Implementation and Evaluation of a Bystander Naloxone Training Course.

Introduction: Bystander provision of naloxone is a key modality to reduce opioid overdose-related death. Naloxone training courses are available, but no standardized program exists. As part of a bystander empowerment course, we created and evaluated a brief naloxone training module. Methods: This was a retrospective evaluation of a naloxone training course, which was paired with Stop the Bleed training for hemorrhage control and was offered to administrative staff in an office building. Participants worked in an organization related to healthcare, but none were clinicians. The curriculum included the following topics: 1) background about the opioid epidemic; 2) how to recognize the signs of an opioid overdose; 3) actions not to take when encountering an overdose victim; 4) the correct steps to take when encountering an overdose victim; 5) an overview of naloxone products; and 6) Good Samaritan protection laws. The 20-minute didactic section was followed by a hands-on session with nasal naloxone kits and a simulation mannequin. The course was evaluated with the Opioid Overdose Knowledge (OOKS) and Opioid Overdose Attitudes (OOAS) scales for take-home naloxone training evaluation. We used the paired Wilcoxon signed-rank test to compare scores pre- and post-course. Results: Twenty-eight participants completed the course. The OOKS, measuring objective knowledge about opioid overdose and naloxone, had improved scores from a median of 73.2% (interquartile range [IQR] 68.3%-79.9%) to 91.5% (IQR 85.4%-95.1%), P < 0.001. The three domains on the OOAS score also showed statistically significant results. Competency to manage an overdose improved on a five-point scale from a median of 2.5 (IQR 2.4-2.9) to a median of 3.7 (IQR 3.5-4.1), P < 0.001. Concerns about managing an overdose decreased (improved) from a median of 2.3 (IQR 1.9-2.6) to median 1.8 (IQR 1.5-2.1), P < 0.001. Readiness to intervene in an opioid overdose improved from a median of 4 (IQR 3.8-4.2) to a median of 4.2 (IQR 4-4.2), P < 0.001. Conclusion: A brief course designed to teach bystanders about opioid overdose and naloxone was feasible and effective. We encourage hospitals and other organizations to use and promulgate this model. Furthermore, we suggest the convening of a national consortium to achieve consensus on program content and delivery.

First-trimester glycosylated hemoglobin (HbA1c) and maternal characteristics in the prediction of gestational diabetes: An observational cohort study.

INTRODUCTION: This study aimed to investigate the extent to which gestational diabetes mellitus (GDM) can be predicted in the first trimester by combining a marker of growing interest, glycosylated hemoglobin A1c (HbA1c), and maternal characteristics. MATERIAL AND METHODS: This observational study was conducted in the outpatient obstetric department of our institution. The values of HbA1c and venous random plasma glucose were prospectively assessed in the first trimester of pregnancy. We determined maternal characteristics that were independent predictors from the regression analysis and calculated areas under the receiver-operating curves by combining the maternal age, body mass index, previous history of GDM, and first-degree family history for diabetes mellitus. Moreover we investigated the predictive capability of HbA1c to exclude GDM. Patients with a first-trimester HbA1c level of 6.5% (48 mmol/mol) or more were excluded. The study was registered at ClinicalTrials.gov ID: NCT02139254. RESULTS: We included 785 cases with complete dataset. The prevalence of GDM was 14.7% (115/785). Those who developed GDM had significantly higher HbA1c and random plasma glucose values (p < 0.0001 and p = 0.0002, respectively). In addition, they had a higher body mass index, were more likely to have a history of GDM and/or a first-degree family history of diabetes. When these maternal characteristics were combined with the first-trimester HbA1c and random plasma glucose the combined area under the receiver operating characteristics curve was 0.76 (95% CI 0.70-0.81). CONCLUSIONS: Our results indicate that HbA1c and random plasma glucose values combined with age, body mass index, and personal and family history, allow the identification of women in the first trimester who are at increased risk of developing GDM.

Incidence of Pediatric Cannabis Exposure Among Children and Teenagers Aged 0 to 19 Years Before and After Medical Marijuana Legalization in Massachusetts.

Importance: Pediatric health care contacts due to cannabis exposure increased in Colorado and Washington State after cannabis (marijuana) policies became more liberal, but evidence from other US states is limited. Objective: To document the incidence of pediatric cannabis exposure cases reported to the Regional Center for Poison Control and Prevention (RPC) before and after medical marijuana legalization (MML) in Massachusetts. Design, Setting, and Participants: Cross-sectional comparison of pediatric cannabis exposure cases 4 years before and after MML in Massachusetts. The exposure cases included those of 218 children and teenagers aged between 0 and 19 years, as reported to the RPC from 2009 to 2016. Census data were used to determine the incidence. Data analysis was performed from November 12, 2018, to July 20, 2019. Exposure: Cannabis products. Main Outcomes and Measures: Incidence of RPC-reported cannabis exposure cases, both single substance and polysubstance, for the age group of 0 to 19 years, and cannabis product type, coingestants, and clinical effects. Results: During the 8-year study period (2009-2016), the RPC received 218 calls involving cannabis exposure (98 single substance, 120 polysubstance) in children and teenagers aged 0 to 19 years, representing 0.15% of all RPC calls in that age group for that period. Of the total exposure cases, males accounted for 132 (60.6%) and females 86 (39.4%). The incidence of single-substance cannabis calls increased from 0.4 per 100 000 population before MML to 1.1 per 100 000 population after (incidence rate ratio, 2.4; 95% CI, 1.5-3.9), a 140% increase. The age group of 15 to 19 years had the highest frequency of RPC-reported cannabis exposures (178 calls [81.7%]). The proportion of all RPC calls due to single-substance cannabis exposure increased overall for all age groups from 29 before MML to 69 afterward. Exposure to edible products increased after MML for most age groups. Conclusions and Relevance: Pediatric cannabis exposure cases increased in Massachusetts after medical marijuana was legalized in 2012, despite using childproof packaging and warning labels. This study provides additional evidence suggesting that MML may be associated with an increase in cannabis exposure cases among very young children, and extends prior work showing that teenagers are also experiencing increased cannabis-related health system contacts via the RPC. Additional efforts are needed to keep higher-potency edible products and concentrated extracts from children and teenagers, especially considering the MML and retail cannabis sales in an increasing number of US states.

Intravenous immunoglobulin, HLA allele typing and HLAMatchmaker facilitate successful transplantation in highly sensitized pediatric renal allograft recipients.

The use of intravenous immunoglobulin (IVIG) in sensitized transplant candidates has resulted in reduced HLA antibody levels and shorter transplant wait times. In addition, the HLAMatchmaker program has been used to identify acceptable mismatches to permit transplantation in highly sensitized patients. We used IVIG desensitization in conjunction with high resolution HLA allele typing and HLAMatchmaker grading of donor offers to facilitate successful transplantation in two highly sensitized children who were awaiting second renal transplants. Both patients lost their initial transplant in <10 days to accelerated acute rejection, and were on dialysis for an average of 50 months with high panel reactive antibody (PRA) levels. They were started on monthly IVIG infusions (2 g/kg/dose). Within one wk following their third and fifth IVIG doses, both patients received a crossmatch compatible, deceased donor renal transplant selected by HLAMatchmaker as a suitable donor offer. Both patients remain rejection free with excellent renal function 19 and 15 months post-transplant, respectively. In conclusion, combining IVIG therapy and donor selection by HLA humoral epitope matching permitted successful transplantation of two highly sensitized children. Further studies in larger numbers of patients with longer follow-up are needed to determine the individual role played by, and relative importance of each component of this combined strategy.

Getting ready: developing an educational intervention to prepare African American women for breast biopsy.

Focus groups with African American women who had experienced a breast biopsy were conducted during the process of "getting ready" for a breast biopsy educational study in which the intervention's educational materials and study instruments were developed and pre-tested. Recommendations were made for revising the breast biopsy educational booklet. As a result of the focus group discussions, changes were made in several of the graphics, the design and size of the booklet, and the tone of the piece. In addition, language describing the biopsy procedure was further simplified. The outcomes of this study were culturally tailored study materials to be used in an educational intervention to prepare African American women undergoing a breast biopsy procedure.

Clinical nurse specialists' knowledge specific to Medicare structures and processes.

PURPOSE: The purpose of this study was to describe clinical nurse specialists' (CNSs) knowledge of Medicare structures and processes using a multiple-choice examination. DESIGN: This descriptive study used the survey method with a convenient sample. SETTING: Potential subjects received the research study packet at the address designated by them for membership mailings sent from the National Association of Clinical Nurse Specialists (NACNS). SAMPLE: The population of interest was practicing CNSs. The accessible population was NACNS members drawn from the 2002 mailing list organized by zip code. Every third mailing label was skipped. The remaining list members (N = 950) received a study packet. There was a 14.42% response rate with 137 respondents. Eighty-two percent held a master's degree in nursing. METHODS: A 46 item multiple-choice examination was developed based upon a content map established after a review of the available Medicare-related literature and consultation with Medicare advanced practice nurse providers. Content validity was established. Survey packets with the instrument, Scantron answer key, informational letter, and demographic profile were sent to potential subjects. Returned responses were keyed for correct answers. Relationships between demographic variables, raw score, and self-reported Medicare expertise were analyzed. Qualitative data elicited on the demographic form were thematically analyzed. FINDINGS: The examination had a.67 coefficient. Correlation of examination raw score to self-reported Medicare content expertise was 0.982 (P =.000). One third of the examination questions were incorrectly answered by 30% or more of respondents. Percentage correct scores ranged from 60.9 to 95.7 (M = 62.7%; SD = 10.46). Respondents offered 40 comments. Eleven comments related to a self-recognized Medicare knowledge deficit. Four responses highlighted that graduate studies had not provided them with the knowledge necessary for understanding reimbursement issues. Ten respondents expressed an interest in locating some type of educational resource addressing the Medicare system, reimbursement processes, and opportunities. CONCLUSIONS: Findings suggest that NACNS members have Medicare program knowledge deficits. Respondents recognize their deficiencies and are interested in obtaining more information about Medicare but are uncertain as to available resources or networking opportunities that might support them in this process. Graduate nursing programs may need to evaluate the amount of information provided within curriculums specific to insurance reimbursement and Medicare structures and processes. Study limitations include the low response rate and indeterminate sample representativeness. IMPLICATIONS FOR PRACTICE: Educators should examine CNS curriculums to ensure the adequacy of Medicare program information. Continuing education programs and conference workshops addressing Medicare information should be offered to CNSs interested in increasing their expertise or exploring provider opportunities. There may be entrepreneurial opportunities available to CNSs interested in developing an expertise in Medicare programs. Future research studies should quantify potential benefits to Medicare beneficiaries when CNSs participate as providers.