settings.

Effect of a congregation-based intervention on uptake of HIV testing and linkage to care in pregnant women in Nigeria (Baby Shower): a cluster randomised trial.

BACKGROUND: Few effective community-based interventions exist to increase HIV testing and uptake of antiretroviral therapy (ART) in pregnant women in hard-to-reach resource-limited settings. We assessed whether delivery of an intervention through churches, the Healthy Beginning Initiative, would increase uptake of HIV testing in pregnant women compared with standard health facility referral. METHODS: In this cluster randomised trial, we enrolled self-identified pregnant women aged 18 years and older who attended churches in southeast Nigeria. We randomised churches (clusters) to intervention or control groups, stratified by mean annual number of infant baptisms (<80 vs ≥80). The Healthy Beginning Initiative intervention included health education and on-site laboratory testing implemented during baby showers in intervention group churches, whereas participants in control group churches were referred to health facilities as standard. Participants and investigators were aware of church allocation. The primary outcome was confirmed HIV testing. This trial is registered with ClinicalTrials.gov, identifier number NCT 01795261. FINDINGS: Between Jan 20, 2013, and Aug 31, 2014, we enrolled 3002 participants at 40 churches (20 per group). 1309 (79%) of 1647 women attended antenatal care in the intervention group compared with 1080 (80%) of 1355 in the control group. 1514 women (92%) in the intervention group had an HIV test compared with 740 (55%) controls (adjusted odds ratio 11·2, 95% CI 8·77-14·25; p<0·0001). INTERPRETATION: Culturally adapted, community-based programmes such as the Healthy Beginning Initiative can be effective in increasing HIV screening in pregnant women in resource-limited settings. FUNDING: US National Institutes of Health and US President's Emergency Plan for AIDS Relief.